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IDF Meta Def Final PDF
IDF Meta Def Final PDF
IDF Meta Def Final PDF
consensus
worldwide
definition
of the
METABOLIC
SYNDROME
No part of this publication may be reproduced or
transmitted in any form or by any means without the
prior written permission of the International Diabetes
Federation (IDF). Requests to reproduce or translate
IDF publications should be addressed to:
IDF Communications
Avenue Emile De Mot 19,
B-1000 Brussels, Belgium
by fax at +32-2-5385114 or
by e-mail at communications@idf.org
2
The IDF worldwide definition of the metabolic
syndrome was developed during a unique
consensus workshop on the initiative of
Professors Sir George Alberti and Paul Zimmet.
The workshop was held on behalf of the IDF
Task Force on Epidemiology and Prevention.
3
The metabolic syndrome
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The metabolic syndrome is a cluster In addition, people with metabolic
of the most dangerous heart attack syndrome have a fivefold greater
risk factors: diabetes and raised risk of developing type 2 diabetes.5
fasting plasma glucose, abdominal They would add to the 230 million
obesity, high cholesterol and high people worldwide who already have
blood pressure.1-4 diabetes6a, one of the most common
chronic diseases worldwide and
It is estimated that around 20-25 per the fourth or fifth leading cause of
cent of the worlds adult population death in the developed world. The
have the metabolic syndrome and clustering of cardiovascular disease
they are twice as likely to die from (CVD) risk factors that typifies
and three times as likely to have a the metabolic syndrome is now
heart attack or stroke compared considered to be the driving force for
with people without the syndrome. a new CVD epidemic.
4
Diabetes and
the metabolic syndrome
driving the CVD epidemic
Each year, 3.2 million people around what is now known as the Metabolic
the world die from complications Syndrome. This clustering of
associated with diabetes. In countries metabolic abnormalities that occur
with a high diabetes incidence, such in the same individual appear to
as those in the Pacific and the Middle confer a substantial additional
East, as many as one in four deaths cardiovascular risk over and above
in adults aged between 35 and 64 the sum of the risk associated with
years is due to the disease. Type 2 each abnormality.8,9
diabetes, which accounts for 90 per
cent of all diabetes, has become one However, even before levels of
of the major causes of premature blood glucose are high enough
illness and death, mainly through for a person to be diagnosed with
the increased risk of CVD which is diabetes, hyperglycaemia and related
responsible for up to 80 per cent of changes in blood lipids (increase in
these deaths.6b,7 triglycerides and decrease in the
good cholesterol HDL-c) increase
In most people with glucose a persons risk of CVD.8 The more
intolerance or type 2 diabetes, there components of the metabolic
is a multiple set of risk factors that syndrome that are evident, the higher
commonly appear together, forming is the cardiovascular mortality rate.10
5
Global burden
6
What causes
the metabolic syndrome?
The underlying cause of the much glucose in the blood) and will
metabolic syndrome continues to be diagnosed with type 2 diabetes.
challenge the experts but both insulin Even before this happens, damage
resistance and central obesity are is occurring to the body, including a
considered significant factors.13,14 build-up of triglycerides which further
Genetics, physical inactivity, ageing, a impairs insulin sensitivity.
proinflammatory state and hormonal
changes may also have a causal Central obesity
effect, but the role of these may vary Obesity is associated with insulin
depending on ethnic group.15,16 resistance and the metabolic
syndrome. Obesity contributes to
Insulin resistance hypertension, high serum cholesterol,
Insulin resistance occurs when cells low HDL-c and hyperglycaemia, and is
in the body (liver, skeletal muscle independently associated with higher
and adipose/fat tissue) become less CVD risk.13,17,18 The risk of serious
sensitive and eventually resistant health consequences in the form
to insulin, the hormone which of type 2 diabetes, coronary heart
is produced by the beta cells in disease (CHD) and a range of other
the pancreas to facilitate glucose conditions, including some forms
absorption. Glucose can no longer of cancer, has been shown to rise
be absorbed by the cells but with an increase in body mass index
remains in the blood, triggering (BMI),19 but it is an excess of body fat
the need for more and more insulin in the abdomen, measured simply
(hyperinsulinaemia) to be produced by waist circumference, that is more
in an attempt to process the glucose. indicative of the metabolic syndrome
The production of ever-increasing profile than BMI.20-22 The International
amounts of insulin weakens and may Obesity Task Force (IOTF) reports that
eventually wear out the beta cells. 1.7 billion of the worlds population
Once the pancreas is no longer able is already at a heightened risk of
to produce enough insulin then a weight-related, non-communicable
person becomes hyperglycaemic (too diseases such as type 2 diabetes.23
7
The need for early
diagnosis and treatment:
the IDF worldwide definition
of metabolic syndrome
8
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9
Worldwide definition
for use in clinical practice
* If BMI is >30kg/m, central obesity can be assumed and waist circumference does not need to be
measured.
10
for the diagnosis of the syndrome in (ApoB), small dense LDL and small
the new definition. Insulin resistance, HDL particles, all of which are
which is difficult to measure in day-to- independently atherogenic30, and
day clinical practice, is not an essential which is commonly observed in
requirement. people with both type 2 diabetes
and the metabolic syndrome.
Atherogenic dyslipidaemia Low HDL-c and high TG levels
describes the combination of are frequently found with insulin
raised triglycerides (TG) and low resistance, with or without type 2
concentrations of HDL-c together diabetes31, and both are risk factors
with elevated apolipoprotein B for coronary heart disease (CHD).32,33
Waist
Country/Ethnic group
circumference
Europids* Male 94 cm
In the USA, the ATP III values
(102 cm male; 88 cm female)
are likely to continue to be used for Female 80 cm
clinical purposes
South Asians Male 90 cm
Based on a Chinese, Malay and
Asian-Indian population Female 80 cm
Male 90 cm
Chinese
Female 80 cm
Male 90 cm
Japanese**
Female 80 cm
Ethnic South and Central Use South Asian recommendations until more
Americans specific data are available
Use European data until more specific data
Sub-Saharan Africans
are available
Eastern Mediterranean and Use European data until more specific data
Middle East (Arab) populations are available
* In future epidemiological studies of populations of Europid origin, prevalence should be given
using both European and North American cut-points to allow better comparisons.
** Originally different values were proposed for Japanese people but new data support the use of
the values shown above.
11
2005 CE/A Martinez Alonso
12
Platinum standard
definition
additional metabolic
measurements for research
Table 3: Additional metabolic measurements for research
The IDF consensus group has criteria for CVD and/or diabetes.
highlighted a number of other The use of these additional factors
parameters that appear to be related in research will also allow further
to the metabolic syndrome (Table 3) modification of the definition if
which should be included in research necessary and the validation of the
studies to help determine the new clinical definition in different
predictive power of these extra ethnic groups.
13
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Recommendations
for treatment
15
Table 4: IDF recommended treatment of the individual components of the
metabolic syndrome
Atherogenic dyslipidaemia
Primary aims for therapy:
Lower TG (as well as lowering ApoB and non-HDL cholesterol)
Raise HDL-c levels
Reduce LDL-c levels (elevated levels represent a high risk in the metabolic syndrome)
Options:
Fibrates (PPAR alpha agonists) improve all components of atherogenic dyslipidaemia
and appear to reduce the risk for CVD in people with metabolic syndrome. The Veterans
Affairs High-Density Lipoprotein Intervention Trial (VA-HIT) showed that raising HDL-c
concentrations using a fibrate in patients with well-established CHD and both a low HDL-c
and a low LDL-c level will significantly reduce the incidence of major coronary events.31
Statins to reduce all ApoB-containing lipoproteins and to achieve ATP III goals for LDL-c as
well as for non-HDL-c (ATP III, 2001). Several clinical studies have confirmed the benefits of
statin therapy.3739
Fibrates in combination with statins but may be complicated by side effects.
16
The group awaits with interest the effects. In addition, emerging
results of ongoing thiazolidinedione therapies such as incretin mimetics,
and fibrate outcomes studies, as well dipeptidyl peptidase IV inhibitors,
as the publication of clinical data for protein tyrosine phosphatase 1B
the new generation of PPAR agonists inhibitors, and the endocannabinoid
which interact with both PPAR alpha receptor blocking agents offer
and gamma receptors, thereby potential as future therapies for the
combining lipid and glycaemic metabolic syndrome.
Future work
The IDF consensus group hopes that the aetiology of the metabolic
this new definition, emphasizing the syndrome
importance of central obesity with the best and most predictive
modifications according to ethnic definition of the metabolic
group, will be adopted worldwide syndrome and its components
and prove convenient and useful in the relationship of blood pressure
clinical practice and epidemiological to the other components of the
studies. This should encourage the syndrome
clinical diagnosis of the metabolic the relationship between different
syndrome and the identification of constellations of factors to CVD
patients at considerably increased outcomes
risk of developing CVD and/or type 2 the relationship of simple
diabetes. and complex measures of the
components of the metabolic
A single worldwide definition syndrome to clinical events
will enable easier comparison of the true impact of effective
data from different studies and treatment of all components of
an ongoing refinement as more the syndrome on CVD risk
information becomes available and better identification of high risk
as the following areas of further patients with metabolic syndrome
research are explored: in different populations.
17
Frequently Asked
Questions
18
people with type 2 diabetes who also In practice:
present the metabolic syndrome carry
a much higher risk of CVD than those How is central obesity measured?
who have type 2 diabetes alone. Central obesity is a prerequisite risk
factor for metabolic syndrome which
Is the risk of CVD greater in the can be easily assessed using waist
metabolic syndrome than the sum circumference. The waist measurement
of its parts? can be taken with a tape measure in
Some studies have shown a purely a horizontal plane, midway between
additive risk whilst others show a the inferior margin of the ribs and
greater interaction. Whichever is true the superior border of the iliac crest.
the metabolic syndrome provides Ethnic specific values should be taken
a useful tool to identify high risk into account (see Table 2).
people and to institute treatment.
Have criteria been adapted to
How can cardiovascular risk be children and adolescents?
prevented and treated? A further consensus meeting has been
Lifestyle change is the best way held by IDF on this subject and criteria
by far to prevent increased risk of to diagnose metabolic syndrome
cardiovascular disease and diabetes. in children and adolescents will be
If that fails then the individual risk published in late 2006 or 2007.
factors will require treatment with
appropriate pharmacological agents. Have ATP III come in line with the
new IDF criteria?
How can the metabolic syndrome Apart from not making waist
be diagnosed in clinical practice? circumference the central and
The initial step is to measure waist essential component, the most
circumference. This can be done by recent ATP III criteria are now in line
people themselves. If that is raised with those of IDF.
then the factors should be checked:
blood pressure and a fasting blood
sample for glucose, triglycerides and
HDL-cholesterol.
19
References
20
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New England Journal of Medicine
9 Golden SH, Folsom AR, Coresh J et al. 1991;324:733-9
Risk factor grouping related to insulin
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on subclinical atherosclerosis: the et al. Factor analysis of the metabolic
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10 Hu G, Qiao Q, Tuomilehto J et al for the
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Arch Intern Med 2004;164:1066-76 18 Carey VJ, Walters EE, Colditz GA et al.
Body fat distribution and risk of non-
11 World Health Organization. Prevention of insulin-dependent diabetes in women:
diabetes mellitus. Technical Report Series the Nurses Health Study. Am J Epidemiol
no. 844. WHO, Geneva, 1994 1997;145:614-19
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