The document discusses metabolic syndrome, which is a cluster of conditions that increases the risk of heart disease and diabetes. It occurs when someone has 3 or more risk factors such as high blood pressure, low HDL cholesterol, and pre-diabetes or diabetes. Short bursts of high-intensity exercise may be more effective at improving metabolic syndrome risk factors than longer periods of moderate exercise, though more research is still needed.

1. METABOLIC
SYNDROME
DR . MOUSA BIN SAMHAN AL ENAZY
CONSULTANT PHYSICION OF FAMILY
MEDICINE

2. INTRODUCTION
Obesity is an important modifiable risk factor for
many chronic diseases, including cardiovascular
disease (CVD), type 2 diabetes, hypertension,
hypercholesterolaemia, certain types of cancer,
osteoarthritis, gallbladder disease and mental
health problems The traditional CVD risk factors of
smoking, hypertension and hypercholesterolaemia
have been the main focus of prevention and
treatment programs for several decades, with only
limited attention given to obesity Recent
guidelines show increasing recognition that global
risk — integrating a person’s individual risk factors
with age, sex and any vascular disease already
present — is central to risk factor assessment and
management.
In recent years, a clustering of risk factors
(hyperglycaemia, hypertension,
hypertriglyceridaemia, low levels of high-density
lipoprotein [HDL] cholesterol, and
overweight/obesity) identified as “metabolic
syndrome” (MetS) has gained widespread
recognition. MetS is strongly associated with an
increased risk of type 2 diabetes and CVD.
according to US National Cholesterol Education
Program Adult Treatment Panel III (NCEP ATP III)
criteria . International Diabetes foundation (IDF)
criteria &American heart association criteria .

3. Metabolic Syndrome
Also called: Insulin resistance syndrome, Metabolic Syndrome X
Metabolic syndrome is a group of conditions that put you at risk for heart
disease and diabetes. These conditions are
• High blood pressure
• High blood sugar levels
• High levels of triglycerides, a type of fat, in your blood
• Low levels of HDL, the good cholesterol, in your blood
• Too much fat around your waist
Not all doctors agree on the definition or cause of metabolic syndrome. The
cause might be insulin resistance. Insulin is a hormone your body produces to
help you turn sugar from food into energy for your body. If you are insulin
resistant, too much sugar builds up in your blood, setting the stage for
disease.
The Role of Diet in Metabolic Syndrome
A new study has implicated meat, fried food and, surprisingly, diet soda in the
development of metabolic syndrome. More research will now be needed to confirm
and explain these intriguing findings.
Metabolic syndrome is a cluster of conditions that increases the risk for heart disease
and stroke. Doctors consider someone to have metabolic syndrome when they have 3
or more risk factors, which include elevated blood pressure, low HDL (good
cholesterol) levels and diabetes or pre-diabetes.

4. Various aspects of diet have been linked to metabolic syndrome in previous studies,
but the diet's role in the syndrome's genesis isn't well understood. Dr. Lyn M. Steffen
at the University of Minnesota's School of Public Health and her colleagues set out to
take a broad look at the relationship between metabolic syndrome and dietary intake.
They used data from 9,514 middle-aged adults enrolled in the multicenter
Atherosclerosis Risk in Communities (ARIC) study. The study was initiated by NIH's
National Heart, Lung and Blood Institute (NHLBI) to investigate the factors that
contribute to atherosclerosis (the buildup of cholesterol and fat in the walls of arteries)
and the incidence of cardiovascular diseases.
ARIC assessed dietary intake, both at the beginning of the study and 6 years later, by
using a 66-item food frequency questionnaire. By 9 years later, nearly 40% of the
study's participants had developed metabolic syndrome. The new analysis of ARIC
data appeared in the February 19, 2008, issue of Circulation.
The study found that a Western dietary pattern—characterized by high intakes of
refined grains, processed meat, fried foods and red meat—was associated with a
greater risk of developing metabolic syndrome. Upon closer analysis, the researchers
found that those who ate the most meat were more likely to develop metabolic
syndrome. In particular, hamburgers, hot dogs and processed meats were each
associated with higher rates of metabolic syndrome. Fried foods were also associated
with an increased risk.
The researchers didn't find any association, positive or negative, between metabolic
syndrome and whole grains, refined grains, nuts, coffee or fruits and vegetables. On
the other hand, they found that those who ate more dairy were less likely to develop
metabolic syndrome.
Strikingly, diet soda was strongly associated with an increased risk for metabolic
syndrome, although sweetened beverages such as juices and regular soda were not.
Other recent studies have found links between diet soda and metabolic syndrome as
well as weight gain. As a possible explanation, findings in rodents suggest that
artificial sweeteners may lead to increased intake because they may interfere with the
body's ability to properly assess how many calories are in foods.
These findings, however intriguing, are not conclusive. Whole grains have been found
in previous studies to lower the risk of metabolic syndrome, but this study didn't.
Certain foods in themselves may not play a role in causing metabolic syndrome, but
rather may serve as markers for other behaviors that do lead to metabolic syndrome.
More research into what causes metabolic syndrome will hopefully clear up the
confusion.

5. High-intensity exercise better at improving metabolic
syndrome risk factors
Study highlights:
• Short bursts of high-intensity exercise, rather than longer spells of
moderate-intensity, exercise may improve the health of people with metabolic
syndrome.
• The findings could have implications for rehabilitation programs.
• Once previously sedentary people with metabolic syndrome can comfortably
exercise at a moderate intensity, they could consider more vigorous exercise,
if they can do it without adverse symptoms, according to American Heart
Association spokesperson.
DALLAS, July 8 — In a small study, short, vigorous exercise appeared to
reduce metabolic risk factors better than longer spells of moderate intensity
exercise according to a report in Circulation: Journal of the American Heart
Association.
Forty-six percent of metabolic syndrome patients who participated in a 4-
month, intense aerobic interval training (AIT) program had fewer metabolic
syndrome risk factors compared to 37 percent of patients following a
moderate training plan.
Metabolic syndrome — estimated to affect 24 percent of the U.S. adult
population — is a clustering of metabolic risk factors that increase your
vulnerability to coronary heart disease, stroke, peripheral vascular diseases
and other diseases related to plaque build-ups in artery walls. As defined by
the World Health Organization, the risk factors include type 2 diabetes,
obesity (body-mass index of 30 or greater), abdominal obesity, high
triglycerides, low high-density lipoprotein (HDL) cholesterol, high blood
pressure, insulin resistance, glucose intolerance and microalbuminuria.

6. To determine what kind of exercise works best against the metabolic
syndrome, researchers divided 32 patients (average age 52) into three
groups. One group used a high-intensity aerobic-interval training for four
months. Another used a less-intense regimen called “moderate continuous-
training” (CME). Another did not exercise.
“The current study suggests that exercise in general and AIT in particular is
partly or fully able to reverse metabolic syndrome, suggesting that this may be
a promising treatment strategy,” said Arnt Erik Tjønna, M.Sc., lead author of
the study and a doctoral candidate in clinical medicine at the Norwegian
University of Science and Technology in Trondheim, Norway. “Guidelines
calling for 30 minutes of exercise of moderate intensity may be too general for
this population.”
Patients in both exercise groups lost roughly the same weight and waist
circumference. Thus, AIT’s ability to cause patients’ hearts to beat faster —
and thus absorb and use oxygen — seems to
be why patients in this group became healthier than those in the CME group,
researchers said.
Patients in the AIT group increased their ability to absorb oxygen by 35
percent, while those in the CME increased their ability to absorb oxygen by
only 16 percent.
“To get good results in maximal oxygen intake, we have to train the heart,
because the heart’s pumping capacity seems to be the limiting factor when we
talk about maximal oxygen intake in these patients,” Tjønna said. “AIT trained
the heart muscles the most and made them pump more oxygen.”
This group also outperform the CME group in several other key measures,
including endothelial function, blood pressure, insulin sensitivity, fasting
glucose, HDL cholesterol and mitochondrial biogenesis (the ability of cells to
produce fuel for work).
Given the small number of patients studied, a larger study is needed before
formally changing guidelines about how to manage the metabolic syndrome
through exercise, he said.
The American Heart Association and other health organizations recommend
that patients with the metabolic syndrome undertake moderate-intensity
physical activity, at least 30 minutes on most days of the week. But this study
challenges those recommendations.
Barry Franklin, Ph.D., an American Heart Association spokesperson and an
author of the association’s physical activity guidelines, noted that several
recent epidemiological and clinical studies now suggest that if the total energy

7. expenditure of exercise is held constant, exercise performed at a vigorous
intensity appears to convey greater cardioprotective benefits than exercise of
a moderate intensity.
“However, these added benefits must be weighed against the potential for
increased musculoskeletal and cardiovascular complications as well as
reduced compliance,” said Franklin, co- and director of the William Beaumont
Hospital Cardiac Rehab and Exercise Laboratories in Royal Oak, Michigan.
“Accordingly, when previously sedentary individuals can comfortably exercise
at a moderate intensity, they should consider the goal of more vigorous
exercise, provided that it is sustainable and can be achieved without adverse
signs or symptoms.”
Co-authors are: Sang Jun Lee, Ph.D.; Oivind Rognmo, M.S.; Tomas Stolen,
M.S.; Anja Bye, M.S.; Per Magnus Haram, Ph.D.; Jan Pål Loennechen, Ph.D.;
Qusay Y. Al-Share, M.S.; Eirik Skogvoll, Ph.D.; Stig A. Slordah, Ph.D.; Ole J.
Kemi, Ph.D.; Sonia M. Najjar, Ph.D.; and Ulrik Wisloff, Ph.D.
The study was funded by the Norwegian Council of Cardiovascular Disease,
the Norwegian Research Council, St. Olav’s University Hospital, Torstein
Erbo’s Foundation, the U.S. National Institutes of Health and the U.S.
Department of Agriculture. Disclosures for individual authors are available on
the manuscript.
Statements and conclusions of study authors that are published in the
American Heart Association scientific journals are solely those of the
study authors and do not necessarily reflect association policy or
position. The American Heart Association makes no representation or
warranty as to their accuracy or reliability.

8. • Do you know a healthy body can live up to 120 years?
• Why is that even with proper dieting, so many people have died young from organ
failure such as heart attack, liver cirrhosis, diabetes, and cancer?
• Is there a missing link in health Science?
• Do you Know?
All food is, at least potentially, a poison, until converted into simple structures..........
• Do you know that to prolong life, we need to complement nutritional health with
metabolic health?
• What is metabolism?
• What cause the metabolic disorder?
• Do you know the human red blood cells undergo the process of natural metabolism
every 120 days?
• Treat the Problem, NOT just the symptoms
• How can Enzyme Catalyst help?
• Health Digest & Health Today magazine articles:
A new answer to prolonging life Let Your Body Perform At Its Peak
(Article from HealthToday, APRIL 2005 (Article from HealthDigest, APR/MAY
issue) 2005 issue)
- Metabolic health—the missing link in - What are Enzymes?
prolonging life - Types of Enzyme
- What causes metabolic disorder/ syndrome? - Enzyme Benefits
- Enzymes cannot function without enzyme - Syndromes common to Enzyme deficiency
catalyst
- The wonders of fermentation
- Enzyme supplements in the market
Metabolic Syndrome Health Destroyer

9. The mortality rate for metabolic syndrome is 2.5 times higher that for Non-
Metabolic Syndrome.
(Highlighted in the American Medical Association and "Chung Hwa Daily" Medical website)
As many as 1 in 4 American adults and 40% of adults age 40 or older have metabolic
syndrome, an increase of 61% over the last decade.
(CNN.COM, metabolic syndrome, march 9, 2004)
Bodies deficient in nutrients and overloaded with toxic waste are creating an epidemic in the
United States where 65% of Americans are chronically ill and 20% of teenagers are
suffering from premature aging.
('Food enzymes For Health & Longevity'by Dr. Edward Howell)
The Discovery That Proper Dieting Alone Cannot Prolong Life
Scientists have discovered that a healthy body can live up to 120 years! Then why is it that
even with proper dieting, so many people have died young from organ failure such as heart
attack, liver cirrhosis, diabetes, and cancer? Is There A Missing Link in Health Science?
Thanks to molecular biology, scientists can now see minute molecules that form our body
called cells & enzymes. Many people cannot enjoy long life because their cells & enzymes fail
to work at peak optimal level. This results in metabolic disorder that brings on many fatal
illnesses.
We now know that to prolong life, we need to complement nutritional health with metabolic
health. Nutritional health can be maintained by nutrients from food, but metabolic health can
only be preserved by consuming Enzyme Catalyst.
Metabolic Health - The Missing Link in Prolonging Life

10. Healthy metabolism is the continual process of breakdown and renewal performed inside
cells, as well between cells, that result in growth, energy production, waste elimination, and
the control of your bodily functions such as digesting food, distributing food nutrients in the
blood, breathing, blinking, walking, talking, etc.
What Causes Metabolic Disorder / Syndrome?
Cells are power plants that are managed by enzymes. Enzymes are enhanced by Enzyme
Catalyst (co-enzymes and co-factors). When certain enzymes become weak or inactive, they
will trigger off abnormal cell behaviour, causing one power plant (cell) to shut down after
another in a chain reaction that seriously damages your metabolic health thus resulting in
chronic diseases such as heart disease, hypertension, diabetes, renal failure, cancer and etc.
Treat the Problem, NOT Just the Symptoms
When encountering the early symptoms of metabolic disorder, most people will seek fast
relief for the symptoms only. Example: antacids for gastric, charcoal pills for gas, etc. This
may retard the symptoms for a while, but the problem still remains. The correct way is to
follow-up quickly by boosting your enzymatic system with Enzyme Catalyst!
Enzymes Cannot Function Without Enzyme Catalyst
Co-factors and Co-enzymes (Enzyme Catalyst) are essential for cells to perform at peak
optimal level. All metabolism functions that support life, such as bone and tissue formation,
blood coagulation and circulation, etc., depend on the well-being of enzymes. And, enzymes
will only remain healthy when they are supported by Enzyme Catalyst. The best Enzyme
Catalyst is a broad spectrum variety derived from bioactive plant micro-nutrients extracted
through the process of fermentation.
DR-
XENIJI
ENZYME
CATALYST
• DR-XENIJI ~
Metabolism
Helper
• What Does More
Than 1000 Days
of Fermentation
Do?
• More Than 7
Wonders of 1000
Days of
Fermentation
• Health Benefits of
DR-XENIJI
• Effectiveness of
DR-XENIJI
• About
Muscovado,
Inventor of DR-
XENIJI &
International
Recognition

11. • Testimonials
• Q&A with Dr. Shingoro Matsuura
DR-XENIJI ~ Metabolism Helper
DR-XENIJI is a fermented fruit and vegetable food supplement whose production involves a
muscovado base with over 50 kinds of plants including fruits, root vegetables, grains and
seaweeds, carefully selected and repeatedly fermented and matured for three years and
three months (1185 days).
There are a hundred or more manufacturing processes to a finished product and a large
number of effective microorganisms have formed special ecological system in a cask and
worked during the process of fermenting.
DR-XENIJI made in this way is useful for your health maintenance.
With increasing concerns about health or wellness among people, various health foods are
distributed on the market right now. Therefore, a large number of consumers have required
objective evaluation and accurate information of health foods, and also definite guideline on
health foods has been required simultaneously.
DR-XENIJI is an enzyme catalyst that can help to activate the action of all 3 types of enzymes
(digestive, metabolic and food enzymes) to promote healthy metabolism in our body. The
uniqueness of DR-XENIJI lies in 3 factors -
• More than 1000 days of fermentation
• Clinically Proven
• Inventor's credentials and worldwide recognitions
DR-XENIJI: A Miracle of
More than 1000 days AND MORE!
What Does More Than 1000
Days of Fermentation Do?
• Breaks down plant
nutrients from raw
complex forms into
bioactive fine micro-forms
(Enzyme Catalyst) that
can be easily absorbed
even by an unborn baby.
• Creates a host of bioactive
micronutrients that will
energize the cancer-
fighting cells in our body,
and lower the risk of
cancer. Releases the
health-giving goodness of
the skin and seeds of
fruits. Skin pigments of fruits like grape and apple contain high bio-active energies
that reduce the risk of skin cancer. The seeds of fruits are highly beneficial. The rape
seed, for example, is one of the most powerful sources of anti-oxidant that fights free
radicals, prevents senility, inhibits blood vessel blockages, and actually protects our
brain and nervous system!

12. • Releases a broad spectrum of co-enzymes and co-factors so that our body benefits
from the full range that enhances the effectiveness of our entire metabolic system
instead of just one specific organ.
More Than 7 Wonders of 1000 Days of Fermentation
1. DR-XENIJI was initially developed to provide nourishment for pregnant mothers
and development of healthy fetus.
2. More than 1000 days of fermentation allows all nutrients from the fruit and
vegetables to be fully fermented, hence creating the most Bio-active Board
Spectrum co-factor and co-enzyme. The activation of digestive and metabolic
processes requires different co-enzyme and co-factors that can be found in DR-
XENIJI, the broad spectrum co-factor and co-enzyme.
3. More than 1000 days of fermentation produces bioactive micro-fine nutrients
that are in predigested form ready to be absorbed by cells, hence ensuring the
effectiveness and efficiency of metabolism in cells.
4. Bioactive micro-fine nutrients are fast absorbed in our body therefore less energy is
required for metabolism of food and nutrients, hence reducing the stress levels in the
body which leads to improved health.
5. More than 1000 days of fermentation allows the
capturing of full spectrum of phytonutrients and
energy from all seasons of 52 types of fruits and
vegetables together with Muscovado (raw brown
sugar).
6. More than 1000 days of fermentation allows fruits and
vegetables to ferment naturally. No heating or
chemicals are required to sterilize or to quicken the
fermentation process, hence all nutrients are
preserved.
7. Because it is a broad spectrum co-factor/co-enzyme, it acts as a booster catalyst for
metabolic processes in our body, hence it has a positive effects on illnesses
related to metabolic disorders.*
a.Boosted Activity of NK Cells by 6.5 Folds
b.Absorption of Sugar into Bloodstream Curbed by 80%
c.Lower Hypertension Causing ACE** Activity Levels by 90%
All the above illnesses are related to metabolic processes not being performed at their peak
optimal level in the cells.
Health Benefits of DR-XENIJI
1. *Increases cancer fighting cells and reduces abnormal cell mutation.
Clinical Proof: DR-XENIJI boosted the activity of NK cells (cancer fighting cells) by as
much as 6.5 fold within a mere 24 hours.
2. *Inhibits the accumulation of blood sugar in controlling diabetes
Clinical Proof: DR-XENIJI inhibits the absorption of blood sugar into the body by as
much as 80%.
3. *Regulates cell activity
- Stimulates and balances enzyme activity levels in cells:
- Heightens up the low enzyme activity level of lethargic people.
- Lowers down the high enzyme activity level of renal-hypertension sufferers,
normalizing high blood pressure.
- Clinical Proof: 50 mg/ml of DR-XENIJI lowers high blood pressure by 90%. (Source
of point 1, 2 & 3: refer to (a) below)
4. Increases the fertility rate of couples with low fertility
Hundreds of couples with low fertility, some of them have been married for more
than 10 years without conceiving had benefited from DR-XENIJI.
5. Improves digestion for better nutrients absorption and utilization

13. 6. Enhances vitality by effectively converting nutrients into energy
7. Improves detoxification and bowel movement thus reducing toxic
accumulation
Effectiveness of DR-XENIJI
Some benefits of improved healthy metabolism
Children: Adults:
• •
Helps
Enhances nutrition absorption maintain normal metabolism to
• Promote intellectual (brain) regulate cholesterol levels
development • Prevent accumulation of excessive fat
• Maximizes the metabolism of nutrients • Helps regulate blood glucose uptake
for healthy physical growth by the body
• Helps normalize renal high blood
pressure
• Reduce the risk of cancer cell
Expectant Mothers: formation
• Helps in
absorption of
nutrients Elders:
• Helps in • D
optimal and e
healthy growth l
of the fetus a
• Increases energy levels y
• Reduces complication of pregnancy
aging process
• Invigorates and maintains efficiency of
body organs
Effectiveness
• FAST – ACTING: In clinical tests, DR-XENIJI boosted the activity of NK cells (cancer
fighting cells) by as much as 6.5 folds within a mere 24 hours.
• EASILY ABSORBED BY THE BODY
• Completely safe for consumption by anyone – even pregnant mothers and little
babies.

14. New Guidelines for Diagnosis and Management of
Metabolic Syndrome CME
News Author: Laurie Barclay, MD
CME Author: Désirée Lie, MD, MSEd
Disclosures
To earn CME credit, read the news brief along with the CME information that follows
and answer the test questions.
Release Date: September 13, 2005; Valid for credit through September 13, 2006
This activity has expired.
CME in this activity indicates that it was developed according to ACCME guidelines
and was certified for credit by an accredited CME provider. Medscape cannot attest
to the timeliness of expired CME activities.
Sept. 13, 2005 — The American Heart Association (AHA) and the National Heart, Lung, and Blood
Institute (NHLBI) have issued guidelines for the diagnosis and management of the metabolic syndrome.
The executive summary, a synopsis of the full scientific statement explaining the new guidelines, is
published in the Sept. 12 Rapid Access issue of Circulation.
"The metabolic syndrome has received increased attention in the past few years," write Scott M.
Grundy, MD, panel chair, and colleagues from the AHA and the NHLBI. "It consists of multiple,
interrelated risk factors of metabolic origin that appear to directly promote the development of
atherosclerotic cardiovascular disease (ASCVD). This constellation of metabolic risk factors is strongly
associated with type 2 diabetes mellitus [DM] or the risk for this condition."
The panel found that the metabolic syndrome is a complex disorder, with no single factor as the cause.
However, the most important risk factors were abdominal obesity and insulin resistance. Other

15. metabolic risk factors are atherogenic dyslipidemia (elevated triglyceride levels and apolipoprotein B,
small low-density lipoprotein cholesterol [LDL-C] particles, and low high-density lipoprotein HDL
cholesterol [HDL-C] concentrations), high blood pressure (BP), high plasma glucose levels, a
prothrombotic state, and a proinflammatory state. Other conditions that may promote the metabolic
syndrome include sedentary lifestyle, aging, hormonal imbalance, and genetic or ethnic predisposition.
Prospective population studies suggest that the metabolic syndrome is associated with approximately a
twofold increase in relative risk for ASCVD, and a fivefold increase in risk for developing diabetes.
"The presence of the syndrome is associated with increased long-term risk for both ASCVD and type 2
diabetes mellitus, and thus requires attention in clinical practice," the authors write. "Lifestyle
interventions deserve prime consideration for risk reduction across a lifetime; these interventions include
weight control, increased physical activity, and a diet designed to reduce the risk for ASCVD."
Goals for lifestyle intervention for abdominal obesity are to reduce body weight by 7% to 10% during the
first year of treatment and continued weight loss thereafter to achieve desirable weight (body mass
index, < 25 kg/m2) and waist circumference of less than 40 in. for men and less than 35 in. for women.
Recommended physical activity is of moderate intensity for 30 to 60 minutes five to seven days a week.
Diet should reduce intakes of saturated fat (< 7% of total calories), trans fat, cholesterol levels (< 200
mg/day), and total fat (25% - 35% of total calories). Most dietary fat should be unsaturated, and simple
sugars should be limited.
Other overall conclusions of the panel were that the National Cholesterol Education Program Adult
Treatment Panel III (NCEP-ATP III) criteria for clinical diagnosis of the metabolic syndrome were robust
and clinically useful, and they recommended maintaining the NCEP-ATP III criteria with minor
modifications.
The NCEP-ATP III definition requires defined abnormalities in any three of five clinical measures: waist
circumference, elevated triglyceride levels, HDL-C levels, BP, and fasting glucose level. Modifications
recommended by the panel include adjustment of waist circumference to lower thresholds when
individuals or ethnic groups are prone to insulin resistance; considering triglyceride levels, HDL-C levels,
and BP to be abnormal when drug treatment is prescribed; clarifying that elevated BP refers to a level
exceeding the threshold for either systolic or diastolic pressure; and lowering the threshold for elevated
fasting glucose level from 110 to 100 mg per dL.
For patients with the metabolic syndrome who have a relatively high 10-year risk for ASCVD, the
guidelines state that drug therapy of both major and metabolic risk factors can help lower risk. They
suggest using pharmacotherapy according to present recommendations by the AHA, NHLBI, and
American Diabetes Association (ADA) for individual risk factors, but not specifically to reduce risk for
type 2 DM independent of treatments to prevent ASCVD.
The panel described specific treatment of metabolic risk factors for prevention of ASCVD or treatment of
type 2 DM, including treatment of atherogenic dyslipidemia, hypertension, elevated glucose levels,
prothrombotic state, and proinflammatory state.
"Additional research is required both to better understand the underlying pathophysiology of the
metabolic syndrome and to identify new targets for therapy," the panel concludes.
Members of the writing group disclose various financial arrangements with NHLBI, AHA, Cincinnati
Children's Hospital Medical Center, Pfizer, Astra-Zeneca, Abbott Laboratories, University of Colorado
Health Sciences, William Beaumont Hospital, Pfizer, University of Texas, Southwestern Medical Center,
GlaxoSmithKline, Merck, KOS Department of Veterans Affairs, Reynolds, National Institutes of Health,
Sanofi, Children's Hospital Oakland Research Institute, Bristol-Myers Squibb, University of North
Carolina Medical School, Johnson & Johnson, Medtronic, Intuitive Surgery, Saint Luke's Hospital of
Kansas City, CV Therapeutics, CV Outcomes, Outcomes Instruments, Inc., University of Washington,
Emory University, Atlanta VA Medical Center, Kidney Foundation, Amcyte, Diamedica, Inc., Aventis,
Diamedica, Inc., Kowa Research Institute, Mankind Corp., Novartis, Sanyko, Sanofi-Synthelabo, Sanofi
Aventis, Takeda, Hartford Hospital, Schering-Plough, Bristol-Myers Squibb, and/or Reliant.
Circulation. Posted online Sept. 12, 2005.

16. Learning Objectives for This Educational Activity
Upon completion of this activity, participants will be able to:
• Describe modifications to the updated NCEP-ATP III criteria for the metabolic syndrome by the
AHA and NHLBI writing group.
• Compare the similarities and differences in diagnosis and management of the metabolic
syndrome by the International Diabetes Federation (IDF) vs the updated NCEP-ATP III reports.
Clinical Context
The metabolic syndrome consists of multiple, interrelated risk factors that promote the development of
ASCVD, and the constellation strongly is associated with type 2 DM or the risk for type 2 DM, according
to the current authors. Prospective population studies show a twofold increased risk for ASCVD events
in patients with the metabolic syndrome and a fivefold risk of developing type 2 DM with relatively high
long-term risks for both conditions. The NCEP-ATP III proposed a simple set of diagnostic criteria based
on clinical measures that have been widely used in clinical and epidemiologic studies, according to this
report. This executive summary is a synopsis of a full scientific statement from the AHA and the NHLBI
writing group that is intended to provide up-to-date guidance for professionals on the diagnosis and
management of the metabolic syndrome in adults.
Study Highlights
• The NCEP-ATP III criteria for the metabolic syndrome are based on the presence of 3 or more
of the following: increased waist circumference, elevated triglyceride levels, BP, fasting glucose
level, and reduced HDL-C levels.
• Increased waist circumference is not a required criterion for diagnosing the metabolic
syndrome in the NCEP-ATP III criteria.
• The AHA and NHLBI writing group affirms the overall utility and validity of the NCEP-ATP III
criteria and proposed that they should continue to be used with modifications.
• The recommended modifications are (1) adjustment of waist circumference to lower thresholds
when individuals or ethnic groups are prone to insulin resistance, (2) allowing triglyceride and
HDL-C levels and BP to be counted as abnormal when a person is prescribed drug treatment
for these conditions, (3) clarifying that elevated BP is defined as an elevation of either systolic
or diastolic BP, and (4) reducing the threshold for elevated glucose level from 110 mg per dL or
higher to 100 mg per dL or higher in accordance with the ADA revised definition of impaired
fasting glucose (IFG).
• The IDF has proposed clinical criteria similar to those of the NCEP-ATP III with identical
thresholds for triglyceride and HDL-C levels, BP, and plasma glucose.
• The IDF criteria are different in that the waist circumference thresholds are adjusted to different
ethnic groups.
• The IDF criteria require that increased waist circumference be an element of the metabolic
syndrome because abdominal obesity reflects both concepts of obesity and insulin resistance.
• In the U.S. population, updated NCEP-ATP III and IDF criteria identify essentially the same
people as having the metabolic syndrome.
• Clinical Management of Metabolic Syndrome:
o Recommendations for management of the metabolic syndrome are virtually identical
in the updated NCEP-ATP III and IDF reports.
o First-line recommendations for reducing ASCVD risk include smoking cessation,
reducing LDL-C levels, BP, and glucose levels to recommended goals.
o Long-term risks are of high priority in management.
o Lifestyle interventions include weight loss in obese subjects, increased physical
activity, and dietary modification.
o Recommendations for drug therapy follow those of the AHA, NHLBI, and ADA.
o For dyslipidemia, the 10-year risks for ASCVD are defined by four risk categories of
elevated LDL-C levels: high risk (> 20%), moderately high risk (10% - 20% with 2 or
more risk factors), moderate risk (< 10% with 2 or more risk factors), and lower risk (<
10% with 0 - 1 risk factor).
o Risk stratification is used for target LDL-C levels.

17. o LDL-lowering standard drugs include statins, ezetimibe, and bile-acid sequestrants.
Other drugs that promote moderate reduction are nicotinic acid and fibrates, which
are considered to be secondary drugs.
o If the triglyceride level is higher than 500 mg per dL, then lowering the triglyceride
level to 500 mg per dL or less takes primacy over LDL-C lowering.
o After LDL-C and non HDL-C goals are achieved, a tertiary target is raising HDL-C
level. No specific goals for raising HDL-C levels are specified.
o BP management follows the Joint National Committee 7 guidelines. Individuals with
prehypertension should use lifestyle modification, whereas those with higher BPs
should use drug therapy. In the presence of renal disease or type 2 DM, the goal of
BP reduction should be less than 130/80 mm Hg.
o Subjects with IFG should practice lifestyle change, especially weight reduction and
increased physical activity. Drug therapies are not recommended.
o In patients with ASCVD in whom aspirin is contraindicated, clopidogrel should be
considered.
Pearls for Practice
• The AHA and NHLBI recommends modifications to the NCEP-ATP III criteria as follows: (1)
adjustment of waist circumference to lower thresholds when individuals or ethnic groups are
prone to insulin resistance, (2) allowing triglyceride and HDL-C levels and BP to be counted as
abnormal when a person is prescribed drug treatment for these conditions, (3) clarifying that
elevated BP is defined as an elevation of either systolic or diastolic BP, and (4) reducing the
threshold for elevated glucose level from 110 mg per dL or higher to 100 mg per dL or higher in
accordance with the ADA revised definition of IFG.
• The NCEP-ATP III and IDF have similar management guidelines for the metabolic syndrome
but differ in that the IDF requires increased waist circumference to be a criterion for diagnosis
and adjusts the definition of increased waist circumference to ethnicity.
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18. Diabetes epidemic expands: Blame "metabolic syndrome"?
Seems like the diabetes epidemic just won't quit. Type 2 diabetes affects almost 10
percent of American adults, and 1.5 million people get the diagnosis every year.
Globally, 200 million are expected to have this grave condition by 2010...
National Cancer Institute
Diabetes is a blood-sugar disorder related to the hormone insulin, which cells need to
remove sugar from the blood. A high level of blood sugar damages small blood
vessels, like those in the heart, kidney and eye. The two forms of diabetes kill about
250,000 Americans per year, and cost more than $130 billion. Diabetes is the major
cause of kidney failure, limb amputation, and vision loss in American adults. Diabetes
at least doubles the risk of heart disease.
DIABETES TYPE 1 AND 2
Type 1: Causes: autoimmune, genetic, and environmental factors. Insulin required daily.
Includes 5 to 10 percent of diagnosed diabetics in United States. Symptoms: increased thirst,
urination and hunger, weight loss, blurred vision, extreme fatigue.
Type 2: Risk factors: age, obesity, family history, physical inactivity, and certain ethnicities.
About 80 percent are overweight or obese. Symptoms: fatigue, frequent urination, increased
thirst and hunger, weight loss, blurred vision, and slow healing of wounds. Some people have
no symptoms.

19. The explosion of diabetes mostly concerns type 2 (which used to be called "adult-
onset diabetes," but now also strikes some kids). Unlike type 1, type 2 does not
appear suddenly, but now seems to be the end of a process that begins with a
condition called "metabolic syndrome."
In other words, type 2 diabetes is the culmination of a group of common conditions,
including high blood pressure, abdominal obesity and abnormal blood levels of
several fats. As the body stops responding to insulin, beta cells in the pancreas are
forced to crank out more of the hormone. Type 2 does not appear until they wear out,
says Richard Bergman, professor of medicine, endocrinology, diabetes and
metabolism at the University of Southern California. "Metabolic syndrome leads to
the need for more insulin secretion, but if the beta cells do not fail, you do not have
diabetes."
U.S. INCIDENCE OF DIABETES (BOTH TYPES)
From 1980 to 2005, diabetes diagnoses grew 124 percent, to 7.4 per 1000 people. The parallel
increase in both lines shows that the rise is not due to an aging population. Notice the lines spiking
in the 1990s? Graph: CDC
Bergman adds that almost all of the genes known to affect type 2 diabetes "are
related to beta cell function," and this helps explain the pattern of disease seen in the
population: Some ethnic groups, particularly Asians, African Americans and
American Indians, "are not as equipped to compensate for a degree of insulin

20. resistance, and as they become more obese, get more visceral fat, they become
more at risk for type 2."
Other factors implicated in metabolic syndrome and diabetes include growing
obesity, a surge in high-fat fast-foods, a sedentary lifestyle, and perhaps the rising
use of high-fructose corn syrup over the last 30 years or so.
A simplified view of the role of metabolic syndrome in disease
Cross my heart?
Metabolic syndrome also plays a major role in cardiovascular disease, and is actually
as harmful to the heart as smoking two packs of cigarettes a day, says Francisco
Lopez-Jimenez, a cardiologist at the Mayo Clinic in Rochester, Minn. Even as
doctors dispute the significance and exact definition of metabolic syndrome, Lopez-
Jimenez finds it useful. "It's still controversial as a new diagnosis... because every
single component has a name already: hypertension, obesity, abnormal cholesterol."

21. Skeptics raise an obvious question, he admits: "What is the value of creating a new
diagnosis, when everybody already has a name for these things, and the treatment is
still the same?" But by unifying measurements that may seem trivial in isolation,
metabolic syndrome makes a difference to patients, Lopez-Jimenez says. "If the
blood sugar is a bit high, the waist circumference slightly abnormal, it would very
likely qualify for metabolic syndrome, but without that term, they would not leave the
office with clear sense of the risk for diabetes or cardiovascular disease. If they see
everything
as only mildly abnormal, they would not
have a strong enough motivation to
change behavior."
Diabetics have many of the common risk factors
Graph: CDC
As a preventive cardiologist, Lopez-
Jimenez stresses that metabolic
syndrome is a risk factor for heart attack
and stroke, not just diabetes. "Every
component of metabolic syndrome has
been linked to cardiovascular disease.
Although some people develop heart
disease without diabetes, in many cases
diabetes is the intermediate point
between the metabolic syndrome and heart disease."
The strong links among metabolic syndrome, cardiovascular disease and diabetes
are not fully understood, says Lopez-Jimenez. "The approach has been that high
blood sugar is the bad guy, but it's probably beyond that, because several studies
have failed to show significant reductions in cardiovascular events just by controlling
blood sugar. People with diabetes have a constellation of abnormalities. Patients with
type 2 have very high insulin levels, and that in itself can affect the cardiovascular
system, making the kidneys absorb more salt, making the blood pressure go up, and
changing the metabolism of cholesterol." High insulin "by itself can be linked to
several measures" of hardening of the arteries. (We promise to revisit this subject...)
What is metabolic syndrome?
Metabolic syndrome (AKA insulin resistance syndrome, X syndrome, diabesity),
is linked to cardiovascular disease and type 2 diabetes. One common definition
comes from the National Cholesterol Education Program, which includes:
Abdominal obesity: waist circumference above 35 inches (female) or 40 inches (male);
Low level of high-density lipoprotein (HDL, or "good cholesterol");

22. Elevated fasting glucose test;
Insulin resistance (the body does not respond properly to the hormone); and
High blood pressure (over 130/80).
Metabolic syndrome may be grim, but it's not all gloom and doom, especially if you
can control your weight and activity.
So let's get moving: Want to reverse metabolic syndrome?
There are 1 2 3 pages in this feature plus a bibliography and credits page
Megan Anderson, project assistant; Terry Devitt, editor; S.V. Medaris, designer/illustrator;
David Tenenbaum, feature writer; Amy Toburen, content development executive

23. ©2008, University of Wisconsin, Board of Regents

24. Metabolic syndrome is a collection of heart disease risk
factors that increase your chance of developing heart
disease, stroke and diabetes. The percentage of people
with metabolic syndrome increases with age, affecting
more than 40 percent over the age of 60. Populations
particularly at risk include Mexican Americans (32
percent), African-American males (26 percent) and
African-American females (57 percent).
Metabolic syndrome is diagnosed when a person has at
least three of the following heart disease risk factors (a
person can develop any one of these fi ve risk factors by
itself, but they tend to occur together):
• A waistline of 40 inches or more for men and 35
inches or more for women
• A blood pressure of 130/85 mm Hg or higher or are
on blood pressure medications
• A triglyceride level above 150 mg/dl
• A fasting blood glucose (sugar) level greater than 100
mg/dl or are on glucose lowering medications
• A “good cholesterol” (HDL) less than 40 mg/dl (men)
or under 50 mg/dl (women)
Another cause of metabolic syndrome may be related to
“insulin resistance”. Consistently high levels of insulin
and glucose are linked to many harmful changes in the
body, including:
• Damage to the lining of arteries, a key step toward the
development of heart disease or stroke.
• Changes in the kidneys’ ability to remove salt, leading
to high blood pressure, heart disease and stroke.
• An increase in triglyceride levels, resulting in an
increased risk of developing cardiovascular disease.
• An increased risk of blood clot formation, which can
block arteries and cause heart attacks and strokes.
• A slowing of insulin production, which can signal the
start of type 2 diabetes.
Since physical inactivity and excess weight are the main
underlying contributors to the development of metabolic
syndrome, getting more exercise and losing weight can
help reduce or prevent the complications associated
with this condition. Your doctor may also prescribe
medications to manage some of your underlying
problems. To reduce your risk:
• Lose weight: Moderate weight loss, in the range of 5
percent to 10 percent of body weight, can help restore
your body’s ability to recognize insulin and greatly
reduce the chance that the syndrome will evolve into a
.more serious illness

25. The Metabolic Syndrome
S ince cardiovascular (heart and blood vessel) disease is the leading cause of death for adults
in developed countries,
many medical studies focus on treating or preventing heart disease and stroke. The metabolic
syndrome, a
collection of unhealthy body measurements and abnormal laboratory test results, may identify
persons at high
risk for developing cardiovascular disease. Aggressive lifestyle modification and possible use of
medications to treat the
conditions that make up the metabolic syndrome may reduce a person’s chances of developing
heart disease or stroke.
The metabolic syndrome has also been called syndrome X or insulin resistance syndrome. The
February 15, 2006, issue of
JAMA includes an article about the metabolic syndrome.
DEFINITION OF THE METABOLIC SYNDROME FOR MORE INFORMATION
• National Heart, Lung,
and Blood Institute
www.nhlbi.nih.gov
• American Heart Association
www.americanheart.org
• American Diabetes Association
www.diabetes.org
INFORM YOURSELF
To find this and previous JAMA
Patient Pages, go to the Patient
Page link on JAMA’s Web site at
www.jama.com. Many are available in
English and Spanish. A Patient Page on
coronary artery disease was published
in the November 24, 2004, issue; and
one on weight gain and diabetes was
published in the August 25, 2004,

26. issue.
Janet M. Torpy, MD, Writer
Cassio Lynm, MA, Illustrator
Richard M. Glass, MD, Editor
850 JAMA, February 15, 2006—Vol 295, No. 7
Sources: National Heart, Lung, and Blood Institute; American Heart Association; National Cholesterol Education
Program; American Diabetes Association
The JAMA Patient Page is a public service of JAMA. The information and recommendations
appearing on this page are appropriate in most instances, but they are not a substitute for
medical diagnosis. For specific information concerning your personal medical condition, JAMA
suggests that you consult your physician. This page may be photocopied noncommercially
by physicians and other health care professionals to share with patients. To purchase bulk
reprints, call 203/259-8724.
• Abdominal (waist) circumference greater than 40 inches for men or 35 inches for
women
• High blood pressure (hypertension)
• Hyperglycemia (fasting blood sugar more than 110 mg/dL)
• Elevated triglycerides (a type of fat in the bloodstream)
• Low levels of high-density lipoprotein, also known as HDL or “good cholesterol”
Having at least 3 of the above measurements means that an individual has metabolic
syndrome and is at risk for developing type 2 diabetes, coronary heart disease, heart
attack, or stroke.
TREATING THE METABOLIC SYNDROME
Lifestyle modifications include weight loss, regular exercise, stopping smoking, and
reducing dietary fat intake. Losing just 10% of excess body weight lowers blood
pressure and improves insulin resistance. Some persons may be able to treat high blood
pressure and hyperglycemia by altering their lifestyle alone. In many individuals, lifestyle
modification is not adequate, and medications must be used to decrease blood pressure,
lower triglycerides, and increase the level of HDL.
Because these problems are often linked, treating one aspect of the metabolic syndrome
may help the other issues. For example, regular exercise can help you lose weight,
reduce blood pressure, and manage hyperglycemia and insulin resistance. Combining
healthful eating with a regular exercise program is the cornerstone of treating the
metabolic syndrome and reducing risk for heart disease, stroke, diabetes, and other
medical problems.
PREVENTION
• Exercise regularly throughout your life.
• Encourage children to have daily physical activity and make healthful food choices.
• Eat a healthful, balanced diet low in saturated fats and high in nutrient-rich fruits and
vegetables.
• Do not smoke.
• Recognize that you may have a genetic (inherited) predisposition for diabetes, heart
disease, and the metabolic syndrome.
• Have regular medical check-ups and initiate early treatment for high blood pressure.
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