As discussed in the previous blog, found here, adipose tissue is very hormonally active and can lead to adiposopathy or ‘sick fat’ with metabolic consequences. Truncal obesity, a marker of increased visceral fat, correlates most highly with increased adipokine release, causing a host of downstream effects. These include vascular inflammation and endothelial dysfunction, peripheral insulin resistance, lipid abnormalities, and increased blood pressure, all of which are hallmark findings seen in metabolic syndrome, the principal discussion of this blog.

Metabolic syndrome is not a disease itself but rather refers to a constellation of clinical findings that all independently increase the risk of developing atherosclerotic cardiovascular disease. Metabolically active adipose tissue is the primary driver behind these findings, but a sedentary lifestyle and predisposing genetic factors also contribute. Like polycystic ovarian syndrome, different clinical criteria are utilized to make the diagnosis, but the most utilized criteria, the National Cholesterol Education Program (NCEP) and Adult Treatment Panel III (ATP III), is what should be utilized for ABOM board prep. There are minor diagnostic differences between adults and children, as summarized in the table below.

Alarmingly, nearly 35% of adults met the criteria for metabolic syndrome based on NHANES data (2011-2016), an increase from 22% in the 1998-1994 cohort. Body weight itself is a significant risk factor; only 5% of those with body mass indexes (BMI) in the normal range meet diagnostic criteria compared to 22% and 60% for those in the overweight and obesity categories, respectively. The 5% with a normal BMI displayed the same ‘metabolic obesity’ as others with this condition- a good reminder that a normal BMI does not equal a healthy BMI (check out The Obesity Paradox blog here).

Regardless of BMI, a diagnosis of metabolic syndrome equates to increased cardiovascular disease (CVD), which should prompt aggressive management of risk factors, including targeting excess adipose tissue. The two primary treatment goals, as agreed upon by multiple major societies, are twofold:

  1. Treat underlying etiologies by increasing physical activity and target weight reduction.
  2. Treat CVD risk factors that persist despite therapeutic lifestyle modifications. Statin therapy should be administered similarly to the general population, based on the CVD risk profile, as metabolic syndrome is not considered a coronary equivalent nor synergistically increases CVD compared to any individual component. However, individualized treatment via shared decision-making should always be considered.

Intensive lifestyle interventions, focusing on increased physical activity and weight reduction via a multimodal approach, drive the mortality rate down and promote the reversal of metabolic syndrome.

Looking at the pediatric population, the prevalence is approximately 9%, with a significantly increased prevalence of up to 39% and 50% in those with class II and class III obesity, respectively. Ethnic variances are comparable to adults, with the highest incidence in Mexican Americans, followed by non-Hispanic White Americans, then non-Hispanic Black Americans. Also similarly, treatment is aimed toward lifestyle modifications with an emphasis on healthy dietary patterns, increased physical activity with decreased sedentary behavior, and weight reduction.

In summary, be familiar with the criteria for metabolic syndrome in both children and adults. Know that the two most highly correlated risks of this syndrome include CVD and type II diabetes mellitus, although numerous other adipose-based chronic diseases, such as metabolic-associated dysfunctional liver disease, are increased. Intensive lifestyle modification is the initial treatment, with pharmacotherapy and other more aggressive approaches adjunctive.

Sample Question

A 14-year-old adolescent male is being evaluated for excess weight at a family medicine visit. After undergoing a comprehensive physical examination with appropriate testing, he is diagnosed with metabolic syndrome. Which of the following diagnostic criteria is most likely present in this patient?

A. Diagnosis of obstructive sleep apnea

B. Low HDL levels

C. Treatment of hypercholesterolemia

D. Left ventricular hypertrophy

E. Family history of coronary artery disease

Next Week: Monthly Knowledge Check. This is a review checklist of must-know items for ABOM exams based on the previous four blog topics (Gastroplasty, Cohen’s Syndrome, active adipose tissue, and metabolic syndrome). In addition, this will include a brief explanation of the correct answers to previous sample questions.

Bonus (October): I took the exam….now what?! by Carolynn Francavilla, MD, FOMA, ABOM

For more practice questions, check out the following:

  • Obesity Medicine Board Review Questions (2026): Qs 95 and 122.
  • Obesity Medicine Practice Tests (2026): Qs 154 and 216.

(Copyright 2026) Obesity Medicine Board Review Questions, LLC: obesitymedicinereview.com

Featured image: Modified from VectorStock (image license purchased)

Copyediting by Kelly Smith

Now available: A full line of ABOM study resources with 775+ challenging questions in a mobile or book format. Access to both formats is available in a discounted Ultimate Package, which also includes a Pass Guarantee (if you fail the exam in 2026, you get the 2027 edition free), 50 bonus questions released in August, and the newest book, Obesity Medicine: Sample Questions and Study Blogs, which includes all the updated previous study blogs in a paperback format. Check it out here!