Lifestyle modification in the management of the metabolic syndrome: achievements and challenges

Figures & data

Table 1 Diagnostic criteria of the MS, according to the most popular proposals (National Cholesterol Education Program, International Diabetes Federation, and the Joint Interim Statement of several International Associations and Agencies)

Criteria for diagnosis	NCEP (ATP-III)^Citation2	IDF^Citation4	Joint Interim Statement^Citation5
	Any three of the following	Visceral obesity + two of the remaining	Any three of the following
Visceral obesity	Waist circumference >102 cm (M) or >88 cm (F)	Waist circumference ≥94 cm (M) or ≥88 cm (F)a	Waist circumference ≥94 cm (M) or ≥88 cm (F)a
Atherogenic dyslipidemia	HDL-Chol <40 mg/dL (M) or <50 mg/dL (F)	HDL-Chol <40 mg/dL (M) or <50 mg/dL (F)	HDL-Chol <40 mg/dL (M) or <50 mg/dL (F)
	Triglycerides ≥150 mg/dL or drug-treated	Triglycerides ≥150 mg/dL or drug-treated	Triglycerides ≥150 mg/dL or drug-treated
Altered glucose regulation	Blood glucose ≥110 mg/dL or treated for diabetesb	Blood glucose ≥100 mg/dL or treated for diabetes	Blood glucose ≥100 mg/dL or treated for diabetes
Elevated arterial pressure	Arterial pressure ≥130/85 mmHg or treated for hypertension	Arterial pressure ≥130/85 mmHg or treated for hypertension	Arterial pressure ≥130/85 mmHg or treated for hypertension

a Notes: These cutoffs are valid for Caucasians. Different cutoffs are reported for individuals of different ethnic origin;

b Later reduced to 110 mg/dL.

Abbreviations: NCEP, National Cholesterol Education Program; IDF, International Diabetes Federation; ATP-III, Adult Treatment Panel III.

Table 2 Main topics to cover when educating patients on MS and on lifestyle modification

1. Definition and diagnosis

The MS is a cluster of conditions that increase the risk of developing vascular disease (heart disease, strokes, and peripheral vascular disease) For diagnosis, see Table 1

2. Prevalence

MS affects up to 25% of the population in the United States^Citation7 and 15% of the population in Europe^Citation9

It increases with age (<10% in individuals aged 20–29, 20% in individuals aged 40–49, and 45% in individuals aged 60–69)^Citation7

The ‘obesity epidemic’ is considered the main factor responsible for the increasing prevalence of MS^Citation6

3. Causes

It is linked to insulin resistance.^Citation1 The causes of insulin resistance have not yet been completely clarified. It probably involves a variety of genetic and environmental factors. Both being overweight and inactive contribute to the disease state

4. Consequences

MS increases the risk of developing type 2 diabetes^Citation11 and CVD and the risk for CVD mortality^Citation10

Other conditions that are associated with MS are, notably, polycystic ovary syndrome, fatty liver, cholesterol, gallstones, asthma, sleep disturbances, and some forms of cancer^Citation6

5. Management

Weight loss with lifestyle modification (hypocaloric diet, increased physical activity, and cognitive behavior therapy to help patients modify eating and activity habits) is the key procedure to manage MS.^Citation2 Research data indicate that a lifestyle intervention produce a marked reduction in the prevalence of MS and a decline of body weight, waist circumference, fasting glucose, triglycerides, and blood pressure.^Citation21 The treatment may be delivered in groups and/or individually by a multidisciplinary team trained in lifestyle modification, which includes a registered dietitian, a behavioral psychologist, and an exercise specialist, coordinated by a physician. It includes weekly sessions for the first 6 months, followed by two sessions a month in the following 6 months

Specific treatment of lipid (eg, hypertriglyceridemia) and nonlipid risk factors (eg, hypertension and hyperlycemia) may be added to the lifestyle modification^Citation2

Abbreviation: CVD, cardiovascular disease.

Table 3 Practical recommendations for diet and physical exercise in lifestyle modification programs

Dietary recommendations ^Citation16

1000–1200 kcal/day for overweight women, and 1200–1600 kcal/day for overweight men and heavier for more active women

The diet should provide ≥55% calories from carbohydrates, ≤30% from lipids (7%–10% from saturated fats), and ~15% from proteins

Total calories should be moderately increased according to the daily amount of physical activity

Diets are designed to create a calorie deficit of 500–1000 kcal/day, producing a weight loss of 0.5–1.0 kg/week

Physical exercise recommendations ^Citation77

Engage in moderate-to-vigorous exercise for at least 60 min on most days (at least 5 days/week)

Walking may be the favorite exercise, as unstructured exercise may be included in routine daily activities

Check the baseline number of steps by a pedometer, then add 500 steps at 3-day intervals to a target value of 10,000–12,000 steps/day

Jogging (20–40 min/day), biking, or swimming (45–60 min/day) may replace walking

Physical exercise is intended to produce a calorie deficit of at least 400 kcal/day, favoring weight loss, maintaining muscle mass, and preventing weight cycling

Notes: The aim of behavior therapy is to provide patients with cognitive and behavioral skills to modify their lifestyle. Accordingly, these recommendations should not be intended as prescriptions, but should be tailored on patients’ preferences.

Figure 1 An example of cognitive restructuring.

Notes: According to the cognitive model, the link between an activating event A) and the emotional or behavioral consequence C) is influenced by the belief B) about the activating event. When the belief contains cognitive bias (eg, as all-or-nothing thinking) as in the scenario on the left, the consequence tends to be unfavorable. However, if the beliefs about that event have been adequately challenged and substituted with more functional thoughts, the consequences are more favorable (scenario on the right).⁹⁴

Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults Executive summary of the third report of the National Cholesterol Education Program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III) JAMA 2001 285 19 2486 2497 11368702

 PubMed Web of Science ®Google Scholar

Alberti KG Zimmet P Shaw J IDF Epidemiology Task Force Consensus Group The metabolic syndrome–a new worldwide definition Lancet 2005 366 9491 1059 1062 16182882

 PubMed Web of Science ®Google Scholar

Alberti KG Eckel RH Grundy SM Harmonizing the metabolic syndrome: a joint interim statement of the International Diabetes Federation task force on epidemiology and prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity Circulation 2009 120 16 1640 1645 19805654

 PubMed Web of Science ®Google Scholar

Ford ES Giles WH Dietz WH Prevalence of the metabolic syndrome among US adults: findings from the third National Health and Nutrition Examination Survey JAMA 2002 287 3 356 359 11790215

 PubMed Web of Science ®Google Scholar

Hu G Qiao Q Tuomilehto J Balkau B Borch-Johnsen K Pyorala K DECODE Study Group Prevalence of the metabolic syndrome and its relation to all-cause and cardiovascular mortality in non-diabetic European men and women Arch Intern Med 2004 164 10 1066 1076 15159263

 PubMedGoogle Scholar

Grundy SM Brewer HBJr Cleeman JI Smith SCJr Lenfant C American Heart Association; National Heart, Lung, and Blood Institute Definition of metabolic syndrome: report of the National Heart, Lung, and Blood Institute/American Heart Association conference on scientific issues related to definition Circulation 2004 109 3 433 438 14744958

 PubMed Web of Science ®Google Scholar

Ferrannini E Haffner SM Mitchell BD Stern MP Hyperinsulinaemia: the key feature of a cardiovascular and metabolic syndrome Diabetologia 1991 34 6 416 422 1884900

 PubMed Web of Science ®Google Scholar

Lorenzo C Williams K Hunt KJ Haffner SM Trend in the prevalence of the metabolic syndrome and its impact on cardiovascular disease incidence: the San Antonio Heart Study Diabetes Care 2006 29 3 625 630 16505517

 PubMed Web of Science ®Google Scholar

Lakka HM Laaksonen DE Lakka TA The metabolic syndrome and total and cardiovascular disease mortality in middle-aged men JAMA 2002 288 21 2709 2716 12460094

 PubMed Web of Science ®Google Scholar

Orchard TJ Temprosa M Goldberg R The effect of metformin and intensive lifestyle intervention on the metabolic syndrome: the Diabetes Prevention Program randomized trial Ann Intern Med 2005 142 8 611 619 15838067

 PubMed Web of Science ®Google Scholar

Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults–the evidence report National Institutes of Health Obes Res 1998 6 Suppl 2 51S 209S 9813653

 PubMedGoogle Scholar

US Department of Health and Human Services, U.S. Department of Agriculture Dietary Guidelines for Americans, 2005 6th ed Washington, DC US Government Printing Office 2005

 Google Scholar

Ellis A Reason and Emotion in Psychotherapy New York, NY Stuart 1962

 Google Scholar