Metabolic Syndrome
Risk, Diagnosis, and Treatment

LEARNING OUTCOME AND OBJECTIVES:  Upon completion of this continuing education course, you will demonstrate knowledge of evidence-based guidelines related to caring for patients with metabolic syndrome. Specific learning objectives to address potential knowledge gaps include:

• Describe the group of patient characteristics that make up metabolic syndrome.
• Discuss the causes and risk factors of metabolic syndrome, including comorbid conditions.
• Discuss how to recognize metabolic syndrome and diagnostic parameters.
• Outline management strategies for the treatment of metabolic syndrome.
• Explain recommended lifestyle changes for prevention of metabolic syndrome.

WHAT IS METABOLIC SYNDROME?

Metabolic syndrome (also called insulin resistance syndrome or syndrome X) is a preventable condition that reflects the modern world’s way of living—a sedentary lifestyle and overnutrition, resulting in excess adiposity. With the number of people who are overweight or obese around the world, the incidence of metabolic syndrome is increasing. One quarter of the developed world’s population is estimated to have this syndrome, including 3%–5% of children and adolescents, as well as about 1 in 3 adults in the United States (Anagnostics, 2023; NHLBI, 2022c; Noubiap et al., 2022).

A syndrome is a group of symptoms and physical findings that occur together and characterize a particular abnormality or condition for which a direct cause is not necessarily understood. The group of characteristics that make up metabolic syndrome include:

• Excess body fat, especially around the waist, defined as a waist circumference ≥40 inches in males and ≥35 inches in females
• Elevated serum triglycerides ≥150 mg/dL or on drug treatment to reduce triglycerides
• Low serum high-density lipoprotein (HDL) cholesterol, <40 mg/dL in males and <50 mg/dL in females, or on drug treatment for low HDL cholesterol
• Elevated blood pressure ≥130/85 mmHg or on drug treatment for hypertension
• Fasting plasma glucose ≥100 mg/dL or on drug treatment for elevated blood glucose

Having any three of these five criteria constitutes a diagnosis of metabolic syndrome and increases the risk of developing type 2 diabetes and heart disease (Meigs, 2023).

Causes and Risk Factors for Metabolic Syndrome

There are several causes for metabolic syndrome, and each affects the other. Some of the causes can be controlled; others cannot.

The major cause of metabolic syndrome is an individual’s weight, especially abdominal adiposity. These fat cells can raise levels of chemicals (fatty acids) that, in turn, can elevate levels of other chemicals and hormones affecting the way the body controls blood sugar levels. Additionally, the body may not respond well to the hormone insulin, affecting how much glucose muscles and organs absorb from blood. This is referred to as insulin resistance.

These two factors—free fatty acids and insulin resistance—can raise “bad” LDL cholesterol and lower “good” HDL cholesterol. Insulin resistance can raise blood pressure and blood triglyceride levels.

In addition, the immune system can cause the extra fat cells to produce chemicals that increase inflammation. This can result in atherosclerosis, a buildup of a waxy substance consisting of cholesterol, cellular waste products, calcium, and fibrin inside blood vessels. These “plaques” can rupture, break off, and obstruct blood vessels, culminating in a myocardial infarction or ischemic stroke. Inflammation can contribute to insulin resistance, high blood pressure, and heart and blood vessel diseases (NHLBI, 2022a).

Risk factors that can be controlled include:

• Lifestyle habits:
• Inactivity
• Unhealthy diet and large-sized portions
• Poor quality and inadequate amount of sleep
• Smoking
• Alcohol use
• Occupation (working long-term night shifts or on schedules that change or rotate, which increases risk of metabolic syndrome due to misalignment of circadian rhythm)

Risk factors that may not be possible to control include:

• Age
• Environment (e.g., low socioeconomic status)
• Family history or genetics (e.g., diabetes, metabolic syndrome)
• Other medical conditions or treatments:
• Overweight and obesity
• Chemotherapy
• Hormone changes related to polycystic ovary syndrome
• Nonalcoholic fatty liver disease, a contributor to diabetes pathophysiology
• Immune system skin issues such as psoriasis
• Sleep deprivation, obstructive sleep apnea, and circadian rhythm disorders
• Some medications for treatment of allergies, bipolar disorder, depression, HIV, and schizophrenia
• Sex
  (NHLBI, 2022a)

Comorbid Diseases Associated With Metabolic Syndrome

People with metabolic syndrome are at risk for a long list of health problems, including:

• Type 2 diabetes mellitus
• Carotid atherosclerosis, arterial aging, aortic stiffening, and vascular conditions, including stroke, peripheral vascular disease, and coronary artery disease
• Nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis, which can lead to cirrhosis, liver failure, or liver cancer
• Gall bladder and kidney damage
• Endothelial dysfunction, vascular remodeling, and thrombosis, including deep vein thrombosis (DVT) and pulmonary embolism (PE)
• Pregnancy complications
• Erectile dysfunction
• Serious complications from infections
  (Alshammary et al., 2021; ALF, 2023; Stewart & Kline, 2020)

RECOGNIZING AND DIAGNOSING METABOLIC SYNDROME

The first step in making a diagnosis of metabolic syndrome requires the recognition of cues (signs and symptoms), followed by interpretation and validation of the interpretation with diagnostic studies.

Signs and Symptoms of Metabolic Syndrome

A patient who presents with the following signs and symptoms raises the concern for metabolic syndrome and leads to further exploration. These signs and symptoms may include:

• Obesity, particularly abdominal adiposity
• Symptoms of hyperglycemia, including polyuria, polyphagia, blurry vision, restlessness, fatigue especially after eating a meal, and poor wound healing
• Retinopathy, which can result in visual impairment
• Peripheral neuropathy, including numbness, impairment of balance, weakness, tremors, cramps, and gait abnormalities
• Chest pain (angina)
• Shortness of breath
• Acanthosis nigricans, a brown to black hyperpigmentation of the skin with poorly defined margins and a velvety texture usually found in skin folds (axilla, navel, groin, neck)
• Xanthomas and xanthelasmas, yellow lipid deposits under the skin of the elbows, joints, tendons, knees, hands, feet, buttocks, and eyelids (xanthelasmas)
• Female hirsutism (male-patterned hair growth)
  (Wang, 2020; Ikomi, 2022; Davidson & Pradeep, 2023; Dahl, 2021; Culala,2021)

Diagnosing Metabolic Syndrome

Assessment for a diagnosis of metabolic syndrome begins with a medical and social history, review of systems, and physical examination.

HISTORY AND REVIEW OF SYMPTOMS

A medical history offers important information that can help to confirm the diagnosis and determine the extent of the problem. A person who has metabolic syndrome may already have been diagnosed with some components of the syndrome, such as obesity, hypertension, or dyslipidemia. A major complication of the syndrome (e.g., atherosclerotic artery disease, ischemic heart disease, diabetes) may also be present.

Because metabolic syndrome involves a patient’s diet and lifestyle, a history should include dietary habits as well as exercise and level of activity. A history of polycystic ovary syndrome (PCOS), immune system diseases such as psoriasis or treatment for cancer (both of which affect regulation of systemic metabolic homeostasis), history of gestational diabetes, sleep problems such as apnea, as well as medications used to treat allergies, bipolar disorder, depression, HIV, and schizophrenia should be obtained, all of which elevate risk for metabolic syndrome.

Family history is important because genetics can play a major role in the development of the syndrome. A family history that includes obesity, type 2 diabetes, and/or insulin resistance greatly increases the chance that the patient will develop metabolic syndrome.

Social history can be significant, providing clues to other risk factors, such as smoking, which reduces insulin sensitivity and contributes to abdominal obesity in both sexes. Heavy alcohol consumption (five or more drinks on any day or 15 or more per week for men, and four or more on any day or eight or more drinks per week for women) correlates with low serum HDL cholesterol levels, raised serum triglycerides, higher waist circumferences, and hyperinsulinemia. In contrast, mild-to-moderate consumption (no more than one to two drinks per day for men and no more than one drink per day for women) lowers the level of insulin and serum lipids. Obstructive sleep apnea decreases the level of HDL besides increasing the level of glucose, body weight, insulin resistance, and cardiovascular risk.

A thorough review of systems can be helpful for identifying related problems such as menstrual irregularities seen in polycystic ovarian syndrome (Swarup et al., 2022; Mohamed et al., 2023).

A list of current medications can help assess causes for overweight or obesity. Medications known to increase body weight can include:

• Psychiatric medications
• Antipsychotics (e.g., risperidone, haloperidol)
• Lithium
• Antidepressants
• SSRIs (e.g., citalopram)
• SNRIs (e.g., venlafaxine)
• Tricyclics (e.g., imipramine)
• Antiepileptic medications (e.g., valproate, carbamazepine, gabapentin)
• Antidiabetic medications (e.g., rosiglitazone, insulin)
• Steroids (e.g., prednisone, hormonal contraceptives, inhaled corticosteroids)
• Antihistamines (e.g., diphenhydramine, cetirizine)
  (Singh et al., 2021; Kumar, 2022; Watson, 2022)

Assessing Children and Adolescents

Since 1980, the prevalence of obesity among children and adolescents has almost tripled. Thirty-two percent of children in the United States are now overweight or obese (Johns Hopkins Medicine, 2023).

While assessment of metabolic syndrome in adults relies on criteria established by national or international agencies, assessment among children and adolescents has not been as clear. Most assessments have relied on adaptations based on adult criteria.

Child and adolescent assessment includes:

• General medical history
• Prenatal and birth history:
• Maternal obesity
• Maternal gestational diabetes
• Maternal smoking
• Gestational age
• Birth weight
• Neonatal concerns
• Developmental history, including:
• Any delays in motor, speech, or cognitive developmental and therapy received
• Infant feeding, including breastfeeding and duration
• Timing of introduction of complementary foods
• Current medications, such as:
• Glucocorticoids
• Antiepileptics
• Antipsychotics
• Growth history:
• Height and weight growth trajectories
• Onset of obesity and timing of weight concerns of child, adolescent, and family
• Previous obesity management, whether supervised or self-initiated
• Previous and current dieting and exercise behaviors
• Use of supplements
• Sleep routines, presence of snoring, or possible sleep apnea
• Exercise tolerance
• Specific signs and symptoms, including:
• Acne
• Hirsutism (girls)
• Morning headache and visual disturbance
• Nocturnal enuresis
• Constipation
• Hip and knee joint pain
• Gastrointestinal complaints
• Menstrual history
• Social history, including:
• Use of tobacco, alcohol, or recreational drugs
• Family income and food insecurity
• Behavioral risk factors:
• Nutrition and eating behaviors
• Physical activity
• Sedentary behaviors
• Time spent sitting
• Screen time per day
• Patterns of screen viewing
• Use of social media
(Jebeile et al., 2022)

PHYSICAL EXAM

The physical examination provides crucial information, including elevated blood pressure and abdominal obesity, which are two of the five diagnostic criteria for metabolic syndrome.

The patient is also assessed for physical manifestations of insulin resistance and dyslipidemia (peripheral neuropathy, retinopathy, acanthosis nigricans, hirsutism, xanthomas, xanthelasmas). The clinician listens for arterial bruits, which may indicate atherosclerotic disease (Swarup et al., 2022).

Measuring for Obesity

The most commonly used measure of obesity is body mass index (BMI), which is measured using the formula:

BMI = weight in kilograms ÷ height in meters squared
or
BMI = weight in pounds x 703 ÷ height in inches squared

BODY MASS INDEX CLASSIFICATIONS

Classification		BMI (kg/m2)
(CDC, 2022a)
Normal		18.5–24.9
Overweight		25.0–29.9
Obese	Class 1	30.0–34.9
	Class 2	35.0–39.9
	Class 3 (extreme obesity)	>40.0

BMI is interpreted differently for children and teens even though it is calculated with the same formula. Due to changes in weight and height with age, as well as their relation to body fatness, BMI levels among children and adolescents are expressed relative to other children of the same sex and age (CDC, 2022b).

Body mass index, though common, is a controversial method, as it cannot differentiate fat mass from lean mass or subcutaneous from visceral fat. Also, abdominal adiposity is harmful even when BMI is low. Because it matters where excess weight is carried, waist-to-hip ratio (WHR) is recommended as a more accurate measurement than BMI for determining the risk for developing serious health conditions. WHR has a stronger causal effect on risk of mortality regardless of the levels of adiposity and body composition (Kahn et al., 2022b).

METABOLIC SYNDROME AND WAIST-TO-HIP RATIO

Risk level	WHR (men)	WHR (women)
(Koperska, 2023)
Low	≤0.95	≤0.80
Moderate	0.96–1.0	0.81–0.85
High	>1.0	≥0.86

Measuring Blood Pressure

The second component of metabolic syndrome that can be picked up in a physical exam is high blood pressure. To be used as a diagnostic condition for metabolic syndrome, an adult’s blood pressure must be >130/85 mmHg (AHA, 2023). If a person is already taking antihypertensive medication, it is assumed that their blood pressure would normally be >130/85 mmHg.

BLOOD PRESSURE RANGES (mmHg)

Level	Systolic	And/or	Diastolic
(AHA, 2023)
Normal	<120	and	<80
Elevated	120–129	and	<80
Hypertension, stage 1	130–139	or	80–89
Hypertension, stage 2	>140	or	>90
Hypertensive crisis	>180	and/or	>120

A child or adolescent is diagnosed with hypertension when their average blood pressure is at or above the 95th percentile for their age, sex, and height when measured multiple times over three visits or more (Johns Hopkins Medicine, 2023).

DIAGNOSTIC STUDIES

The most common diagnostic studies for metabolic syndrome are for dyslipidemias, as shown in the table below.

BLOOD LIPID TESTING

Test	Concentrations (in mg/dL)
Fasting blood glucose	Normal: 70–100
Fasting triglycerides	Normal: <150 Borderline high: 150–199 High: 200–299 Very high: >500
Fasting total cholesterol	Normal: <200 Borderline high: 200–239 High: ≥240
Fasting HDL cholesterol	Poor: <40 for men, <50 for women Better: 40–50 for men, 50–59 for women Best: ≥60
LDL cholesterol	Normal: <70 Optimal: <100 Near optimal: 100–129 Borderline high: 130–159 High: 160–189 Very high: ≥190

Metabolic syndrome is characterized by fasting blood triglycerides >150 mg/dL and fasting blood HDL cholesterol <40 mg/dL in men and <50 mg/dL in women (Meigs, 2023).

Additional studies to consider include:

• Hemoglobin A1C (HbA1c)
• Thyroid studies
• Oral glucose tolerance test (AGTT)
• Serum BUN and creatinine
• Uric acid
• Liver studies (alanine transaminase [ALT], aspartate transaminase [AST])

Although not routinely done for the diagnosis of metabolic syndrome, imaging studies may be appropriate for patients with signs and symptoms of complications of the syndrome, such as chest pain, dyspnea, claudication, or obstructive sleep apnea. These may include:

• Rest/stress ECG
• Vascular or rest/stress echocardiography
• Stress single-photon emission computed tomography (SPECT)
• Cardiac positron emission tomography (PET)
• Nocturnal polysomnography testing for sleep-related breathing disorder
  (Wang, 2020; Johns Hopkins Medicine, 2023)

DIFFERENTIAL DIAGNOSES

Additional diagnoses are considered for each of the criteria used to identify patients with metabolic syndrome. For example, in patients with hypertension, investigation for secondary causes—such as obstructive sleep apnea or other sleep-related breathing disorders, renovascular disease, or disorders of renin and aldosterone metabolism—may be warranted under appropriate circumstances.

Alternative causes of hyperglycemia may include not only diabetes mellitus but also thyroid dysfunction, Cushing’s syndrome, and rarer endocrinopathies, such as glucagonomas and pheochromocytomas (Wang, 2020).

TREATING METABOLIC SYNDROME

The individual components of metabolic syndrome—abdominal obesity, high triglycerides, low HDL cholesterol, high blood pressure, and high fasting glucose—would not always be treated if found in isolation. When found together, however, metabolic syndrome is typically diagnosed, indicating the need for treatment. Treatment begins with lifestyle modifications, and pharmacotherapy may be introduced when those changes are insufficient.

Treatment goals for metabolic syndrome are:

• Lowering the risk of heart disease
• Preventing the development of type 2 diabetes
  (NHLBI, 2022b)

Treating metabolic syndrome requires a disciplinary team, including:

• Primary care practitioners, who screen and diagnose metabolic syndrome, treat different components of the syndrome, and make referrals to other professionals
• Endocrinologists, whose goal is to restore hormonal balance and restore metabolism
• Cardiologists, who play an advisory role or a coordinating role as specialists in the overall management of patients with increased cardiometabolic risks
• Nurses, who develop management strategies including education, planning and recommendations for physical exercise, dietary education and planning, medication management, and psychosocial support
• Occupational therapists, who provide knowledge and expertise in environmental supports, barriers, and modifications to support habit formation and change
• Physical therapists, who provide exercise training to improve factors underlying metabolic syndrome
• Dietitians and nutritionists, who counsel patients on nutrition issues and healthy eating habits
  (Dobrowolski et al., 2022; Epley et al., 2021; Noghabi, 2021; Physiopedia, 2023)

Therapeutic Lifestyle Changes

Heart-healthy lifestyle changes, including smoking cessation, are the first line of treatment for metabolic syndrome. Weight loss and increased physical activity are aimed at reversing the direct causes of the condition, and nutrition management is focused on a diet of heart-healthy foods (NHLBI, 2022b).

PHYSICAL ACTIVITY AND EXERCISE

All aspects of metabolic syndrome benefit from increased physical activity. Physical exercise helps with losing weight and maintaining weight loss, and it has additional independent metabolic effects that directly reduce insulin resistance. Physical activity is usually a safe and beneficial treatment for people with metabolic syndrome and its associated consequences of atherosclerotic cardiovascular disease and type 2 diabetes.

The American Heart Association (2021) recommends the following physical activity for adults for overall cardiovascular health:

• Getting at least 150 minutes per week of moderate-intensity aerobic activity or 75 minutes per week of vigorous aerobic activity (or a combination of both), preferably spread through the week
• Moving more and sitting less throughout the day to offset the serious health risks of being sedentary
• Adding intensity, since moderate to vigorous aerobic exercise is best
• Adding muscle by including moderate-to-high-intensity muscle-strengthening activity

Patients may also benefit from partnering with others in activities such as swimming, biking, or walking groups to motivate and support one another to reach their goals.

DIETARY MODIFICATIONS

Exercise alone rarely leads to significant weight loss. A heart-healthy diet is usually also necessary, and nutrition planning is the second critical component of the initial treatment of metabolic syndrome.

FOODS TO AVOID

When recommending dietary changes, it is beneficial at the start to help the patient focus on foods to be phased out, including:

• Refined carbs:
• White flour
• Sugary snacks
• Beverages containing sugar
• Saturated fats (found in):
• Red meat
• Whole-milk dairy products
• Many baked goods
• Trans fats (found in):
• Fried foods
• Margarine
• Baked goods
• Snack foods
• Refrigerated doughs
• Coffee creamers
• Cured meats (which are high in sodium):
• Hot dogs
• Bacon
• Deli meats
• Sausages
• Processed foods, such as packaged foods and fast foods, which contain refined carbs, added sugar, high sodium content, hydrogenated oils, corn syrup, and saturated fats

HEART-HEALTHY FOODS

Once “unhealthy” foods are removed from the diet, meals can be built around heart-healthy alternatives, particularly whole, plant-based foods. A heart-healthy, balanced diet includes:

• Vegetables rich in complex carbohydrates that can help prevent blood sugar spikes, help in weight loss, and lower LDL cholesterol:
• Nonstarchy vegetables (e.g., salad greens, broccoli, peppers)
• Starchy vegetables that are higher in fiber (e.g., beans, lentils, chickpeas)
• Whole grains that reduce postprandial blood glucose and peripheral insulin resistance (e.g., barley; bulgur [cracked wheat]; farro; millet; quinoa; black, brown, and red rice; oats)
• Omega-3 fatty acids to help increase HDL, lower LDL cholesterol, and reduce triglycerides (e.g., nuts, seeds, and fatty fish such as salmon, mackerel, sardines, albacore tuna, anchovies)
  (Cleveland Clinic, 2021)

Diet plans recommended for metabolic syndrome include:

• Mediterranean diet
• Low-carbohydrate diets
• Vegetarian diet
• Intermittent fasting
• DASH diet
  (Cleveland Clinic, 2021)

SMOKING CESSATION

Smoking is a lifestyle factor that can increase the risk for metabolic syndrome since it exerts negative effects on abdominal obesity, blood pressure, blood glucose concentrations, and blood lipid profiles. Smoking may also negatively affect other factors that influence glucose and lipid metabolism. Metabolic syndrome risk may initially increase after smoking cessation possibly due to weight gain (Cleveland Clinic, 2023).

Pharmacologic Management

When lifestyle changes in diet and exercise are insufficient, medications may be introduced to manage the condition’s various components of hypertension, hyperglycemia, dyslipidemia, obesity, and prothrombotic state. Drugs prescribed for metabolic syndrome are listed in the table below.

MEDICATIONS FOR METABOLIC SYNDROME

Drug class	Examples
(NHLBI, 2022b; Mayo Clinic, 2022a; Meigs, 2023)
Antihypertensives	ACE inhibitors Angiotensin II receptor blockers Diuretics Beta blockers Calcium channel blockers
Dyslipidemia medications	Statins such as Lipitor and simvastatin Niacin Bile acid resins such as Questran
Hyperglycemia medications	Metformin (Glucophage) Rosiglitazone (Avandia) GLP-1 inhibitors (Ozempic injectable, Trulicity injectable)
Anti-obesity medications	Liraglutide (Saxenda) injectable Orlistat (Xenical by prescription, low-dose over-the-counter Alli) Phentermine (Adipex-P, Lomaira) Phentermine-Topiramate (Qsymia) Semaglutide (Wegovy injectable)
Prothrombin state medication	Low-dose aspirin to reduce heart attacks and stroke

Cognitive Behavioral Therapy

Changing one’s lifestyle requires guidance and determination. Losing weight and making other lifestyle changes is challenging. The therapeutic process often involves working with a practitioner, such as an occupational therapist, to identify and alter recurring negative patterns of thought and behavior.

Cognitive behavioral therapy (CBT) trains individuals to recognize automatic thoughts, assess them objectively, and develop alternative, more balanced, and rational thoughts. CBT concentrates on modifying problematic behaviors through:

• Setting mutually agreed-upon goals
• Eliminating maladaptive behaviors that prevent goal achievement
• Replacing maladaptive behaviors with constructive behaviors that meet the agreed-upon goals

Research has shown that CBT focused on changes in lifestyle are effective in the reduction of metabolic syndrome and cardiovascular risk factors (Nash, 2022).

Surgery

Bariatric surgery may be recommended when diet and exercise have failed to effectively reduce severe obesity and when the patient has serious health problems because of excessive weight. Some surgical procedures limit how much a person can eat, while others work by reducing the body’s ability to absorb nutrients. Some procedures do both. It is important that patients who undergo bariatric surgery receive life-long lifestyle support and medical monitoring.

TYPES OF BARIATRIC SURGERY

• Roux-en-Y gastric bypass (gastric bypass) is one of the most common bariatric surgical procedures. The surgeon creates a small pouch the size of a walnut at the top of the stomach and attaches a narrow portion of the small intestine directly to the pouch. Since the pouch can hold only about 1 ounce of food, this limits the amount of food a person can eat as well as the calories and nutrients absorbed.
• Laparoscopic adjustable gastric banding (lap banding) is a procedure that involves placing a band with an inflatable balloon around the upper part of the stomach. The band restricts the size of the stomach as well as narrows the opening to the rest of the stomach. A port placed under the skin in the abdominal area is connected and used to inflate or deflate the band to adjust the size. This procedure restricts the amount of food intake with an early feeling of fullness.
• Sleeve gastrectomy (gastric sleeve) is a procedure involving the surgical removal of about 80% of the stomach. The remaining part of the stomach is formed into a smaller tube-like structure. The smaller stomach restricts the amount of food intake and decreases the production of ghrelin (a hormone that regulates the appetite).
• Duodenal switch with biliopancreatic diversion begins with the removal of a large part of the stomach, leaving the connection to the first part of the small intestine (duodenum). The middle section of the small intestine is closed off and reattached to the end of the intestine, allowing the bile and pancreatic juices to flow normally. As a result, the patient has a smaller stomach, restricting food intake as well as limiting absorption because food bypasses most of the small intestine.
  (Mayo Clinic, 2022b)

POSTSURGICAL MANAGEMENT

Patients must be educated preoperatively so that they understand they will require lifelong follow-up by a multidisciplinary team to monitor body weight and compliance with the post-surgical regimen necessary for long-term success and micronutrient deficiency detection.

Post discharge, patient management includes assessment of hydration and micronutrient status, as well as assessment of medical comorbid conditions, such as hypertension, diabetes, and sleep apnea. Additional comorbid illness that may develop long-term include:

• Dumping syndrome
• Marginal or gastrojejunal ulcers
• Cholelithiasis
• Nephrolithiasis
• Depression
• Post sleeve gastrectomy stenosis
  (Hamad, 2023)

PREVENTING METABOLIC SYNDROME

At each stage of life, strategies can be implemented to reduce the chance of developing metabolic syndrome. Many metabolic disorders cannot be prevented, as their causes are either genetic or unknown. Metabolic syndrome, however, can be prevented by applying the same measures recommended for management of the syndrome after it has developed.

Prevention measures for adults include:

• Eating heart-healthy foods
• Aiming for and maintaining a healthy weight
• Reducing sedentary time and getting regular physical activity
• Managing stress
• Quitting smoking and avoiding secondhand smoke
• Limiting alcohol intake
• Getting enough good-quality sleep
  (NHLBI, 2022b)

In order to prevent metabolic syndrome in children and adolescents, the American Academy of Pediatrics recommends:

• Improving what children and adolescents eat and drink to help prevent obesity and the development of insulin resistance
• Encouraging physical activity, which can improve blood pressure, cholesterol, and sensitivity to the effects of insulin
• Monitoring screen time, since the number of hours a child spends daily in front of a screen is directly related to body mass index and calories consumed per day
• Getting adequate sleep, since short sleep duration inversely predicts cardiometabolic risk in teens
• Avoiding tobacco smoke exposure, which greatly increases a child’s risk for developing heart disease
  (Magge, 2021)

CONCLUSION

Metabolic syndrome is a common health problem and has reached epidemic proportions in the United States and around the world. Having metabolic syndrome increases the risk that a person may develop diabetes and cardiovascular disease, especially in men over 45 years of age and women over 55 years of age. The syndrome is the combination of:

• Insulin resistance
• Excess intra-abdominal fat
• Unhealthy levels of fats in the blood (high triglycerides and low HDL cholesterol)
• High blood pressure

Treatment of metabolic syndrome begins with therapeutic lifestyle changes. Weight loss, improved diet, and regular physical exercise are important elements of the initial treatment program as well as key measures for prevention. Medications may be recommended to treat those components of metabolic syndrome (e.g., high blood pressure, hypercholesterolemia) that do not improve sufficiently with therapeutic lifestyle changes alone. More drastic measures to reduce obesity include different forms of bariatric surgery.