Citrome et al. (1) seem to agree with our review (2) of all the shortcomings associated with the metabolic syndrome, yet they claim it is somehow still an aid in identifying risk factors and in the “ongoing education of practitioners,” both of which may improve health care. This seems perplexing because what must occur prior to making the “diagnosis” is knowledge of the components, and thus, a priori, the provider must be familiar with the cardiovascular disease (CVD) risk factors that comprise the concept and that the factors must be monitored. Moreover, many other CVD risk factors (e.g., LDL cholesterol, smoking, age, family history) do not require a phrase to prompt doctors to test, yet medical history taking and cholesterol testing do not seem to have suffered because of the absence of an associated syndrome.
Giugliano and Esposito (3) highlight a very important concept. That is, current definitions of the syndrome are “polluted by inclusion of patients with frank diseases.” We couldn’t agree more, and that error compounds the inability of the definition to serve a useful purpose. Unfortunately, although there are an innumerable number of articles describing CVD risk in metabolic syndrome patients who were not distinguished by the values of the risk factors present, we have no similar information on risk in so-called borderline patients using current syndrome definitions. Even so, the report by Vasan et al. (4) suggests that borderline risk factors generally convey very little CVD risk. Moreover, if we had this information, we might find that most of the risk was confined to one or two factors and that here too, we don’t need a “syndrome” to tell us what to do.
Cheţa (5) emphasizes the importance of obesity as a major (key) CVD risk factor. We agree but would not go so far as to create a new syndrome. The underlying pathophysiology of obesity that results in other disorders is complex and likely multifactorial. But here too, we don’t need the syndrome label to tell people that being overweight is hazardous to their health. Whether patients respond better when labeled with a “syndrome” or told they have a CVD risk factor(s) is unknown, but we prefer the “truth in labeling” option.
All of these authors (1, 3, 5) suggest that using the ominous “you’ve got the metabolic syndrome” label results in better adherence to recommendations. We would very much like to see the evidence that such labeling leads to improved compliance with recommended changes in lifestyle. It may in fact lead to the reverse (i.e. to denial) or, perhaps worse, may deflect attention from other more important CVD risk factors (e.g., LDL or smoking).
Psaty et al. (6) accurately paraphrased a key message we tried to convey. That is, regardless of what one thinks of the etiology, definition, or purpose of the metabolic syndrome, it remains crucial to appropriately address all cardiovascular risk factors. Borderline values call for lifestyle modification, and overt disease often requires pharmacologic therapy.
