Metabolic syndrome or insulin resistance

John is a 45-year-old man who works a desk job. He used to be very active in his younger days, but over the past decade, his lifestyle has become more sedentary. John loves his food, especially fast food, and rarely finds time to exercise due to his busy schedule. During a routine check-up, his doctor notices that John has gained some weight, particularly around his abdomen. His blood pressure is slightly elevated, and his recent blood tests show high blood sugar and cholesterol levels.

John's doctor tells him that he might be at risk for something called metabolic syndrome. John is confused—he's heard of diabetes and heart disease, but what exactly is metabolic syndrome? And why is it important?

Today, we’re going to unravel this mystery. We’ll discuss what metabolic syndrome is, why it matters, and most importantly, how we can take steps to prevent it and improve our overall health. Whether you're concerned about your own health or that of a loved one, understanding metabolic syndrome is a crucial step toward better health outcomes."

1. GUIDE DR. PREETHY JAWAHAR PROFESSOR & HOD DEPT OF COMMUNITY HEALTH NURSING M.O.S.C COLLEGE OF NURSING, KOLENCHERRY PRESENTED BY SANDHYA C 18TH BATCH Ph.D. SCHOLAR NURSING TUTOR AIMS MANGALAGIRI

2. John is a 45-year-old man who works a desk job. He used to be very active in his younger days, but over the past decade, his lifestyle has become more sedentary. John loves his food, especially fast food, and rarely finds time to exercise due to his busy schedule. During a routine check-up, his doctor notices that John has gained some weight, particularly around his abdomen. His blood pressure is slightly elevated, and his recent blood tests show high blood sugar and cholesterol levels.

3. Objectives

4. Table of content 1. Introduction 2. Epidemiology 3. Need of the Topic 4. Objectives 5. Review Of literature 6. Origin of the Term 7. Metabolic Syndrome 8. Causes and Risk Factors 9. Pathophysiology 10. Diagnostic Criteria 11. Management 12. Pharmacological Interventions 13. Bariatric surgery 14. GOI initiatives 15. Role of Nurse 16. Summary

5. welcome Metabolic Syndrome: A Common Comorbidity of Diabetes Mellitus

6. 1. Introduction Metabolic Syndrome ( MetS ) previously known as Syndrome X , Insulin Resistance Syndrome , and Deadly Quartet , has been recognized since the 1980s and has gained increasing recognition over the past three decades as there is strong evidence linking MetS to IHD and T2DM which necessitates a comprehensive approach to tackle this challenge. MetS is a complex of interconnected cardiometabolic disorders that includes obesity , insulin resistance, high blood pressure, reduced levels of serum high density cholesterol (HDL-c) and increased level of serum triglycerides. MetS primarily results from a combination of over nutrition and sedentary lifestyles that both lead to excess adiposity , and ultimately to the other metabolic derangements  The diagnosis of metabolic syndrome necessitates the presence of 3 or more of these metabolic abnormalities, signaling an urgent need for proactive identification and intervention strategies.

7. 2. Epidemiology

8. Prevalence of metabolic syndrome among adolescents by state in India, CNNS 2016–18. NCEP ATP III criteria modified for age was used for metabolic syndrome. Results for Haryana and Nagaland are not presented as the sample size was < 50

9. Rural-urban and gender differences in metabolic syndrome in the aging population from southern India: Two parallel, prospective cohort studies  Published: April 19, 2022

10. 3. Need of the Topic The prevalence of metabolic syndrome is rising globally, paralleling increase in obesity and sedentary lifestyles. The economic burden is notably high both in terms of OOPE and CHE due to the associated healthcare costs for managing its complications, including cardiovascular diseases and diabetes. Metabolic syndrome represents a significant public health challenge due to its complex etiology and the severity of its associated risks. Effective prevention and management strategies, including lifestyle modifications and pharmacological interventions , are essential to mitigate its impact.

11. 4. Objectives

12. 5. Review of literature Metabolic syndrome and Diabetes Mellitus Authors and Year Title Objectives Methodology Results Merlit James,  Treesa , P Varghese, Raghav Sharma, Sharad Chand,  2020 June Association Between Metabolic Syndrome and Diabetes Mellitus According to International Diabetic Federation and National Cholesterol Education Program Adult Treatment Panel III Criteria: a Cross-sectional Study To identify the occurrence of metabolic syndrome and to evaluate the gender-associated difference in each component of metabolic syndrome by using International Diabetic Federation (IDF) and National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III)criteria. This is a cross-sectional study conducted in 350 type II diabetes mellitus patients. All the study participants within 30-80 years were enrolled. Subjects with type I DM and pregnant women were excluded from the study. The occurrence of metabolic syndrome among the diabetic population was found to be 42.28% and 28.85% using the IDF and the NCEP ATP III criteria respectively. It was observed that the prevalence was found to be higher in females than males as per IDF and NCEP ATP III criteria and was found to be statistically significant (p < 0.001).

13. Review of literature ….. Metabolic syndrome and Lifestyle factors Authors and Year Title Objectives Methodology Results Kalpana Sharma ,  Sunita Poudyal ,  Hem K Subba  ,  Saurav Khatiwada  2023 May 25 Metabolic syndrome and lifestyle factors among diabetes patients attending in a teaching hospital, Chitwan To find out metabolic syndrome and lifestyle factors among diabetes patients. A cross-sectional survey was carried out among 296 patients with type 2 diabetes mellitus attending Chitwan Medical College Teaching Hospital. Consecutive sampling technique was used to select sample.  Findings revealed that the prevalence of MetS was 66.2% and 58.4% in patients according to (IDF) and (NCEP ATP III) criteria respectively. The most common MetS parameters were raised fasting plasma glucose (94.6%) and abnormal waist circumference (78.4% in IDF criteria) while the least prevalent parameter was reduced HDL level (43.2%).

14. Review of literature ….. Metabolic syndrome and Self-Management Behaviours Authors and Year Title Objectives Methodology Results Aseel Awad Alsaidan  ,  Ashokkumar Thirunavukkarasu  Hassan H Alhassan ,  Ibrahim Abdullah Bin Ahmed ,  Anas Salem Alnasiri  ,  Wejdan Madallah Alhirsan  ,  Nouf Nashmi M Alazmi   2023. Evaluation of Self-Management Behaviors and Its Correlation with the Metabolic Syndrome among the Type 2 Diabetes Mellitus Patients of Northern Saudi Arabia To assess the self-management behaviors and their correlations with MS and other sociodemographic characteristics of the T2DM patients attending outpatient diabetes care clinics. This study is a quantitative cross-sectional study that was conducted from May 2023 to November 2023. A logistic regression analysis was used to identify the predictors of MS. We found that more than one-third (36.5%) of patients had MS according to the NCEP ATP-3 criteria. The prevalence of MS was significantly associated with unsatisfactory self-management behaviors

15. Review of literature ….. Effects of lifestyle modification on metabolic syndrome Authors and Year Title Objectives Methodology Results Kazue Yamaoka and Toshiro Tango 2012 Effects of lifestyle modification on metabolic syndrome: a systematic review and meta-analysis To evaluate the effect of lifestyle modifications on metabolic syndrome ( MetS ) as assessed by its resolution and improved values for its components. This systematic review and meta-analysis investigated the effectiveness of lifestyle changes in managing metabolic syndrome ( MetS ). The analysis included data from eight RCTs with a total of nearly 2,840 participants. Individuals who participated in lifestyle modification interventions (LMI) were about twice as likely to experience complete resolution of MetS compared to controls. Reduced systolic blood pressure by an average of 6.4 mmHg. Reduced diastolic blood pressure by an average of 3.3 mmHg. Decreased triglyceride levels by an average of 12.0 mg/dL. Reduced waist circumference by an average of 2.7 cm. Lowered fasting blood sugar by an average of 11.5 mg/dL.

16. Review of literature ….. Metabolic syndrome and lifestyle modification Authors and Year Title Objectives Methodology Results Yi- Hsin Lin1 Hsuan Huang 2019 Eight-week of low-intensive lifestyle modification does improve insulin resistance in adults with metabolic syndrome To examine the impact of a short term (eight-week) low-intensive LM program on anthropomorphic parameters and insulin resistance in a community-based population A total of 174 adults (67 with MetS ) were enrolled in this retrospective observational study. The effects of the eight-week LM program on anthropomorphic parameters and glucose homeostasis were investigated. After the LM program, most anthropomorphic parameters in both groups were significantly improved (P<0.001).

17. 6. Origin of the term The term “metabolic syndrome” was used in 1977 by Herman Haller who was studying the risk factors associated with atherosclerosis . While finding associations between obesity, diabetes mellitus, high blood lipids, a high uric acid level (predisposes to gout) and fatty liver disease (hepatic steatosis) and how the combined presence of these factors increase the risk of developing atherosclerosis. The next year, Gerald Phillips introduced the concept that a combination of risk factors exist for myocardial infarction that not only predispose to heart disease, but are also associated with an increased risk for obesity and other clinical states. He described the presence of these risk factors as a “constellation of abnormalities” and they included glucose intolerance, hyperinsulinemia and a high level of triglycerides, glucose, cholesterol and insulin.

18. Origin of the term… In 1988, Reaven raised the possibility that insulin resistance (IR) is not only involved in the etiology of type 2 diabetes mellitus (T2DM) but also that of cardiovascular disease (CVD) . Reaven remarked that IR frequently presents in conjunction with a set of abnormalities and described them as syndrome X. The qualifier “metabolic” was added to Reaven’s syndrome X to differentiate it from the pre-existing syndrome X in cardiology .

19. Brainstorming No

20. 7. Metabolic Syndrome Metabolic syndrome is defined as having at least three of five components: Elevated waist circumference ( 80 cm for women; 90 cm for men) Elevated triglycerides ( 150 mg/dL) or drug treatment for elevated triglycerides Low HDL cholesterol (< 40 mg/dL for men; < 50 mg/dL for women or drug treatment for low HDL Elevated blood pressure (systolic 130 mm Hg or diastolic ≥85 mm Hg) or hypertensive drug treatment Elevated fasting glucose ( 100 mg/dl.) or drug treatment for elevated glucose  

21. 8. Causes of Metabolic Syndrome

22. asting Blood Glucose 100 mg/dl   BP systolic >130mmhg and 85 mm hg   Triglycerides 150 mg/dL   HDL <40mg/dl in men and <50 mg/dl in women   WC >80 cm in women and >90 cm in men.   Help me recall the various components of Metabolic Syndrome ???

23. 9. Pathophysiology MetS is a state of chronic low-grade inflammation as a consequence of complex interplay between genetic and environmental factors. Insulin resistance, visceral adiposity, atherogenic dyslipidemia, endothelial dysfunction, genetic susceptibility, elevated blood pressure, hypercoagulable state and chronic stress are the several factors which constitute the syndrome.

24. 9.1 Abdominal Obesity The “ obesity epidemic ” is principally driven by an increased consumption of cheap, calorie dense food and reduced physical activity. Adipose tissue respond rapidly and dynamically to alterations in nutrient excess through adipocytes hypertrophy and hyperplasia. With obesity and progressive adipocytes enlargement, the blood supply to adipocytes may be reduced with consequent hypoxia.

25. Hypoxia has been proposed to be an inciting etiology of necrosis and macrophage infiltration into adipose tissue that leads to an overproduction of biologically active metabolites known as adipocytokines. Adipocytokines includes free fatty acids (FFA), pro-inflammatory mediators (TNF𝛼, IL-6,Leptin, Resistin ). These adipocytokines results in a localized inflammation in adipose tissue that propagates an overall systemic inflammation associated with the development of obesity related comorbidities.

26. NORMAL INSULIN PHYSIOLOGY VS INSULIN RESISTANCE

27. How Insulin Acts (in normal condition)

28. 9.2 Insulin Resistance

29. +Genetics calorie intake physical activity   Visceral Adiposity ROS LOX Activation RAS   Ang II   IL-6 TNF- CRP Fibrinogen   Adipokines Leptin Adinopectin Chemerin   FFA   Glucose uptake Insulin lipogenesis gluconeogenesis TGs   Chronic Inflammation Hormonal Activation Insulin Resistance Metabolic Syndrome CVDs T2DM

30. 9.3 Progression and outcomes of the metabolic syndrome Cardiovascular Disease & Complications Abdominal obesity Multiple borderline Risk factors Multiple Categorical Risk factors Type 2 DM Diabetic Complications Metabolic Syndrome

31. 10. Diagnostic criteria of Metabolic Syndrome Metabolic Syndrome (Met S) using IDF Criteria. Metabolic Syndrome (Met S) using NCEP ATP III Criteria. when 3 or more of the following criteria were satisfied. Metabolic Syndrome (Met S) using WHO-Definition 1. Central obesity (Male ≥ 90 cm & Female ≥ 80 cm) + ANY OF THE TWO BELOW TG ≥ 150 mg/dL Or specific treatment for this lipid abnormality 3. HDL’s < 40 mg/dL in males < 50 mg/dL in females Or specific treatment for this lipid abnormality. 4. BP Systolic BP ≥ 130 or Diastolic BP ≥ 85 mm Hg Or the treatment of previously diagnosed hypertension. 5. Fasting plasma glucose (FPG) ≥ 100 mg/dL (5.6 mmol/L) Or previously diagnosed type II diabetes. Triglycerides ≥ 150 mg/dL Or specific treatment for this lipid abnormality 2. HDL’s < 40 mg/dL in men, < 50 mg/dl in women 3. BP Systolic BP ≥ 130 or Diastolic BP ≥ 85 mm Hg Or known treatment for hypertension 4. Raised Fasting plasma glucose fasting plasma glucose ≥ 150 mg/dL 5 Central obesity waist circumference > 88 cm women, 102 cm in men IGT/IFG/T2DM+any of the two below 1 . Waist: hip ratio: Male > 0.9 Female > 0.85 2. BMI > 30 kg/m 2 3. HDL cholesterol: Male < 35 mg/dL Female < 39 mg/dL 4. Fasting serum TGL > 150 mg/dL 5. BP > 140/90 mm Hg 6. Microalbuminuria (Urinary albumin excretion ≥ 20 ug/min or Albumin: creatinine ratio ≥ 30 mg/g) Metabolic Syndrome (Met S) using IDF Criteria. Metabolic Syndrome (Met S) using NCEP ATP III Criteria. when 3 or more of the following criteria were satisfied. Metabolic Syndrome (Met S) using WHO-Definition

32. FAQs How is metabolic syndrome treated?

33. FAQs What are the main signs and symptoms of metabolic syndrome?

34. 11. Management Type Methods of Treatment Intervention Obesity and Metabolic Syndrome Lifestyle Modifications Food Intake Physical Activity Smoking and Alcohol Cessation Sleep and circadian rhythm Pharmacological Interventions Drugs for Hyperglycemia Drugs for Hypertension Drugs for Dyslipidemia Drugs for Obesity Obesity and Metabolic Syndrome Bariatric Surgery Sleeve gastrectomy Gastric Banding Gastric Bypass Type Methods of Treatment Intervention Obesity and Metabolic Syndrome Lifestyle Modifications Smoking and Alcohol Cessation Sleep and circadian rhythm Pharmacological Interventions Drugs for Hyperglycemia Drugs for Hypertension Drugs for Dyslipidemia Drugs for Obesity Obesity and Metabolic Syndrome Bariatric Surgery Sleeve gastrectomy Gastric Banding Gastric Bypass

35. Scenario Application

36. 11.1 Diet Weight loss is one of the primary interventions to positively affect all MetS conditions Calorie Intake > Calorie Expenditure: The imbalance between energy intake and expenditure is the key cause of overweight and obesity, which are a part of the metabolic syndrome . The National Institute of Nutrition ( NIN ) under the apex health research body said that healthy diets and physical activity can reduce a substantial proportion of coronary heart disease (CHD) and hypertension (HTN) and prevent up to 80 per cent of type 2 diabetes. For overweight patients , the goal is to decrease weight by 7% to 10%. A low-fat diet commonly is recommended. Help patients select foods low in fat and avoid those high in saturated fats and cholesterol, which can increase cholesterol levels. Emphasize that a low-fat diet can accomplish more than just weight loss; it also can reduce cholesterol levels and blood pressure. Encouraging patients to consume plenty of fiber -rich foods, such as whole grains, beans, fruits, and vegetables, which can help lower insulin levels.

37. Meal Planning – DM/ MetS Food Group Quantity Cereals 6 exchanges/day or 2 exchanges/major meal. Pulses 2-3 exchanges/day Vegetables (Exclusive of root vegetables) 500g/day Fruits (2 hours after a major meal and avoiding fruit juices) 1-2 exchanges/day Milk and milk products Half a liter of low-fat milk/day Non vegetarian foods Approximately 100g/serving (size of fist) preferably fish or skinless chicken as second choice Fats and Oils (preferred oils are those with high monounsaturated fatty acid content) About three teaspoons of oil per day or 500g/month.

38. 2/3 cup plain fat free or low-fat yogurt plain soy milk Plate Method

39. The American College of lifestyle medicine promotes a whole food, plant-based diet to prevent, treat and potentially reverse chronic disease.

40. Swapping High calorie foods with healthier foods by ICMR-NIN dietary guidelines for Indians 2024

41. 11.2 Physical activity

42. Guidelines for physical activity It is recommended to do a minimum of 30-60 minutes of moderate-intensity aerobic physical activity per day for at least five days in a week; or 15 minutes of vigorous-intensity aerobic physical activity per day for at least five days in a week depending on age and health condition; or an equivalent combination of moderate and vigorous-intensity activity. Muscle strengthening exercises, activating all muscle groups should be performed for a minimum of two days in a week.

43. 11.3 Alcohol consumption

44. Smoking Cessation S econd largest consumer of tobacco world-wide. Mortality due to tobacco in India is estimated at upwards of 1.3 million. Out of these, one million are attributed to tobacco smoking and the rest to smokeless tobacco use. Government of India launched the National Tobacco Control Programme (NTCP) in the year 2007-08 m-Cessation: A mobile-based strategy that allows people who want to quit to give a missed call to a toll-free number (011-22901701) to receive text messages for support. National Tobacco Quit Line: A toll-free number (1800-11-2356) that provides counselling services to help people quit tobacco.

45. 11.4 Sleep and circadian rhythm Apart from asking about the duration of sleep, its quality should also be ascertained. (e.g. Do you wake up refreshed?) Below, are the main principles of sleep hygiene: one should have approximately 6 to 8 h of sleep per night (1/3 to 1/4 of a day); with regular bedtime and wake-up times; T he bedroom should be as dark as possible. E xposure to blue light from light-emitting electronic devices (e.g. smartphones, tablets) should be minimised at least 1 h before the planned bedtime; Vigorous physical exercise should be avoided within at least 3 h and meals within at least 4 h before the planned bedtime; A lcohol should be avoided in the evening, to ensure optimum quality of sleep.

46. 12. Pharmacological Interventions

47. 13. Bariatric Surgery 1 2 3

48. 14. National Programme for prevention and control of NCDs (NP-NCD) In order to prevent and control major NCDs, Government of India has implemented the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) in all States across the country with the focus on strengthening of infrastructure, development of human resource, emphasis on health promotion, population-based screening (age 30 years & above) early diagnosis, management and referral. For activities up to district level and below under NPCDCS, States are given financial support under the umbrella of NHM. 

49. 14.1 Population-based Screening Initiative (PBS) Population based prevention and control, screening and management initiative for common NCDs (Diabetes, Hypertension and cancer viz. Oral, Breast and Cervical Cancer) is being implemented as a part of comprehensive primary health care under Health Wellness Centre in National Health Mission (NHM). Under this initiative, persons more than 30 years of age are targeted. Prevention, control & screening services are being provided through trained frontline workers (ASHA, ANM & MPWs), and the referral support and continuity of care is ensured though PHC, CHC, District Hospitals and other tertiary care institutions. PBS can help in better management of diseases by the way of early stage of detection, follow up, treatment adherence. It will also generate awareness on the risk factors of NCDs.

50. 14.2 Objectives of NPCDCS Health promotion through behaviour change with involvement of community, civil society, community based organizations, media etc. Population based screening and Opportunistic screening at all levels in the health care delivery system from sub-centre and above for early detection of diabetes, hypertension and common cancers. Outreach camps are also envisaged. To prevent and control chronic Non-Communicable Diseases , especially common Cancer, Diabetes and Hypertension. To build capacity at various levels of health care for prevention, early diagnosis, treatment, rehabilitation, IEC/BCC and operational research. To support for diagnosis and cost-effective treatment at primary, secondary and tertiary levels of health care. To support for development of database of NCDs through Surveillance System and to monitor NCD morbidity and mortality and risk factors.

51. 14.3 Strategies

52. Ayushman Bharat Health and wellness centers Care at community level Care at the Health and Wellness Centre- Sub Health Centers Care at the Referral Site** Population empanelment, support screening for universal screening for population – age 30 years and above for Hypertension, Diabetes, and three common cancers – Oral, Breast and Cervical Cancer Screening and treatment compliance for Hypertension and Diabetes, with referral if needed Diagnosis, treatment and management of complications of Hypertension and Diabetes Prevention, Screening and Management of Non-Communicable diseases

53. 15. Nursing interventions Metabolic syndrome can be controlled largely through lifestyle changes (the preferred treatment). The major role of Nurse is to help patients make recommended lifestyle changes, teaching them about risk factors and how to alter them. Pointing out that dietary modifications that may help prevent or control diabetes thereby lowering the CVD risk.

54. 15.1 Start with education

55. 15.2 Encourage goal setting

56. 15.3 Provide ongoing support Behavior change is hard, and patients need ongoing support to make lasting changes. Nurses can provide ongoing support by checking in with patients regularly, offering encouragement, and helping patients to troubleshoot any challenges they may encounter. For example, a patient who has quit smoking may experience cravings or withdrawal symptoms. The nurse can provide support by offering tips for managing cravings, providing encouragement, and referring the patient to a support group or smoking cessation program.

57. 15.4 Use motivational interviewing Motivational interviewing is a technique that nurses can use to help patients to identify their own reasons for change. Instead of telling patients what they should do, nurses can ask open-ended questions and listen actively to the patient's responses. For example, a patient who is resistant to exercise may have underlying fears or beliefs that are holding them back. The nurse can use motivational interviewing to help the patient to explore their feelings and identify their own motivations for change.

58. 15.5 Model healthy behaviors Nurses can empower healthy lifestyle change by modeling healthy behaviors themselves. Patients are more likely to take advice from healthcare professionals who practice what they preach. For example, a nurse who eats a healthy diet, exercises regularly, and manages stress effectively can serve as a role model for patients. The nurse can share their own experiences with behavior change and offer practical tips for patients who are struggling to make changes.

59. 15.6 Advocate for policy change Nurses can also empower healthy lifestyle change by advocating for policy change at the local, state, and national levels. By supporting policies that promote healthy behaviors , such as smoke-free laws, safe walking and biking routes, and healthy food options in schools and workplaces, nurses can create environments that support healthy choices. For example, a nurse may advocate for a policy that requires workplaces to provide healthy meal options in the cafeteria or for more parks and green spaces in underserved communities.

60. 16. Summary Metabolic Syndrome Clustering of Metabolic risk factors Increased waist circumference Elevated TG Low HDL-C Elevated BP Insulin Resistance / Elevated FBS Lifestyle Factors Weight gain Sedentary lifestyle Unhealthy diet Elevated stress Behavioral Change Attitude Barriers Commitment Demonstrate Self-Monitoring Efficacy Follow-up Increased CVD Risk Diabetes Mellitus

61. Conclusion It was emphasized that by empowering patients with knowledge in making mindful choices today, we can pave the way for a healthier tomorrow. The collective goal is to combat metabolic syndrome with every step taken towards a balanced lifestyle."

62. References Khanal P, Mandar BK, Patil BM, Hullatti KK. In silico Antidiabetic Screening of Borapetoside C, Cordifolioside A and Magnoflorine .  Indian J Pharm Sci.  2019; 81 :550–55. [ Google Scholar ] Khanal P, Patil BM, Mandar BK, et al. Network pharmacology-based assessment to elucidate the molecular mechanism of anti-diabetic action of Tinospora cordifolia.  Clin Phytosci .  2019; 5 :35. doi : 10.1186/s40816-019-0131-1. [ CrossRef ] [ Google Scholar ] James M, Varghese TP, Vijayan A, Anagha PP, Muhas C, Hyder M. Link between Metabolic Syndrome and Diabetes Mellitus: A Pathophysiological Implication.  Int J Sci Technol Res.  2019; 11 :1935–40. [ Google Scholar ] Rezaianzadeh A, Namayandeh SM, Sadr SM. National Cholesterol Education Program Adult Treatment Panel III Versus International Diabetic Federation Definition of Metabolic Syndrome, Which One is Associated with Diabetes Mellitus and Coronary Artery Disease?  Int J Prev Med.  2012; 3 :552–58. [ PMC free article ] [ PubMed ] [ Google Scholar ] Faizal R, George L, Lakshmanan P, Varghese TP. Assesment of diabetes related quality of life and the impact of pharmaceutical care in its improvement. J Coastal Life Med. 2016: 4; 649 – 51. Nsiah K, Shang O, Boateng KA, Mensah FO. Prevalence of metabolic syndrome in type 2 diabetes mellitus patients.  Int J Appl Basic Med Res.  2015; 5 :133–38. doi : 10.4103/2229-516X.157170. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

63. References…. Alberti KG, Zimmet P, Shaw J. Metabolic syndrome e a new world-wide definition. A consensus statement from the international diabetes federation. Diabet Med. 2006;23:469e480. . Han TS, Lean MEJ. A clinical perspective of obesity, metabolic syndrome and cardiovascular disease. J Royal Soc Med Cardiovas Dis. 2016;5:1e13. National Cholesterol Education Program (NCEP). Expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (adult treatment panel III). 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) final report. Circulation. 2002;106:3143e3421. Mohanan PP. Metabolic syndrome in Indian population: public health implication. Hypertens J. 2016;2:1e6. Saklayen MG. The global epidemic of the metabolic syndrome. Curr Hypertens Rep. 2018 Feb 26;20:12. https:// doi.org /10.1007/s11906-018-0812-z (published online). PMCID: PMC5866840; PMID: 29480368. Eckel RH, Grundy SM, Zimmet PZ. The metabolic syndrome. Lancet. 2005;365:1415e1428

64. References Delvari A, Forouanafar MH, Alikhani S et al. First Nationwide Study of the Prevalence of the Metabolic Syndrome and Optimal Cutoff Points of Waist Circumference in the Middle East. Dongfeng Gu, Reynolds K, Wu Xigui , Chen Jing, Duan Xiufang , Reynolds RF. Prevalence of the metabolic syndrome and overweight among adults in China. Lancet. 2005;365:1398e1405. Basit A, Shera AS. Prevalence of metabolic syndrome in Pakistan. Metab Syndrome Relat Disord . 2008;6:171-175. Deedwania PC, Gupta R. Management issues in the metabolic syndrome. JAPI. 2006;54:797-810. Scott M. Grundy, Metabolic Syndrome: Connecting and Reconciling Cardiovascular and Diabetes Worlds, Journal of the American College of Cardiology, Volume 47, Issue 6,2006, Pages 1093-1100, ISSN 0735-1097, https:// doi.org /10.1016/j.jacc.2005.11.046.(https:// www.sciencedirect.com /science/article/ pii /S0735109705031098) Nick. (2022, April 6). Back to Basics: Type 2 diabetes and the metabolic syndrome - Issues and Answers.  Issues and Answers .  https://www.issuesandanswers.org/type-2-diabetes-and-the-metabolic-syndrome/