If you combined elements of poor cardiovascular health, diabetes, and obesity, you’d have a condition called “metabolic syndrome.” This is a serious medical condition that doesn't get enough attention. Metabolic syndrome is a precursor to coronary artery disease.

The following 5 criteria are used to diagnose metabolic syndrome. If you have 3 or more of these criteria, then you have metabolic syndrome:

• Obesity: waist circumference greater than 40 inches in men or greater than 35 inches in women
• Elevated Fasting Blood Glucose: 110 mg/dL or greater
• Elevated Triglycerides: 150 mg/dL or greater
• Low HDL-Cholesterol: less than 40 mg/dL in men or less than 50 mg/dL in women
• High Blood Pressure: 130/85 or above

The risk of cardiovascular disease increases as the number of metabolic syndrome findings increase…ie., having 2 of the 5 criteria is worse than having just 1, having 3 is worse than 2, etc. (Malik S, et al. 2004) (Wannamethee SG, et al. 2005).

Here is the calculated increased risk of a heart attack compared to a person with none of the metabolic syndrome criteria (Sattar N, et al. 2003):

Clearly, metabolic syndrome is a very serious condition!

One risk factor missing from this list, I feel, is "resting heart rate greater than 65 beats per minute." In fact, it could be the most important detail to focus on (Emaus A, et al. 2008) (Katzmarzyk PT, et al. 2005). Hang on to that thought for a few more paragraphs....

HISTORY: OTHER NAMES FOR METABOLIC SYNDROME

Gerald Reavens, MD, recognized this constellation of symptoms as a distinct clinical condition in 1988 and named it “Syndrome X” (yes, really), though it was actually described as early as 1923 (Janiszewski PM, et al. 2008).

The first "official" recognition of this health problem appeared in 2001 with the publication of guidelines by the National Cholesterol Education Program Adult Treatment Panel III (ATP-III).

Over the years, this condition was given several different names. It has also been called "Reaven's syndrome", "dysmetabolic syndrome", and "insulin-resistance syndrome" (Mitka M. 2004). Eventually, it came to be known by the term we use today: metabolic syndrome. "Cardiometabolic disease" is another term the medical profession has been using recently.

Use of the word “metabolic” is logical because these people do have something wrong with their metabolism. Blood glucose and blood triglycerides are both elevated. Cholesterol levels also indicate an unhealthy state: the HDL-cholesterol (the “good” cholesterol) is too low and, often, the LDL-cholesterol (often termed the “bad” cholesterol) is too high.

PREVALENCE OF METABOLIC SYNDROME IN THE U.S.

Data from the CDC’s ongoing NHANES surveys show that, in the early 1990’s, 23% of adults in the US qualified as having metabolic syndrome (Ford ES, et al. 2002) (Park Y-W, et al. 2003).

Subsequent NHANES surveys between 2003 and 2012 revealed the prevalence in US adults had climbed to an alarming 34% (Aguilar M, et al. 2015) (Hirode G, et al. 2020).

But don't be misled by a prevalence rate that has held steady during that time frame:

• 34% of adults in 2000: nearly 67 million affected
• 34% of adults in 2010: 75 million affected

Even more worrisome is that 9.8% of US teenagers also have metabolic syndrome! (Lee AM, et al. 2016).

In my opinion, just ONE teenager with metabolic syndrome is too many! If a person develops this condition in their teenage years, it increases their risk for cardiovascular disease as an adult (Morrison JA, et al. 2007).

Currently, a shocking ONE-QUARTER of the US population has metabolic syndrome!

GENETIC DISEASE vs. LIFESTYLE CONDITION?

Is metabolic syndrome caused by genetics?

In a small number of patients, metabolic syndrome does have a genetic basis:

A study of 4 generations of a family with some members displaying the same triad of findings -- elevated blood pressure, elevated cholesterol, and low magnesium levels -- led to the discovery of a common genetic defect (Science October 21, 2004) (Hampton T. 2004).

Nevertheless, in most people with metabolic syndrome, their metabolism is malfunctioning because (a) they are overweight, (b) they don’t get enough exercise, and/or (c) they consume an unhealthy diet.

Being Sedentary Can Lead to Metabolic Syndrome

After only several weeks of being sedentary, your body’s ability to process (metabolize) substrates such as glucose, triglycerides, and cholesterol becomes less efficient. This, then, shows up as elevations in blood glucose, blood triglycerides, and an undesirable cholesterol profile:

• After 21 days: Healthy, young males volunteered to have one arm immobilized in a cast. After 21 days, energy metabolism in the muscles of that arm dropped by 45% even though there was no change in muscle size (Kitahara A, et al. 2003).

• After 14 days: In a separate study, healthy, young males allowed one leg to be immobilized in a cast. After 14 days, protein synthesis in the muscles of that leg had decreased by 31% (Wall BT, et al. 2013).

• After 5 days: When endurance athletes spent 5 days doing no exercise training, their insulin sensitivity worsened to match what is found in untrained (non-exercising) people (Mujika I, et al. 2001).

• After 18 hours: And in one of the most dramatic examples of how quickly metabolism shuts down, Marc Hamilton, PhD, and colleagues demonstrated (in rats) that the activity of an enzyme responsible for lipid metabolism dropped by a whopping 94% after only 18 hours of no use of that leg muscle! (Bey L, et al. 2003).

Thus, it isn't surprising that "hours spent sitting" increases the risk of metabolic syndrome (Ford ES, et al. 2005):

Imagine how much higher the risk must be for someone who sits all day long: accountants, cab drivers, long-haul truck drivers, seamstresses.

And, this can happen independently of gaining weight! (Staiano AE, et al. 2014)

Though, weight gain is still a substantial risk factor for metabolic syndrome. Obviously, exercise is important for that, too.

Because too much sitting and especially poor aerobic fitness are critical factors in the development of metabolic syndrome, it might be more accurate to call it “exercise-deficiency syndrome”. Medical professionals need to start thinking of health problems like these as what they really are: a disruption of normal physiology, not a genetic/biochemical disease.

And we can't overlook dietary factors in patients with metabolic syndrome...

Dietary Causes of Metabolic Syndrome

Data from the Framingham Heart Study revealed that drinking 1 or more soft drinks per day increased the risk of developing the metabolic syndrome by 48% compared to people who drank less than that (Dhingra R, et al. 2007). That's a huge increase in risk from such a small amount of soft drink!

Catherine Shanahan, MD, in her book "Deep Nutrition" (2016), identifies 2 food ingredients as her biggest concerns: sugar (and other refined carbs), and certain types of plant oils. She explains how sugar promotes diabetes and disrupts blood lipids, and how some plant oils create other medical problems.

More specifically, researchers at UC Riverside have recently published 2 studies showing the detrimental metabolic effects of fructose and soybean oil (Deol P, et al. 2015) (Deol P, et al. 2017):

They found that adding fructose to the diets of mice starting at birth led to more weight gain and more type-2 diabetes compared to mice that consumed regular chow. No big surprise there.

However, when mice were fed a diet enhanced with soybean oil (ie., without fructose), weight gain and diabetes were worse. When fructose and soybean oil were added at the same time, both of these problems worsened even more.

Do you consume a lot of processed and ultra-processed foods? If so, start looking closely at the Ingredients list on the labels of these food products. Chances are, you'll see sugar or one of its other names, and soybean oil listed.

TREATING METABOLIC SYNDROME WITH DRUGS

Because metabolic syndrome is a constellation of medical problems, these patients may require 3 or 4 or even 5 drugs: one or several drugs to lower blood pressure, a drug to lower blood glucose, and another drug to lower triglycerides. And, who knows?...their physician might just give them a drug for weight-loss, too! And if they have a low HDL-cholesterol, then the odds are that their LDL-cholesterol is elevated. So, they’ll probably get a statin for that. (The way things are heading, half of our population is going to be on a statin in the near future!)

Thus, treating metabolic syndrome with drugs is costly, poses the risk of drug interactions and side effects, and, most importantly, it overlooks the importance of diet and exercise.

Only using drugs to manage metabolic syndrome doesn’t make much sense. Imagine treating the symptoms of iron-deficiency anemia without first replenishing iron stores:

People who are anemic have low energy. Would it make any sense to try and fix this by giving them a CNS-stimulant, or, telling them to consume more caffeine? Of course not. Their energy levels will automatically improve when their iron balance is restored because fixing that will, in turn, improve oxygen delivery to every cell in the body.

WHY EXERCISE IS A BETTER STRATEGY THAN DRUG THERAPY

If a person with metabolic syndrome is overweight, then losing weight should be a goal. But, research shows that improving aerobic fitness reduces the risks of metabolic syndrome even in people who are obese (Katzmarzyk PT, et al. 2005).

In general, when people perform aerobic exercise regularly:

• Blood pressure may normalize. Aerobic exercise can be effective for lowering blood pressure.

• Elevated blood glucose and blood triglycerides normalize. You don’t have to be an exercise physiologist to understand that exercise increases the body’s demand for energy substrates such as carbohydrates (glucose) and fats (triglycerides). Exercise improves the actions of insulin. This stimulates cells to absorb glucose from the bloodstream. Triglycerides are also utilized more readily. In general, exercise is very effective for lowering an elevated triglyceride level. Thus, exercise addresses 2 more of the abnormal findings in metabolic syndrome.

• Cholesterol metabolism improves. There is a constant dynamic process occurring between cholesterol storage and cholesterol retrieval in the body. Think of LDL and HDL as transportation vehicles for cholesterol: The LDL “particle” shuttles cholesterol from the liver to other areas of the body where it is stored for later needs. The HDL “particle” brings cholesterol back to the liver where it is used to make estrogen, testosterone, and vitamin D.

In people who don’t exercise, the retrieval side of the cholesterol cycle is not very active. So, the storage phase dominates. In this scenario, circulating levels of HDL are low because the body is not “calling out” for HDL to bring cholesterol back to the liver.

However, when a person performs aerobic exercise regularly, the retrieval phase is stimulated. People who maintain a high degree of aerobic fitness demonstrate high circulating levels of HDL-cholesterol. HDL-cholesterol levels increase in direct proportion to how many miles people run per week. High levels of HDL-cholesterol simply reflect that the retrieval side of the cholesterol cycle has been revved-up. This is how aerobic exercise corrects an abnormally low HDL.

• Weight loss may occur. And, of course, aerobic exercise is always important in weight loss. Losing weight also helps to lower blood pressure and improve fasting blood glucose.

In fact, aerobic exercise improves all 5 of the findings in metabolic syndrome. And if "poor aerobic fitness" (ie., resting heart rate above 65 beats per minute) was part of the diagnostic criteria of metabolic syndrome, it would address that, too:

(*n/e = not effective)

So, aerobic exercise is the perfect prescription for people with metabolic syndrome!

Bottom line? While exercise can improve all aspects of the metabolic syndrome, it might not reverse all of them completely. However, that doesn’t mean that you shouldn’t try.

EXERCISE FOR METABOLIC SYNDROME: WHAT TYPE AND HOW MUCH?

OK, exercise is beneficial for people with metabolic syndrome. But, what type of exercise? And, how much?

Reverse Metabolic Syndrome with Aerobic Exercise

Aerobic types of exercise are definitely effective:

Brisk Walking:

A review of research on this (Janiszewski PM, et al. 2008) shows that moderate-intensity aerobic exercise (example: brisk walking) for 30 minutes per day 5 days per week can:

• lower blood pressure by 3-4 points
• lower fasting blood glucose by 15%
• lower blood triglycerides by 12%
• increase HDL-cholesterol by 4%
• decrease waist circumference by 6%

How many drugs would be needed to match those results?!!

Reverse Metabolic Syndrome with Cycling:

The HERITAGE Family Study revealed that riding a stationary bicycle at a fairly high intensity for 50 minutes a day, 3 days per week, produced improvements in all parameters of the metabolic syndrome except for low HDL-cholesterol levels. At the end of this 20-week study, 32 of the 105 subjects were no longer classified as having metabolic syndrome (Katzmarzyk PT, et al. 2003).

Now, for many people, riding a bike at a high intensity for nearly an hour straight several times per week doesn't sound very appealing, especially if you are overweight and out-of-shape. It turns out that doing high-intensity aerobic exercise in short bursts might be even more effective:

Reverse Metabolic Syndrome with High-Intensity Interval Exercise (HIIT):

Researchers in Norway compared a "traditional" exercise regimen of sustained moderate-intensity (aerobic) exercise to a regimen of short bursts of high-intensity (aerobic) exercise in 32 patients with metabolic syndrome (Tjonna AE, et al. 2008).

Both groups exercised on a treadmill 3 times a week for 16 weeks:

• the continuous group exercised for 47 minutes per session at 70% of their maximum HR

• the interval group warmed up for 10 minutes, then performed 4 high-intensity intervals at 90% of maximum HR. Each interval lasted for 4 minutes. Between each interval, they reduced their exercise intensity to 70% for 3 minutes. After the 4th interval, a 5-min cool down period was done. This adds up to a total of 40 minutes on the treadmill.

Subjects who performed moderate-intensity continuous exercise lost more weight. However, more subjects in the high-intensity interval exercise group were able to reverse their metabolic syndrome. Why?

Note the much greater improvement in aerobic capacity (VO2max) in the interval exercise group. This suggests that improving aerobic capacity is more important than losing weight for reversing metabolic syndrome.

Reverse Metabolic Syndrome with Resistance Exercise

Resistance exercise (eg., weight lifting) is also beneficial for metabolic syndrome, but the results are less predictable than for aerobic exercise:

A study conducted at Duke University evaluated 234 subjects with metabolic syndrome. They were separated into 3 groups:

• one group performed aerobic exercise (walking/jogging 12 miles per week)
• one group performed resistance exercise (8 different exercises using Cybex machines)
• the 3rd group performed both aerobic and resistance exercise

All of the exercise programs lasted 8 months.

At the end of the study, it was apparent that the aerobic exercise program was much more effective than working out on Cybex machines. Curiously, the combination program was only slightly better than aerobic exercise by itself. The researchers concluded that the extra time required to perform both aerobic and resistance exercise wasn’t really worth the small additional benefits compared to performing aerobic exercise alone (Bateman LA, et al. 2011).

Aerobic exercise appears to be more beneficial than resistance exercise for metabolic syndrome. A regular walking program can be helpful and higher intensity exercise is even better. If you can find a knowledgeable certified personal trainer to develop a specific plan for you, that would be superb. But, if not, I offer some tips below.

PREVENTING METABOLIC SYNDROME BY STAYING FIT

What if you don’t currently have metabolic syndrome? If you maintain your fitness, will this reduce your chances of developing it?

Yes! Both aerobic exercise and strength exercise have been shown to reduce the chances of developing metabolic syndrome:

Prevent Metabolic Syndrome with Aerobic Exercise

Researcher Paul T. Williams, PhD, has published several reports based on a survey of over 100,000 runners in the National Runners' Health Study. These data revealed that, separately, walking and running each reduced the incidence of diabetes, hypertension, and cholesterol problems, and, as a result, these people required medication for these health problems much less often:

• Walking: Those who walked faster and longer had a lower incidence of these health problems compared to those who walked slower or walked shorter distances (Williams PT. 2008a).

• Running: A similar trend was discovered: both longer total distance run per week and a higher degree of aerobic fitness correlated with a lower incidence of these 3 health problems (Williams PT. 2008b).

Whether you choose walking, jogging, swimming, riding a bike, playing basketball or tennis, maintaining your aerobic fitness level is key:

• A study of 1069 middle-aged men in Finland (participants in the Kuopio Ischemic Heart Disease Study) revealed that men with poor aerobic fitness (VO2max less than 29 ml/kg/min) had nearly 7 times the risk of developing metabolic syndrome compared to men with acceptable aerobic fitness (VO2max above 35 ml/kg/min) (Lakka TA, et al. 2003).

• A much larger analysis from the ongoing Aerobics Center Longitudinal Study (ACLS) at the Cooper Clinic in Dallas evaluated roughly 9000 men and nearly 1500 women. Their fitness level was noted and they were followed for 5 years. It was found that people who maintained a high degree of aerobic fitness were the least likely to develop metabolic syndrome. This trend was especially evident in men though it was apparent in women as well. The protective effect of aerobic fitness remained significant even after adjusting for potentially contributing factors (LaMonte MJ, et al. 2005).

Prevent Metabolic Syndrome with Resistance Exercise

A separate report from the ACLS at the Cooper Clinic showed that the risk of developing metabolic syndrome could also be reduced by maintaining muscle strength:

Between 1980 and 2003, 3233 men, aged 20 to 80 years, who were initially free of metabolic syndrome had 2 or more clinical examinations, including baseline muscular strength and cardiorespiratory fitness assessment. Mean duration of follow-up was 6.7 years.

Statistical analysis revealed that the risk of developing metabolic syndrome was incrementally reduced by each successive category of muscular strength...ie., as strength improved, the likelihood of developing metabolic syndrome went down.

Researchers found that maintaining muscular strength was effective for reducing the development of metabolic syndrome whether the man was overweight or obese, or, normal weight (Jurca R, et al. 2005).

"Muscular strength was inversely associated with metabolic syndrome incidence, independent of age and body size," the authors write. "Potential benefits of greater muscular strength presumably through resistance exercise training should be considered in primary prevention of metabolic syndrome."

DOES REGULAR EXERCISE PREVENT DEATHS DUE TO METABOLIC SYNDROME?

So far, I’ve explained that:

• being sedentary increases your chances of developing metabolic syndrome
• several types of exercise can reverse metabolic syndrome
• exercising regularly can prevent metabolic syndrome from ever occurring

But, does regular exercise actually reduce the rate of death from metabolic syndrome?

Yes! Another report from the Cooper Clinic's Aerobics Center Longitudinal Study showed that men with the metabolic syndrome who have poor aerobic fitness have 3.5-times the risk of dying from cardiovascular disease compared to men with metabolic syndrome who have good aerobic fitness (Katzmarzyk PT, et al. 2004). This illustrates how protective aerobic fitness is!

“STEPS” YOU SHOULD TAKE

If you have metabolic syndrome, you are in a very unhealthy state! Fortunately, metabolic syndrome is yet another serious health problem that can be reversed and prevented with a regular exercise program. Even brisk walking can be helpful. Here are some tips:

• See your physician: First, if you currently have metabolic syndrome (or any of the health problems that it represents), check with your personal physician before beginning a new exercise program.

• Get some running shoes: After you receive the go-ahead from your physician, buy a good pair of running shoes. Even if all you do is walk, you’ll appreciate good running shoes. Shoes designed for walking are also available. But, while you can walk in running shoes, you probably don’t want to run in walking shoes. In other words, you have both options covered with running shoes!

• Use a heart rate monitor: Consider buying a heart rate monitor, a pedometer, or an activity tracker. The heart rate monitor will help you gauge the intensity of your exercise sessions. The pedometer or activity tracker will tell you how much activity you get each day.

• Walk...fast!: Aerobic exercise is more effective than resistance exercise for metabolic syndrome so start with that. Go for a brisk walk 5 days per week. Brisk walking is described as “walking with a purpose.” Swing your arms. Get your heart rate up. Try to walk for 30 minutes. When you can, throw in a short (30-60-second) jog.

• Monitor your aerobic fitness: As your aerobic fitness improves, your resting heart rate will be slower. Once or twice per month, assess your resting heart rate. This is best done when you first wake up, even before you sit up in bed. As your aerobic fitness improves, your resting heart rate will decrease. If your resting heart rate is 65 beats per minute or lower, and you aren’t lightheaded when you stand up, you can feel fairly confident that your cardiovascular health is pretty good.

• Diet: Eliminate soda pop. Be aware of processed foods that contain added sugar and high-fructose corn syrup and try to minimize those, too. Also reduce your consumption of other refined carbohydrates. Consider following a Mediterranean diet pattern or a plant-based diet like Dr. Joel Fuhrman's "Nutritarian" diet.

Do this for the rest of your life!

QUESTIONS

Q: To reverse metabolic syndrome, is it more important to lose weight or improve aerobic fitness?

ANSWER: Both are important. If you are obese, losing weight will help. But, increasing your aerobic fitness will also improve your cardiometabolic parameters, even if you don't get your body weight back down into a desirable range (Lee S, et al. 2005).

SUMMARY

Metabolic syndrome is a potentially serious health condition. Many people have no symptoms. Regular exercise and improvements in diet can be very effective. Metabolic syndrome should be thought of as "exercise-deficiency syndrome."

FOR MORE INFORMATION

Readers may also be interested in these reviews:

• Exercise for Coronary Artery Disease
• Exercise for Diabetes Mellitus
• Exercise for Hypertension
• Health and Fitness Targets
• Nutrition Basics: Fructose, Public Enemy #1?
• Walking

EXPERT HEALTH and FITNESS COACHING

Stan Reents, PharmD, is available to speak on this and a variety of exercise-related topics. (Here is a downloadable recording of one of his Health Talks.) He also provides a one-on-one Health Coaching Service. Contact him through the Contact Us page.

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ABOUT THE AUTHOR

Stan Reents, PharmD, is a former healthcare professional. He has been a member of the American College of Lifestyle Medicine (ACLM) and a member of the American College of Sports Medicine (ACSM). In the past, he has been certified as a Health Fitness Specialist by ACSM, as a Certified Health Coach by ACE, as a Personal Trainer by ACE, and as a tennis coach by USTA. He is the author of Sport and Exercise Pharmacology (published by Human Kinetics) and has written for Runner's World magazine, Senior Softball USA, Training and Conditioning and other fitness publications.