Paul Zimmet & George AlbertiPaul Zimmet & George AlbertiCo-ChairmenCo-Chairmen

The Metabolic Syndrome: International Diabetes Federation (IDF)

consensus definition

METABOLIC SYNDROME

A cluster of risk factors for diabetes and cardiovascular disease

The Metabolic Syndrome

A cluster of risk factors for diabetes and cardiovascular disease consisting of:• Central (abdominal) obesity• Diabetes, IFG and IGT • Hypertension• Dyslipidaemia

(“Deadly Quartet”)

International Diabetes Federation (IDF) consensus definition

In 2004, the IDF held an expert workshop to examine how the currently available definitions for the Metabolic Syndrome could be improved and developed with the aim of reaching a consensus for the introduction of a new and unifying definition.

THE ORIGINS

• 1920s

• 1940s/50s – Vague

• 1967 – Avogaro & Crepaldi

• 1988 - Reaven

Kylin E:

Studien ϋber das Hypertonie-Hyperglykämie

– Hyperurika miesyndrome

1923

Kylin 1923 Description

“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

Crepaldi 1965 Description

The 2000 WHO Working Group attempt to describe & define the

Metabolic Syndrome was an initiative to create interest and debate – it was never meant to

be the final answer.

Metabolic Syndrome – WHO 1999

At least 1 ofAt least 1 of

• Type 2 diabetesType 2 diabetes• IGTIGT• Insulin resistanceInsulin resistance

• HypertensionHypertension• ObesityObesity• Raised TG or low HDLRaised TG or low HDL• MicroalbuminuriaMicroalbuminuria

at least 2 ofat least 2 of++ MetabolicMetabolicsyndromesyndrome

• HyperuricemiaHyperuricemia• HypercoagulabilityHypercoagulability• HyperleptinemiaHyperleptinemia

Not required for definition,Not required for definition,

but may be part of the syndromebut may be part of the syndrome

Risk Factor CriterionAbdominal ObesityMen Women

Waist Circumference>102 cm (>40 in) >88 cm (>35 in)

Triglycerides 150 mg/dLHDL-CholesterolMenWomen

<40 mg/dL<50 mg/dL

Blood Pressure 130/85 mm HgFasting Glucose 110 mg/dL

NCEP ATP III. JAMA. 2001;285:2486-2497.

The Metabolic Syndrome (ATP III) & Criteria

EGIR Definition of Metabolic Syndrome: 1999

• Insulin resistance + 2 or more of:• Central obesity (94 cm -M; 80 cm - F)• TG >2.9 mM OR HDL <1.0• Hypertension (> 140/90)• FPG > 6.1 mM

The Metabolic Syndromein Australia; Different Prevalences

for Different Criteria

19.022.4

25.3

0

5

10

15

20

25

30

WHO NCEP EGIR

Prevalence of the Metabolic Syndromein Australian Adults (>25 years): AusDiab

Metabolic Syndrome prevalence:3 definitions in Australians - AusDiab

12.012.0

0.80.84.24.2

2.02.0

4.34.3 4.84.8

4.84.8

ATP III (22.4%)

EGIR (19.0%)

WHO (25.3%)

RESULT

Confusion!!!

“Consensus Means That A Lot Of

People Say Collectively What No

One Believes Individually”.

Abba Eban

Central obesity: a driving force for cardiovascular disease & diabetes

“Balzac” by RodinFront

Back

Developing A New Definition of the Metabolic Syndrome: IDF Objectives

Needs:

• To identify individuals at high risk of developing

cardiovascular disease (and diabetes)

• To be useful for clinicians

• To be useful for international comparisons

The new IDF definition focusses on abdominal obesity rather than insulin resistance

International Diabetes Federation (IDF) Consensus Definition 2005

International Diabetes Federation (IDF) Consensus Definition 2005

Central ObesityWaist circumference – ethnicity specific*

– for Europids: Male > 94 cm Female > 80 cm

plus any two of the following:Raised triglycerides > 150 mg/dL (1.7 mmol/L)

or specific treatment for this lipid abnormality

Reduced HDL cholesterol < 40 mg/dL (1.03 mmol/L) in males< 50 mg/dL (1.29 mmol/L) in femalesor specific treatment for this lipid abnormality

Raised blood pressure Systolic : > 130 mmHg orDiastolic: > 85 mmHg orTreatment of previously diagnosed hypertension

Raised fasting plasma glucose

Fasting plasma glucose > 100 mg/dL (5.6 mmol/L) or Previously diagnosed type 2 diabetesIf above 5.6 mmol/L or 100 mg/dL, OGTT is strongly recommended but is not necessary to define presence of the syndrome.

TG

IFG & Diabetes

AbdominalObesity

BP

HDL

Apo BLittle LDL

PAI-1

Adipo-nectin

InsulinResistance*

CRP

* HOMA, euglycemic clamp, fasting insulin etc

Microalb

Tests Recommended for Research: May Be Added To Definition Later

OGTT

Treatment of Metabolic Syndrome: 2005

AspirinDiet, Exercise, Lifestyle change

Stop smoking

CB1 Receptor Blocker

Oral hypoglycaemics

AntihypertensivesStatins & Fibrates

Insulin

ACEI &/or A2 receptor blockers

Primary management for the Metabolic Syndrome is healthy lifestyle promotion. This includes:

• moderate calorie restriction (to achieve a 5-10% loss of body weight in the first year)

• moderate increases in physical activity

• change dietary composition to reduce saturated fat and total intake, increase fibre and, if appropriate, reduce salt intake.

Recommendations for treatment

• Appropriate & aggressive therapy is essentialfor reducing patient risk of cardiovascular disease

• Lifestyle measures should be the first action• Pharmacotherapy should have beneficial effects on

– Glucose intolerance/diabetes– Obesity– Hypertension– Dyslipidaemia

• Ideally, treatment should address all of the components of the syndrome and not the individual components

Management of the Metabolic Syndrome

Summary: new IDF definition for the Metabolic Syndrome

The new IDF definition addresses both clinical and research needs:

• provides a simple entry point for primary care physicians to diagnose the Metabolic Syndrome

• providing an accessible, diagnostic tool suitable for worldwide use, taking into account ethnic differences

• establishing a comprehensive ‘platinum standard’ list of additional criteria that should be included in epidemiological studies and other research into the Metabolic Syndrome