Obesity and metabolic syndrome

Last updated: May 23, 2022

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Obesity and metabolic syndrome are two very common and interrelated conditions with immense public health implications. Most individuals with obesity have metabolic comorbidities, although metabolically healthy obesity is possible. Metabolic syndrome refers to a constellation of medical conditions that increase the risk of several health problems, primarily atherosclerotic cardiovascular disease, type 2 diabetes, and hepatic steatosis. These conditions are insulin resistance (considered the main risk factor), hypertension, dyslipidemia, and abdominal obesity. The initial treatment of metabolic syndrome typically focuses on initiating lifestyle changes that promote weight reduction, such as dietary modifications and physical exercise. Weight reduction often results in lowered blood pressure and triglyceride levels, as well as increased insulin sensitivity. Lifestyle modifications are recommended to all patients, but some may also benefit from pharmacological treatment or bariatric surgery. Comorbid conditions, such as persistent hypertension and insulin resistance, should be treated appropriately (e.g., ACE inhibitors, metformin).

Metabolic syndrome [1]

Abdominal obesity (i.e., accumulation of fat in visceral tissue) is strongly associated with an atherogenic and hyperglycemic state.

Obesity [3]

The relation between an individual's height and weight is commonly assessed using the Body Mass Index (BMI).

Interpretation of Body Mass Index
Underweight < 18.5 kg/m2
Healthy weight 18.5–24.9 kg/m2
Overweight ≥ 25–29.9 kg/m2 [4]
Class 1 obesity 30–34.9 kg/m2
Class 2 obesity 35–39.9 kg/m2
Class 3 obesity ≥ 40 kg/m2
  • Obesity: an excessive accumulation of fat tissue that results in increased health risks
  • Metabolically healthy obesity (MHO): obesity without metabolic syndrome [5][6]
  • Normal-weight obesity: Individuals with a normal BMI may still have elevated body fat content and therefore be at increased risk for metabolic comorbidities. [3]

The worldwide prevalence of metabolic syndrome is estimated to be 20–25%. [8][9]

Obese children and adolescents are at a high risk of obesity in adulthood and developing the associated complications.

Epidemiological data refers to the US, unless otherwise specified.

Initial screening [14]

  • All adult patients should be regularly screened for obesity by measuring height and weight and calculating BMI.
  • An elevated BMI should prompt a more comprehensive evaluation to identify indications for early interventions. [14]

Comprehensive assessment of a patient with overweight or obesity [15][16]

Perform at baseline and repeat at least once a year to detect comorbidities and associated conditions. Assessment allows for early treatment and evaluation of the patient's response to therapeutic interventions.

All patients who are overweight or obese should be screened for metabolic syndrome.

Clinical evaluation [16]

Laboratory studies [2][17]

Additional screening

Depending on clinical evaluation, screening for associated conditions may be indicated.

Approach [2][15][16]

Lifestyle modifications, the primary treatment for metabolic syndrome and obesity, can lead to weight reduction, increased insulin sensitivity, and reduction of cardiovascular risk factors. [15]

General measures [15][20]

  • Lifestyle modifications: The following recommendations are indicated for all patients.
    • Dietary changes
      • Calorie restriction: 1200–1500 kcal per day in women; 1500–1800 kcal per day in men
      • Diet low in carbohydrates, sodium, cholesterol, saturated fats, and trans fats [2]
      • Consumption of fruit, vegetables, low-fat dairy, fish, and whole grains
    • Physical activity [2]
      • Most patients: at least 30 minutes of moderate aerobic activity 5–7 times per week (e.g., brisk walking)
      • High-risk patients (e.g., history of cardiovascular disease, congestive heart failure): medically supervised exercise programs
  • Additional measures (if applicable)

Pharmacological management of obesity [15][16]

Before starting pharmacological treatment, discuss the side effects and limitations of the drugs with the patient and emphasize the importance of maintaining dietary changes and physical activity. Ensure regular follow-up to assess side effects and success. [16]

Weight loss drugs [15][16]
Class Considerations Agents [16]
Lipase inhibitors
Sympathomimetics
  • Contraindicated in patients with:
Opioid antagonists/norepinephrine-dopamine reuptake inhibitors
GLP-1 agonists

Start therapy with small doses and escalate gradually depending on tolerance. Follow up every 1–3 months to assess side effects and success of the treatment, and modify therapy as necessary. [16]

Bariatric surgery [15][19][21]

Bariatric surgery is a valid option if sufficient weight loss cannot be achieved through lifestyle modifications with or without pharmacological intervention. [22]

Bariatric surgery is an effective treatment for achieving weight loss and reducing metabolic risk factors; however, clinicians must weigh these benefits against the risks associated with surgery.

We list the most important complications. The selection is not exhaustive.

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  1. Alberti KGMM, Eckel RH, Grundy SM, et al. Harmonizing the Metabolic Syndrome. Circulation. 2009; 120 (16): p.1640-1645. doi: 10.1161/circulationaha.109.192644 . | Open in Read by QxMD
  2. Grundy SM, Cleeman JI, Daniels SR, et al. Diagnosis and management of the metabolic syndrome: an American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement. Circulation. 2005; 112 (17): p.2735-2752. doi: 10.1161/CIRCULATIONAHA.105.169404 . | Open in Read by QxMD
  3. Cornier M-A, Després J-P, Davis N, et al. Assessing Adiposity. Circulation. 2011; 124 (18): p.1996-2019. doi: 10.1161/cir.0b013e318233bc6a . | Open in Read by QxMD
  4. Garvey WT, Mechanick JI, Brett EM, et al. American Association of Clinical Endocrinologists and American College of Endocrinology Comprehensive Clinical Practice Guidelines for Medical Care of Patients with Obesity. Endocr Pract. 2016; 22 (Supplement 3): p.1-203. doi: 10.4158/ep161365.gl . | Open in Read by QxMD
  5. Eckel N, Meidtner K, Kalle-Uhlmann T, Stefan N, Schulze MB. Metabolically healthy obesity and cardiovascular events: A systematic review and meta-analysis. Eur J Prev Cardiol. 2015; 23 (9): p.956-966. doi: 10.1177/2047487315623884 . | Open in Read by QxMD
  6. Mongraw-Chaffin M, Foster MC, Anderson CAM, et al. Metabolically Healthy Obesity, Transition to Metabolic Syndrome, and Cardiovascular Risk. J Am Coll Cardiol. 2018; 71 (17): p.1857-1865. doi: 10.1016/j.jacc.2018.02.055 . | Open in Read by QxMD
  7. Moyer VA. Screening for and Management of Obesity in Adults: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2012 . doi: 10.7326/0003-4819-157-5-201209040-00475 . | Open in Read by QxMD
  8. Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults. Circulation. 2013; 129 (25 suppl 2): p.S102-S138. doi: 10.1161/01.cir.0000437739.71477.ee . | Open in Read by QxMD
  9. Apovian CM, Aronne LJ, Bessesen DH, et al. Pharmacological Management of Obesity: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2015; 100 (2): p.342-362. doi: 10.1210/jc.2014-3415 . | Open in Read by QxMD
  10. Zafar U, Khaliq S, Ahmad HU, Manzoor S, Lone KP. Metabolic syndrome: an update on diagnostic criteria, pathogenesis, and genetic links. Hormones. 2018; 17 (3): p.299-313. doi: 10.1007/s42000-018-0051-3 . | Open in Read by QxMD
  11. Li C, Hsieh M-C, Chang S-J. Metabolic syndrome, diabetes, and hyperuricemia. Curr Opin Rheumatol. 2013; 25 (2): p.210-216. doi: 10.1097/bor.0b013e32835d951e . | Open in Read by QxMD
  12. Aminian A, Chang J, Brethauer SA, Kim JJ. ASMBS updated position statement on bariatric surgery in class I obesity (BMI 30–35 kg/m2). Surg Obes Relat Dis. 2018; 14 (8): p.1071-1087. doi: 10.1016/j.soard.2018.05.025 . | Open in Read by QxMD
  13. Zhao XQ. Pathogenesis of atherosclerosis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. http://www.uptodate.com/contents/pathogenesis-of-atherosclerosis.Last updated: May 17, 2016. Accessed: March 28, 2017.
  14. Mechanick JI, Apovian C, Brethauer S, et al. Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures – 2019 update: cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists. Surg Obes Relat Dis. 2020; 16 (2): p.175-247. doi: 10.1016/j.soard.2019.10.025 . | Open in Read by QxMD
  15. Poirier P, Cornier M-A, Mazzone T, et al. Bariatric Surgery and Cardiovascular Risk Factors. Circulation. 2011; 123 (15): p.1683-1701. doi: 10.1161/cir.0b013e3182149099 . | Open in Read by QxMD
  16. Tune JD, Goodwill AG, Sassoon DJ, Mather KJ. Cardiovascular consequences of metabolic syndrome. Transl Res. 2017; 183 : p.57-70. doi: 10.1016/j.trsl.2017.01.001 . | Open in Read by QxMD
  17. Perrone-Filardi P, Paolillo S, Costanzo P, Savarese G, Trimarco B, Bonow RO. The role of metabolic syndrome in heart failure. Eur Heart J. 2015; 36 (39): p.2630-2634. doi: 10.1093/eurheartj/ehv350 . | Open in Read by QxMD
  18. Blokhin IO, Lentz SR. Mechanisms of thrombosis in obesity. Curr Opin Hematol. 2015; 20 (5): p.437-444. doi: 10.1097/MOH.0b013e3283634443 . | Open in Read by QxMD
  19. Bureau C, Laurent J, Robic MA, et al. Central obesity is associated with non-cirrhotic portal vein thrombosis. J Hepatol. 2016; 64 (2): p.427-432. doi: 10.1016/j.jhep.2015.08.024 . | Open in Read by QxMD
  20. Shin D, Song WO. Prepregnancy body mass index is an independent risk factor for gestational hypertension, gestational diabetes, preterm labor, and small- and large-for-gestational-age infants. J Matern Fetal Neonatal Med. 2015; 28 (14): p.1679-86. doi: 10.3109/14767058.2014.964675 . | Open in Read by QxMD
  21. Besiroglu H, Otunctemur A, Ozbek E. The Relationship Between Metabolic Syndrome, Its Components, and Erectile Dysfunction: A Systematic Review and a Meta-Analysis of Observational Studies. J Sex Med. 2015; 12 (6): p.1309-1318. doi: 10.1111/jsm.12885 . | Open in Read by QxMD
  22. Anstey KJ, Cherbuin N, Budge M, Young J. Body mass index in midlife and late-life as a risk factor for dementia: a meta-analysis of prospective studies. Obes Rev. 2011; 12 (5): p.e426-e437. doi: 10.1111/j.1467-789x.2010.00825.x . | Open in Read by QxMD
  23. Micucci C, Valli D, Matacchione G, Catalano A. Current perspectives between metabolic syndrome and cancer. Oncotarget. 2016; 7 (25): p.38959-38972. doi: 10.18632/oncotarget.8341 . | Open in Read by QxMD
  24. Gallagher EJ, LeRoith D. Epidemiology and Molecular Mechanisms Tying Obesity, Diabetes, and the Metabolic Syndrome With Cancer. Diabetes Care. 2013; 36 (Supplement_2): p.S233-S239. doi: 10.2337/dcs13-2001 . | Open in Read by QxMD
  25. Virani SS, Alonso A, Aparicio HJ, et al. Heart Disease and Stroke Statistics—2021 Update: A Report From the American Heart Association. Circulation. 2021 . doi: 10.1161/cir.0000000000000950 . | Open in Read by QxMD
  26. Saklayen MG. The Global Epidemic of the Metabolic Syndrome. Curr Hypertens Rep. 2018; 20 (2). doi: 10.1007/s11906-018-0812-z . | Open in Read by QxMD
  27. Belete R, Ataro Z, Abdu A, Sheleme M. Global prevalence of metabolic syndrome among patients with type I diabetes mellitus: a systematic review and meta-analysis. Diabetology & Metabolic Syndrome. 2021; 13 (1). doi: 10.1186/s13098-021-00641-8 . | Open in Read by QxMD
  28. Al-Mutairi N. Associated Cutaneous Diseases in Obese Adult Patients: A Prospective Study from a Skin Referral Care Center. Medical Principles and Practice. 2011; 20 (3): p.248-252. doi: 10.1159/000323597 . | Open in Read by QxMD
  29. Camilleri M, Malhi H, Acosta A. Gastrointestinal Complications of Obesity. Gastroenterology. 2017; 152 (7): p.1656-1670. doi: 10.1053/j.gastro.2016.12.052 . | Open in Read by QxMD
  30. Lim SS, Kakoly NS, Tan JWJ, et al. Metabolic syndrome in polycystic ovary syndrome: a systematic review, meta-analysis and meta-regression. Obes Rev. 2018; 20 (2): p.339-352. doi: 10.1111/obr.12762 . | Open in Read by QxMD
  31. Pan A, Keum N, Okereke OI, et al. Bidirectional Association Between Depression and Metabolic Syndrome: A systematic review and meta-analysis of epidemiological studies. Diabetes Care. 2012; 35 (5): p.1171-1180. doi: 10.2337/dc11-2055 . | Open in Read by QxMD

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