Mudslinging? Does "metabolic syndrome" mean anything?


There's another important debate in the BMJ this week. The question is: Should medicine dump the "metabolic syndrome"?

The American Heart Association states on its website:

The metabolic syndrome is characterized by a group of metabolic risk factors in one person. They include:

* Abdominal obesity (excessive fat tissue in and around the abdomen)
* Atherogenic dyslipidemia (blood fat disorders — high triglycerides, low HDL cholesterol and high LDL cholesterol — that foster plaque buildups in artery walls)
* Elevated blood pressure
* Insulin resistance or glucose intolerance (the body can’t properly use insulin or blood sugar)
* Prothrombotic state (e.g., high fibrinogen or plasminogen activator inhibitor–1 in the blood)
* Proinflammatory state (e.g., elevated C-reactive protein in the blood)

People with the metabolic syndrome are at increased risk of coronary heart disease and other diseases related to plaque buildups in artery walls (e.g., stroke and peripheral vascular disease) and type 2 diabetes. The metabolic syndrome has become increasingly common in the United States. It’s estimated that over 50 million Americans have it.

In the BMJ this week, diabetes and metabolism specialist Edwin Gale says YES, the metabolic syndrome should be dumped, claiming that this "diagnosis" has little practical value.

But clinicians George Alberti and P Z Zimmet say NO - it should not be dumped because it increases the detection of people at high risk of diabetes and heart disease. They characterize the syndrome’s critics as living in a specialized academic world, out of touch with the "real world" of primary care.

BMJ editor Fiona Godlee writes:

"Is there anything edifying in this refined form of mud slinging? The BMJ invites the combatants into the pit (though we do ask them to bring their own mud), so it’s fair to assume we think there is, even though the 7th century Chinese sage Seng Ts’an said "The struggle between ‘for’ and ‘against’ is the mind’s worst disease." I for one came away from reading these two well argued pieces with a conclusion (and you will no doubt draw others). Since there is uncertainty as to whether it’s clinically useful for GPs to measure people’s waists, we need a randomised trial. Alberti and Zimmet say that focusing on the syndrome results in better management of people with type 2 diabetes, but they give no reference so I assume no "real world" trial has yet been done."

I applaud the BMJ for fostering this debate. In another part of her editor's note, Godlee notes:

We must constantly doubt the products of academia—Robert Merton called this "organised scepticism."

Sounds better than mudslinging.


"What's in a name?" I think if the name of "metabolic syndrome" helps at least one GP to remember some common sense, i.e. a 5 foot tall 35 year old woman with a familial history of diabetes should NOT have a waist circumference significantly greater than her hip circumference. She would have a higher CV risk simply by the fact if she is also sedentary. One doesn't really need a RCT to tell you that.

The classic signs have always been there, whether in one individual or in Western society. The name of metabolic syndrome helps health insurance companies define some risk on the combination of co-factors, for better or worst.

On August 26, 2005, I posted another entry on this blog about metabolic syndrome. It read (in part):

"The Reuters wire service reports that "the world's top two diabetes organizations have questioned the existence of a medical condition widely cited by drug firms, in a move that could hamper prospects for Sanofi-Aventis's new drug Acomplia. The American Diabetes Association and European Association for the Study of Diabetes said in a joint statement on Thursday that 'metabolic syndrome' -- which has come to be seen as a predictor of cardiovascular disease -- was poorly defined, inconsistently used and in need of further research. Doctors should not diagnose people with the 'syndrome' or treat it as a separate condition until the science behind it is clear, according to a paper to be published in the September issue of Diabetes Care and Diabetologia."

Reuters reports that the "strongly worded warning was a setback for Sanofi, which is keen to position its anti-obesity drug Acomplia as a medicine to treat 'metabolic syndrome.' "

The naming of new diseases and new syndromes to help sell drugs is well documented in books by Moynihan, Goozner, Avorn, Angell and others. It is refreshing to see scientists put up a STOP sign in at least one case."

That's what I wrote then.

Today I remind readers of what BMJ editor Fiona Godlee wrote last week: "We must constantly doubt the products of academia—Robert Merton called this 'organised scepticism.' "

And another favorite of mine - sometimes attributed to Mark Twain: "It ain't what people don't know that hurts them; it's what they know that just ain't so."


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This page contains a single entry by Gary Schwitzer published on March 22, 2008 12:35 PM.

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