Consequences of the metabolic syndrome

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The metabolic syndrome is associated with increased risk of a variety of disease outcomes, including diabetes, peripheral arterial disease (the association with cardiovascular disease is discussed in Chapter 10), fatty liver and non-alcoholic steatohepatosis (discussed in Chapter 11), polycystic ovary syndrome (discussed in Chapter 12), gallstones, asthma, sleep apnoea and selected malignant diseases.

Studies that have described the association between the metabolic syndrome and diabetes and cardiovascular disease morbidity and mortality (including all-cause mortality where available) are summarized in Tables 1.4 and 1.5. The findings vary with the criteria for the metabolic syndrome, the definition of the outcome and the population studied, but the relative risk of diabetes is at least threefold higher among people with the metabolic syndrome than among those without the syndrome. Relative risks of the metabolic syndrome were generally highest for coronary heart disease mortality, intermediate for cardiovascular disease mortality and lowest (and not necessarily statistically significantly elevated) for all-cause mortality. Data are generally only available from populations in developed countries. The prevalence of the metabolic syndrome using standard definitions is likely to have different implications for relative risk of diabetes and cardiovascular disease in different populations, and extrapolations should not be made across populations.

Most studies are based on a cohort design that prevents the potential for survival bias associated with cross-sectional study designs. The only cross-sectional study design quoted in Table 1.5 reported no independent effect of the metabolic syndrome on the prevalence of cardiovascular disease beyond that associated with the individual components of the syndrome and diabetes (Alexander etal., 2003). This finding contrasts with those of a cohort study, which found that metabolic syndrome was a stronger predictor of coronary heart disease, cardiovascular disease and total mortality than its individual components (Malik etal., 2004). Based on data from the Framingham Offspring Study of 3323 men and women (mean age 52 years) with an 8-year follow-up it has been estimated that the metabolic syndrome (as defined using ATP-III criteria) contributed almost half of the population-attributable risk for diabetes and approximately a quarter of all incident cardiovascular disease (Grundy etal., 2004).

Table 1.4 Summary of studies describing the relative risk of diabetes associated with the metabolic syndrome


Population and

Age group


Definition of the



Relative risk (RR),

year of




metabolic syndrome

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