1、Steven M.Haffner,MDlEnvironmental causes are responsible for the epidemic of the metabolic syndrome(NCEP)Treatment:reduce obesity and increase activitylInsulin resistance is the underlying cause of the metabolic syndrome(WHO)Treatment:a)reduce obesity and increase activity b)insulin sensitizerslInfl
2、ammation is the underlying cause of the metabolic syndromeTreatment:a)reduce obesity and increase activity b)insulin sensitizers c)statins,ACE Inhibitors,ARBsExpert Panel on Detection,Evaluation,and Treatment of High Blood Cholesterol in Adults.JAMA 2001;285:2486-2497.Reaven G.Diabetes.1988;37:1565-
3、1607.HDL-CHypertensionAdapted from Reaven G.Drugs.1999;58(suppl):19-20HemodynamicNovel RiskFactors*The Expert Panel on Detection,Evaluation,and Treatment of High Blood Cholesterol in Adults.JAMA.2001;285:2486-2497.*The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus:Follow-
4、up report on the diagnosis of diabetes mellitus.Diabetes Care 26:3160-3167,2003Risk FactorDefining LevelAbdominal obesity(Waist circumference)Men102 cm(40 in)Women88 cm(35 in)TG150 mg/dLHDL-C Men40 mg/dL Women130/85 mm HgFasting glucose110(100)*mg/dL*2003 New ADA IFG criteria(Expert Panel,Diabetes C
5、are 26:3160-3167,2003)lInsulin resistance(type 2 diabetes,IFG,IGT)*lPlus any 2 of the following:Elevated BP(140/90 or drug Rx)Plasma TG 150 mg/dlHDL 35 mg/dl(men);30 and/or W/H 0.9(men),0.85(women)Urinary albumin 20 mg/min;Alb/Cr 30 mg/gWHO.Definition,Diagnosis and Classification of Diabetes Mellitu
6、s and Its Complications:Report of a WHO Consultation.Geneva:WHO,1999.*Note that 1999 WHO uses hyperinsulinemic euglycemic clamp whereas 1998 WHO and EGIR use HOMA-IR.lBMI 25 kg/m2lWaist circumferenceMen 40”Women 35”lSedentary LifestylelAge 40lNon-Caucasian ethnicitylFamily History of DM,HTM,or CVDlH
7、istory of glucose intolerance or gestational diabeteslPersonal Dx of HTN,TGL,low HDL or CVDlAcanthosis nigricanslPolycystic ovarian syndrome(PCOS)lNonalcoholic fatty liver disease(NAFLD)lCancer(obesity related)lTriglycerides 150 mg/dllHDL cholesterolMen 40 mg/dlWomen 135/85lBlood glucose2-hour 140 m
8、g/dl,ORFasting 110 125 mg/dl4049Age,years2029505970Ford ES et al.JAMA 2002;287:356-359.Prevalence,%MenWomenFord ES et al.JAMA 2002;287:356-359.WhiteAfrican American25%MenWomen16%28%Mexican AmericanOther21%23%26%36%20%DM(n=1,430)NGT(n=1,808)IFG/IGT(n=685)All(n=3,928)Isomaa B et al.Diabetes Care.2001;
9、24:683-689.Prevalence of CHD(%)YesNoP=.049.2%Metabolic Syndrome4.1%11.0%5.3%27.1%P=.06P.00113.5%21.4%P.0015.5%Lakka HM et al.JAMA 2002;288:2709-2716.Cumulative Hazard,%026812Follow-up,yearMetabolic Syndrome:Cardiovascular Disease MortalityRR(95%CI),3.55(1.986.43)410CHD Prevalence%of Population=No MS
10、/No DM54.2%MS/No DM28.7%DM/No MS2.3%DM/MS14.8%8.7%13.9%7.5%19.2%Alexander CM et al.Diabetes 2003;52:1210-1214.ln=2,815(age 25-64)Both NCEP and WHO metabolic syndrome,509NCEP alone,n=197WHO alone,n=199l12.7 year follow-up(229 deaths)lThree populations consideredOverall populationNo CVD at baselineNo
11、CVD or diabetes at baseline(primary prevention)Hunt,K(Circulation,2004;110:1245-1251)Hunt,K(Circulation,2004;110:1245-1251)Baseline StatusNCEPWHOGeneral Population2.53(1.74,3.67)1.63(1.13,2.36)No CVD2.71(1.74,4.20)1.63(1.06,2.52)No CVD or DM2.01(1.13,3.57)0.74(0.37,1.48)Hunt,K(Circulation,2004;110:1
12、245-1251)WomenMenNCEP3.93(1.83,8.28)1.81(0.72,1.57)WHO2.70(1.36,5.37)1.15(0.65,2.06)Hunt,K(Circulation,2004;110:1245-1251)Baseline StatusWomenMen1.No DM,No NCEP MS1.001.002.No DM,Yes NCEP MS2.07(0.72,6.00)1.96(0.99,3.88)3.Yes DM,No NCEP MS3.53(0.75,16.7)2.34(0.70,7.82)4.Yes DM,Yes NCEP MS8.19(3.51,1
13、9.1)3.09(1.49,6.43)VariableOddsRatioLower 95%LimitUpper 95%LimitWaist circumference1.130.851.51Triglycerides1.120.711.77HDL cholesterol*1.741.182.58Blood pressure*1.871.372.56Impaired fasting glucose0.960.601.54Diabetes*1.551.072.25Metabolic syndrome0.940.541.68*Significant predictors of prevalent C
14、HDCopyright 2003 American Diabetes AssociationFrom Diabetes,Vol.52,2003;1210-1214Reprinted with permission from The American Diabetes Association.Ref.Lorenzo et al,Diabetes Care,2003,26:3153-3159 NCEPdefinition%YesNoNoYesIGTBMI per kg/m2HDL-C per mg/dl decreaseSBP per mm HgFPG per mg/dlStern MP et a
15、l.Ann Intern Med 2002;136:575-581.%in Lowest Quartile of SiHanley AJ et al.Diabetes 2003;52:2740-2747.OverallHispanicsNon-Hispanic whitesAfrican AmericansNeitherNCEP OnlyWHO OnlyBothWeight loss induced by diet and increased physical activity is the cornerstone of therapy Weight loss induced by drug
16、therapy can also improve specific features of the metabolic syndromeBariatric surgery is the most effective weight loss therapy for extremely obese subjects and improves all features of the metabolic syndrome80-85%of diabetic subjects in North America and Europe have the metabolic syndromeHowever,mo
17、st subjects with the metabolic syndrome do not have diabetesStatin therapy(4S,HPS,CARE,CARDS)is effective in diabetic subjectsBlood pressure therapy is(UKPDS,SYST-Euro,HOT)is effective in diabetic subjectsNo randomized clinical trials on hypertension therapy have presented subgroup analysis on non-d
18、iabetic subjects with the metabolic syndromeLipid therapy in the metabolic syndromeStatin therapy,positive 4S(Pyorala,Diabetes Care,2004)Statin therapy not significant in other statin trials(HPS,ASCOT,WOSCOPS)but no evidence of heterogeneityNone of these studies used contemporary definitionsIntroduc
19、es concept of very high risk patients with optional LDL-C goal 200 mg/dl plus non-HDL-C 130 mg/dl with low HDL-C 40 mg/dl)Acute coronary syndromeGrundy et al,Circulation,2004;110:227-239.lWeight loss induced by behavioral therapy(weight loss and increased activity),selected pharmacotherapy,and baria
20、tric surgerylTreat existing risk factorsa)Should management be intensified over and above global risk?b)Yes,but probably not CHD risk equivalentlUse of insulin sensitizing therapies in nondiabetic subjects with MSa)No for metabolic syndrome alone(no clinical trials)b)Do OGTT three outcomes:1)DM(trea
21、t)2)IGT 3)NGT(no treatment)c)Perhaps for IGT subjects(clinical trials available DPP,STOP-NIDDM,TRIPOD)lThe metabolic syndrome predicts the development of both diabetes and CHD lInsulin resistance and obesity characterize most individuals with the metabolic syndrome,although insulin resistance and ob
22、esity are not required features of the NCEP metabolic syndromelInitial therapy for the metabolic syndrome should consist of caloric restriction and increased physical activitylConventional cardiovascular risk factors such as lipids and blood pressure should be treated in individuals with the metabol
23、ic syndrome,although no national recommendations have so far suggested intensification of risk factor managementlNo consensus exists on whether insulin sensitizers should be used in nondiabetic individuals with the metabolic syndrome演讲完毕，谢谢观看！Thank you for reading!In order to facilitate learning and use,the content of this document can be modified,adjusted and printed at will after downloading.Welcome to download!汇报人：XXX 汇报日期：20XX年10月10日
