Comment

Cardiopulmonary outcomes in people with impaired lung

function: the role of metabolic syndrome
Roham Sadeghimakkia and Abd A. Tahranib,∗
a
Public Health Nutrition Research Group, London Metropolitan University, London, UK
b
Institue of Metabolism and Systems Research (IMSR), University of Birmingham, Birmingham, UK

Impaired lung function, either with airflow limitation or In the study by Marott et al., people with versus The Lancet Regional
with preserved ratio impaired spirometry (PRISm), is without metabolic syndrome had higher absolute 5-year Health - Europe
common globally and associated with increased cardio- risks of all-cause mortality, cardiac/respiratory mortality, 2023;35: 100796
respiratory morbidity, cause-specific mortality and and hospital admissions for ischaemic heart disease Published Online 18
November 2023
overall mortality.1,2 In this context, understanding the and/or heart failure and respiratory disease across the
https://doi.org/10.
impact of metabolic syndrome on cardiopulmonary three lung function phenotypes (normal, PRISm and
1016/j.lanepe.2023.
outcomes is clinically important, given the growing airflow limitation), regardless of the severity of PRISm 100796
global prevalence of metabolic syndrome, driven in part or airflow limitation. The risk of these outcomes was
by the increasing obesity rates, and its associations with also increased in individuals with PRISm/airflow limi-
major adverse cardiovascular events and all-cause tation with or without metabolic syndrome relative to
mortality.3,4 those with normal lung function and no metabolic
In this issue of The Lancet Regional Health – Europe, syndrome. Notably, individuals with severe PRISm and
Marott et al. examined the contribution of metabolic metabolic syndrome had the highest hazard ratio (95%
syndrome to increased cardiopulmonary morbidity and confidence interval) of 5.32 (3.76–7.54) for all-cause
mortality observed in adults with impaired lung func- mortality. Furthermore, metabolic syndrome explained
tion.5 For this purpose, the authors utilised the data 13% and 27% of the influence of lung function
from well-characterised 106,845 adults aged 44–75 impairment (PRISm or airflow limitation) on hospital-
years, from the prospective Copenhagen General Pop- isation with ischaemic heart disease and/or heart failure
ulation Study, who were followed up for 15 years. and all-cause mortality, respectively.
Metabolic syndrome was defined based on the presence These results clearly demonstrate that metabolic
of 3 out of 5 criteria related to dyslipidaemia, hyper- syndrome was associated with increased cardiopulmo-
glycaemia, hypertension and central obesity per Amer- nary morbidity and mortality among individuals with
ican Heart Association recommendations. Baseline lung lung function impairment in the Danish population.
function was classified as normal, PRISm and airflow Interestingly, high-sensitivity C-reactive protein and
limitation based on the forced expiratory volume during fibrinogen explained a higher proportion of the influ-
the first second (FEV1), forced vital capacity (FVC) and ence of lung function impairment on all-cause mortality
FEV1/FVC ratio. Study outcomes were based on real- compared with metabolic syndrome, suggesting the
world data from the national registries. contribution of multiple additional factors to the
Overall, 14% and 6% of the study population were observed findings.
categorised as having airflow limitation and PRISm, The study has several strengths and limitations, as
respectively. Metabolic syndrome was common in the discussed by the authors. There are, however, addi-
study population (23%), with a higher prevalence in the tionally important aspects to consider. Denmark is a
PRISm group (39%) compared with the airflow limita- high-income country with lower daily smoking rates and
tion and normal-lung-function groups (23% and 22%, social inequalities compared with other European and
respectively). This increased prevalence of metabolic developed countries,7,8 limiting the generalisability of
syndrome in individuals with PRISm is not surprising the findings. It is also noteworthy that there are two
given the well-described mechanical and inflammatory different waist circumference cutoffs to define central
links between abdominal obesity, as a major component adiposity, and the authors used the criteria requiring
of metabolic syndrome, and the “restrictive” spirometric higher waist circumference values, potentially including
pattern.6 individuals with more advanced metabolic disease in
their analyses. Whether using lower cutoffs could
DOI of original article: https://doi.org/10.1016/j.lanepe.2023.100759
change the findings needs to be explored.
*Corresponding author. Institute of Metabolism and Systems Research The findings of the current study have important
(IMSR), University of Birmingham, Edgbaston, Birmingham B15 2TT, public health and clinical implications because meta-
UK. bolic syndrome is preventable and treatable. Addressing
E-mail address: [email protected] (A.A. Tahrani).
metabolic syndrome, as a part of a wider multifactorial
© 2023 The Authors. Published by Elsevier Ltd. This is an open access
article under the CC BY-NC-ND license (http://creativecommons.org/ lifestyle intervention, can be potentially effective in
licenses/by-nc-nd/4.0/). reducing the burden of impaired lung function.9

www.thelancet.com Vol 35 December, 2023 1

 Comment

The current analysis does not provide details about the author and not Novo Nordisk. Novo Nordisk had no role in this
contribution of the individual components of metabolic manuscript.
syndrome to the observed associations with adverse
outcomes to guide policy and treatment strategies.
References
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Writing – original draft: RS. Writing – review & editing: RS and AAT.
intervention strategies for metabolic syndrome: a scoping review
Both authors approved the final version submitted to the journal. and strategic framework for future research. Medicina (B Aires).
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Declaration of interests 10 Joseph JJ, Deedwania P, Acharya T, et al. Comprehensive man-
RS declares no conflict of interest. agement of cardiovascular risk factors for adults with type 2 dia-
AAT is currently an employee of and has shares in Novo betes: a scientific statement from the American Heart Association.
Nordisk. The views expressed in this manuscript are those of the Circulation. 2022;145:e722–e759.

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