In a move that initially seems surprising, the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) released a joint statement questioning the utility of the term "metabolic syndrome," and discouraging doctors from using it.
Metabolic syndrome is a constellation of metabolic disorders related to obesity and the resulting insulin resistance, including the insulin resistance itself, high LDL cholesterol, low HDL cholesterol, high triglycerides, and hypertension. ( Read about metabolic syndrome here.) People with metabolic syndrome can be considered to have a form of "pre-diabetes," and whether or not they eventually develop diabetes itself, the existence of the syndrome produces an extremely high risk of cardiovascular disease. In the last 5 years, doctors - especially family doctors, internists and cardiologists - have begun to pay a lot of attention to the diagnosis and treatment of metabolic syndrome.
The two diabetes associations have now objected to the use of the term metabolic syndrome. They say that this is not a discrete disease in itself, but merely a clustering of cardiovascular risk factors, and have asked doctors to stop "labeling millions of people with a presumed disease that does not stand on firm ground." Doctors, they say, should not try to treat this presumed disease as a whole, but should simply address each one of the risk factors encompassed by metabolic syndrome individually. They especially object to the use of metabolic syndrome as a specific target of therapy in clinical trials, such as those testing rimonabant. How can investigators and drug companies, they ask, target a disease that may not even exist?
The joint statement is very perplexing to the tens of thousands of doctors who have been trying to help their patients cope with metabolic syndrome.
When DrRich was in medical school, he learned that a "disease" was an abnormal medical condition with a single underlying cause. On the other hand, a "syndrome" was a clustering of symptoms or medical conditions that seemed to be related, but which were not clearly tied together by one underlying cause. Metabolic syndrome is just what the name implies - a syndrome. It is a clustering of metabolic abnormalities that appears to be fundamentally related to obesity and insulin resistance - but because no firm underlying cause has been identified, it is merely a syndrome and not a disease.
Admittedly DrRich hasn't been to medical school in many decades, and perhaps definitions have changed. But it seems to him that the ADA and the EASD protest too much. They vociferously object to doctors treating metabolic syndrome as a "presumed disease," when, as near as DrRich can tell, nobody is doing that. It's a syndrome, a constellation of related metabolic abnormalities without an identifiable single underlying cause; and it is a syndrome that has drastic consequences, and that deserves to be brought to patients' attention and treated. The treatment, like the syndrome itself, is multifactorial, and involves weight loss, exercise, and control of lipid abnormalities and hypertension. If, eventually, a single treatment (whether or not it is rimonabant) can be found that treats all aspects of metabolic syndrome, I guess we'll have to apologize to the ADA/EASD, but I for one won't feel too badly about that.
So what is really going on here? As DrRich has pointed out in the past, the priorities of doctors, in today's tough medical environment, can be listed as: 1) maintaining one's viability as a practitioner, 2) protecting one's professional turf, and 3) doing the best we can for patients, in that order. Most reasonable people would object to this priority list, pointing out that Priority 3 should be Priority 1. Point granted. But bear in mind that doctors who do not take care of Priorities1 and 2 will not for long have the opportunity to do Priority 3. In any case, most ostensibly inexplicable behavior on the part of practitioners or their professional societies can be understood by examining these priorities.
DrRich suspects that what the ADA/EASD are doing here is engaging is turf protection. The concept of the metabolic syndrome has non-specialists paying a lot more attention to conditions related to diabetes (specifically, to insulin-resistance and related conditions) than they ever have in the past. Indeed, in recent years, non-diabetes-specialists are engaging numerous active clinical trials aimed at insulin-resistance conditions (i.e., metabolic syndrome.) One suspects that the relatively small ADA, viewing the recent efforts of the American Heart Association and American College of Cardiology in this regard, is beginning to feel like Netscape did in the mid-1990s when Microsoft decided to enter the browser business. This, of course, is pure speculation, but something must explain the otherwise nearly inexplicable effort to quash the metabolic syndrome.