CASE REPORTS

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A CASE OF METABOLIC SYNDROME

	WHO (1998)	IDF (2004)
Criteria for diagnosis	Type 2 DM or Impaired Glucose Tolerance (IGT) and any 2 of the following factors	Central obesity plus any 2 of the other following factors
Hypertension	BP > 140/90 mmHg and/or currently on antihypertensive therapy	Systolic BP ≥130 or diastolic BP ³85 mmHg, or currently on antihypertensive therapy
Dyslipidemia	Tg > 1.7 mmol/L (150 mg/dL) and/or HDL-C < 0.9 mmol/L (35 mg/dL) in men and < 1.0 mmol/L (40 mg/dL) in women	Tg > 1.7 mmol/L, or treatment for this lipid abnormality or HDL-C < 1.03 mmol/L (40 mg/dL) in men and < 1.29 mmol/L (50 mg/dL) in women or treatment for this lipid abnormality.
Obesity	BMI > 30 kg/m2 and/or waist/hip ratio > 0.9 in men and >0.85 in women	Central obesity (waist circumference ≥94 cm for men and ≥80 cm for Europeans women.
Glucose	Type 2 DM or IGT	Fasting plasma glucose ≥5.6 mmol/L (100 mg/dL), or previously diagnosed type 2 DM (If FBS> 5.6 mmol/L, an oral glucose tolerance test [OGTT] is strongly recommended, but is not necessary to define presence of the syndrome.)
Other	Microalbuminuria (overnight urinary albumin excretion rate > 20 mcg/min or 30 mg/g Cr)

DISCUSSION

Metabolic syndrome affects approximately 25% of adults and is particularly increasing due to central obesity.¹ A few criteria were used to define metabolic syndrome but we describe the more commonly adopted definition by the World Health Organization (WHO) and the much discussed recent criteria defined by the International Federation of Diabetes Mellitus (IDF criteria)² [see table 1].

Essentially, metabolic syndrome revolves around the management of a cluster of chronic diseases such as diabetes mellitus, hypertension, dyslipidaemia, and obesity. There is no single treatment for patients with metabolic syndrome but rather early detection and management of these chronic diseases and modification of the risk factors. All these chronic conditions are ‘bread and butter’ problems encountered in general practice and yet it is difficult to achieve optimal control. The most important modifiable risk factors include smoking and patient should be advised to stop it.³

Insulin resistance
There is general agreement that insulin resistance is the underlying cause of metabolic syndrome. Insulin resistance and the resulting hyperinsulinaemia have been implicated in the development of glucose intolerance and the progression of type 2 diabetes mellitus, hypertension, polycystic ovarian syndrome, hypercoagulability and vascular inflammation as well as eventual development of CVD.⁴ Recently IDF has proposed central obesity as an important component of metabolic syndrome because it is highly correlated with other components of metabolic syndrome and is easily measured using waist circumference.⁵

Weight loss

One of the important aspects of management for metabolic syndrome is weight reduction. A realistic goal for weight reduction is to reduce body weight by 7-10% over a period of 6-12 months.³ This is achieved by encouraging patient to focus on exercise and improve their personal level of activity. Great benefit occurs when sedentary persons incorporate moderate intensity exercises into their lifestyle.¹ Regular physical training and endurance exercise training can induce body fat loss and a mobilization of abdominal and visceral adipose tissue can increase insulin sensitivity and improve the atherogenic lipoprotein profile.⁶ However, the goals set must be realistic and achievable, and should be adjusted according to the patient’s level of acceptance and compliance.⁷ DASH (dietary advice to stop systolic hypertension) diet should be emphasized and this includes fruits, vegetables, low fat dairy products, whole grains, fish, polyunsaturated and monounsaturated fats.⁸ There is a need to develop a national comprehensive plan to prevent and treat the obesity epidemic as it is closely related to metabolic syndrome. ⁹

Hypertension

The other important aspect of management is to optimize patient’s blood pressure.¹⁰ The ADA10  and JNC 7 ¹⁰  recommend the goal of blood pressure for a patient with diabetes mellitus to be less than 130/80 mmHg. Angiotensin converting enzyme (ACE) inhibitors, which can prevent microvascular, and macrovascular complications as well as the progression of albuminuria¹⁰, are preferred therapeutic agent unless contraindicated otherwise.

 

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