Paul Zimmet AO MD PhD

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The Metabolic Syndrome Resolving the Controversy
on Criteria
Paul Zimmet AO MD PhD International Diabetes
Institute Australia
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Epidemic Type 2 Diabetesand the Hidden IGT
Epidemic 2004
97 million known cases
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Epidemic Type 2 Diabetesand the Hidden IGT
Epidemic 2004
97 million known cases
97 million undiagnosed cases
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Epidemic Type 2 Diabetesand the Hidden IGT
Epidemic 2004
97 million known cases
97 million undiagnosed cases,
314 million persons with Impaired Glucose
Tolerance
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Epidemic Type 2 Diabetesand the Hidden IGT
Epidemic 2004
. . . and the cardiovascular diseaseepidemic to
follow through the Metabolic Syndrome. . .
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CREPALDIS SYNDROME

• seems to suggest a peculiar syndrome including
  hyperlipemia, obesity and diabetes. The
  development of ischaemic heart disease and
  hypertension is often found in these patients.
• Avogaro Crepaldi, 1965

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VARIOUS DEFINITIONS

• Included in definition

• Not included in definition

• ADA 01

• ATPIII 01

• ICD-9 00

• WHO 98

• AHA 01

• IDF 00

• Explicitly included in definition

• Closely associated with insulin resistance

• Related to a state of insulin resistance

• Explicitlyincluded in definition

• Observed in people who are insulin-resistant

• Syndromealso knownas insulin
  resistancesyndrome

• Insulinresistance

• Low HDL

• Hypertension

• High TG

• Central obesity

• Glucoseintolerance

• Diabetes

• High LDL

Diabetes
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The WHO attempt to describe define the
Metabolic Syndrome was an initiative to create
interest and debate it was never meant to be
the final answer.
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(No Transcript)
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Metabolic Syndrome WHO 1999
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The Metabolic Syndrome (ATP-3) Criteria
NCEP ATP III. JAMA. 20012852486-2497.
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EGIR Definition of Metabolic Syndrome 1999

• Insulin resistance 2 or more of
• Central obesity (94 cm -M 80 cm - F)
• TG gt2.9 mM OR HDL lt1.0
• Hypertension (140/90)
• FPG 6.1 mM

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The Metabolic Syndromein Australia
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Prevalence of the Metabolic Syndromein
Australian Adults (gt25 years) AusDiab
gt25 years
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Metabolic Syndrome Prevalence3 Definitions in
Australians - AusDiab
WHO (25.3)
NCEP (22.4)
4.8
4.3
12.0
4.8
4.2
0.8
2.0
EGIR (19.0)
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METABOLIC SYNDROME

• Aetiology
• Insulin resistance??
• Central obesity??
• Endothelial dysfunction??

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Central Obesity rather than Insulin Resistance
the Driving Force?
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Prevalence Of The Metabolic Syndrome According To
ATP III Definition
Age range
45-49 20-75 30-79 32 30-79 30-79 50-69 25 21 25
30-64
Obesity criteria adjusted to waist circumference
appropriate for an Indian population
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Prevalence of Central Obesity in Singapore
Men
Women
Women gt88 cm (ATPIII) gt80 cm (Asian) Men gt102 cm
(ATPIII) gt90 cm (Asian)
Tan CE et al Diabetes Care 2004
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Obesity CVD Risk Factors in Chinese Males Hong
Kong
Likelihood ratio for diabetes, hypertension,
dyslipidemia or albuminuria at various BMI
(kg/m2) cutoff values
BMI kg/m2
Ko et al. Int J Obesity 1999
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Prevalence of Metabolic Syndrome ATP-3 versus
Asia Pacific recommendations - Korea
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Prevalence
12.4
9.8
9.0
10
5.2
0
ATP3
Asia-Pacific
ATP3
Asia-Pacific
Waist Circumference
Lee W-Y et al DRCP 2004
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A New Definition Barriers Challenges

• Insufficient epidemiological data to make key
  decisions eg criteria cut-offs
• Ethnic (genetic cultural) differences in risk
  factors eg Asian BMI, WHR risk
• Gender differences in RF prevalence eg IGT IFG
• Age-related risk factor differences
• Methodological differences access to assays
• Different levels of acculturation
• Political influences

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NEW PROPOSED IDF CRITERIA

• Abdominal obesity WC but not if BMIgt30
  (ethnic/country specific) plus
• TG elevated
• HDL decreased
• Blood pressure
• Fasting glucose If gt5.6 mmol/l then OGTT is
  advised, or known Type 2 diabetes

Abdominal obesity plus 2 of the others qualifies
Prepared by Scott Grundy
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Prepared by Scott Grundy
Grundy Platinum/Gold Research
CRP
Adipo- nectin
IR
?TG IFG/IGT T2DM
? BP
Abdominal Obesity
Microalb
?HDL
PAI-1
Apo B Little LDL
New Clinical Syndrome
HOMA, euglycemic clamp, F insulin etc
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New Denition of the Metabolic Syndrome

• Needs
• To identify individuals at high risk of
  developing cardiovascular disease (and diabetes)
• To be useful for clinicians
• To be useful for international comparisons