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==Etiology==
==Etiology==
The exact mechanisms of the complex pathways of metabolic syndrome are not yet completely known. The pathophysiology is extremely complex and has been only partially elucidated. Most patients are older, obese, sedentary, and have a degree of [[insulin resistance]]. The most important factors in order are:
The exact mechanisms of the complex pathways of metabolic syndrome are not yet completely known. The pathophysiology is extremely complex and has been only partially elucidated. Most patients are older, obese, sedentary, and have a degree of [[insulin resistance]]. Stress can also be a contributing factor. The most important factors are:
#weight
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#aging
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==Risk Factors==
==Risk Factors==
===Stress===
Prolonged [[Stress (biology)|stress]] can be an underlying cause of Metabolic syndrome by upsetting the hormonal balance of the [[Hypothalamic-pituitary-adrenal axis]] (HPA-axis).<ref>{{cite book
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}}</ref> A dysfunctional HPA-axis causes high cortisol levels to circulate which results in raising [[glucose]] and insulin levels.<ref>{{cite book
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}}</ref> High Cortisol levels can also cause loss of muscle bulk, accumulation of [[Adipose tissue|visceral fat]] and raised levels of clotting factor.<ref>{{cite book
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}}</ref> All of these factors contribute to the damage of the edothelial lining of the artery wall which results in [[endothelial dysfunction]] or [[coronary artery disease]] which is then accelerated by further high levels of [[blood sugar]], [[insulin]], [[cortisol]], and [[adrenaline]].<ref>{{cite book
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}}</ref> Raised levels of [[Coagulation|blood-clotting factors]] are also "directly and consistently associated with an increased risk of heart disease."<ref>{{cite book
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===Overweight and Obesity===
===Overweight and Obesity===
{{Main|Central obesity}}
{{Main|Central obesity}}

Revision as of 14:15, 1 December 2009

See also: Syndrome X
Metabolic syndrome
SpecialtyEndocrinology, internal medicine Edit this on Wikidata

Metabolic syndrome is a combination of medical disorders that increase the risk of developing cardiovascular disease and diabetes.[1] It affects one in five people, and prevalence increases with age. Some studies estimate the prevalence in the USA to be up to 25% of the population.[2]

Metabolic syndrome is also known as metabolic syndrome X, syndrome X, insulin resistance syndrome, Reaven's syndrome, and CHAOS (Australia)[3]. A similar condition in overweight horses is referred to as equine metabolic syndrome; it is unknown if they have the same etiology.

History

The term "metabolic syndrome" dates back to at least the late 1950s, but came into common usage in the late 1970s to describe various associations of risk factors with diabetes that had been noted as early as the 1920s.[4][5]

  • The Marseilles physician Dr. Jean Vague, in 1947, observed that upper body obesity appeared to predispose to diabetes, atherosclerosis, gout and calculi.[6]
  • Avogaro, Crepaldi and co-workers described six moderately obese patients with diabetes, hypercholesterolemia, and marked hypertriglyceridemia all of which improved when the patients were put on a hypocaloric, low-carbohydrate diet.[7]
  • In 1977, Haller used the term "metabolic syndrome" for associations of obesity, diabetes mellitus, hyperlipoproteinemia, hyperuricemia, and Hepatic steatosis when describing the additive effects of risk factors on atherosclerosis.[8]
  • The same year, Singer used the term for associations of obesity, gout, diabetes mellitus, and hypertension with hyperlipoprotenemia.[9]
  • In 1977 and 1978, Gerald B. Phillips developed the concept that risk factors for myocardial infarction concur to form a "constellation of abnormalities" (i.e., glucose intolerance, hyperinsulinemia, hyperlipidemia [hypercholesterolemia and hypertriglyceridemia], and hypertension) that is associated not only with heart disease but also with aging, obesity and other clinical states. He suggested there must be an underlying linking factor, the identification of which could lead to the prevention of cardiovascular disease; he hypothesized that this factor was sex hormones.[10][11]
  • In 1988, in his Banting lecture, Gerald M. Reaven proposed insulin resistance as the underlying factor and named the constellation of abnormalities Syndrome X. Reaven did not include abdominal obesity, which has also been hypothesized as the underlying factor, as part of the condition.[12]

The terms "metabolic syndrome," "insulin resistance syndrome," and "syndrome X" are now used specifically to define a constellation of abnormalities that is associated with increased risk for the development of type 2 diabetes and atherosclerotic vascular disease (e.g., heart disease and stroke).

Etiology

The exact mechanisms of the complex pathways of metabolic syndrome are not yet completely known. The pathophysiology is extremely complex and has been only partially elucidated. Most patients are older, obese, sedentary, and have a degree of insulin resistance. Stress can also be a contributing factor. The most important factors are:

  1. weight
  2. genetics[13][14][15][16]
  3. stress
  4. aging
  5. sedentary lifestyle, i.e., low physical activity and excess caloric intake.[17]

There is debate regarding whether obesity or insulin resistance is the cause of the metabolic syndrome or if they are consequences of a more far-reaching metabolic derangement. A number of markers of systemic inflammation, including C-reactive protein, are often increased, as are fibrinogen, interleukin 6 (IL–6), Tumor necrosis factor-alpha (TNFα), and others. Some have pointed to a variety of causes including increased uric acid levels caused by dietary fructose.[18][19][20]

Pathophysiology

It is common for there to be a development of visceral fat, after which the adipocytes (fat cells) of the visceral fat increase plasma levels of TNFα and alter levels of a number of other substances (e.g., adiponectin, resistin, PAI-1). TNFα has been shown not only to cause the production of inflammatory cytokines but possibly to trigger cell signaling by interaction with a TNFα receptor that may lead to insulin resistance [citation needed]. An experiment with rats that were fed a diet one-third of which was sucrose has been proposed as a model for the development of the metabolic syndrome. The sucrose first elevated blood levels of triglycerides, which induced visceral fat and ultimately resulted in insulin resistance [21]. The progression from visceral fat to increased TNFα to insulin resistance has some parallels to human development of metabolic syndrome.

Risk Factors

Stress

Prolonged stress can be an underlying cause of Metabolic syndrome by upsetting the hormonal balance of the Hypothalamic-pituitary-adrenal axis (HPA-axis).[22] A dysfunctional HPA-axis causes high cortisol levels to circulate which results in raising glucose and insulin levels.[23] High Cortisol levels can also cause loss of muscle bulk, accumulation of visceral fat and raised levels of clotting factor.[24] All of these factors contribute to the damage of the edothelial lining of the artery wall which results in endothelial dysfunction or coronary artery disease which is then accelerated by further high levels of blood sugar, insulin, cortisol, and adrenaline.[25] Raised levels of blood-clotting factors are also "directly and consistently associated with an increased risk of heart disease."[26]

Overweight and Obesity

Main article: Central obesity

Central adiposity is a key feature of the syndrome, reflecting the fact that the syndrome's prevalence is driven by the strong relationship between waist circumference and increasing adiposity. However, despite the importance of obesity, patients that are of normal weight may also be insulin-resistant and have the syndrome.[27]

Sedentary lifestyle

Physical inactivity is a predictor of CVD events and related mortality. Many components of the metabolic syndrome are associated with a sedentary lifestyle, including increased adipose tissue (predominantly central); reduced HDL cholesterol; and a trend toward increased triglycerides, blood pressure, and glucose in the genetically susceptible. Compared with individuals who watched television or videos or used their computer for more less one hour daily, those that carried out these behaviors for greater than four hours daily have a twofold increased risk of the metabolic syndrome.[27]

Aging

The metabolic syndrome affects 44% of the U.S. population older than age 50. A greater percentage of women older than age 50 have the syndrome than men. The age dependency of the syndrome's prevalence is seen in most populations around the world.[27]

Diabetes Mellitus

Main article: Diabetes Mellitus

It is estimated that the large majority (~75%) of patients with type 2 diabetes or impaired glucose tolerance (IGT) have the metabolic syndrome. The presence of the metabolic syndrome in these populations is associated with a higher prevalence of CVD than found in patients with type 2 diabetes or IGT without the syndrome.[27] Hypoadiponectinemia has been shown to increase insulin resistance[28], and is considered to be a risk factor for developing metabolic syndrome.[29]

Coronary Heart Disease

Main article: Coronary disease

The approximate prevalence of the metabolic syndrome in patients with coronary heart disease (CHD) is 50%, with a prevalence of 37% in patients with premature coronary artery disease ( age 45), particularly in women. With appropriate cardiac rehabilitation and changes in lifestyle (e.g., nutrition, physical activity, weight reduction, and, in some cases, Drugs), the prevalence of the syndrome can be reduced.[27]

Lipodystrophy

Main article: Lipodystrophy

Lipodystrophic disorders in general are associated with the metabolic syndrome. Both genetic (e.g., Berardinelli-Seip congenital lipodystrophy, Dunnigan familial partial lipodystrophy) and acquired (e.g., HIV-related lipodystrophy in patients treated with highly active antiretroviral therapy) forms of lipodystrophy may give rise to severe insulin resistance and many of the metabolic syndrome's components.[27]

Signs and symptoms

Symptoms and features are:

Associated diseases and signs are: hyperuricemia, fatty liver (especially in concurrent obesity) progressing to non-alcoholic fatty liver disease, polycystic ovarian syndrome (in women), and acanthosis nigricans.

Diagnosis

There are currently two major definitions for metabolic syndrome provided by the International Diabetes Federation[30] and the revised National Cholesterol Education Program, respectively. The revised NCEP and IDF definitions of metabolic syndrome are very similar and it can be expected that they will identify many of the same individuals as having metabolic syndrome. The two differences are that IDF state if BMI>30 kg/m2 central obesity can be assumed and waist circumference does not need to be measured. However, this potentially excludes any subject without increased waist circumference if BMI<30, whereas, in the NCEP definition, metabolic syndrome can be diagnosed based on other criteria and the IDF uses geography-specific cut points for waist circumference, while NCEP uses only one set of cut points for waist circumference regardless of geography. These two definitions are much closer to each other than the original NCEP and WHO definitions.

IDF

International Diabetes Federation[30] The IDF consensus worldwide definition of the metabolic syndrome (2006)

Central obesity (defined as waist circumference# with ethnicity specific values)

AND any two of the following:

  • Raised triglycerides : > 150 mg/dL (1.7 mmol/L), or specific treatment for this lipid abnormality.
  • Reduced HDL cholesterol: < 40 mg/dL (1.03 mmol/L) in males, < 50 mg/dL (1.29 mmol/L) in females, or specific treatment for this lipid abnormality
  • Raised blood pressure : systolic BP > 130 or diastolic BP >85 mm Hg, or treatment of previously diagnosed hypertension.
  • Raised fasting plasma glucose :(FPG)>100 mg/dL (5.6 mmol/L), or previously diagnosed type 2 diabetes. If FPG >5.6 mmol/L or 100 mg/dL, OGTT Glucose tolerance test is strongly recommended but is not necessary to define presence of the Syndrome.

# If BMI is >30 kg/m², central obesity can be assumed and waist circumference does not need to be measured

WHO

The World Health Organization criteria (1999) require presence of diabetes mellitus, impaired glucose tolerance, impaired fasting glucose or insulin resistance, AND two of the following:

  • blood pressure: ≥ 140/90 mmHg
  • dyslipidaemia: triglycerides (TG): ≥ 1.695 mmol/L and high-density lipoprotein cholesterol (HDL-C) ≤ 0.9 mmol/L (male), ≤ 1.0 mmol/L (female)
  • central obesity: waist:hip ratio > 0.90 (male); > 0.85 (female), and/or body mass index > 30 kg/m2
  • microalbuminuria: urinary albumin excretion ratio ≥ 20 mg/min or albumin:creatinine ratio ≥ 30 mg/g

EGIR

The European Group for the Study of Insulin Resistance (1999) requires insulin resistance defined as the top 25% of the fasting insulin values among non-diabetic individuals AND two or more of the following:

  • central obesity: waist circumference ≥ 94 cm (male), ≥ 80 cm (female)
  • dyslipidaemia: TG ≥ 2.0 mmol/L and/or HDL-C < 1.0 mmol/L or treated for dyslipidaemia
  • hypertension: blood pressure ≥ 140/90 mmHg or antihypertensive medication
  • fasting plasma glucose ≥ 6.1 mmol/L

NCEP

The US National Cholesterol Education Program Adult Treatment Panel III (2001) requires at least three of the following:[31]

  • central obesity: waist circumference ≥ 102 cm or 40 inches (male), ≥ 88 cm or 36 inches(female)
  • dyslipidaemia: TG ≥ 1.695 mmol/L (150 mg/dl)
  • dyslipidaemia: HDL-C < 40 mg/dL (male), < 50 mg/dL (female)
  • blood pressure ≥ 130/85 mmHg
  • fasting plasma glucose ≥ 6.1 mmol/L (110 mg/dl)

American Heart Association/Updated NCEP

There is confusion as to whether AHA/NHLBI intended to create another set of guidelines or simply update the NCEP ATP III definition. According to Scott Grundy, University of Texas Southwestern Medical School, Dallas, Texas, the intent was just to update the NCEP ATP III definition and not create a new definition.[32][33]:

  • Elevated waist circumference:
    • Men — Equal to or greater than 40 inches (102 cm)
    • Women — Equal to or greater than 35 inches (88 cm)
  • Elevated triglycerides: Equal to or greater than 150 mg/dL
  • Reduced HDL (“good”) cholesterol:
    • Men — Less than 40 mg/dL
    • Women — Less than 50 mg/dL
  • Elevated blood pressure: Equal to or greater than 130/85 mm Hg or use of medication for hypertension
  • Elevated fasting glucose: Equal to or greater than 100 mg/dL (5.6 mmol/L) or use of medication for hyperglycemia

Other

High-sensitivity C-reactive protein (hs-CRP) has been developed and used as a marker to predict coronary vascular diseases in metabolic syndrome, and it was recently used predictor for non-alcoholic fatty liver disease in correlation with serum markers that indicated lipid and glucose metabolism.[34]

Prevention

Various strategies have been proposed to prevent the development of metabolic syndrome. These include increased physical activity (such as walking 30 minutes every day),[35] and a healthy, reduced calorie diet.[36] There are many studies that support the value of a healthy lifestyle as above. However, one study stated that these measures are effective in only a minority of people, primarily due to a lack of compliance with lifestyle and diet changes.[17] The International Obesity Taskforce states that interventions on a sociopolitical level are required to reduce development of the metabolic syndrome in populations.[37]

A 2007 study of 2,375 male subjects over 20 years suggested that daily intake of a pint of milk or equivalent dairy products more than halved the risk of metabolic syndrome.[38] Other studies both support and dispute the authors' findings.[39]

Therapy

The first line treatment is change of lifestyle (i.e., caloric restriction and physical activity). However, drug treatment is frequently required. Generally, the individual disorders that comprise the metabolic syndrome are treated separately. Diuretics and ACE inhibitors may be used to treat hypertension. Cholesterol drugs may be used to lower LDL cholesterol and triglyceride levels, if they are elevated, and to raise HDL levels if they are low. Use of drugs that decrease insulin resistance, e.g., metformin and thiazolidinediones, is controversial; this treatment is not approved by the U.S. Food and Drug Administration.

A 2003 study indicated that cardiovascular exercise was therapeutic in approximately 31% of cases. The most probable benefit was to triglyceride levels, with 43% showing improvement; but fasting plasma glucose and insulin resistance of 91% of test subjects did not improve.[17] Many other studies have supported the value of increased physical activity and restricted caloric intake (exercise and diet) to treat metabolic syndrome.

Controversy

The clinical value of the metabolic syndrome has recently come under fire. It is asserted that different sets of conflicting and incomplete diagnostic criteria are in existence, and that when confounding factors such as obesity are accounted for, diagnosis of the metabolic syndrome has a negligible association with the risk of heart disease.[40]

These concerns have led to the American Diabetes Association and the European Association for the Study of Diabetes to issue a joint statement identifying eight major concerns on the clinical utility of the metabolic syndrome.[41]

It is not contested that cardiovascular risk factors tend to cluster together, but what is contested is the assertion that the metabolic syndrome is anything more than the sum of its constituent parts.

See also

References

  1. ^ MedlinePlus: Metabolic Syndrome
  2. ^ Ford ES, Giles WH, Dietz WH (2002). Prevalence of metabolic syndrome among US adults: findings from the third National Health and Nutrition Examination Survey. JAMA 287(3):356-359. PMID 11790215
  3. ^ In his case studies poster presented at the Chronic Fatigue Syndrome Conference in Sydney, Australia (February 12-13, 1998), Dr Allen E. Gale, Consultant Physician (Allergy), identifies the acronym CHAOS as an abbreviation for Coronary artery disease, Hypertension, Atherosclerosis, Obesity, and Stroke.
  4. ^ Joslin EP. The prevention of diabetes mellitus. JAMA 1921;76:79–84.
  5. ^ Kylin E. [Studies of the hypertension-hyperglycemia-hyperuricemia syndrome] (German). Zentralbl Inn Med 1923;44: 105-27.
  6. ^ Vague J. La diffférenciacion sexuelle, facteur déterminant des formes de l'obésité. Presse Med 1947;30:339-40.
  7. ^ Avogaro P, Crepaldi G, Enzi G, Tiengo A. Associazione di iperlipidemia, diabete mellito e obesità di medio grado. Acta Diabetol Lat 1967;4:572-590.
  8. ^ Haller H. [Epidemiology and associated risk factors of hyperlipoproteinemia] (German). Z Gesamte Inn Med 1977;32(8):124-8. PMID 883354.
  9. ^ Singer P. [Diagnosis of primary hyperlipoproteinemias] (German). Z Gesamte Inn Med 1977;32(9):129-33. PMID 906591.
  10. ^ Phillips GB. Sex hormones, risk factors and cardiovascular disease. Am J Med 1978;65:7-11. PMID 356599.
  11. ^ Phillips GB. Relationship between serum sex hormones and glucose, insulin, and lipid abnormalities in men with myocardial infarction. Proc Natl Acad Sci U S A 1977;74:1729-1733. PMID 193114.
  12. ^ Reaven GM. Banting lecture 1988. Role of insulin resistance in human disease. Diabetes 1988;37:1595-607. PMID 3056758.
  13. ^ Pollex, R.L.; Hegele, R.A. (2006), "Genetic determinants of the metabolic syndrome", Nat Clin Pract Cardiovasc Med, 3 (9): 482–9, PMID 16932765
  14. ^ Poulsen, P.; Vaag, A.; Kyvik, K.; Beck-nielsen, H. (2001), "Genetic versus environmental aetiology of the metabolic syndrome among male and female twins", Diabetologia, 44 (5): 537–543, doi:10.1007/s001250051659, retrieved 2009-04-29
  15. ^ Groop, Leif (2000), "Genetics of the metabolic syndrome", British Journal of Nutrition (83): S39–S48, doi:10.1017/S0007114500000945, retrieved 2009-04-29
  16. ^ Bouchard, G. (1995), "Genetics and the metabolic syndrome", International journal of obesity, 19: 52–59, retrieved 2009-04-29
  17. ^ a b c Katzmaryk,, Peter T (October 2003). "Targeting the Metabolic Syndrome with Exercise: Evidence from the HERITAGE Family Study". Med. Sci. Sports Exerc. 35 (10): 1703–1709. doi:10.1249/01.MSS.0000089337.73244.9B. Retrieved 2007-06-24. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)CS1 maint: extra punctuation (link)
  18. ^ Nakagawa T, Hu H, Zharikov S, Tuttle KR, Short RA, Glushakova O, Ouyang X, Feig DI, Block ER, Herrera-Acosta J, Patel JM, Johnson RJ (2006). "A causal role for uric acid in fructose-induced metabolic syndrome". Am J Phys Renal Phys. 290 (3): F625–F631. doi:10.1152/ajprenal.00140.2005. PMID 16234313.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  19. ^ Hallfrisch J (1990). "Metabolic effects of dietary fructose". Faseb J. 4 (9): 2652–2660. PMID 2189777.
  20. ^ Reiser S, Powell AS, Scholfield DJ, Panda P, Ellwood KC, Canary JJ (1989). "Blood lipids, lipoproteins, apoproteins, and uric acid in men fed diets containing fructose or high-amylose cornstarch". Am J Clin Nutr. 49 (5): 832–839. PMID 2497634.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  21. ^ Fukuchi S, Hamaguchi K, Seike M, Himeno K, Sakata T, Yoshimatsu H. (1 June 2004). "Role of Fatty Acid Composition in the Development of Metabolic Disorders in Sucrose-Induced Obese Rats". Exp Biol Med. 229 (6): 486–493. PMID 15169967.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  22. ^ The Great Cholesterol Con: The Truth About What Really Causes Heart Disease and How to Avoid It. John Blake. 2008-09-05. p. 212. ISBN 9781844546107. {{cite book}}: Cite has empty unknown parameters: |accessyear=, |accessmonth=, and |origdate= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
  23. ^ The Great Cholesterol Con: The Truth About What Really Causes Heart Disease and How to Avoid It. John Blake. 2008-09-05. p. 217. ISBN 9781844546107. {{cite book}}: Cite has empty unknown parameters: |accessyear=, |accessmonth=, and |origdate= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
  24. ^ The Great Cholesterol Con: The Truth About What Really Causes Heart Disease and How to Avoid It. John Blake. 2008-09-05. p. 218. ISBN 9781844546107. {{cite book}}: Cite has empty unknown parameters: |accessyear=, |accessmonth=, and |origdate= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
  25. ^ The Great Cholesterol Con: The Truth About What Really Causes Heart Disease and How to Avoid It. John Blake. 2008-09-05. p. 230. ISBN 9781844546107. {{cite book}}: Cite has empty unknown parameters: |accessyear=, |accessmonth=, and |origdate= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
  26. ^ The Great Cholesterol Con: The Truth About What Really Causes Heart Disease and How to Avoid It. John Blake. 2008-09-05. p. 231. ISBN 9781844546107. {{cite book}}: Cite has empty unknown parameters: |accessyear=, |accessmonth=, and |origdate= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
  27. ^ a b c d e f Fauci, Anthony S. (2008). Harrison's principles of internal medicine. McGraw-Hill Medical. ISBN 0-07-147692-X.
  28. ^ Lara-Castro C, Fu Y, Chung BH, Garvey WT (2007). "Adiponectin and the metabolic syndrome: mechanisms mediating risk for metabolic and cardiovascular disease". Curr. Opin. Lipidol. 18 (3): 263–70. doi:10.1097/MOL.0b013e32814a645f. PMID 17495599. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  29. ^ Renaldi O, Pramono B, Sinorita H, Purnomo LB, Asdie RH, Asdie AH (2009). "Hypoadiponectinemia: a risk factor for metabolic syndrome". Acta Med Indones. 41 (1): 20–4. doi:10.1267/science.040579197. PMID 19258676. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  30. ^ a b The IDF consensus worldwide definition of the metabolic syndrome. PDF
  31. ^ 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;285:2486-97. PMID 11368702.
  32. ^ Grundy SM, Brewer HB, Cleeman JI, Smith SC, Lenfant D, for the Conference Participants. 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;109:433-438.
  33. ^ American Heart Association's description of Syndrome X
  34. ^ Kogiso T, Moriyoshi Y, Shimizu S, Nagahara H, Shiratori K (2009). "High-sensitivity C-reactive protein as a serum predictor of nonalcoholic fatty liver disease based on the Akaike Information Criterion scoring system in the general Japanese population". J. Gastroenterol. 44: 313. doi:10.1007/s00535-009-0002-5. PMID 19271113. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  35. ^ Lakka TA, Laaksonen DE (2007). "Physical activity in prevention and treatment of the metabolic syndrome". Applied physiology, nutrition, and metabolism = Physiologie appliquée, nutrition et métabolisme. 32 (1): 76–88. doi:10.1139/h06-113. PMID 17332786.
  36. ^ Feldeisen SE, Tucker KL (2007). "Nutritional strategies in the prevention and treatment of metabolic syndrome". Appl Physiol Nutr Metab. 32 (1): 46–60. doi:10.1139/h06-101. PMID 17332784.
  37. ^ James PT, Rigby N, Leach R (2004). "The obesity epidemic, metabolic syndrome and future prevention strategies". Eur J Cardiovasc Prev Rehabil. 11 (1): 3–8. doi:10.1097/01.hjr.0000114707.27531.48. PMID 15167200.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  38. ^ Elwood, PC (2007). "Milk and dairy consumption, diabetes and the metabolic syndrome: the Caerphilly prospective study". J Epidemiol Community Health. 61 (8): 695–698. doi:10.1136/jech.2006.053157. PMID 17630368. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
  39. ^ Snijder MB, van der Heijden AA, van Dam RM; et al. (2007). "Is higher dairy consumption associated with lower body weight and fewer metabolic disturbances? The Hoorn Study". Am. J. Clin. Nutr. 85 (4): 989–95. PMID 17413097. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
  40. ^ Richard Kahn (2008). "Metabolic syndrome—what is the clinical usefulness?". Lancet. 371: 1892–1893. doi:10.1016/S0140-6736(08)60731-X.
  41. ^ Kahn R, Buse J, Ferrannini E, Stern M (2005). "The metabolic syndrome: time for a critical appraisal. Joint statement from the American Diabetes Association and the European Association for the Study of Diabetes". Diabetes Care. 28: 2289–2304. doi:10.2337/diacare.28.9.2289. PMID 16123508.{{cite journal}}: CS1 maint: multiple names: authors list (link)

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