Obesity and metabolic syndrome

Last updated: November 30, 2023

Summarytoggle arrow icon

Obesity and metabolic syndrome are two very common and interrelated conditions with immense public health implications. Most individuals with obesity have metabolic comorbidities, although metabolically healthy obesity is possible. Metabolic syndrome refers to a constellation of medical conditions that increase the risk of several health problems, primarily atherosclerotic cardiovascular disease, type 2 diabetes, and hepatic steatosis. These conditions are insulin resistance (considered the main risk factor), hypertension, dyslipidemia, and abdominal obesity. The initial treatment of metabolic syndrome typically focuses on initiating lifestyle changes that promote weight reduction, such as dietary modifications and physical exercise. Weight reduction often results in lowered blood pressure and triglyceride levels, as well as increased insulin sensitivity. Lifestyle modifications are recommended to all patients, but some may also benefit from pharmacological treatment or bariatric surgery. Comorbid conditions, such as persistent hypertension and insulin resistance, should be treated appropriately (e.g., ACE inhibitors, metformin).

Definitiontoggle arrow icon

Metabolic syndrome [1]

  • Definition: a constellation of medical conditions that commonly manifest together and significantly increase the risk for cardiovascular disease and type 2 diabetes mellitus
  • Criteria for metabolic syndrome: ≥ 3 must be present (i.e., the patient is either diagnosed with or receiving treatment for the condition)

Abdominal obesity (i.e., accumulation of fat in visceral tissue) is strongly associated with an atherogenic and hyperglycemic state.

Obesity [3]

The relation between an individual's height and weight is commonly assessed using the Body Mass Index (BMI).

Interpretation of Body Mass Index
Underweight < 18.5 kg/m2
Healthy weight 18.5–24.9 kg/m2
Overweight ≥ 25–29.9 kg/m2 [4]
Class 1 obesity 30–34.9 kg/m2
Class 2 obesity 35–39.9 kg/m2
Class 3 obesity ≥ 40 kg/m2
  • Obesity: an excessive accumulation of fat tissue that results in increased health risks
  • Metabolically healthy obesity (MHO): obesity without metabolic syndrome [5][6]
  • Normal-weight obesity: Individuals with a normal BMI may still have elevated body fat content and therefore be at increased risk for metabolic comorbidities. [3]

Epidemiologytoggle arrow icon

The worldwide prevalence of metabolic syndrome is estimated to be 20–25%. [8][9]

Obese children and adolescents are at a high risk of obesity in adulthood and developing the associated complications.

Epidemiological data refers to the US, unless otherwise specified.

Clinical featurestoggle arrow icon

Diagnosticstoggle arrow icon

Initial screening [14]

  • All adult patients should be regularly screened for obesity by measuring height and weight and calculating BMI.
  • An elevated BMI should prompt a more comprehensive evaluation to identify indications for early interventions. [14]

Comprehensive assessment of a patient with overweight or obesity [15][16]

Perform at baseline and repeat at least once a year to detect comorbidities and associated conditions. Assessment allows for early treatment and evaluation of the patient's response to therapeutic interventions.

All patients who are overweight or obese should be screened for metabolic syndrome.

Clinical evaluation [16]

Laboratory studies [2][17]

Additional screening

Depending on clinical evaluation, screening for associated conditions may be indicated.

Treatmenttoggle arrow icon

Approach [2][15][16]

Lifestyle modifications, the primary treatment for metabolic syndrome and obesity, can lead to weight reduction, increased insulin sensitivity, and reduction of cardiovascular risk factors. [15]

Bariatric surgery is a valid option if sufficient weight loss cannot be achieved through lifestyle modifications with or without pharmacological intervention. [20]

General measures [2][15]

  • Lifestyle modifications: The following recommendations are indicated for all patients.
    • Dietary changes
      • Calorie restriction: 1200–1500 kcal per day in women; 1500–1800 kcal per day in men
      • Diet low in carbohydrates, sodium, cholesterol, saturated fats, and trans fats [2]
      • Consumption of fruit, vegetables, low-fat dairy, fish, and whole grains
    • Physical activity [2]
      • Most patients: at least 30 minutes of moderate aerobic activity 5–7 times per week (e.g., brisk walking)
      • High-risk patients (e.g., history of cardiovascular disease, congestive heart failure): medically supervised exercise programs
  • Additional measures (if applicable)

Pharmacological management of obesity [15][16]

Before starting pharmacological treatment, discuss the side effects and limitations of the drugs with the patient and emphasize the importance of maintaining dietary changes and physical activity. Ensure regular follow-up to assess side effects and success. [16]

Weight loss drugs [15][16]
Class Considerations Agents [16]
Lipase inhibitors
  • Contraindicated in patients with:
Opioid antagonists/norepinephrine-dopamine reuptake inhibitors
GLP-1 agonists

Start therapy with small doses and escalate gradually depending on tolerance. Follow up every 1–3 months to assess side effects and success of the treatment, and modify therapy as necessary. [16]


  • Mechanism of action: Reversibly inhibits gastric and pancreatic lipase, resulting in a decrease in fat breakdown and absorption
  • Indication: weight loss in obese patients
  • Recommendation: should be taken with meals containing fat
  • Adverse effects: gastrointestinal side effects

Complicationstoggle arrow icon

We list the most important complications. The selection is not exhaustive.

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Referencestoggle arrow icon

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