A Controversy that Care Managers Should Know About

 PART II

In part one of this series, we introduced the idea of “walking cardiovascular time-bombs” — people who should be identified and treated aggressively to decrease cardiovascular risk. We presented a set of criteria (Adult Treatment Panel III, or ATP III) for a clustering of risk factors known as metabolic syndrome (MetS) and related published statistics and potential effects. Part two addresses the divide in the medical community over how to define the condition and how case managers can best approach patients with MetS.

Persons with MetS are estimated to have twice the risk of developing coronary disease and five times the risk of developing diabetes. Death rates from cardiovascular disease and all other causes also increase, according to a study published in the Journal of the American Medical Association in 2005. These facts represent a call to arms for the nation’s health care providers.

To a practicing clinician and care manager, it’s easy to apply the ATP III MetS criteria. Only a tape measure and established office process are required to make sure every patient’s blood pressure and waist circumference are measured and blood work checked (for blood work, we seek a triumvirate that includes fasting blood glucose, HDL cholesterol, and triglycerides). One can imagine that in a perfect system clinicians and care managers would work together to identify individuals at increased cardiovascular risk and help them decrease those risks. However, when it comes to MetS, the system is far from perfect.

Three Definitions of Metabolic Syndrome

More than three different criteria currently exist for MetS, all sponsored by credible medical organizations. Below are definitions from the ATP III, the World Health Organization (WHO) and the International Diabetes Federation (IDF).

As you can see, there are differences in how each expert group approaches risk identification. ATP III, the most straightforward set of MetS criteria to apply, highlights cardiovascular risk associated with obesity, identifying the root causes to be overweight/obesity, physical inactivity and certain genetic factors. The WHO designates MetS for persons having the potential for diabetes, and therefore an abnormal glucose handling coupled with other criteria (including microalbuminuria, an independent predictor of cardiovascular risk) is required. Meanwhile, the IDF requires central obesity as the foundation of its definition and requires a slightly lower blood glucose level > 100 mg/dl).

Importantly, none of the MetS definitions (including criteria and cut points) are based on the results of prospective clinical trials, but instead are based on expert consensus panel statements. Therefore each group brings their own expertise and bias to the MetS definitions.