Table 4: Multidisciplinary approach to the MetS.

A: assessmentCalculate Framingham risk score: high risk (10-year risk ≥20%), moderately high risk (10-year risk 10% to 20%), or lower to moderate risk (10-year risk ≤10%).
Make diagnosis of MetS using the diagnostic criteria.

A: aspirin High risk: aspirin definitely beneficial.
High-intermediate risk (10–20%): aspirin likely to be beneficial.
Low-intermediate risk (6–10%): “individual clinical judgment”, depending on sex and risk of bleeding.
Low risk (<6%): Risk of haemorrhage outweighs the benefits.

B: BP control Initiate treatment: categorical hypertension (BP ≥ 140/≥90 mm Hg).
Patients with established diabetes (≥130/≥80 mm Hg).
ACEIs/ARBs first line agent may reduce incident diabetes mellitus.
Beta-blockers and thiazides may have an adverse effect on impaired glucose tolerance but outweighed by the benefits of reaching BP goal and lowering the risk of CVD events.

C: cholesterol
First target: LDL
Second target: non-HDL
Third target: HDL
Fourth target: CRP
Statin to achieve LDL-C <100 mg/dL in high-risk, <130 mg/dL in intermediate-risk, and <160 mg/dL in low risk patients.
Statin intensification, consider niacin and/or fibrates once statin maximized. Consider fibrates, especially for those with combined hypertriglyceridemia/low HDL-C.
Consider further reduction in LDL-C with statin therapy to mitigate a risk of low HDL-C, consider niacin.
Statin therapy for those with high sensitivity CRP (hsCRP) ≥3 mg/dL.

D: diabetes prevention/diet Intensive lifestyle modification is the most important therapy.
Weight reduction of 5–10% of preintervention weight over a period of four to six months.
Sodium intake of <65–100 mmol/day with a goal of 90–120 mmol of potassium per day.
Mediterranean diet: high consumption of fruits, vegetables, legumes, and grains, moderate alcohol intake, a moderate-to-low consumption of dairy products and meats/meat products, and a high monounsaturated- to-saturated fat ratio.
DASH diet: rich in fruits, vegetables, and low-fat dairy products, and low in saturated and total fat intake.
Consider low glycemic index food, complex unrefined carbohydrates, viscous soluble fibres, protein intake of 10–35% of total calorie intake and 25% to 35% of calories as total fat.
Metformin is second line in delaying the onset of T2DM.
Thiazolidinediones (Pioglitazones) and alpha-glucosidase inhibitors (Acarbose) have shown benefit in smaller studies and are therefore third line.

E: exerciseDaily moderate intensity activity of minimum 30 minutes for most days of the week.
Recommend use of pedometer with goal >10,000 steps/day.