Using the New Metabolic Syndrome Severity Z Score During Prediabetes Treatment

A cornerstone of preventative cardiovascular nursing is education and counseling on lifestyle behaviors and change. Have you ever wondered if all that intense focus on lifestyle makes a difference in either the behaviors, risk factors, and progression to either type 2 diabetes (T2DM) or cardiovascular disease (CVD) for your patients with Metabolic Syndrome (METS)? Efforts to prevent diabetes are key given the risk it confers toward CVD. A recently reported analysis of data (1) from the Diabetes Prevention Program supports efforts to reduce the components of METS (waist circumference, glucose, and systolic blood pressure) in order to reduce the risk of T2DM and CVD.

Diabetes Prevention Program

The Diabetes Prevention Program was originally conducted as a randomized controlled trial to test prediabetes treatments, including usual care, metformin, or intensive lifestyle modification. (2)  Around 3,234 persons (mean age 50.6 years) with prediabetes participated between 1996 and 1999. The intensive lifestyle modification component had goals of achieving and maintaining >7% reduction in body weight. It used a strategy of a low calorie, low-fat diet and moderate physical activity such as brisk walking of around 150 minutes per week. After 2.8 years of follow up, the trial was stopped early due to the superior achievement of lifestyle intervention over metformin and usual care in the onset of T2DM.

METS is defined by the Adult Treatment Panel III (ATP-III) as the presence of abnormal values in three of 5 criteria:

  • elevated waist circumference
  • high blood pressure
  • high triglycerides
  • low HDL
  • high fasting glucose 

Applying MetS

DeBoer and colleagues (1) created a METS severity score based on sex and ethnicity, which they labeled MetS-Z , thus augmenting the “present/not present” or dichotomous nature of these criteria, and they validated it in prior studies. (2, 3) The MetS-Z was further applied to the Diabetes Prevention Program data to determine whether reductions in MetS-Z were associated with reduced risk of T2DM and CVD.

For risk of T2DM within 1-5 years, they found the strongest associations with 1-year changes in MetS-Z and waist circumference. For risk of CVD, the greatest relationship was with a 1-year change in MetS-Z, glucose, and systolic blood pressure. Using mediation analysis to determine what factors created by the lifestyle modification were associated with risk, the T2DM effect was mediated by changes in MetS-Z, waist circumference, glucose and triglycerides at 1 year, whereas the effect of metformin was mediated by MetS-Z and glucose. Importantly, the overall change in waist circumference as a marker of visceral obesity was a high-risk predictor within the lifestyle intervention. A reduction in waist circumference was affiliated with reduced risk for both T2DM and CVD.

Helping patients make lifestyle changes that address the MetS severity and specifically reduce elevated glucose and waist circumference could be essential for reducing the risk for future T2DM and CVD.  Reduction of METS components and its overall severity score may be enhanced by emphasizing to at-risk patients not only the presence of abnormal values but also their severity.

Further study may help determine if tracking initial severity and early responses to treatment are beneficial in motivating METS patients to make crucial lifestyle changes to reduce their T2DM and CVD risk. 


  1. DeBoer MD, Filipp SL, Gurka MJ. Use of a metabolic syndrome severity z score to track risk during treatment of prediabetes: an analysis of the diabetes prevention program. Diabetes Care. 2018;41(10):dc181079.
  2. Knowler WC, Barrett-Connor E, Fowler SE,et al.; Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393–403
  3. DeBoer MD, Gurka MJ,Woo JG, Morrison JA. Severity of the metabolic syndrome as a predictor of type 2 diabetes between childhood and adulthood: the Princeton Lipid Research Cohort Study. Diabetologia 2015;58:2745–2752
  4. DeBoer MD, Gurka MJ, Golden SH, et al. Independent associations between metabolic syndrome severity and future coronary heart disease by sex and race. J Am Coll Cardiol 2017; 69:1204–1205

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