Metabolic Syndrome (MetS) was first described in 1975 and later recognized by the World Health Organization (WHO) in 1998.
While the specific criteria have evolved, MetS generally refers to a constellation of conditions that increase an individual’s risk of type 2 diabetes, stroke and heart disease. The risk factors include abdominal obesity, hypertension, hyperlipidemia, insulin resistance and elevated blood glucose. An association with hepatic steatosis was, in fact, reported in Haller’s work in 1977, although it did not make it into later descriptions and criteria.
The National Cholesterol Education Program and International Diabetes Federation adopted this common criteria for MetS in the early 2000s, yet the practical utility of implementation in clinical practice was unclear and the concept lost some momentum. Few clinicians would dispute the association of these conditions with each other and the risks they confer upon patients for adverse cardiovascular outcomes.
So, why was this concept of MetS ultimately not as impactful on clinical care as anticipated? And why are many clinicians in recent years referring to cardiometabolic disease instead of MetS?
The prime issue
As a concept, cardiometabolic disease is a single underlying disease state with obesity at its foundation that manifests differently in individual patients. It’s more inclusive than MetS as it also encompasses individuals with diagnosed chronic diseases—such as diabetes, cardiovascular disease and fatty liver disease—not just the biometric abnormalities that characterize MetS.
Of course, environment, behavior and genetics also play a role in how any given individual presents, but physicians are finally realizing that these manifestations are symptoms of the underlying disorder: cardiometabolic disease. As a result, by treating them in siloed specialties, we are doing patients a disservice. In fact, individuals with cardiometabolic disease are two times more likely to die from coronary heart disease: the leading cause of death for both men and women in the U.S., which accounts for nearly one-quarter of all deaths. Additionally, these individuals are three times more likely to have a heart attack or stroke.
Care teams instead need to:
- Help patients and colleagues think about cardiometabolic disease holistically
- Address obesity according to the latest evidence and guidelines as a disease; and
- Focus on reducing the risk of adverse cardiovascular events.
The growing problem of cardiometabolic disease
Despite the first description of MetS in 1977 and then the recognition of cardiometabolic disease by the World Health Organization and healthcare leaders, factors contributing to cardiovascular outcomes of cardiometabolic diseases are “growing faster than our ability to combat it,” according to a report by the American Heart Association (AHA). And these challenges come with a greater financial burden. The AHA notes that stroke and heart failure are the most expensive chronic conditions in Medicare fee-for-service, and the soaring expenses associated with MetS could surpass those of other chronic diseases, such as diabetes and Alzheimer’s, in the near future.
Studies also show that obesity is driving a rise in non-alcoholic fatty liver disease (NAFLD), which is closely related to insulin resistance and another risk factor in CMS. And it’s so commonplace now, NAFLD has surpassed the hepatitis C virus as the most common cause of liver transplants.
How a holistic approach can make a difference
Recognizing MetS as a constellation of conditions was a good first step, but ultimately did little to influence clinical care and outcomes. The difference now is that we are thinking about cardiometabolic disease as a single pathology with various manifestations and many physicians and institutions are changing the way they practice to adapt to that understanding.
Here’s what that should look like:
Identify high-risk patients with proper screening and document diagnoses. Abdominal obesity is a strong risk factor, yet, despite being rarely measured, waist circumference is a better indicator for cardiometabolic disease than body mass index. Therefore, measure what matters, document it and diagnose it. Physicians often find that up to 50% of obese patients do not have a documented diagnosis of obesity.
Risk stratify patients according to clinical guidelines. Obese patients should be screened for end organ damage. Blood pressure, lipids, hemoglobin A1c, liver function tests and sleep studies are all appropriate screenings for most of these patients and will determine their risk and treatment plans. Leverage technology that aggregates the important clinical markers within existing practice workflow. These types of solutions can help streamline processes and more quickly identify patients who are at risk of end-organ damage.
Educate patients on their risk and lifestyle change. Offer patients resources to help them understand the relationship between cardiometabolic disease, individual manifestations and cardiovascular risk. Since this can be a challenge to do during a busy day filled with appointments—and patients may be too overwhelmed in office to process the information—an effective way to reach them is through digital resources. These can be shared directly with the patient, and read at their convenience, to help them understand the science behind weight loss, CMS and cardiovascular outcomes.
Stay current on uses for existing medications. In recent years, a series of new indications for existing medications, such as antidiabetic drugs, have been issued that can benefit cardiovascular and renal patients. Blood glucose control in a patient who also has fatty liver disease may look different than patients who do not have hepatic steatosis. Decision support tools embedded in the clinical workflow can help keep you up-to-date on the latest clinical guidelines that would benefit cardiometabolic disease patients.
From medical research and experience within a practice, it's clear that physicians and care teams need to keep a close eye on patients who present with obesity and an array of end-organ manifestations of cardiometabolic disease. By building multidisciplinary teams, putting effective processes in place, using technology to help identify risk, analyzing patient data and educating patients on managing their conditions, practices can take a holistic approach to reduce cardiovascular risk in patients with cardiometabolic disease, dramatically improving population health outcomes.