G Model
DSX-181; No. of Pages 2 Diabetes & Metabolic Syndrome: Clinical Research & Reviews xxx (2010) xxx–xxx
Contents lists available at ScienceDirect
Diabetes & Metabolic Syndrome: Clinical Research & Reviews journal homepage: www.elsevier.com/locate/dsx
Editorial
Is it ‘‘science’’. . . or is it ‘‘turf’’ guarding?
The world is facing a pandemics of type 2 diabetes (T2DM) and atherosclerotic cardiovascular diseases (ASCVD) which are increasing in tsunamic proportions. The major brunt of the T2DM pandemic will be felt in the poor and developing countries which will see an increase of 170%, whilst the developed world would see an increase of around 30% in the prevalence rates [1–4]. When one considers the socio-economic as well as the health costs associated with T2DM, ASCVD and their attendant morbidities and mortalities, it would be obvious to everyone that the aim of all involved with health care, especially of non communicable diseases, should be to take immediate steps to try and stem this looming disaster. The presence of the metabolic syndrome confers a two-fold increase in the risk for major CVD events and a five-fold increase in the lifetime risk for T2DM [5,6]. Though the precise increase in the risk may vary depending on the population being studied, from a clinical viewpoint the presence of the metabolic syndrome identifies a person at higher lifetime risk for major CVD events and/or T2DM, even if the short-term risk for these events may be mild to moderate. It also allows a simple and cost effective manner of showing how one must look at the looming problem and take an overall management rather than a narrow single risk approach [7]. The metabolic syndrome, like most new concepts, has had its opponents who raised many questions about the very concept of the metabolic syndrome and moreover have questioned the very need for a concept such as the metabolic syndrome [8–19]. At the same time, it also has had its proponents, some of who have played a leading role in its defense and have repeatedly responded to the doubts raised by those who have been traditionally opposed to the very concept of, and need for, the metabolic syndrome [3–7,20–24]. Questions have been raised whether the opposition to the metabolic syndrome is based entirely in scientific grounds, or is it also a matter to ‘‘turf’’ guarding. The increasing involvement and interest in the metabolic syndrome by many specialist groups in diabetes, hypertension, lipids, obesity and cardiology worldwide, has caused the removal of the metabolic syndrome from the diabetes monopoly ‘‘turf’’ [5]. From being the trunk of the ‘‘metabolic’’ tree, it is fast becoming one of the branches! In which case, should one be surprised by the publication of the recent report of a WHO Expert Consultation group [25] which basically reiterates the old arguments, though in a more nuanced manner, which had been used by those opposing the concept of the metabolic syndrome from its initial stages. The report points out that, despite an exponential increase in the number of research papers on the subject, no single unifying pathophysiological mechanism has been agreed, and the equivalence of the risk factors and their cut-off points across different populations has not been
established. The criteria used to diagnose the metabolic syndrome have major limitations including: the dichotomisation of risk factors; the attribution of relative as opposed to absolute risk; the differing predictive value of risk-factor combinations; the inclusion of individuals with established diabetes and heart disease; and the omission of important risk factors for predicting diabetes and CVD. A formal diagnosis of the metabolic syndrome is rarely made in routine clinical practice, and the concept has not been widely adopted in national guidelines for the prediction of CVD or diabetes. The end recommendation was that whilst, it may be considered useful as an educational concept, it should be considered a pre-morbid condition with limited practical utility as a diagnostic or management tool. Seeing that most of the arguments put forward by the group had already been raised and answered, in the past, what was the new evidence that has brought about this change in thinking? Previously Zimmet and Alberti [20], opposing the ADA/EASD viewpoint [8,9] had written that ‘‘The ADA/EASD attempt to disregard the metabolic syndrome will only confuse health professionals at all levels. The utility of the syndrome as a public health initiative has been put at risk by a statement that has come ‘‘out of the blue’’ and does not reflect the past intellectual and constructive contributions of some of its individual authors! Debate is always welcomed, but misconstrued criticism can only harm the initiatives of others in the CVD, diabetes, and other related fields who were making progress in raising awareness of patients toward riskfactor clustering. The ADA/EASD stance may also hinder research and fund-raising, baffle the public, and weaken its confidence in clinical scientists as well as delay treatment advances. This reflects a total lack of foresight and vision.’’ In view of the looming pandemics of T2DM and ASCVD, the major brunt of which would be faced by the poor and developing countries, least able to withstand the ‘‘tsunami’’, can the same not be said of the WHO Expert Consultation report? [25] Long ago in history, Nero could fiddle whilst Rome burnt. . . but in today’s day and world, can the W.H.O., given its global remit, afford to take such a laissez-faire attitude? Normally, one would like to keep the discussions and debates in a scientific milieu and not make it personal. But in a response to the doubts raised by the ADA/EASD [8,9] statement, Zimmet and Alberti, [20] said, ‘‘some investigators in the diabetes field, after embracing the concept wholeheartedly for about 15 years, are having ‘‘second thoughts’’ about the metabolic syndrome, not unreasonable in a rapidly changing field, providing that there are cogent arguments to do so.’’ Several of the authors of the statement have been vigorous proponents of the metabolic syndrome. Specifically, they go on to question the opposition by one of the authors in the joint ADA/EASD paper, pointing out that
1871-4021/$ – see front matter ß 2010 Diabetes India. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.dsx.2010.05.020
Please cite this article in press as: Sadikot SM. Is it ‘‘science’’. . . or is it ‘‘turf’’ guarding?. Diab Met Syndr: Clin Res Rev (2010), doi:10.1016/j.dsx.2010.05.020
G Model
DSX-181; No. of Pages 2 2
Editorial / Diabetes & Metabolic Syndrome: Clinical Research & Reviews xxx (2010) xxx–xxx
just a couple of years back Professor Ferrannini had been quoted as saying at the Endocrine Society’s 85th Annual Meeting: ‘‘Glycemic abnormality predicts hypertension and increased blood pressure predicts glycemic abnormality, with hyperinsulinemia an important additional predictive factor, Ferrannini noted, further suggesting the usefulness of the concept of metabolic syndrome. The metabolic syndrome exists, and he asserted, ‘It predicts itself so it’s not just an innocent cluster.’ They ask. . . So what has led to the change in his (Ferrannini) thinking? Moreover, they also raised the possibility [20], albeit indirectly, of the ADA and the EASD guarding their turf by quoting Fogoros, ‘‘Perhaps the last words should be with Richard N. Fogoros, MD, writing as ‘‘Dr Rich’’ on a Web site: Dr Rich suspects that what the ADA/EASD are doing here is engaging in turf protection. The concept of the metabolic syndrome has non-specialists paying a lot more attention to conditions related to diabetes (specifically, to insulinresistance and related conditions) than they ever have in the past. Indeed, in recent years, non-diabetes-specialists are engaging numerous active clinical trials aimed at insulin-resistance conditions (i.e., metabolic syndrome.) One suspects that the relatively small ADA, viewing the recent efforts of the American Heart Association and American College of Cardiology in this regard, is beginning to feel like Netscape did in the mid-1990s when Microsoft decided to enter the browser business. This, of course, is pure speculation, but something must explain the otherwise nearly inexplicable effort to quash the metabolic syndrome.’’ [26] Some of the views put forth by Fogoros may be coming true as one keeps hearing of changes in University Hospital environments, especially in the developed world, where diabetes units are slowly being made an integral part of cardiology departments, although one must admit that one does not have specific figures for this. What is of interest is that a closer look at the members constituting the WHO Expert Consultation group shows the vast majority of them to be experts in the ‘‘diabetes’’ field! Further more, a key member of this WHO Expert Consultation group [25] is someone who up to the very recent times was a leading proponent of the metabolic syndrome concept and the key player in its harmonization [4,20,21,27,28]. The same question asked about Ferrannini can be put to many of the members of the WHO Expert Consultation group. Is it ‘‘science’’. . . or is it ‘‘turf’’ guarding? Take your pick! Financial disclosures None. Conflict of interest None. References [1] King H, Aubert RE, Herman WH. Global burden of diabetes, 1995—2025: prevalence, numerical estimates, and projections. Diabetes Care 1998;21:1414–31. [2] Reddy KS, Yusuf S. Emerging epidemic of cardiovascular disease in developing countries. Circulation 1998;97:596–601.
[3] International Diabetes Federation. Rationale for new IDF worldwide definition of metabolic Syndrome, Available at http://www.idf.org/webdata/docs/Meta bolic_syndrome_rationale.pdf/;2009 [accessed May 1, 2010]. [4] Zimmet P, Alberti G, Shaw J. Global and societal implications of the diabetes epidemic. Nature 2001;414:782–7. [5] Eckel R, Grundy S, Zimmet P. The metabolic syndrome. Lancet 2005;365: 1415–28. [6] Grundy SM. Metabolic syndrome: connecting and reconciling cardiovascular and diabetes worlds. J Am Coll Cardiol 2006;47:1093–100. [7] Grundy S. Does a diagnosis of metabolic syndrome have value in clinical practice? Am J Clin Nutr 2006;83:1248–51. [8] Kahn R, Buse J, Ferrannini E, Stern M. The metabolic syndrome: time for a critical appraisal: joint statement from the American Diabetes Association and the European Association for the Study of Diabetes. Diabetologia 2005;48: 1684–99. [9] Kahn R, Buse J, Ferrannini E, Stern M. The metabolic syndrome: time for a critical appraisal: joint statement from the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 2005;28: 2289–304. [10] Kahn R. The metabolic syndrome (emperor) wears no clothes. Diabetes Care 2006;29:1693–6. [11] Gale E. The myth of the metabolic syndrome. Diabetologia 2005;48:1679–83. [12] Vinicor F, Bowman B. The metabolic syndrome: the emperor needs some consistent clothes: response to Davidson and Alexander. Diabetes Care 2004;27:1243. [13] Greenland P. Critical questions about the metabolic syndrome. Circulation 2005;112:3675–6. [14] Meigs J. The metabolic syndrome: may be a guidepost or detour to preventing type 2 diabetes and cardiovascular disease. BMJ 2003;327:61–2. [15] Reaven G. Insulin resistance, cardiovascular disease, and the metabolic syndrome: how well do the emperor’s clothes fit? Diabetes Care 2004;27:1011–2. [16] Reaven G. The metabolic syndrome: requiescat in pace. Clin Chem 2005;51: 931–8. [17] Reaven G. Counterpoint: just being alive is not good enough. Clin Chem 2005;51:1354–7. [18] Reaven G. The metabolic syndrome: is this diagnosis necessary? Am J Clin Nutr 2006;83:1237–47. [19] Reaven G. The metabolic syndrome or the insulin resistance syndrome? Different names, different concepts, and different goals. Endocrinol Metab Clin North Am 2004;33:283–303. [20] Zimmet P, Alberti G. The metabolic syndrome: perhaps an etiologic mystery but far from a myth—where does the International Diabetes Federation stand? Medscape Diabetes Endocrinol 2005; 7(2). Available at http://www.med scape.-com/viewarticle/514211 [accessed April 1, 2010]. [21] Zimmet P, Alberti G, Shaw J. Mainstreaming the metabolic syndrome: a definitive definition. This new definition should assist both researchers and clinicians. Med J Aust 2005;183:175–6. [22] Grundy S. Does the metabolic syndrome exist? Diabetes Care 2006;29:1689– 92. [23] Grundy S. Point: the metabolic syndrome still lives. Clin Chem 2005;51:1352– 4. [24] Grundy S, Haffner S, Kunos G, Jensen M. Managing Cardiometabolic risk: will new approaches improve success? Available at http://www.medscape.com/ viewprogram/5700_pnt [last accessed April 1, 2010]. [25] Simmons R, Alberti G, Gale E, Colagiuri S, Tuomilehto J, Qiao Q, et al. The metabolic syndrome: useful concept or clinical tool? Report of a WHO Expert Consultation. Diabetologia 2010;53:600–5. [26] Fogoros RN. Does metabolic syndrome exist? Available at: http://heartdisease.about.com/od/diabetesmetabolicsynd/a/metsynyn.htm [accessed April 4, 2010]. [27] International Diabetes Federation. The IDF consensus worldwide definition of the metabolic syndrome, Available at http://www.idf.org/webdata/docs/IDF_ Metasyndrome_definition.pdf [last accessed April 1, 2010]. [28] Alberti K, Eckel R, Grundy S, Zimmet P, Cleeman J, Donato K, et al. Harmonizing the metabolic syndrome. A joint interim statement of the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity. Circulation 2009;120:1640–5.
S.M. Sadikot 50, Manoel Gonsalves Rd. Bandra (W), Mumbai 400050, India E-mail address: [email protected]
Please cite this article in press as: Sadikot SM. Is it ‘‘science’’. . . or is it ‘‘turf’’ guarding?. Diab Met Syndr: Clin Res Rev (2010), doi:10.1016/j.dsx.2010.05.020
DSX-181; No. of Pages 2 Diabetes & Metabolic Syndrome: Clinical Research & Reviews xxx (2010) xxx–xxx
Contents lists available at ScienceDirect
Diabetes & Metabolic Syndrome: Clinical Research & Reviews journal homepage: www.elsevier.com/locate/dsx
Editorial
Is it ‘‘science’’. . . or is it ‘‘turf’’ guarding?
The world is facing a pandemics of type 2 diabetes (T2DM) and atherosclerotic cardiovascular diseases (ASCVD) which are increasing in tsunamic proportions. The major brunt of the T2DM pandemic will be felt in the poor and developing countries which will see an increase of 170%, whilst the developed world would see an increase of around 30% in the prevalence rates [1–4]. When one considers the socio-economic as well as the health costs associated with T2DM, ASCVD and their attendant morbidities and mortalities, it would be obvious to everyone that the aim of all involved with health care, especially of non communicable diseases, should be to take immediate steps to try and stem this looming disaster. The presence of the metabolic syndrome confers a two-fold increase in the risk for major CVD events and a five-fold increase in the lifetime risk for T2DM [5,6]. Though the precise increase in the risk may vary depending on the population being studied, from a clinical viewpoint the presence of the metabolic syndrome identifies a person at higher lifetime risk for major CVD events and/or T2DM, even if the short-term risk for these events may be mild to moderate. It also allows a simple and cost effective manner of showing how one must look at the looming problem and take an overall management rather than a narrow single risk approach [7]. The metabolic syndrome, like most new concepts, has had its opponents who raised many questions about the very concept of the metabolic syndrome and moreover have questioned the very need for a concept such as the metabolic syndrome [8–19]. At the same time, it also has had its proponents, some of who have played a leading role in its defense and have repeatedly responded to the doubts raised by those who have been traditionally opposed to the very concept of, and need for, the metabolic syndrome [3–7,20–24]. Questions have been raised whether the opposition to the metabolic syndrome is based entirely in scientific grounds, or is it also a matter to ‘‘turf’’ guarding. The increasing involvement and interest in the metabolic syndrome by many specialist groups in diabetes, hypertension, lipids, obesity and cardiology worldwide, has caused the removal of the metabolic syndrome from the diabetes monopoly ‘‘turf’’ [5]. From being the trunk of the ‘‘metabolic’’ tree, it is fast becoming one of the branches! In which case, should one be surprised by the publication of the recent report of a WHO Expert Consultation group [25] which basically reiterates the old arguments, though in a more nuanced manner, which had been used by those opposing the concept of the metabolic syndrome from its initial stages. The report points out that, despite an exponential increase in the number of research papers on the subject, no single unifying pathophysiological mechanism has been agreed, and the equivalence of the risk factors and their cut-off points across different populations has not been
established. The criteria used to diagnose the metabolic syndrome have major limitations including: the dichotomisation of risk factors; the attribution of relative as opposed to absolute risk; the differing predictive value of risk-factor combinations; the inclusion of individuals with established diabetes and heart disease; and the omission of important risk factors for predicting diabetes and CVD. A formal diagnosis of the metabolic syndrome is rarely made in routine clinical practice, and the concept has not been widely adopted in national guidelines for the prediction of CVD or diabetes. The end recommendation was that whilst, it may be considered useful as an educational concept, it should be considered a pre-morbid condition with limited practical utility as a diagnostic or management tool. Seeing that most of the arguments put forward by the group had already been raised and answered, in the past, what was the new evidence that has brought about this change in thinking? Previously Zimmet and Alberti [20], opposing the ADA/EASD viewpoint [8,9] had written that ‘‘The ADA/EASD attempt to disregard the metabolic syndrome will only confuse health professionals at all levels. The utility of the syndrome as a public health initiative has been put at risk by a statement that has come ‘‘out of the blue’’ and does not reflect the past intellectual and constructive contributions of some of its individual authors! Debate is always welcomed, but misconstrued criticism can only harm the initiatives of others in the CVD, diabetes, and other related fields who were making progress in raising awareness of patients toward riskfactor clustering. The ADA/EASD stance may also hinder research and fund-raising, baffle the public, and weaken its confidence in clinical scientists as well as delay treatment advances. This reflects a total lack of foresight and vision.’’ In view of the looming pandemics of T2DM and ASCVD, the major brunt of which would be faced by the poor and developing countries, least able to withstand the ‘‘tsunami’’, can the same not be said of the WHO Expert Consultation report? [25] Long ago in history, Nero could fiddle whilst Rome burnt. . . but in today’s day and world, can the W.H.O., given its global remit, afford to take such a laissez-faire attitude? Normally, one would like to keep the discussions and debates in a scientific milieu and not make it personal. But in a response to the doubts raised by the ADA/EASD [8,9] statement, Zimmet and Alberti, [20] said, ‘‘some investigators in the diabetes field, after embracing the concept wholeheartedly for about 15 years, are having ‘‘second thoughts’’ about the metabolic syndrome, not unreasonable in a rapidly changing field, providing that there are cogent arguments to do so.’’ Several of the authors of the statement have been vigorous proponents of the metabolic syndrome. Specifically, they go on to question the opposition by one of the authors in the joint ADA/EASD paper, pointing out that
1871-4021/$ – see front matter ß 2010 Diabetes India. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.dsx.2010.05.020
Please cite this article in press as: Sadikot SM. Is it ‘‘science’’. . . or is it ‘‘turf’’ guarding?. Diab Met Syndr: Clin Res Rev (2010), doi:10.1016/j.dsx.2010.05.020
G Model
DSX-181; No. of Pages 2 2
Editorial / Diabetes & Metabolic Syndrome: Clinical Research & Reviews xxx (2010) xxx–xxx
just a couple of years back Professor Ferrannini had been quoted as saying at the Endocrine Society’s 85th Annual Meeting: ‘‘Glycemic abnormality predicts hypertension and increased blood pressure predicts glycemic abnormality, with hyperinsulinemia an important additional predictive factor, Ferrannini noted, further suggesting the usefulness of the concept of metabolic syndrome. The metabolic syndrome exists, and he asserted, ‘It predicts itself so it’s not just an innocent cluster.’ They ask. . . So what has led to the change in his (Ferrannini) thinking? Moreover, they also raised the possibility [20], albeit indirectly, of the ADA and the EASD guarding their turf by quoting Fogoros, ‘‘Perhaps the last words should be with Richard N. Fogoros, MD, writing as ‘‘Dr Rich’’ on a Web site: Dr Rich suspects that what the ADA/EASD are doing here is engaging in turf protection. The concept of the metabolic syndrome has non-specialists paying a lot more attention to conditions related to diabetes (specifically, to insulinresistance and related conditions) than they ever have in the past. Indeed, in recent years, non-diabetes-specialists are engaging numerous active clinical trials aimed at insulin-resistance conditions (i.e., metabolic syndrome.) One suspects that the relatively small ADA, viewing the recent efforts of the American Heart Association and American College of Cardiology in this regard, is beginning to feel like Netscape did in the mid-1990s when Microsoft decided to enter the browser business. This, of course, is pure speculation, but something must explain the otherwise nearly inexplicable effort to quash the metabolic syndrome.’’ [26] Some of the views put forth by Fogoros may be coming true as one keeps hearing of changes in University Hospital environments, especially in the developed world, where diabetes units are slowly being made an integral part of cardiology departments, although one must admit that one does not have specific figures for this. What is of interest is that a closer look at the members constituting the WHO Expert Consultation group shows the vast majority of them to be experts in the ‘‘diabetes’’ field! Further more, a key member of this WHO Expert Consultation group [25] is someone who up to the very recent times was a leading proponent of the metabolic syndrome concept and the key player in its harmonization [4,20,21,27,28]. The same question asked about Ferrannini can be put to many of the members of the WHO Expert Consultation group. Is it ‘‘science’’. . . or is it ‘‘turf’’ guarding? Take your pick! Financial disclosures None. Conflict of interest None. References [1] King H, Aubert RE, Herman WH. Global burden of diabetes, 1995—2025: prevalence, numerical estimates, and projections. Diabetes Care 1998;21:1414–31. [2] Reddy KS, Yusuf S. Emerging epidemic of cardiovascular disease in developing countries. Circulation 1998;97:596–601.
[3] International Diabetes Federation. Rationale for new IDF worldwide definition of metabolic Syndrome, Available at http://www.idf.org/webdata/docs/Meta bolic_syndrome_rationale.pdf/;2009 [accessed May 1, 2010]. [4] Zimmet P, Alberti G, Shaw J. Global and societal implications of the diabetes epidemic. Nature 2001;414:782–7. [5] Eckel R, Grundy S, Zimmet P. The metabolic syndrome. Lancet 2005;365: 1415–28. [6] Grundy SM. Metabolic syndrome: connecting and reconciling cardiovascular and diabetes worlds. J Am Coll Cardiol 2006;47:1093–100. [7] Grundy S. Does a diagnosis of metabolic syndrome have value in clinical practice? Am J Clin Nutr 2006;83:1248–51. [8] Kahn R, Buse J, Ferrannini E, Stern M. The metabolic syndrome: time for a critical appraisal: joint statement from the American Diabetes Association and the European Association for the Study of Diabetes. Diabetologia 2005;48: 1684–99. [9] Kahn R, Buse J, Ferrannini E, Stern M. The metabolic syndrome: time for a critical appraisal: joint statement from the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 2005;28: 2289–304. [10] Kahn R. The metabolic syndrome (emperor) wears no clothes. Diabetes Care 2006;29:1693–6. [11] Gale E. The myth of the metabolic syndrome. Diabetologia 2005;48:1679–83. [12] Vinicor F, Bowman B. The metabolic syndrome: the emperor needs some consistent clothes: response to Davidson and Alexander. Diabetes Care 2004;27:1243. [13] Greenland P. Critical questions about the metabolic syndrome. Circulation 2005;112:3675–6. [14] Meigs J. The metabolic syndrome: may be a guidepost or detour to preventing type 2 diabetes and cardiovascular disease. BMJ 2003;327:61–2. [15] Reaven G. Insulin resistance, cardiovascular disease, and the metabolic syndrome: how well do the emperor’s clothes fit? Diabetes Care 2004;27:1011–2. [16] Reaven G. The metabolic syndrome: requiescat in pace. Clin Chem 2005;51: 931–8. [17] Reaven G. Counterpoint: just being alive is not good enough. Clin Chem 2005;51:1354–7. [18] Reaven G. The metabolic syndrome: is this diagnosis necessary? Am J Clin Nutr 2006;83:1237–47. [19] Reaven G. The metabolic syndrome or the insulin resistance syndrome? Different names, different concepts, and different goals. Endocrinol Metab Clin North Am 2004;33:283–303. [20] Zimmet P, Alberti G. The metabolic syndrome: perhaps an etiologic mystery but far from a myth—where does the International Diabetes Federation stand? Medscape Diabetes Endocrinol 2005; 7(2). Available at http://www.med scape.-com/viewarticle/514211 [accessed April 1, 2010]. [21] Zimmet P, Alberti G, Shaw J. Mainstreaming the metabolic syndrome: a definitive definition. This new definition should assist both researchers and clinicians. Med J Aust 2005;183:175–6. [22] Grundy S. Does the metabolic syndrome exist? Diabetes Care 2006;29:1689– 92. [23] Grundy S. Point: the metabolic syndrome still lives. Clin Chem 2005;51:1352– 4. [24] Grundy S, Haffner S, Kunos G, Jensen M. Managing Cardiometabolic risk: will new approaches improve success? Available at http://www.medscape.com/ viewprogram/5700_pnt [last accessed April 1, 2010]. [25] Simmons R, Alberti G, Gale E, Colagiuri S, Tuomilehto J, Qiao Q, et al. The metabolic syndrome: useful concept or clinical tool? Report of a WHO Expert Consultation. Diabetologia 2010;53:600–5. [26] Fogoros RN. Does metabolic syndrome exist? Available at: http://heartdisease.about.com/od/diabetesmetabolicsynd/a/metsynyn.htm [accessed April 4, 2010]. [27] International Diabetes Federation. The IDF consensus worldwide definition of the metabolic syndrome, Available at http://www.idf.org/webdata/docs/IDF_ Metasyndrome_definition.pdf [last accessed April 1, 2010]. [28] Alberti K, Eckel R, Grundy S, Zimmet P, Cleeman J, Donato K, et al. Harmonizing the metabolic syndrome. A joint interim statement of the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity. Circulation 2009;120:1640–5.
S.M. Sadikot 50, Manoel Gonsalves Rd. Bandra (W), Mumbai 400050, India E-mail address: [email protected]
Please cite this article in press as: Sadikot SM. Is it ‘‘science’’. . . or is it ‘‘turf’’ guarding?. Diab Met Syndr: Clin Res Rev (2010), doi:10.1016/j.dsx.2010.05.020
