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AHA and ADA Declare Truce in Metabolic Syndrome Squabble


DALLAS ? The American Diabetes Association (ADA) and the American Heart Association (AHA) have decided to paper over their differences on the validity of the metabolic syndrome as a treatable diagnosis.

DALLAS, June 26 ? The American Diabetes Association (ADA) and the American Heart Association (AHA) have decided to paper over their public differences on the validity of the metabolic syndrome as a treatable diagnosis.

To that end, both groups today issued a joint statement declaring that they remain "unified and committed to reducing the burden of diabetes and cardiovascular disease."

The statement, which was being simultaneously published by Diabetes Care and Circulation, Journal of the American Heart Association, said the widespread publicity over the divergent views of the usefulness of metabolic syndrome as a diagnosis was becoming counterproductive to the overriding goals of both groups.

"Unfortunately, some of the medical press have positioned the scientific issues related to the metabolic syndrome as a 'battle' between the American Diabetes Association and the American Heart Association, implicitly suggesting that cardiovascular disease risk factor identification and treatment is now questionable," they wrote. "We are concerned that the presumed dispute will lead to a reduction in the favorable trend of many aspects of cardiovascular disease risk factor reduction."

The joint statement was co-authored by AHA president Robert Eckel, M.D., ADA president Robert A. Rizza, M.D., along with Rose Marie Robertson, M.D., and Richard Kahn, Ph.D., chief science officers of the AHA and the ADA, respectively.

The joint statement emphasized agreement. It backed an emphasis on treating "a core set of risk factors (pre-diabetes, hypertension, dyslipidemia, and obesity)" as well as smoking. The statement sidestepped the genesis of the still-simmering disagreement-a dispute that neither group tried to hide--the definition of metabolic syndrome.

Last year the ADA signed onto a European Association for the Study of Diabetes (EASD) statement published in the August issue of Diabetes Care. It said, "We found that the metabolic syndrome has been imprecisely defined, there is a lack of certainty regarding its pathogenesis, and there is considerable doubt regarding its value as a cardiovascular disease risk marker. Our analysis indicates that too much critically important information is missing to warrant its designation as a 'syndrome.' Until much needed research is completed, clinicians should evaluate and treat all cardiovascular disease risk factors without regard to whether a patient meets the criteria for diagnosis of the 'metabolic syndrome.'"

A month later the AHA, along with the National Heart, Lung, and Blood Institute, issued an updated statement on metabolic syndrome, which it declared a real and growing health problem. The AHA/NHLBI statement included one major change-it identified fasting glucose as a key risk factor and dropped the threshold for elevated fasting glucose from 110 mg/dL to 100 mg/dL or higher, which matched the glucose threshold endorsed by the ADA.

In a series of back and forth comments made at the European Society of Cardiology meeting and the EASD in last September, the two organizations traded soft jabs. Dr. Eckel, who is himself an endocrinologist at the University of Colorado, said the diabetologists raised some valid points about the metabolic syndrome definition. But he added there are "no doubts that the metabolic syndrome exists."

At the same time Dr. Rizza of the Mayo Clinic in Rochester, Minn., said he was not at all disturbed by the difference of opinion. "The real issue is whether the concept of metabolic syndrome adds value to treatment of persons with diabetes." He suggested it did not.

Dr. Kahn said from the ADA standpoint, "there doesn't appear to be any evidence that a metabolic syndrome diagnosis is helpful. To step back and say this (metabolic syndrome) doesn't exist is a train that is hard to stop and reverse, but more and more people are challenging the concept?I think the tide is actually turning on this concept."

Now, however, the AHA and ADA say they are putting their disagreements aside in pursuit of the greater goal-"a reduction in heart disease, stroke and new- onset diabetes."

To that end they suggested that a useful tool for estimating risk of diabetes and cardiovascular disease is http://www.diabetes.org/diabetesphd/default.jsp, a free assessment tool that has been "extensively validated" in a number of studies yet is "rarely used in clinical practice."

A low tech approach, which they say may also be an effective first step, is "simply ascertaining a person's blood glucose level, blood pressure, LDL cholesterol level, and tobacco use and noting the presence of obesity."

In a vague reference to metabolic syndrome, the statement cautioned that even "borderline abnormalities, especially if they are multiple, may well presage future problems and should be addressed."

The AHA/NHLBI defined metabolic syndrome as a group of metabolic risk factors in one person. Those risk factors include abdominal obesity, atherogenic dyslipidemia, elevated blood pressure, insulin resistance, prothrombotic state and proinflammatory state.

Finally, the AHA/ADA statement concluded that despite "many unresolved scientific issues, a number of cardiometabolic risk factors have been clearly shown to closely related to diabetes and cardiovascular disease: fasting/postprandial hyperglycemia, overweight/obesity, elevated systolic and diastolic blood pressure, and dyslipidemia. Although pharmacologic therapy is often indicated when overt disease is detected, in the early stages of these conditions, lifestsyle modification with attention to weight loss and physical activity may well be sufficient."

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