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older couple cooking
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The Metabolic Syndrome

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The metabolic syndrome is the name of a cluster of risk factors that, when they appear together, dramatically raise your risk of heart disease, heart failure, stroke and diabetes, as well as other non-cardiovascular conditions. Like smoking, it’s one of the strongest predictors of heart disease. “Nearly one in three Americans have metabolic syndrome. Many people don’t recognize that they have the condition and underestimate the risks it presents,” says Chiadi E. Ndumele, M.D., M.H.S. , cardiologist at the Johns Hopkins Ciccarone Center for the Prevention of Heart Disease. “Understanding that you have metabolic syndrome in the first place can help motivate you to make the needed changes.” 

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Most people who have metabolic syndrome already have a closely related condition called insulin resistance, which is when the body stops responding to insulin (a hormone produced in the pancreas). After the food we eat is converted into a type of sugar called glucose, insulin is what enables the glucose to enter the body’s cells and be used as energy. For someone who is insulin resistant, however, the glucose builds up in the blood, setting the stage for damage.


“The good news is that there are several promising strategies for combating metabolic syndrome and reducing your risk,” Ndumele says. Try to stick to these four pillars of self-care:

  • Eat a heart-healthy diet . Whether your heart is still healthy or is showing signs of trouble, you can significantly reduce your risks by sticking to a Mediterranean-style diet , says Ndumele. Choose meals high in vegetables, fruits, nuts, whole grains and olive oil, low in saturated fat and low-glycemic foods.
  • Stick to an exercise plan . Fitness helps improve all heart markers, from blood pressure to weight. Aim for 30 to 60 minutes a day, most days of the week, Ndumele suggests.
  • Keep a healthy weight . Find out from your doctor where you fall on the body-mass index (BMI), which calculates whether you’re the right weight for your height. Aim for a BMI below 25. Where your weight is located matters, too. So measure your waist—you want to stay below the target of 40 inches (men) or 35 inches (women).
  • Continue to adhere to medical advice for overall health . It’s important to work with your doctor to assess your overall risk of metabolic syndrome and related heart problems, says Ndumele. Get key markers (such as blood pressure, cholesterol, and blood sugar) checked as recommended by your doctor. If you’ve been prescribed medication for high blood pressure, high cholesterol or insulin resistance, be sure to take it as directed.


A diagnosis of metabolic syndrome comes after the identification of at least three of the following five key risk factors.

  1. Too much fat at the waist . Although obesity in general raises your risk of metabolic syndrome, excess belly fat (being “apple-shaped”) is the riskiest kind of fat, defined as more than 40 inches around the waist for men, or more than 35 inches for women. Ask your doctor about different measurements for your ethnicity, Ndumele says. “Individuals of Asian descent are thought to have an increased risk at a lower threshold of belly fat, for example.”
  2. High blood pressure . This is defined as a reading of 130/85 mm/Hg or higher, or being on medication to treat high blood pressure. Even if only one of the two blood pressure numbers is too high, it’s considered a risk factor.
  3. High triglyceride levels . This means a reading of 150 mg/dL or greater, or being on medicine to treat high triglycerides. Triglycerides are a type of fat found in the blood.
  4. Low HDL cholesterol (also known as “good cholesterol”) . This is defined as a reading of less than 40 mg/dL for men, or less than 50 mg/dL for women. HDL cholesterol helps clear damaging cholesterol from your arteries.
  5. High fasting glucose (blood sugar) . This means a fasting reading of 100 mg/dL or higher, or being on medication to treat high blood sugar. A fasting blood sugar count of 100 to 125 mg/DL (after fasting) indicates prediabetes , and above 126 mg/dL indicates diabetes.

A different set of guidelines from the International Diabetes Federation calls for a diagnosis of metabolic syndrome if there’s too much belly fat plus at least two of the four traits, Ndumele says.


The goal of metabolic syndrome treatment is to reduce the risk of heart disease and diabetes by controlling the associated problematic health conditions (high blood pressure, high cholesterol, diabetes, insulin resistance). “A study in which 53 percent of people had metabolic syndrome at the start found that over three years, intensive lifestyle changes—mainly diet and exercise—resulted in the lowest risk of developing diabetes and the lowest risk of developing metabolic syndrome in those who didn’t have it,” Ndumele says. Recommended changes include:

  • Losing weight . Most people with metabolic syndrome are urged to lose weight in order to reach a healthier body mass index (BMI). Your doctor can help you identify a plan and pace that makes the most sense for you.
  • Adopting a healthier diet . What you really need is not a weight-loss diet but a new eating plan. If finding or following a plan is hard for you, consider asking your doctor or a nutritionist to help you, or to recommend resources to get you started.
  • Moving more . Even if you’ve never exercised before, you can start now and markedly reduce your risks. Even moderate amounts of activity will make a difference with heart markers. Walking is a good starter plan for many people. “I tell my patients to get an activity tracker,” Ndumele says. “Aim for 5,000 steps a day and work up to at least 10,000 steps a day.” Talk to your doctor to get the go-ahead on the types of workouts you want to try.
  • Quitting smoking and avoiding secondhand smoke . Ask your doctor about support programs that can help. If you don’t smoke, try not to be around people who do.
  • Limiting alcohol . Drinking heavily can raise blood pressure and contribute extra empty calories.
  • Taking your prescribed medications . In addition to the medications used to treat high blood pressure, high cholesterol or high blood sugar, those individuals at very high risk may be prescribed metformin or other medications to help manage diabetes, or low-dose aspirin to help reduce the risk of cardivascular disease.

Bariatric (weight loss) surgery may be considered if you’re morbidly obese and if lifestyle changes and medications fail to help.

Living With

Consider a diagnosis of metabolic syndrome to be a wake-up call about the serious state of your heart health. It can be a powerful incentive to effect the changes you need to make.

  • Focus on your whole lifestyle . There are no quick fixes for metabolic syndrome. Because it’s a complex condition, you’ll need to change the way you approach eating, exercise and your overall well-being for the rest of your life.
  • Aim for weight loss that’s slow but steady —the result of a better diet and more exercise. Avoid crash diets, liquid diets, fad diets and fasts (anything that’s unusual and unsupervised).
  • Know all the risks . In addition to heart disease, stroke and diabetes, you may also be monitored and, if needed, treated, for conditions that are known to accompany metabolic syndrome. These can include polycystic ovarian syndrome, gallstones, asthma, sleep disturbances and fatty liver disease.


As Johns Hopkins researchers study the interconnected mechanisms of heart disease, diabetes, obesity and other related health issues, they continue to add to the understanding of how—and why—to manage these conditions. For example, studies have revealed:

Metabolic syndrome doubles the risk of congestive heart failure . In a large study of nearly 7,000 men and women, ages 45 to 84, Johns Hopkins heart specialists found alarming risks between the five markers of the metabolic syndrome and inflammation leading to heart failure.

Exercise helps fight metabolic syndrome in older adults . Johns Hopkins researchers contributed some of the first research to show that in adults ages 55 to 75 (a group at higher risk of metabolic syndrome) the risk can be slashed through a program of moderate exercise training. The program involved 60-minute workouts three times a week.


Insulin (in-suh-lin): A hormone made by the cells in your pancreas. Insulin helps your body store the glucose (sugar) from your meals. If you have diabetes and your pancreas is unable to make enough of this hormone, you may be prescribed medicines to help your liver make more or make your muscles more sensitive to the available insulin. If these medicines are not enough, you may be prescribed insulin shots.


Mediterranean diet: Traditional cuisine of countries bordering the Mediterranean Sea, shown to reduce the risk for heart disease, diabetes, some cancers and dementia. On the menu: Plenty of fruits, vegetables and beans, along with olive oil, nuts, whole grains, seafood; moderate amounts of low-fat yogurt, low-fat cheese and poultry; small amounts of red meat and sweets; and wine, in moderation, with meals.


Prediabetes: When blood glucose (also called blood sugar) levels are higher than normal and not yet high enough to be diagnosed with diabetes. That’s an A1C of 5.7 percent to 6.4 percent (a way to estimate your 3-month average blood sugar reading), a fasting blood glucose level of 100 to 125 mg/dl, or an OGTT (oral glucose tolerance test) two hour blood glucose of 140 to 199 mg/dl.

Prediabetes is also sometimes called impaired glucose tolerance or impaired fasting glucose.


Saturated fat: A type of fat found in abundance in butter, whole milk, ice cream, full-fat cheese, fatty meats, poultry skin, and palm and coconut oils. Saturated fat raises levels of heart-threatening LDL cholesterol in your bloodstream. It can also interfere with your body’s ability to absorb blood sugar easily. Limiting saturated fat can help control your risk for heart disease.


Whole grains: Grains such as whole wheat, brown rice and barley still have their fiber-rich outer shell, called the bran, and inner germ. It provides vitamins, minerals and good fats. Choosing whole grain side dishes, cereals, breads and more may lower the risk for heart disease, type 2 diabetes and cancer and improve digestion, too.

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