"The metabolic syndrome... is dead": these reports are an exaggeration

Gender-Affirming Hormone Treatment and Metabolic Syndrome Among Transgender Veterans

Importance

Gender-affirming hormone treatment (GAHT) is a common therapy for transgender individuals to reduce gender dysphoria and improve quality of life. Clarifying the long-term effects of GAHT remains a priority in transgender health research.

Objective

To explore whether sex hormones (estradiol and testosterone) are associated with the development of metabolic syndrome in transgender veterans compared with cisgender veterans.

Design, Setting, and Participants

This retrospective, longitudinal cohort study used International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis codes for gender dysphoria from the Veterans Health Administration national database to identify transfeminine and transmasculine veterans receiving documented feminizing (estradiol) or masculinizing (testosterone) treatment from January 1, 2006, to December 31, 2019, and for whom the GAHT initiation date and metabolic syndrome component-related data were available. Transgender veterans were matched to cisgender referents.

Exposure

Gender-affirming hormone treatment.

Main Outcomes and Measures

Metabolic syndrome z-scores were calculated based on body mass index, systolic blood pressure, and levels of high-density lipoprotein cholesterol, triglycerides, and blood glucose. Changes in mean z-scores were compared among the transgender and cisgender groups before and after the index date (corresponding to GAHT initiation) using a repeated-measures analysis of variance model.

Results

The cohort included 1290 participants: 645 transgender (494 [38.3%] transfeminine, 151 [11.7%] transmasculine) and 645 cisgender (280 [21.7%] female, 365 [28.3%] male). Mean (SD) age at the index date was 41.3 (13.2) years. Metabolic syndrome z-scores changed significantly over time and differed significantly across groups. Overall, transmasculine veterans had the greatest percentage increase in mean (SEM) z-scores after vs before the index date (298.0% [57.0%]; P < .001), followed by cisgender females (108.3% [27.5%]; P < .001), cisgender males (49.3% [27.5%]; P = .02), and transfeminine persons (3.0% [10.7%]; P = .77).

Conclusions and Relevance

In this cohort study, in both cisgender and transgender veterans, estradiol was associated with reduced metabolic syndrome risk, whereas testosterone was associated with increased risk. However, transmasculine individuals had the greatest risk and transfeminine individuals had the lowest risk of metabolic syndrome associated with these hormones. This is relevant for the management of metabolic syndrome risk factors in cisgender and transgender individuals and to potentially predict the risk of atherosclerotic cardiovascular disease, type 2 diabetes, systolic hypertension, insulin resistance, and nonalcoholic fatty liver disease.

The Definition and Prevalence of Obesity and Metabolic Syndrome: Correlative Clinical Evaluation Based on Phenotypes

Increase in the prevalence of obesity has become a major worldwide health problem in adults as well as among children and adolescents. In the last four decades, studies have revealed that the significant increase in the prevalence of obesity has become a pandemic. Obesity is the result of complex interactions between biological, genetic, environmental, and behavioral factors. Indeed, almost all of the children suffering from obesity in early childhood face with being overweight or obese in adolescence. Different phenotypes have different risk factors in the clinical evaluation of obesity. Individuals suffering from metabolically unhealthy obesity (MUO) are at an excess risk of developing cardiovascular diseases (CVDs), several cancer types, and metabolic syndrome (MetS), whereas the metabolically healthy obesity (MHO) phenotype has a high risk of all-cause mortality and cardiometabolic events but not MetS. While most obese individuals have the MUO phenotype, the frequency of the MHO phenotype is at most 10-20%. Over time, approximately three-quarters of obese individuals transform from MHO to MUO. Total adiposity and truncal subcutaneous fat accumulation during adolescence are positively and independently associated with atherosclerosis in adulthood. Obesity, in general, causes a large reduction in life expectancy. However, the mortality rate of morbid obesity is greater among younger than older adults. Insulin resistance (IR) develops with the central accumulation of body fat. MHO patients are insulin-sensitive like healthy normal-weight individuals and have lower visceral fat content and cardiovascular consequences than do the majority of MUO patients. MetS includes clustering of abdominal obesity, dyslipidemia, hyperglycemia, and hypertension. The average incidence of MetS is 3%, with a 1.5-fold increase in the risk of death from all causes in these patients. If lifestyle modifications, dietary habits, and pharmacotherapy do not provide any benefit, then bariatric surgery is recommended to reduce weight and improve comorbid diseases. However, obesity treatment should be continuous in obese patients by monitoring the accompanying diseases and their consequences. In addition to sodium-glucose co-transporter-2 (SGLT2) inhibitors, the long-acting glucagon-like peptide-1 (GLP-1) receptor agonist reduces the mean body weight. However, caloric restriction provides more favorable improvement in body composition than does treatment with the GLP-1 receptor (GLP1R) agonist alone. Combination therapy with orlistat and phentermine are the US Food and Drug Administration (FDA)-approved anti-obesity drugs. Recombinant leptin and synthetic melanocortin-4-receptor agonists are used in rarely occurring, monogenic obesity, which is due to loss of function in the leptin-melanocortin pathway.

High residual cardiovascular risk after lipid-lowering: prime time for Predictive, Preventive, Personalized, Participatory, and Psycho-cognitive medicine

As time has come to translate trial results into individualized medical diagnosis and therapy, we analyzed how to minimize residual risk of cardiovascular disease (CVD) by reviewing papers on "residual cardiovascular disease risk". During this review process we found 989 papers that started off with residual CVD risk after initiating statin therapy, continued with papers on residual CVD risk after initiating therapy to increase high-density lipoprotein-cholesterol (HDL-C), followed by papers on residual CVD risk after initiating therapy to decrease triglyceride (TG) levels. Later on, papers dealing with elevated levels of lipoprotein remnants and lipoprotein(a) [Lp(a)] reported new risk factors of residual CVD risk. And as new risk factors are being discovered and new therapies are being tested, residual CVD risk will be reduced further. As we move from CVD risk reduction to improvement of patient management, a paradigm shift from a reductionistic approach towards a holistic approach is required. To that purpose, a personalized treatment dependent on the individual's CVD risk factors including lipid profile abnormalities should be configured, along the line of P5 medicine for each individual patient, i.e., with Predictive, Preventive, Personalized, Participatory, and Psycho-cognitive approaches.

Metabolic syndrome and cognitive deficits in the Greek cohort of Epirus Health Study

BACKGROUND

Metabolic syndrome is considered an important risk factor for cognitive decline and dementia. However, the evidence in middle-aged individuals is still conflicting. The aim of the study was to explore the association between metabolic syndrome and its individual components with cognitive function and to investigate possible interaction between sex, age and genetic predisposition for metabolic syndrome and Alzheimer's disease in a middle-aged Greek cohort.

METHODS

A total of 2,077 healthy adults (mean age: 46.7 years) were included in the primary cross-sectional analysis and 305 of them in secondary prospective analyses. Metabolic syndrome was defined by the revised National Cholesterol Education-Adult Treatment Panel III and the International Diabetes Federation criteria. Cognitive function was measured primarily with the Trail Making, Verbal fluency and Logical Memory test, and in secondary prospective analyses with online versions of Posner cueing task, an emotional recognition task, Corsi block-tapping task and Stroop task.

RESULTS

Multivariable linear regressions showed an association of metabolic syndrome with lower performance in attention (β=1.62 seconds, 95% CI=0.20, 3.04) and memory (β=-0.62 words, 95% CI=-1.19, -0.05) that could be driven by associations with elevated fasting glucose and abdominal obesity. Similar associations were observed in the secondary prospective analyses.

CONCLUSION

In summary, metabolic syndrome was associated with cognitive deficits in domains related with the cognitive profile of vascular cognitive impairment.

Dynamic behavior of metabolic syndrome progression: a comprehensive systematic review on recent discoveries

BACKGROUND

The assessment of the natural history of metabolic syndrome (MetS) has an important role in clarifying the pathways of this disorder.

OBJECTIVE

This study purposed to provide a rational statistical view of MetS progression pathway.

METHODS

We performed a systematic review in accordance with the PRISMA Statement until September 2019 in the Medline/PubMed, Scopus, Embase, Web of Science and Google Scholar databases. From the 68 found studies, 12 studies were eligible for review finally.

RESULTS

The selected studies were divided in 2 groups with Markovian and non-Markovian approach. With the Markov approach, the most important trigger for the MetS chain was dyslipidemia with overweight/obesity in the under-50 and with hypertension in the over-50 age group, where overweight/obesity was more important in women and hypertension in men. In non-Markov approach, the most common trigger was hypertension. Transition probability (TP) from no component to MetS were higher in all Markovian studies in men than in women. In the Markovians the combination of dyslipidemia with overweight/obesity and in non-Markovians, hyperglycemia with overweight/obesity were the most common combinations. Finally, the most important components, which predict the MetS, were 2-component states and hyperglycemia in Markovian approach and overweight/obesity in non-Markovians.

CONCLUSIONS

Among the components of the MetS, dyslipidemia and hypertension seems to be the main developer components in natural history of the MetS. Also, in this chain, the most likely combination over time that determines the future status of people seems to be the combination of dyslipidemia with obesity or hyperglycemia. However, more research is needed.

Risk for cardiovascular disease associated with metabolic syndrome and its components: a 13-year prospective study in the RIVANA cohort

Background

We aimed to investigate the association of metabolic syndrome (MetS) and its single components with cardiovascular risk and estimated their impact on the prematurity of occurrence of cardiovascular events using rate advancement periods (RAPs).

Methods

We performed prospective analyses among 3976 participants (age range: 35–84, 55% female) in the Vascular Risk in Navarre (RIVANA) Study, a Mediterranean population-based cohort. MetS was defined based on the modified criteria of the American Heart Association/National Heart, Lung, and Blood Institute and the International Diabetes Federation. The primary endpoint was major cardiovascular event (a composite of myocardial infarction, stroke, or mortality from cardiovascular causes). Secondary endpoints were incidence of non-fatal myocardial infarction and non-fatal stroke, cardiovascular mortality, and all-cause mortality. Cox proportional hazards models, adjusted for potential confounders, were fitted to evaluate the association between MetS and its single components at baseline with primary and secondary endpoints.

Results

During a median follow-up of 12.8 years (interquartile range, 12.5–13.1), we identified 228 primary endpoint events. MetS was associated with higher risk of incidence of major cardiovascular event, cardiovascular and all-cause mortality, but was neither associated with higher risk of myocardial infarction nor stroke. Compared with participants without MetS, the multivariable hazard ratio (95% confidence interval [CI]) among participants with MetS was 1.32 (1.01–1.74) with RAP (95% CI) of 3.23 years (0.03, 6.42) for major cardiovascular event, 1.64 (1.03–2.60) with RAP of 3.73 years (0.02, 7.45) for cardiovascular mortality, and 1.45 (1.17–1.80) with RAP of 3.24 years (1.21, 5.27) for all-cause mortality. The magnitude of the associations of the single components of MetS was similar than the predicted by MetS. Additionally, for each additional trait of MetS, incidence of major cardiovascular event relatively increased by 22% (1.22, 95% CI 1.09–1.36) with RAP of 2.31 years (0.88, 3.74).

Conclusions

MetS was independently associated with CVD risk, cardiovascular and all-cause mortality. Components of the MetS were associated with similar magnitude of increased CVD, which suggests that MetS was not in excess of the level explained by the presence of its single components. Further research should explore the association of different combinations of the components of MetS with CVD.

Metabolic syndrome in haemodialysis patients: prevalence, determinants and association to cardiovascular outcomes

BACKGROUND

In the general population, metabolic syndrome (MetS) is predictive of major adverse cardiovascular events (MACE). Waist circumference (WC), a component of the MetS criteria, is linked to visceral obesity, which in turn is associated with MACE. However, in haemodialysis (HD) patients, the association between MetS, WC and MACE is unclear.

METHODS

In a cross-sectional study of 1000 HD patients, we evaluated the prevalence and characterised the clinical predictors of MetS. The relationship between MetS and its components, alone or in combination, and MACE (coronary diseases, peripheral arteriopathy, stroke or cardiac failure), was studied using receiver operating characteristics (ROC) curves and logistic regression.

RESULTS

A total of 753 patients were included between October 2011 and April 2013. The prevalence of MetS was 68.5%. Waist circumference (> 88 cm in women, 102 cm in men) was the best predictor of MetS (sensitivity 80.2; specificity 82.3; AUC 0.80; p <  0.05). In multivariate analysis, MetS was associated with MACE (OR: 1.85; 95CI 1.24-2.75; p <  0.01), but not WC alone. There was a stronger association between the combination of abdominal obesity, hypertriglyceridaemia and low high-density lipoprotein cholesterol with MACE after exclusion of impaired fasting glucose and hypertension.

CONCLUSIONS

MetS is frequent and significantly associated with MACE in our haemodialysis cohort and probably in other European dialysis populations as well. In HD patients, a new simplified definition could be proposed in keeping with the concept of the "hypertriglyceridaemic waist".

[Not Available]

Objectif

Étudier le risque de mortalité présenté par l’obésité centrale chez les personnes de poids normal, déterminer une mesure clinique pour aider à dépister ce phénotype et examiner les moyens de réduire ce risque.

Qualité des données

La recherche n’a relevé que des études de cohorte prospectives (niveau II) ayant comparé des participants qui présentaient une obésité centrale et un poids normal à des participants dont l’indice de masse corporelle (IMC) était élevé. Des études de niveau I de bonne qualité ont démontré l’effet des interventions liées à l’alimentation et à l’exercice sur l’obésité centrale et la mortalité.

Message principal

Les participants centralement obèses malgré un IMC normal et qui sont atteints de dyslipidémie athérogène présentent un risque comparable, sinon supérieur, de mortalité que les participants qui sont centralement obèses en plus d’être en surpoids ou obèses selon l’IMC. Le rapport entre le tour de taille et la taille^* serait la mesure clinique la plus pragmatique de l’obésité centrale. Le régime méditerranéen est une intervention efficace pour stopper la prise pondérale tout en réduisant la ceinture abdominale. Un faible niveau d’exercice réduit aussi le tour de taille. La perte pondérale ne doit pas constituer l’objectif.

Conclusion

Un rapport entre le tour de taille et la taille de plus de 0,5 malgré un IMC normal indique un risque élevé de mortalité par atteinte cardiométabolique. Ce risque serait équivalent, voire supérieur, au risque présenté par les patients centralement obèses en plus d’être en surpoids ou obèses. De légères interventions liées à l’alimentation et à l’exercice sont efficaces pour réduire ce risque.

Normal-weight central obesity: Unique hazard of the toxic waist

OBJECTIVE

To examine the mortality risk presented by normal-weight central obesity, to identify a clinical measure to aid in the identification of this phenotype, and to explore the means for mitigation of this risk.

QUALITY OF EVIDENCE

Only prospective cohort studies (level II) comparing participants with central obesity at normal weight with those at higher levels of body mass index (BMI) were found. Good level I studies were available to demonstrate the effect of diet and exercise interventions on central obesity and mortality.

MAIN MESSAGE

Participants with atherogenic dyslipidemia who are centrally obese at normal BMI are at similar, and possibly higher, mortality risk compared with those who are centrally obese and overweight or obese according to their BMI. Waist-to-height ratio might be the most pragmatic clinical measure of central obesity. The Mediterranean diet is an effective intervention to prevent ongoing weight gain while reducing abdominal girth. Low levels of exercise can also reduce waist circumference. Weight loss need not be an objective.

CONCLUSION

A waist-to-height ratio exceeding 0.5 at normal BMI identifies elevated mortality risk for cardiometabolic disease. This risk might equal or exceed that of centrally obese patients who are overweight or obese. Modest dietary and exercise interventions can be effective in mitigation of this risk.

Metabolic syndrome, inflammation and atherothrombosis

Extensive research of the past decades altered our traditional concept about the genesis of atherosclerosis fundamentally. Today, the crucial role of inflammation in the formation and progression of atherosclerotic plaques is indisputable. Patients at high risk for developing cardiovascular disease, owing to poor diet, obesity and low physical activity have been shown to exhibit a particular inflammatory pattern.

Therefore, the present review highlights the crosslink between the metabolic syndrome (MetS), adipose tissue, adipokines and selected inflammatory cytokines in the context of atherothrombosis and cardiovascular disease.

The Definition and Prevalence of Obesity and Metabolic Syndrome

Increase in prevalence of obesity has become a worldwide major health problem in adults, as well as among children and adolescents. Furthermore, total adiposity and truncal subcutaneous fat accumulation during adolescence are positively and independently associated with atherosclerosis at adult ages. Centrally accumulation of body fat is associated with insulin resistance, whereas distribution of body fat in a peripheral pattern is metabolically less important. Obesity is associated with a large decrease in life expectancy. The effect of extreme obesity on mortality is greater among younger than older adults. In this respect, obesity is also associated with increased risk of several cancer types. However, up to 30% of obese patients are metabolically healthy with insulin sensitivity similar to healthy normal weight individuals, lower visceral fat content, and lower intima media thickness of the carotid artery than the majority of metabolically "unhealthy" obese patients.Abdominal obesity is the most frequently observed component of metabolic syndrome. The metabolic syndrome; clustering of abdominal obesity, dyslipidemia, hyperglycemia and hypertension, is a major public health challenge. The average prevalence of metabolic syndrome is 31%, and is associated with a two-fold increase in the risk of coronary heart disease, cerebrovascular disease, and a 1.5-fold increase in the risk of all-cause mortality.

Roles of the gut in the metabolic syndrome: an overview

The metabolic syndrome is a cluster of risk factors (central obesity, hyperglycaemia, dyslipidaemia and arterial hypertension), indicating an increased risk of diabetes, cardiovascular disease and premature mortality. The gastrointestinal tract is seldom discussed as an organ system of principal importance for metabolic diseases. The present overview connects various metabolic research lines into an integrative physiological context in which the gastrointestinal tract is included. Strong evidence for the involvement of the gut in the metabolic syndrome derives from the powerful effects of weight-reducing (bariatric) gastrointestinal surgery. In fact, gastrointestinal surgery is now recommended as a standard treatment option for type 2 diabetes in obesity. Several gut-related mechanisms that potentially contribute to the metabolic syndrome will be presented. Obesity can be caused by hampered release of satiety-signalling gut hormones, reduced meal-associated energy expenditure and microbiota-assisted harvest of energy from nondigestible food ingredients. Adiposity per se is a well-established risk factor for hyperglycaemia. In addition, a leaky gut mucosa can trigger systemic inflammation mediating peripheral insulin resistance that together with a blunted incretin response aggravates the hyperglycaemic state. The intestinal microbiota is strongly associated with obesity and the related metabolic disease states, although the mechanisms involved remain unclear. Enterorenal signalling has been suggested to be involved in the pathophysiology of hypertension and postprandial triglyceride-rich chylomicrons; in addition, intestinal cholesterol metabolism probably contributes to atherosclerosis. It is likely that in the future, the metabolic syndrome will be treated according to novel pharmacological principles interfering with gastrointestinal functionality.

Metabolic syndrome is independently associated with increased 20-year mortality in patients with stable coronary artery disease

Background

Data regarding long-term association of metabolic syndrome (MetS) with adverse outcomes are conflicting. We aim to determine the independent association of MetS (based on its different definitions) with 20 year all-cause mortality among patients with stable coronary artery disease (CAD).

Methods

Our study comprised 15,524 patients who were enrolled in the Bezafibrate Infarction Prevention registry between February 1, 1990, and October 31, 1992, and subsequently followed-up for the long-term mortality through December 31, 2014. MetS was defined according to two definitions: The International Diabetes Federation (IDF); and the National Cholesterol Education Program–Third Adult Treatment Panel (NCEP).

Results

According to the IDF criteria 2122 (14%) patients had MetS, whereas according to the NCEP definition 7446 (48%) patients had MetS. Kaplan–Meier survival analysis showed that all-cause mortality was significantly higher among patients with MetS defined by both the IDF (67 vs. 61%; log rank-p < 0.001) as well as NCEP (67 vs. 54%; log rank-p < 0.001) criteria. Multivariate adjusted mortality risk was 17% greater [Hazard Ratio (HR) 1.17; 95% Confidence Interval (CI) 1.07–1.28] in patients with MetS according to IDF and 21% (HR 1.21; 95% CI 1.13–1.29) using the NCEP definition. Subgroup analysis demonstrated that long-term increased mortality risk associated with MetS was consistent among most clinical subgroups excepted patients with renal failure (p value for interaction < 0.05).

Conclusions

Metabolic syndrome is independently associated with an increased 20-year all-cause mortality risk among patients with stable CAD. This association was consistent when either the IDF or NCEP definitions were used.

Trial registration retrospective registered

Electronic supplementary material

The online version of this article (doi:10.1186/s12933-016-0466-6) contains supplementary material, which is available to authorized users.

Dysfunctional adipose tissue and low-grade inflammation in the management of the metabolic syndrome: current practices and future advances

The ongoing worldwide obesity epidemic makes the metabolic syndrome an increasingly important entity. In this review, we provide a short background on the metabolic syndrome, we discuss recent developments in the three main options that have been identified for intervention in the metabolic syndrome, i.e. lifestyle and surgical and pharmacological interventions, and we focus on different views in the literature and also include our own viewpoints on the metabolic syndrome. In addition, we discuss some emerging treatment targets for adipose tissue dysfunction and low-grade inflammation, i.e. activation of the inflammasome and the complement system, and consider some selected opportunities for intervention in these processes.

The clinical value of metabolic syndrome and risks of cardiometabolic events and mortality in the elderly: the Rotterdam study

Background

To evaluate the clinical value of metabolic syndrome based on different definitions [American Heart Association/National Heart, Lung and Blood Institute (AHA/NHLBI), International Diabetes Federation (IDF) and European Group for the Study of Insulin Resistance (EGIR)] in middle-aged and elderly populations.

Methods

We studied 8643 participants from the Rotterdam study (1990–2012; mean age 62.7; 57.6 % female), a large prospective population-based study with predominantly elderly participants. We performed cox-proportional hazards models for different definitions, triads within definitions and each separate component for the risk of incident type 2 diabetes mellitus, coronary heart disease, stroke, cardiovascular- and all-cause mortality.

Results

In our population of 8643 subjects, metabolic syndrome was highly prevalent (prevalence between 19.4 and 42.4 %). Metabolic syndrome in general was associated with incident type 2 diabetes mellitus (median follow-up of 6.8 years, hazard ratios 3.13–3.78). The associations with coronary heart disease (median follow-up of 7.2 years, hazard ratios 1.08–1.32), stroke (median follow-up of 7.7 years, hazard ratios 0.98–1.32), cardiovascular mortality (median follow-up of 8.2 years, ratios 0.95–1.29) and all-cause mortality (median follow-up of 8.7 years, hazard ratios 1.05–1.10) were weaker. AHA/NHLBI- and IDF-definitions showed similar associations with clinical endpoints compared to the EGIR, which was only significantly associated with incident type 2 diabetes mellitus. All significant associations disappeared after correcting metabolic syndrome for its individual components.

Conclusions

Large variability exists between and within definitions of the metabolic syndrome with respect to risk of clinical events and mortality. In a relatively old population the metabolic syndrome did not show an additional predictive value on top of its individual components. So, besides as a manner of easy identification of high risk patients, the metabolic syndrome does not seem to add any predictive value for clinical practice.

Electronic supplementary material

The online version of this article (doi:10.1186/s12933-016-0387-4) contains supplementary material, which is available to authorized users.

A new look at the genetic and environmental coherence of metabolic syndrome components

OBJECTIVE

Metabolic syndrome, a clustering of risk factors including insulin resistance, dyslipidemia, central obesity, and hypertension, increases risk for cardiovascular disease and cognitive decline. The etiology of the risk factors' cohesion remains unclear. How genetic and environmental influences explained co-occurrence of metabolic syndrome components was examined.

METHODS

Continuous measures of body mass index (BMI), waist circumference, blood pressure (BP), fasting insulin and glucose, high-density lipoprotein cholesterol (HDL), and triglycerides from 1,193 middle-aged twin men participating in the Vietnam Era Twin Study of Aging at average age 62 (range 56-67) were analyzed using multivariate biometrical modeling.

RESULTS

Four heritable factors were found: adiposity (BMI, waist circumference), insulin resistance (glucose, insulin), lipids (HDL, triglycerides), and BP (systolic, diastolic). Heritabilities were 0.42-0.68. In the best-fitting model, insulin resistance, lipids, and adiposity comprised a higher-order latent genetic factor. Adiposity and BP shared genetic influences independent of the latent genetic factor. All factors aggregated on a latent unique environmental factor.

CONCLUSIONS

Metabolic syndrome components form the equivalent of two genetic factors. BP was genetically unrelated to insulin resistance and lipids. Adiposity was the only characteristic genetically and environmentally related to all other factors. These results inform strategies for gene discovery and prediction of health outcomes.

National lipid association recommendations for patient-centered management of dyslipidemia: part 1--full report

The leadership of the National Lipid Association convened an Expert Panel to develop a consensus set of recommendations for patient-centered management of dyslipidemia in clinical medicine. An Executive Summary of those recommendations was previously published. This document provides support for the recommendations outlined in the Executive Summary. The major conclusions include (1) an elevated level of cholesterol carried by circulating apolipoprotein B-containing lipoproteins (non-high-density lipoprotein cholesterol and low-density lipoprotein cholesterol [LDL-C], termed atherogenic cholesterol) is a root cause of atherosclerosis, the key underlying process contributing to most clinical atherosclerotic cardiovascular disease (ASCVD) events; (2) reducing elevated levels of atherogenic cholesterol will lower ASCVD risk in proportion to the extent that atherogenic cholesterol is reduced. This benefit is presumed to result from atherogenic cholesterol lowering through multiple modalities, including lifestyle and drug therapies; (3) the intensity of risk-reduction therapy should generally be adjusted to the patient's absolute risk for an ASCVD event; (4) atherosclerosis is a process that often begins early in life and progresses for decades before resulting a clinical ASCVD event. Therefore, both intermediate-term and long-term or lifetime risk should be considered when assessing the potential benefits and hazards of risk-reduction therapies; (5) for patients in whom lipid-lowering drug therapy is indicated, statin treatment is the primary modality for reducing ASCVD risk; (6) nonlipid ASCVD risk factors should also be managed appropriately, particularly high blood pressure, cigarette smoking, and diabetes mellitus; and (7) the measurement and monitoring of atherogenic cholesterol levels remain an important part of a comprehensive ASCVD prevention strategy.

Metabolic syndrome and neurotrophins: effects of metformin and non-steroidal antiinflammatory drug treatment

OBJECTIVE

Metabolic syndrome (MS) presents with central obesity, impaired glucose metabolism, dyslipidemia and hypertension. Our aim was to examine the effect of metformin treatment either alone or in combination with non-steroidal anti-inflammatory drugs (NSAID) on plasma levels of nerve growth factor (NGF) and brain-derived neurotrophic factor (BDNF) in patients with early stage MS (MS-es) and generalized MS (MS-ge).

MATERIALS AND METHODS

The study compared 35 female patients with MS-es (mean age of 43.39±1.54 years) and 40 patients with MS-ge (mean age of 45.69±2.18 years) to 10 age-matched controls each. Patients with MS-es were administered 850 mg metformin twice daily. The patients with MS-ge were divided into two groups of 20 patients per group. One group received metformin alone, while the other group received metformin in combination with 500 mg aspirin and 150 mg Diclac daily. Plasma NGF and BDNF levels were measured by ELISA. Statistical data analysis was performed using ANOVA.

RESULTS

Plasma NGF and BDNF levels were significantly higher in MS-es patients and lower in MS-ge patients than in controls. NGF levels were decreased in both groups after treatment with metformin. NGF levels were significantly higher in MS-ge patients on combined therapy than in those on metformin only.

CONCLUSION

The combination of metformin and NSAID treatment is more effective than metformin alone on NGF and BDNF production as well as on metabolism-related anthropometric and laboratory features. This represents a pathogenetic therapeutic mechanism in MS due to its strong anti-inflammatory effect and improves MS-ge symptoms.

Pathophysiological domains underlying the metabolic syndrome: an alternative factor analytic strategy

PURPOSE

Factor analysis (FA) has become part and parcel in metabolic syndrome (MBS) research. Both exploration- and confirmation-driven factor analyzes are rampant. However, factor analytic results on MBS differ widely. A situation that is at least in part attributable to misapplication of FA. Here, our purpose was (i) to review factor analytic efforts in the study of MBS with emphasis on misusage of the FA model and (ii) to propose an alternative factor analytic strategy.

METHODS

The proposed factor analytic strategy consists of four steps and confronts weaknesses in application of the FA model. At its heart lies the explicit separation of dimensionality and pattern selection and the direct evaluation of competing inequality-constrained loading patterns. A high-profile MBS data set with anthropometric measurements on overweight children and adolescents is reanalyzed using this strategy.

RESULTS

The reanalysis implied a more parsimonious constellation of pathophysiological domains underlying phenotypic expressions of MBS than the original analysis (and many other analyses). The results emphasize correlated factors of impaired glucose metabolism and impaired lipid metabolism.

CONCLUSIONS

Pathophysiological domains underlying phenotypic expressions of MBS included in the analysis are driven by multiple interrelated metabolic impairments. These findings indirectly point to the possible existence of a multifactorial etiology.

Excess body mass index loss predicts metabolic syndrome remission after gastric bypass

BACKGROUND

Metabolic syndrome (MS) is a condition associated with obesity that identifies individuals with increased cardiovascular risk. Gastric bypass improves several MS components, such as glucose, lipid metabolism and hypertension. The aim of this study was to evaluate the effect of long-limb gastric bypass on the remission of MS criteria associated with morbid obesity.

METHODS

Obese patients who met the "harmonized" criteria for MS (n = 153) that underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) with a long biliopancreatic limb were prospectively evaluated with regards to body weight, body mass index (BMI), percentage of excess BMI lost (% EBMIL), fasting glucose, blood pressure and lipid profile up to 36 months after surgery.

RESULTS

Before surgery, patients had a BMI of 44.3 ± 0.5 kg/m2; 66% were under anti-diabetic treatment; 78.4% were under anti-hypertensive treatment and 44.3% were under anti-dyslipidemic treatment. After a mean follow-up time of 2.4 ± 0.1 years, MS remission rates were 32.7% at 6 months, 69.7% at 12 months, 63.4% at 24 months, and 59.2% at 36 months; when only 32.9%, 43.4% and 15.8% of patients were still under anti-diabetic, anti-hypertensive and anti-dyslipidemic treatment, respectively. The %EBMIL and BMI were the parameters that showed the highest accuracy to predict the MS remission at all-time points after the surgery.

CONCLUSIONS

Long limb gastric bypass in obese patients results in significant and sustained weight loss which predicts a high remission rate of MS and allows the discontinuation of drug therapy for several metabolic disturbances in most patients.

Approach to identifying and managing atherogenic dyslipidemia: a metabolic consequence of obesity and diabetes

OBJECTIVE

To review the evidence for recognition and management of atherogenic dyslipidemia.

SOURCES OF INFORMATION

High-quality randomized trials and meta-analyses were available to address most questions. North American and European guidelines were reviewed. Of these, the Canadian Cardiovascular Society lipid guidelines were most congruent with current literature.

MAIN MESSAGE

Atherogenic dyslipidemia is characterized by low levels of high-density lipoprotein (HDL), high levels of triglycerides, and a high low-density lipoprotein (LDL) particle number. The condition is highly associated with cardiovascular disease (CVD) and is poorly reflected in Framingham risk score and LDL measurements. Obesity, glucose intolerance, diabetes, and metabolic syndrome are rapidly becoming more common, and are often associated with atherogenic dyslipidemia, affecting long-term CVD risk. Recognition in the office is best achieved by non-HDL or total cholesterol-HDL ratio testing. Treatment success lies in optimizing diet and exercise. Of available medications, statins produce the most benefit and can be titrated to patient tolerance rather than to LDL target levels, which have a poor evidence base. The addition of fenofibrate can be considered in patients with high triglyceride and low HDL levels who have responded poorly to or have not tolerated statins.

CONCLUSION

Growing obesity prevalence creates a CVD risk that might be missed by LDL cholesterol testing alone. Simple calculations from results of a non-fasting lipid panel produce non-HDL levels and total cholesterol-HDL ratio, both of which are superior for predicting risk in all patients. These metrics should be available in lipid panels.

Components of the interleukin-6 transsignalling system are associated with the metabolic syndrome, endothelial dysfunction and arterial stiffness

OBJECTIVE

The metabolic syndrome (MetS) is an increasing epidemiologic challenge and cardiovascular risk factor. Interleukin-6 (IL-6) is a cytokine that exerts its biological function via a complex orchestration of soluble and membrane bound receptors. We have investigated associations between IL-6 and its soluble receptors, soluble IL-6 receptor (sIL-6r) and soluble glycoprotein 130 (sGP130) and the metabolic syndrome. Furthermore, we have investigated possible associations with endothelial dysfunction and arterial stiffness.

METHODS

A total of 563 subjects were included in this study. The Adult Treatment Panel III criteria of the National Cholesterol Education Program were used for the definition of MetS. We used commercially available ELISA to analyse circulating levels of the markers. Pulse wave propagation time (PWP) was determined to assess arterial stiffness.

RESULTS

The criteria for having MetS were filled by 221 subjects. sGP130, sIL-6r and IL-6 levels were elevated in subjects with MetS (p<0.05 for all markers), and are associated with increasing components of MetS. Particularly hypertriglyceridaemia, hypertension and fasting plasma glucose (FPG) seem to carry this association. sGP130 (p<0.01), IL-6 (p<0.05) and partially sIL-6r (p<0.05) correlated with markers of endothelial function (E-selectin, I-CAM-1, V-CAM-1) and inversely with PWP after adjustment for relevant covariates.

CONCLUSION

sGP130, sIL-6r and IL-6 were significantly elevated in subjects with MetS. In addition, sGP130, IL-6 and partially sIL-6r were associated with markers of endothelial function and arterial stiffness. This finding sheds new light on the role of these inflammatory cytokines in subjects with MetS and the development and progression of clinically silent atherosclerosis.

Description and prediction of the development of metabolic syndrome: a longitudinal analysis using a markov model approach

BACKGROUND

Delineating the natural history of metabolic syndrome (MetS) is prerequisite to prevention. This study aimed to build Markov models to simulate each component's progress and to test the effect of different initial states on the development of MetS.

METHODS

MetS was defined with revised AHA/NHLBI criteria. Each reversible multistate Markov chain consisted of 8 states (no component, five isolated component states, 2-component state, and MetS state). Yearly transition probabilities were calculated from a five-year population-based follow up studywhich enrolled 2,247 individuals with mean aged 32.4 years at study entry.

RESULTS

In men, high BP or a 2-component state was most likely to initiate the progress of MetS. In women, abdominal obesity or low HDL were the most likely initiators. Metabolic components were likely to occur together. The development of MetS was an increasing monotonic function of time. MetS was estimated to develop within 15 years in 12.7% of young men with no component, and 2 components developed in 16.3%. MetS was estimated to develop in 10.6% of women with at the age of 47, and 2 components developed in 14.3%. MetS was estimated to develop in 24.6% of men and 27.6% of women with abdominal obesity, a rate higher than in individuals initiating with no component.

CONCLUSIONS

This modeling study allows estimation of the natural history of MetS. Men tended to develop this syndrome sooner than women did, i.e., before their fifth decade of life. Individuals with 1 or 2 components showed increased development of MetS.

Genetic epidemiology of cardiometabolic risk factors and their clustering patterns in Mexican American children and adolescents: the SAFARI Study

Pediatric metabolic syndrome (MS) and its cardiometabolic components (MSCs) have become increasingly prevalent, yet little is known about the genetics underlying MS risk in children. We examined the prevalence and genetics of MS-related traits among 670 non-diabetic Mexican American (MA) children and adolescents, aged 6-17 years (49 % female), who were participants in the San Antonio Family Assessment of Metabolic Risk Indicators in Youth study. These children are offspring or biological relatives of adult participants from three well-established Mexican American family studies in San Antonio, TX, at increased risk of type 2 diabetes. MS was defined as ≥3 abnormalities among 6 MSC measures: waist circumference, systolic and/or diastolic blood pressure, fasting insulin, triglycerides, HDL-cholesterol, and fasting and/or 2-h OGTT glucose. Genetic analyses of MS, number of MSCs (MSC-N), MS factors, and bivariate MS traits were performed. Overweight/obesity (53 %), pre-diabetes (13 %), acanthosis nigricans (33 %), and MS (19 %) were strikingly prevalent, as were MS components, including abdominal adiposity (32 %) and low HDL-cholesterol (32 %). Factor analysis of MS traits yielded three constructs: adipo-insulin-lipid, blood pressure, and glucose factors, and their factor scores were highly heritable. MS itself exhibited 68 % heritability. MSC-N showed strong positive genetic correlations with obesity, insulin resistance, inflammation, and acanthosis nigricans, and negative genetic correlation with physical fitness. MS trait pairs exhibited strong genetic and/or environmental correlations. These findings highlight the complex genetic architecture of MS/MSCs in MA children, and underscore the need for early screening and intervention to prevent chronic sequelae in this vulnerable pediatric population.

Association between non-alcoholic fatty pancreatic disease (NAFPD) and the metabolic syndrome: case-control retrospective study

Background

Fatty liver is associated with insulin resistance, dyslipidemia, and obesity and is therefore considered a phenotype of metabolic syndrome. However, less is known regarding the metabolic abnormalities associated with non-alcoholic fatty pancreatic disease (NAFPD; fatty pancreas). The present study was performed to ascertain whether fatty pancreas is associated with specific metabolic risk factors and with metabolic syndrome as defined by the Adult Treatment Panel III.

Methods

Five-hundred-fifty-seven healthy and consecutive subjects without known hypertension or diabetes and who received a health investigation at the National Taiwan University Hospital Health Management Center were enrolled in this retrospective study. Fatty pancreas was diagnosed via trans-abdominal ultrasonographic findings.

Results

Seventy-two (12.9%) subjects diagnosed with fatty pancreas comprised the fatty pancreas group, and remaining subjects comprised the normal pancreas group. The presence of various demographic and metabolic risk factors was recorded for all subjects, and the two groups were examined for statistically significant differences in these factors. As compared to the absence of fatty pancreas, the presence of the disease was associated with older age and with higher values for each of the following: BMI, abdominal girth/height, abdominal girth (both genders), fasting and postprandial blood glucose, HbA1c, total cholesterol, triglycerides, LDL-cholesterol, systolic blood pressure, and platelet count. In contrast to previously reported findings, serum amylase values were lower in the fatty pancreas as compared to the control group.

Conclusion

The presence of fatty pancreas represents a meaningful manifestation of metabolic syndrome together with obesity.

Blood lead is significantly associated with metabolic syndrome in Korean adults: an analysis based on the Korea National Health and Nutrition Examination Survey (KNHANES), 2008

Background

Although an association between low-level environmental heavy metal exposure and the incidence of metabolic syndrome (MS) has been hypothesized, little research on this topic has been conducted on a population-wide level.

Methods

We analyzed MS status and whole blood lead, mercury, cadmium, manganese, and creatinine-adjusted urine arsenic concentrations in 1,405 subjects, ≥ 20 years of age, who were registered for the Korea National Health and Nutrition Examination Survey, 2008.

Results

Various demographic and biochemical parameters were associated with MS and blood heavy metal status. After adjusting for these variables, lead was the only heavy metal that was significantly associated with MS. Lead concentrations in subjects with MS were significantly higher than those in subjects without MS (p = 0.015). The prevalence of MS and a moderate/high risk for cardiovascular disease, as determined by Framingham risk score, also increased significantly according to the logarithmic transformation of the lead quartile (p < 0.001). The odds ratios and 95% confidence intervals for MS were 1.56 (0.90–2.71), 1.63 (0.94–2.83), and 2.57 (1.46–4.51) for the second, third, and fourth quartiles of the log-transformed lead quartile, respectively, as compared with those of the lowest quartile after multiple adjustments for confounding factors. Serum triglyceride level was the only MS diagnostic component significantly associated with lead level in a multiple linear regression analysis (p = 0.006).

Conclusions

These findings suggest that a higher prevalence of MS is associated with higher blood lead levels in the Korean population.

Balanced pan-PPAR activator bezafibrate in combination with statin: comprehensive lipids control and diabetes prevention?

All fibrates are peroxisome proliferators-activated receptors (PPARs)-alpha agonists with ability to decrease triglyceride and increase high density lipoprotein- cholesterol (HDL-C). However, bezafibrate has a unique characteristic profile of action since it activates all three PPAR subtypes (alpha, gamma and delta) at comparable doses. Therefore, bezafibrate operates as a pan-agonist for all three PPAR isoforms. Selective PPAR gamma agonists (thiazolidinediones) are used to treat type 2 diabetes mellitus (T2DM). They improve insulin sensitivity by up-regulating adipogenesis, decreasing free fatty acid levels, and reversing insulin resistance. However, selective PPAR gamma agonists also cause water retention, weight gain, peripheral edema, and congestive heart failure. The expression of PPAR beta/ delta in essentially all cell types and tissues (ubiquitous presence) suggests its potential fundamental role in cellular biology. PPAR beta/ delta effects correlated with enhancement of fatty acid oxidation, energy consumption and adaptive thermogenesis. Together, these data implicate PPAR beta/delta in fuel combustion and suggest that pan-PPAR agonists that include a component of PPAR beta/delta activation might offset some of the weight gain issues seen with selective PPAR gamma agonists, as was demonstrated by bezafibrate studies. Suggestively, on the whole body level all PPARs acting as one orchestra and balanced pan-PPAR activation seems as an especially attractive pharmacological goal. Conceptually, combined PPAR gamma and alpha action can target simultaneously insulin resistance and atherogenic dyslipidemia, whereas PPAR beta/delta properties may prevent the development of overweight. Bezafibrate, as all fibrates, significantly reduced plasma triglycerides and increased HDL-C level (but considerably stronger than other major fibrates). Bezafibrate significantly decreased prevalence of small, dense low density lipoproteins particles, remnants, induced atherosclerotic plaque regression in thoracic and abdominal aorta and improved endothelial function. In addition, bezafibrate has important fibrinogen-related properties and anti-inflammatory effects. In clinical trials bezafibrate was highly effective for cardiovascular risk reduction in patients with metabolic syndrome and atherogenic dyslipidemia. The principal differences between bezafibrate and other fibrates are related to effects on glucose level and insulin resistance. Bezafibrate decreases blood glucose level, HbA1C, insulin resistance and reduces the incidence of T2DM compared to placebo or other fibrates. Currently statins are the cornerstone of the treatment and prevention of cardiovascular diseases related to atherosclerosis. However, despite the increasing use of statins as monotherapy for low density lipoprotein- cholesterol (LDL-C) reduction, a significant residual cardiovascular risk is still presented in patients with atherogenic dyslipidemia and insulin resistance, which is typical for T2DM and metabolic syndrome. Recently, concerns were raised regarding the development of diabetes in statin-treated patients. Combined bezafibrate/statin therapy is more effective in achieving a comprehensive lipid control and residual cardiovascular risk reduction. Based on the beneficial effects of pan-PPAR agonist bezafibrate on glucose metabolism and prevention of new-onset diabetes, one could expect a neutralization of the adverse pro-diabetic effect of statins using the strategy of a combined statin/fibrate therapy.

Balanced pan-PPAR activator bezafibrate in combination with statin: comprehensive lipids control and diabetes prevention?

All fibrates are peroxisome proliferators-activated receptors (PPARs)-alpha agonists with ability to decrease triglyceride and increase high density lipoprotein- cholesterol (HDL-C). However, bezafibrate has a unique characteristic profile of action since it activates all three PPAR subtypes (alpha, gamma and delta) at comparable doses. Therefore, bezafibrate operates as a pan-agonist for all three PPAR isoforms. Selective PPAR gamma agonists (thiazolidinediones) are used to treat type 2 diabetes mellitus (T2DM). They improve insulin sensitivity by up-regulating adipogenesis, decreasing free fatty acid levels, and reversing insulin resistance. However, selective PPAR gamma agonists also cause water retention, weight gain, peripheral edema, and congestive heart failure. The expression of PPAR beta/ delta in essentially all cell types and tissues (ubiquitous presence) suggests its potential fundamental role in cellular biology. PPAR beta/ delta effects correlated with enhancement of fatty acid oxidation, energy consumption and adaptive thermogenesis. Together, these data implicate PPAR beta/delta in fuel combustion and suggest that pan-PPAR agonists that include a component of PPAR beta/delta activation might offset some of the weight gain issues seen with selective PPAR gamma agonists, as was demonstrated by bezafibrate studies. Suggestively, on the whole body level all PPARs acting as one orchestra and balanced pan-PPAR activation seems as an especially attractive pharmacological goal. Conceptually, combined PPAR gamma and alpha action can target simultaneously insulin resistance and atherogenic dyslipidemia, whereas PPAR beta/delta properties may prevent the development of overweight. Bezafibrate, as all fibrates, significantly reduced plasma triglycerides and increased HDL-C level (but considerably stronger than other major fibrates). Bezafibrate significantly decreased prevalence of small, dense low density lipoproteins particles, remnants, induced atherosclerotic plaque regression in thoracic and abdominal aorta and improved endothelial function. In addition, bezafibrate has important fibrinogen-related properties and anti-inflammatory effects. In clinical trials bezafibrate was highly effective for cardiovascular risk reduction in patients with metabolic syndrome and atherogenic dyslipidemia. The principal differences between bezafibrate and other fibrates are related to effects on glucose level and insulin resistance. Bezafibrate decreases blood glucose level, HbA1C, insulin resistance and reduces the incidence of T2DM compared to placebo or other fibrates. Currently statins are the cornerstone of the treatment and prevention of cardiovascular diseases related to atherosclerosis. However, despite the increasing use of statins as monotherapy for low density lipoprotein- cholesterol (LDL-C) reduction, a significant residual cardiovascular risk is still presented in patients with atherogenic dyslipidemia and insulin resistance, which is typical for T2DM and metabolic syndrome. Recently, concerns were raised regarding the development of diabetes in statin-treated patients. Combined bezafibrate/statin therapy is more effective in achieving a comprehensive lipid control and residual cardiovascular risk reduction. Based on the beneficial effects of pan-PPAR agonist bezafibrate on glucose metabolism and prevention of new-onset diabetes, one could expect a neutralization of the adverse pro-diabetic effect of statins using the strategy of a combined statin/fibrate therapy.

A confirmatory factor analysis of the metabolic syndrome in adolescents: an examination of sex and racial/ethnic differences

Objective

The metabolic syndrome (MetS) is a cluster of clinical indices that signals increased risk for cardiovascular disease and Type 2 diabetes. The diagnosis of MetS is typically based on cut-off points for various components, e.g. waist circumference and blood pressure. Because current MetS criteria result in racial/ethnic discrepancies, our goal was to use confirmatory factor analysis to delineate differential contributions to MetS by sub-group.

Research Design and Methods

Using 1999–2010 data from the National Health and Nutrition Examination Survey (NHANES), we performed a confirmatory factor analysis of a single MetS factor that allowed differential loadings across sex and race/ethnicity, resulting in a continuous MetS risk score that is sex and race/ethnicity-specific.

Results

Loadings to the MetS score differed by racial/ethnic and gender subgroup with respect to triglycerides and HDL-cholesterol. ROC-curve analysis revealed high area-under-the-curve concordance with MetS by traditional criteria (0.96), and with elevations in MetS-associated risk markers, including high-sensitivity C-reactive protein (0.71), uric acid (0.75) and fasting insulin (0.82). Using a cut off for this score derived from ROC-curve analysis, the MetS risk score exhibited increased sensitivity for predicting elevations in ≥2 of these risk markers as compared with traditional pediatric MetS criteria.

Conclusions

The equations from this sex- and race/ethnicity-specific analysis provide a clinically-accessible and interpretable continuous measure of MetS that can be used to identify children at higher risk for developing adult diseases related to MetS, who could then be targeted for intervention. These equations also provide a powerful new outcome for use in childhood obesity and MetS research.

Fibrates are an essential part of modern anti-dyslipidemic arsenal: spotlight on atherogenic dyslipidemia and residual risk reduction

Currently the world faces epidemic of several closely related conditions: obesity, metabolic syndrome and type 2 diabetes (T2DM). The lipid profile of these patients and those with metabolic syndrome is characterized by the concurrent presence of qualitative as well as quantitative lipoprotein abnormalities: low levels of HDL, increased triglycerides, and prevalence of LDL particles that are smaller and denser than normal. This lipid phenotype has been defined as atherogenic dyslipidemia. Overwhelming evidences demonstrate that all components of the atherogenic dyslipidemia are important risk-factors for cardiovascular diseases. Optimal reduction of cardiovascular risk through comprehensive management of atherogenic dyslipidemias basically depends of the presence of efficacious lipid-modulating agents (beyond statin-based reduction of LDL-C). The most important class of medications which can be effectively used nowadays to combat atherogenic dyslipidemias is the fibrates. From a clinical point of view, in all available 5 randomized control trials beneficial effects of major fibrates (gemfibrozil, fenofibrate, bezafibrate) were clearly demonstrated and were highly significant in patients with atherogenic dyslipidemia. In these circumstances, the main determinant of the overall results of the trial is mainly dependent of the number of the included appropriate patients with atherogenic dyslipidemia. In a meta-analysis of dyslipidemic subgroups totaling 4726 patients a significant 35% relative risk reduction in cardiovascular events was observed compared with a non significant 6% reduction in those without dyslipidemia. However, different fibrates may have a somewhat different spectrum of effects. Currently only fenofibrate was investigated and proved to be effective in reducing microvascular complications of diabetes. Bezafibrate reduced the severity of intermittent claudication. Cardinal differences between bezafibrate and other fibrates are related to the effects on glucose metabolism and insulin resistance. Bezafibrate is the only clinically available pan - (alpha, beta, gamma) PPAR balanced activator. Bezafibrate decreases blood glucose level, HbA1C, insulin resistance and reduces the incidence of T2DM compared to placebo or other fibrates. Among major fibrates, bezafibrate appears to have the strongest and fenofibrate the weakest effect on HDL-C. Current therapeutic use of statins as monotherapy is still leaving many patients with atherogenic dyslipidemia at high risk for coronary events because even intensive statin therapy does not eliminate the residual cardiovascular risk associated with low HDL and/or high triglycerides. As compared with statin monotherapy (effective mainly on LDL-C levels and plaque stabilization), the association of a statin with a fibrate will also have a major impact on triglycerides, HDL and LDL particle size. Moreover, in the specific case of bezafibrate one could expect neutralizing of the adverse pro-diabetic effect of statins. Though muscle pain and myositis is an issue in statin/fibrate treatment, adverse interaction appears to occur to a significantly greater extent when gemfibrozil is administered. However, bezafibrate and fenofibrate seems to be safer and better tolerated. Combined fibrate/statin therapy is more effective in achieving a comprehensive lipid control and may lead to additional cardiovascular risk reduction, as could be suggested for fenofibrate following ACCORD Lipid study subgroup analysis and for bezafibrate on the basis of one small randomized study and multiple observational data. Therefore, in appropriate patients with atherogenic dyslipidemia fibrates- either as monotherapy or combined with statins - are consistently associated with reduced risk of cardiovascular events. Fibrates currently constitute an indispensable part of the modern anti-dyslipidemic arsenal for patients with atherogenic dyslipidemia.

Metabolic syndrome is linked to chromosome 7q21 and associated with genetic variants in CD36 and GNAT3 in Mexican Americans

The prevalence of metabolic syndrome (MS) has been rising alarmingly worldwide, including in the United States, but knowledge on specific genetic determinants of MS is very limited. Therefore, we planned to identify the genetic determinants of MS as defined by National Cholesterol Education Program/Adult Treatment Panel III (NCEP/ATPIII) criteria. We performed linkage screen for MS using data from 692 Mexican Americans, who participated in the San Antonio Family Diabetes/Gallbladder Study (SAFDGS). We found strong evidence for linkage of MS on chromosome 7q (LOD = 3.6, empirical P = 6.0 × 10(-5)), between markers D7S2212 and D7S821. In addition, six chromosomal regions exhibited potential evidence for linkage (LOD ≥1.2) with MS. Furthermore, we examined 29 single-nucleotide polymorphisms (SNPs) from the fatty acid translocase (FAT or CD36, 18 SNPs) gene and guanine nucleotide binding protein, α transducing 3 (GNAT3, 11 SNPs) gene, located within the 1-LOD support interval region for their association with MS and its related traits. Several SNPs were associated with MS and its related traits. Remarkably, rs11760281 in GNAT3 and rs1194197 near CD36 exhibited the strongest associations with MS (P = 0.0003, relative risk (RR) = 1.6 and P = 0.004, RR = 1.7, respectively) and several other related traits. These two variants explained ~18% of the MS linkage evidence on chromosome 7q21, and together conferred approximately threefold increase in MS risk (RR = 2.7). In conclusion, our linkage and subsequent association studies implicate a region on chromosome 7q21 to influence MS in Mexican Americans.

Metabolic syndrome and all-cause mortality in older men and women

BACKGROUND

Prevalence of metabolic syndrome (MetS) increases with age, but its association with all-cause mortality in older persons remains uncertain. This study investigated the association of all-cause mortality with MetS and its individual components in older men and women.

METHODS

A total of 917 men and 1043 women aged 65 years and older from two Italian population-based cohorts were included in the study. MetS was defined according to four different definitions: National Cholesterol Education Program (NCEP), NCEP revised according to the American Heart Association and National Heart Lung Blood Institute (NCEP-R), International Diabetes Organization (IDF) and Joint Interim Statement (JIS). All of these definitions include abdominal obesity, hyperglycaemia, hypertriglyceridaemia, low high-density lipoprotein cholesterol and hypertension. Hazard Ratios (HR) and their corresponding 95% confidence interval (95%CI) estimated from multivariable-adjusted Cox regression models were used to investigate the associations of all-cause mortality with baseline MetS status and individual MetS components.

RESULTS

After 6·5 ± 1·8 years of follow-up, there were 179 deaths among women and 193 among men. Mortality risk was increased in women with MetS by any definition, regardless of individual components, but limited to age 70-79 years (NCEP, HR = 2·02, 95%CI, 1·16-3·53; NCEP-R, HR = 2·51, 95%CI, 1·45-4·34; IDF, HR = 2·16, 95%CI, 1·26-3·72; JIS, HR = 2·16, 95%CI, 1·26-3·72). Mortality risk of men was associated with hypertriglyceridaemia below age 70 years (HR = 2·50, 95%CI, 1·19-5·25), but unrelated to MetS status.

CONCLUSIONS

Metabolic Syndrome is associated with all-cause mortality in older women but not in men. The association, however, is limited to a narrow age range.

Impact of traits of metabolic syndrome on β-cell function and insulin resistance in normal fasting, normal glucose tolerant subjects

OBJECTIVE

Metabolic syndrome, impaired fasting glucose (IFG), and impaired glucose tolerance (IGT) predict risk for type 2 diabetes mellitus (T2DM). To determine if increased risk preceded development of these abnormalities, β-cell function and insulin resistance were assessed in euglycemic subjects with and without traits of metabolic syndrome.

METHODS

A total of 562 apparently healthy Latin-American subjects were screened for metabolic syndrome [National Education Cholesterol Program Adult Treatment Panel III (NECP ATP III)]. Early pancreatic insulin response ΔInsulin(0-30)/ΔGlucose(0-30), Matsuda index, disposition index (DI), and homeostasis model assessment of insulin resistance (HOMA-IR) ratio were obtained from oral glucose tolerance testing (0-180 min).

RESULTS

ΔI(0-30)/ΔG(0-30), Matsuda index, DI, and HOMA-IR deteriorated in direct proportion with number of traits of metabolic syndrome, and with increases in glucose levels within the euglycemic range. DI was the most sensitive index. In subjects with 1, 2, 3, and 4-5 traits, DI was 21.4%, 40%, 57%, and 76% lower, respectively, than in subjects with no traits. As a single trait, abdominal obesity was associated with insulin resistance, whereas, low high-density lipoprotein cholesterol (HDL-C), alone or combined with high triglycerides, was not associated with insulin resistance or β-cell dysfunction. Combined impairments in β-cell function and insulin sensitivity were responsible for the increases in fasting and 2-h plasma glucose concentrations within the euglycemic range.

CONCLUSIONS

Impaired β-cell function and increased insulin resistance are present much before development of metabolic syndrome, IFG, or IGT. β-Cell function and insulin sensitivity worsen in direct proportion with number of traits of metabolic syndrome and increases in glucose levels. Compared to abdominal obesity, low HDL-C±high triglycerides may bear a lesser weight in predicting risk of T2DM.

The prevalence of obesity and obesity-related health conditions in a large, multiethnic cohort of young adults in California

PURPOSE

To identify population groups that are most susceptible to obesity-related health conditions at young age.

METHODS

For this population-based cross-sectional study, measured weight and height, diagnosis, laboratory, and drug prescription information were extracted from electronic medical records of 1,819,205 patients aged 20 to 39 years enrolled in two integrated health plans in California in 2007 through 2009.

RESULTS

Overall, 29.9% of young adults were obese. Extreme obesity (body mass index [BMI] ≥ 40 kg/m(2)) was observed in 6.1% of women and 4.5% of men. The adjusted relative risk (RR) for diabetes, hypertension, dyslipidemia, and the metabolic syndrome increased sharply for those individuals with a BMI of 40 or greater, with the sharpest increase in the adjusted RR for hypertension and the metabolic syndrome. The association between weight class and dyslipidemia, hypertension, and the metabolic syndrome but not diabetes was stronger among 20.0- to 29.9-year-olds compared with 30.0- to 39.9-year-olds (P for interaction < .05). For example, compared with their normal weight counterparts of the same age group, young adults with a BMI of 40.0 to 49.9, 50.0 to 59.9, and 60 or greater kg/m(2) had a RR for hypertension of 11.73, 19.88, and 30.47 (95% confidence interval [CI], 26.39-35.17) at 20 to 29 years old, and 9.31, 12.41, and 15.43 (95% CI, 14.32-16.63) at 30 to 39 years old.

CONCLUSIONS

Although older individuals were more likely to be extremely obese, the association between obesity-related health conditions was stronger in younger individuals. Hispanics and Blacks are also more likely to be obese, including extremely obese, putting them at an elevated risk for premature cardiovascular disease and some cancers relative to non-Hispanic Whites.

Central obesity is important but not essential component of the metabolic syndrome for predicting diabetes mellitus in a hypertensive family-based cohort. Results from the Stanford Asia-pacific program for hypertension and insulin resistance (SAPPHIRe) Taiwan follow-up study

Background

Metabolic abnormalities have a cumulative effect on development of diabetes, but only central obesity has been defined as the essential criterion of metabolic syndrome (MetS) by the International Diabetes Federation. We hypothesized that central obesity contributes to a higher risk of new-onset diabetes than other metabolic abnormalities in the hypertensive families.

Methods

Non-diabetic Chinese were enrolled and MetS components were assessed to establish baseline data in a hypertensive family-based cohort study. Based on medical records and glucose tolerance test (OGTT), the cumulative incidence of diabetes was analyzed in this five-year study by Cox regression models. Contribution of central obesity to development of new-onset diabetes was assessed in subjects with the same number of positive MetS components.

Results

Among the total of 595 subjects who completed the assessment, 125 (21.0%) developed diabetes. Incidence of diabetes increased in direct proportion to the number of positive MetS components (P ≪ 0.001). Although subjects with central obesity had a higher incidence of diabetes than those without (55.7 vs. 30.0 events/1000 person-years, P ≪ 0.001), the difference became non-significant after adjusting of the number of positive MetS components (hazard ratio = 0.72, 95%CI: 0.45-1.13). Furthermore, in all participants with three positive MetS components, there was no difference in the incidence of diabetes between subjects with and without central obesity (hazard ratio = 1.04, 95%CI: 0.50-2.16).

Conclusion

In Chinese hypertensive families, the incidence of diabetes in subjects without central obesity was similar to that in subjects with central obesity when they also had the same number of positive MetS components. We suggest that central obesity is very important, but not the essential component of the metabolic syndrome for predicting of new-onset diabetes. (Trial registration: NCT00260910, ClinicalTrials.gov).

Metabolic syndrome in estonia: prevalence and associations with insulin resistance

Recently, it has been suggested that metabolic syndrome should be considered a premorbid condition in younger individuals. We evaluated the prevalence of metabolic syndrome in Estonia and compared the characteristic profiles between morbid metabolic syndrome (previously established diabetes, hypertension, or dyslipidaemia) and premorbid metabolic syndrome subgroups. Our study was a cross-sectional, population-based sample of the general population in Estonia aged 20-74 years (n = 495). Metabolic syndrome was diagnosed by National Cholesterol Education Program Adult Treatment Panel III criteria. Insulin resistance was estimated using the homeostasis model assessment (HOMA-IR). The crude and weighted prevalence of metabolic syndrome was 27.9% and 25.9%, respectively. Despite being significantly younger, the premorbid subgroup showed similar levels of insulin resistance as the morbid subgroup (mean HOMA-IR ± SD 2.73 ± 1.8 versus 2.97 ± 2.1, P = 0.5). The most important attribute of metabolic syndrome is insulin resistance, which already characterises metabolic syndrome in the early stages of its metabolic abnormalities.

Insulin resistance increases the occurrence of new cardiovascular events in patients with manifest arterial disease without known diabetes. the SMART study

Background

Insulin resistance is accompanied by a cluster of metabolic changes, often referred to as metabolic syndrome. Metabolic syndrome is associated with an increased cardiovascular risk in patients with manifest arterial disease. We investigated whether insulin resistance is associated with an increased risk for cardiovascular events in patients with manifest arterial disease without known diabetes and whether this can be explained by the components of the metabolic syndrome or by inflammation.

Methods

Prospective cohort study in 2611 patients with manifest arterial disease without known diabetes. Homeostasis model of insulin resistance (HOMA-IR) was used to quantify insulin resistance. The relation of HOMA-IR with cardiovascular events (vascular death, myocardial infarction or stroke) and all cause mortality was assessed with Cox regression analysis. In additional models adjustments were performed for the single components constituting the metabolic syndrome and for inflammation.

Results

HOMA-IR increases with the number of metabolic syndrome components (mean HOMA-IR ± SD in groups with 0, 1, 2, 3, 4 and 5 metabolic syndrome components: 1.4 ± 0.7; 1.8 ± 1.2; 2.4 ± 1.5; 3.1 ± 1.8; 4.0 ± 2.6; and 5.6 ± 3.6 respectively). High HOMA-IR was independently associated with an increased risk of cardiovascular events (tertile 2 vs. 1 HR 1.92; 95%CI 1.20-3.08) (tertile 3 vs.1 HR 1.78; 95%CI 1.10-2.89) and with all cause mortality (tertile 2 vs. 1 HR 1.80; 95%CI 1.04-3.10) (tertile 3 vs.1 HR 1.56; 95%CI 0.88-2.75). These relations were not influenced by the individual components of metabolic syndrome or by inflammation.

Conclusions

In patients with manifest arterial disease without known diabetes, insulin resistance increases with the number of metabolic syndrome components, and elevated insulin resistance increases the risk of new cardiovascular events.