Primary Care Practitioners’ Perspectives on the Utility of Metabolic Syndrome as a Diagnosis: A Qualitative Study

Abstract

Background/Objectives: Metabolic syndrome (MetSy) comprises a cluster of risk factors—including obesity, dyslipidaemia, hypertension, and impaired glucose metabolism—that increase the risk of cardiovascular disease, type 2 diabetes, and other conditions. There are close ties between the complications and outcomes of obesity and MetSy. The practical value of MetSy as a distinct diagnosis in primary care remains uncertain. This study aimed to explore general practitioners’ (GPs) perspectives on the utility of MetSy for diagnosing and managing patients in light of evolving concepts in the field of metabolic health. Methods: A qualitative study design was employed, with semi-structured interviews conducted among 15 GPs in rural Western Australia. Participants were recruited via GP networks with convenience and snowball sampling. Transcribed interviews were thematically analysed using Braun and Clarke’s reflexive approach, with iterative coding, theme identification, and member checking to ensure trustworthiness. Results: GPs generally recognized MetSy as a constellation of risk factors that heighten the risk of cardiovascular disease. Insulin resistance was frequently identified as a unifying pathophysiological driver. Nevertheless, most participants did not routinely diagnose MetSy in clinical practice, rather focusing on treating individual component conditions (e.g., obesity, hypertension, dyslipidaemia) due to readily available disease-specific guidelines. Only a minority of GPs actively used the MetSy concept for patient education to highlight interconnected risks and the potential benefits of holistic lifestyle interventions. Paucity of dedicated MetSy management guidelines and uncertainty around diagnostic criteria further hindered routine application of the syndrome in practice. Conclusions: While GPs are aware of MetSy and its broad implications, few use it as a distinct clinical tool. Development of tailored guidelines and expanded educational resources would empower GPs to integrate a more holistic, MetSy-focused approach to patient care.

1. Introduction

Metabolic syndrome (MetSy) refers to the presence of a cluster of risk factors including abdominal obesity, impaired glucose metabolism, hypertension, and dyslipidaemia that when found together in an individual, lead to significant complications and poor health outcomes [1,2]. While abdominal obesity is a pillar of MetSy, up to 30% of individuals can be metabolically unhealthy without obesity [3]. Those with MetSy have twice the risk of cardiovascular disease(CVD) and a five times increased relative risk for the development of type 2 diabetes mellitus (T2DM) compared to those without the condition [2,4]. Other conditions associated with the syndrome include Alzheimer’s dementia [5], polycystic ovarian syndrome, fatty liver [6], and various cancers including liver, colorectal, bladder, breast, and pancreatic [7,8,9]. MetSy is a highly prevalent condition, estimated to be three times as prevalent as diabetes globally, with between 13 and 30% of Australians fitting the criteria for a diagnosis depending on the definition used [10]. Globally, its prevalence is estimated to be as high as up to one quarter of the world’s population, with studies showing trends of increasing prevalence, with corresponding increases in mortality and loss of disability-adjusted life years due to MetSy complications [11,12]. The impact of MetSy is likely to become even more significant in the future in light of current global trajectories of obesity and impaired glucose metabolism, two important components of metabolic syndrome [11,12].

While these statistics are alarming, the concept of a metabolic syndrome (MetSy) itself as a clinical entity to be used in practice remains a source of debate. This debate centres around a number of factors including the ability of MetSy to predict risk, in particular, the fact that absolute risk calculators for the individual components of MetSy, such as for CVD and T2DM, have been shown to be more accurate in the prediction of these conditions than the use of the overall syndrome, which has led to questioning of the usefulness of MetSy as a risk predictor [13,14,15,16,17]. Further, since MetSy is heterogenous in nature, some patients may have some components of the syndrome and not others, which contributes to the challenge of using the syndrome in risk prediction since different combinations of risk factors will lead to different overall risk calculations for associated complications [14,18]. A further source of debate around MetSy has been its evolving definitions over time, which have made the performing of epidemiological studies to establish associated risks more challenging, with MetSy, therefore, lacking in a sufficient evidence base to promote its use compared to other risk predictors [1]. In addition, the uncertain pathophysiology of the syndrome has added to the reluctance for its use as a clinical diagnosis by clinicians [19,20,21,22]. Indeed, there is no set of clinical guidelines or clear treatment plan for the management of MetSy as a whole, with management guidelines currently centering around the care of the individual components of MetSy including obesity, hypertension, hyperlipidaemia, and raised blood sugar, but not MetSy itself, thus further weakening the clinical utility of diagnosing the syndrome [23,24].

Nevertheless, more recent developments in the field of metabolic health suggest that it may be short-sighted to dispose of the MetSy concept altogether. First of all, definitions of the metabolic syndrome have changed over the years impacting upon its utility, with a comprehensive review of the history and concepts behind the metabolic syndrome previously described [15]. Initial descriptions of a syndrome linking abdominal obesity, hypertension, hyperglycaemia, and hyperuricaemia to elevated CVD risk [25] in the early 1920s have now evolved to an understanding of MetSy that acknowledges that individuals may be “metabolically unhealthy” even without obesity [2,16,26,27,28]. For example, as acknowledged by the joint International Diabetes Federation, National Heart, Lung, and Blood Institute, American Heart Association, World Heart Federation, International Atherosclerosis Society, and the International Association for the Study of Obesity [29] guidelines, the most current guidelines referenced to in Australian general practice [8], the definition of MetSy includes elevated fasting glucose, dyslipidaemia, and hypertension, but has abdominal obesity included only as a non-essential criteria [8,29]. This changes the profile of those who may be classically identified to be at risk of MetSy and the concomitant cardiovascular and diabetic complications. Secondly, MetSy predicts an increased risk of both CVD and T2DM, a key argument for making a diagnosis of MetSy since it unites the prediction of CVD and T2DM in those with the syndrome rather than predicting the risk of just one of the conditions [16]. As well, it has been argued that MetSy may capture additional risk not accounted for individually in the CVD or T2DM risk tools, but which may not be evident in routine clinical practice and routine clinical testing. These include insulin resistance, prothrombotic and proinflammatory states, and endothelial dysfunction [16]. In addition, although still debated, research increasingly suggests that the underlying pathophysiological basis underlying the component conditions of MetSy fits with a single entity centring around insulin resistance, visceral adiposity and a proinflammatory state [2,15,16,19,30], with insulin resistance being a key driver. Thus, a diagnosis of MetSy goes beyond being a predictor of CVD and T2DM to signalling a risk of conditions with other proinflammatory states such as described previously where insulin resistance increasingly recognised as part of the underlying pathophysiology, e.g., POCS [13,14,16,23]. Other newly described complications linked to this are also now evident, including the newly described cardio-renal metabolic syndrome (CRMS), which describes the renal dysfunction seen in those with a poor metabolic profile and which may also lead to a worse prognosis [31,32] of both CVD and T2DM and increased mortality in those with the syndrome [32,33]. Thus, a diagnosis of MetSy predicts far more than just cardiovascular risk and can alert the treating clinician to a range of potential pathologies and underlying pathophysiological derangements. In accordance with this, management of MetSy as a single entity rather than treating the individual conditions such as hypertension or altered glucose levels may also have potential implications beyond the reduction in risk of either CVD or T2DM for a patients’ health, reducing risk of other related conditions with the same underlying pathophysiology.

Poor metabolic health is increasingly acknowledged as indicating a health status that deserves holistic intervention. Indeed, management strategies are proposed that could target the many components of MetSy and its underlying pathophysiology at once rather than managing each individual component of the syndrome individually (current recommendations) [8,29]. These approaches are now more widely available through multidisciplinary care efforts involving exercise physiology and specific nutritional interventions that target metabolic health [19]. A recent updated review on the diagnosis and treatment of metabolic syndrome for primary care clinicians confirms the need for further research on whether and how to treat the syndrome as whole versus its components [34]. Moreover, the desire to manage metabolic syndrome holistically by clinicians is evidenced by the rise in multidisciplinary metabolic health clinics in Australia and globally and which set out to manage poor metabolic health as the goal in those with obesity, diabetes, and elevated cardiovascular risk. The methods undertaken are usually through nutritional interventions that improve metabolic health through controlling caloric intake as well as carbohydrate intake and macronutrients with personalised exercise interventions to improve not only weight but metabolic profile [35,36,37,38]. Additional body composition analysis and indirect calorimetry to measure fat oxidation and the ability to burn carbohydrates efficiently are tools that have been shown to assist in addressing obesity and poor metabolic health in individuals in real world settings [39]. Despite the success of these interventions in real-life settings and studies, clinicians still appear reluctant to engage with the metabolic syndrome and MetSy as a whole. These presumably reflect older attitudes of more than a decade ago, when Borch-Jonsen and Wareham (2010) [40] proposed that the MetSy should now “rest in peace” [40] and the WHO said MetSy is only useful as an educational tool [17].

In view of recent advances in the area of metabolic health, MetSy may have utility that would make the more frequent use by practitioners of a clinical diagnosis of the syndrome worthy of greater consideration. Barriers to care for obesity have been explored qualitatively in primary care but not MetSy [41,42]. We, therefore, sought to explore primary care clinicians’ understandings and use in practice of the concept of MetSy in diagnosing and managing their patients currently. Primary care is the most appropriate place for the initial diagnosis and provision of interventions for MetSy, given that GPs are at the front-line of care and provide continuity of care where they may witness changes in body mass and other parameters of metabolic health over time in their patients, as well as its complications including CVD and T2DM [8,16]. Moreover, as knowledge surrounding both metabolic health and its dysfunction grows, including that of identification of holistic management strategies for poor metabolic health, GPs’ insights become increasingly important and indeed essential to bridging the gap between evidence and practice, to informing targeted education and shaping guidelines. GPs’ perceptions of MetSy as a clinical diagnosis can reveal barriers to its adoption in practice, as well as the practical challenges of the diagnosis within busy primary care workflows. In this qualitative study we, therefore, explored GPs’ understanding of the concepts of MetSy and whether and how GPs use MetSy as a diagnosis in managing their patients within the newer paradigms of metabolic health.

2. Materials and Methods

The study followed qualitative methodology with semi-structured interviews of GPs located in rural and regional Western Australia. AS was working as a rural GP academic registrar at the time of this study and had an interest in lifestyle interventions for the management of chronic diseases.

Any GP or GP registrar working in rural WA was eligible for enrolment into the study. There were no other exclusion criteria. Recruitment utilised both convenience and snowball sampling. Convenience sampling was aided by the lead researcher’s (AS) established connections with local GP practices as well as rural GP networks (the Midwest GP network, the Rural Clinical School of Western Australia, the Royal Australian College of General Practitioners (RACGP) and Rural Health West). Snowballing aided this approach by leveraging referrals from initial participants, which was valuable in view of the close-knit nature of rural GP communities. While acknowledging the limitations of these sampling methods, we attempted to ensure diversity of our sample to include GPs both junior and senior, in training and fellowed in general practice and with varying levels of interest in metabolic health.

Email flyers were sent to the above groups, and individuals were approached directly or referred by others. Those who expressed interest in the study were followed up with an email containing the participant information sheet and a link to the consent form and a pre-interview Qualtrics survey to collect demographic information (age, gender, practitioner status, graduated or in training, practice owner or employee). Written consent was obtained from all participants.

Semi-structured interviews were undertaken by the principal researcher (AS). The interview guide was developed by the research team informed by the literature and in consultation and piloting with a local GP. Interviews were scheduled for a mutually convenient time and were undertaken either in person or via Zoom/MS Teams and were audio recorded. The interviews explored the concept of MetSy and its utility in current general practice in Australia, i.e., whether GPs used the MetSy diagnosis in practice or managed MetSy in their clinics. The interview guide is included as Supplementary File S1. While topics were steered by the interview guide, the approach was fluid, with the interviews deviating to explore in depth areas of interest relevant to the research question and allowing for exploration of points of interest. Follow-up questions were asked when time permitted.

Analysis proceeded concurrently throughout data collection. Interviews continued until saturation, when no further significant themes and codes were emerging from interviews. A critical qualitative approach was used to identify patterns of meaning in collected interviews through the process of reflexive thematic analysis as per Braun and Clarke’s methodology [43]. Audio files were transcribed using Otter AI software and edited using a verbatim transcription technique. Their transcript was sent to the interviewee for review and editing. Information was de-identified for the purpose of analysis.

Files were uploaded into the NVivo qualitative data management software and subsequently coded by the lead researcher (AS) with iterative re-reading and refinement of codes. A subset of interviews was separately coded by researcher NM with significant agreement with identified themes. Themes were extracted and mapped. Codes were grouped and then arranged to identify relationships. An iterative process was utilised to identify key commonalities between codes and their relationships. The relationships between codes were reviewed within the team, with themes derived through a process of inductive reasoning to formulate a meaningful narrative from the data [43]. Given the flexibility of a reflexive thematic analysis, trustworthiness was maintained by the researchers undertaking the coding reflecting on their focus to describe the findings and create core themes limited to the data and via reflexive dialogue. Bracketing was used to ensure the researchers were aware of their own interests in lifestyle interventions and did not allow themselves to be biased by their personal perspectives. Given the reflexive nature of this analysis, the researchers’ perspectives inevitably shaped the interpretation. The lead researcher (AS) was working as a rural GP academic registrar at the time of this study and had an interest in lifestyle interventions for the management of chronic diseases. This brought a focus on practical, patient-centred approaches to metabolic health. This perspective may have emphasised themes related to holistic care and barriers to implementing MetSy in practice, potentially amplifying GPs’ views on lifestyle-based interventions. The other two authors are a general practitioner (NM) and public health physician (ST) with insights into GP perspectives and community care and public health, respectively. To mitigate undue influence, bracketing was utilised with AS and the team consciously reflect on their own predispositions and biases from formulating appropriate questions for interview through to data analysis to ensure that themes remained grounded in data rather than preconceived interests or assumptions beyond the data. During analysis, reflexive dialogue within the team further balanced interpretations while a presentation of the research findings was given at a health professionals breakfast, which provided an opportunity for further member checking of the conclusions from the analysis.

3. Results

Of the 15 GPs interviewed for this study, 14 were fellows of the Royal Australian College of General Practitioners (RACGP) or Australian College of Rural and Remote Practitioners (WACCRA) with a range of experience from 1 to 30 years since fellowship, and one was a GP registrar. There were approximately equal number of male and female GPs interviewed. Fourteen GPs worked in a multiple practitioner clinic, while one was in solo practice. One GP interviewed had a special interest in metabolic health.

Several themes were identified and are described below:

3.1. Theme 1: Understanding of MetSy

3.1.1. Understanding of Broad Concepts Surrounding MetSy

All GPs were aware of the metabolic syndrome and the broad diagnostic criteria of MetSy. Most understood MetSy as a cluster of risk factors increasing the risk for cardiovascular disease. For example:

“So I think of it as a constellation of, not really symptoms, but I guess criteria or diagnoses or even pre-diagnosis, that increased someone’s likelihood of having a serious cardiovascular condition. So, you know, heart disease or stroke”.

(GP06)

“a conglomerate …package of risk factors, which can then lead to further chronic diseases, such as stroke, MI, or those sorts of things, cardiovascular conditions”.

(GP09)

Some talked about the broader health risk and implications of the diagnosis:

“It is a cluster of risk factors which then puts someone at higher risk of cardiovascular disease, type 2 diabetes and chronic kidney disease”.

(GP01)

However, the range of the conditions that are related to MetSy were not consistently mentioned.

3.1.2. Knowledge of Underlying Pathophysiology of MetSy

GPs interviewed were able to identify potential causes and drivers of MetSy. Most believed that “the driving thing is insulin resistance” (GP04). One GP identified a hormonal imbalance:

“it goes towards having excess of testosterone in your body and also having insulin resistance, leading to androgenisation and polycystic ovary syndrome. Infertility, is also associated with obesity”.

(GP07)

Other underlying causes forwarded by the GPs were that it was “from a genetic makeup or predisposition that leads to changes in the body that increase your risk to cardiovascular consequences” (GP01), or that they were driven “through diet and lifestyle choices” (GP09).

One GP (GP12) linked the effect of maternal wellbeing and adverse childhood events “high cortisol or stress” on the development of MetSy: “an obesogenic environment would lead to childhood obesity and then adult obesity”. This GP believed that “you’ve had years of laying down fatty plaques and endothelial damage before you’re even 30”.

One GP who reported a clinical interest in MetSy described the differing severity and variations in the condition and its progressive nature, which other GPs did not delineate.

“I’ve seen severe forms of it, I’ve seen fairly mild forms of it, but in its severest form, would usually start off in, in childhood, actually, with progressive weight gain, and eventually a rising fasting insulin, and then eventually, type two diabetes with hypertension, hypercholesterolemia, and increased cardiovascular mortality”.

(GP07)

One GP also identified a feedback loop with “obesity making insulin resistance while insulin resistance makes weight loss difficult. And then that’s driving your dyslipidemia as well. And the weight will be driving your hypertension as well” (GP14).

GPs could generally acknowledge that there was an “interplay between” factors (GP06). However, most reported being uncertain regarding how conditions such cardiovascular disease and diabetes and those such as polycystic ovary syndrome were linked through an underlying pathophysiology:

“But as we’re probably going to go into, I think a lot of people don’t really know what it is exactly how it really works. I don’t know that I could tell you exactly how the pathways sort of work”.

(GP04)

3.2. Theme 2: Diagnosis of MetSy

Most GPs interviewed reported that they did not make the diagnosis of MetSy and instead focused on diagnosing the individual conditions of the syndrome in their patients.

Altogether, GPs interviewed reported that they were also not confident about diagnosing MetSy based on available guidelines.

“… I’m not quite sure how many of those criteria you must have, to be diagnosed with metabolic syndrome”.

(GP06)

One GP suggested that the additional conditions of MetSy increased risk of complications but did not necessarily define diagnosis of the syndrome.

“it’s not a magic line in the sand where you’ve got three out of five and therefore now you get the syndrome. […]”.

(GP12)

3.3. Theme 3: Management of MetSy

3.3.1. General Management

Given what many noted to be the poorly defined nature of MetSy and that it was more of a conceptual entity rather than a condition to specifically treat, most of those interviewed found it easier as GPs to “treat individual components…treat the cholesterol, treat the obesity, treat the hypertension or the insulin resistance” (GP14) rather than ‘metabolic syndrome’ as a whole. One GP expressed a sentiment echoed by others, treating the individual conditions compared to the syndrome “doesn’t make much of a difference” as the “management options for hypertension, obesity and diabetes overlap” (GP14).

“It feels like I don’t have any patients who just have metabolic syndrome, where I’m just primarily treating that in isolation. I think the patients who I have with metabolic syndrome have either, hypertension, type two diabetes, obesity, or high cholesterol or high triglycerides. And I admit that I would target treating those things, because it seems easier”.

(GP02)

“Because you’ve got this clinical entity of metabolic syndrome, but then the subcomponents of it are really what you target managing, then you’re absolutely you’re trying to prioritize your management focus onto which one’s the most high risk and relevant sort of thing. And which might be achievable”.

(GP05)

GPs supported using care guidelines for each of the individual conditions, noting “there’s no actual metabolic syndrome guidelines” (GP06) that they could use. Rather, it would “just be the individual condition ones” (GP06) from various bodies such as the RACGP [8] (2013) and the American Heart Association for MetSy (2005) [24,29].

GPs recognised that as well as specific management with medications such as antihypertensives, anti-lipid therapy, and glucose lowering drugs for managing each of the conditions, lifestyle interventions with diet and exercise were important in managing patients who presented with the conditions of the MetSy.

In general, GPs did not consider addressing the underlying pathophysiology of the component conditions of MetSy when determining their treatment plans. However, one GP who had expressed an interest in metabolic syndrome said:

“Yeah, the biggest goal is to reverse the insulin resistance …. And the only way to reverse that is to decrease the percentage body fat. And the best way to do that is diet and exercise. And it has to be a really strict diet. Unfortunately, it has to be regular exercise. And it has to be a combination of the two because one or the other doesn’t really cut it. And then obviously if people are struggling with that, then there are a whole host of medications, diabetic ones, injectables, bariatric surgeries, a whole host of other things that we can use”.

(GP07)

This GP also described that managing one aspect of the syndrome, the insulin resistance, had a snowballing effect with improved health in other areas for the patient.

3.3.2. Patient Education

While most GPs reported that they do not normally diagnose their patients with MetSy or treat the syndrome as a clinical entity, some at times used the concept of MetSy to discuss behavioural change with their patients to enable them to better understand and, therefore, reduce their risks of complications.

“… I would usually have a conversation with the patient if they’re kind of ticking three of the boxes. And that would be stating something like ‘you’ve got several risk factors that increase your risk of heart disease and stroke. And those things all kind of add up to increase your risk overall and make me more concerned about this happening for you’. And so, I would usually explain it like that and explain that we need to treat all the things with changes”.

(GP06)

“I’ve seen people get the certain components treated really well in isolation, but not other components of metabolic syndrome. And I think that metabolic syndrome allows the patient to know that it’s not just one thing, but it’s not insurmountable. And that when one thing improves, often the others improve as well. I think that’s a very helpful thing for a patient because otherwise it can appear overwhelming. When you, after a few consults, say there’s 10 things we need to address, as opposed to this one condition under which umbrella there are things that we will tackle. And synergistically they can affect each other when you start to solve one problem”.

(GP13)

One GP reported a difference in using the MetSy term when explaining risk modification based on the health literacy and educational profile of the patient.

“I think it depends on the demographic. …. I think collectively the term is useful. Just use a slightly different way to describe it, depending on the patient”.

(GP10)

However, others did not find discussing MetSy with their patients helpful in educating them on their risks and preferred to speak to their patients regarding the individual conditions such as hypertension or raised lipids. Some identified that since they themselves did not use the concept in their diagnosis and management plans, it was difficult educating patients about the condition.

“it’s a very complex thing to try and understand…the interplay between all the moving parts of MetSy and to try and educate our patients on what that means for them”.

(GP08)

“I think the patients understand that better [individual conditions]—it’s easier to get them motivated to lower their triglycerides, rather than, you know, work on these fluffy risk factors”.

(GP02)

3.4. Summary and Overall Utility of the MetSy Diagnosis

The key themes found in the study are presented in

Table 1. Themes and subthemes from interviews with GPs regarding the utility of MetSy. Themes in bold and subthemes in italics.

Themes/Subthemes	Findings	Indicative Quote
Understanding of MetSy
What is MetSy?	Wide awareness of MetSy was reported among the GP participants, who understood it largely as a cluster of risk factors increasing the risk of cardiovascular disease.	“It is a cluster of risk factors which then puts someone at higher risk of cardiovascular disease, type 2 diabetes and chronic kidney disease” (GP01).
Underlying Pathophysiology of MetSy
Key driver of Metsy	Insulin resistance was reported by GP participants as a key driver of MetSy.	“I understand at a basic theoretical level that we’re looking at a complex of conditions […] that are mainly driven around insulin resistance” (GP08).
Link between MetSy conditions	However, many GPs reported being unclear about the pathophysiology linking the component conditions of the syndrome.	“But as we’re probably going to go into, I think a lot of people don’t really know what it is exactly how it really works. I don’t know that I could tell you exactly how the pathways sort of work” (GP04).
Diagnosis of MetSy
Clinical Utility of MetSy	Most GP participants did not diagnose MetSy in their patients and were uncertain of the criteria for diagnosis	“I’m not quite sure how many of those criteria you must have, to be diagnosed with metabolic syndrome” (GP06).
Management of MetSy
Preference to treating individual conditions	GP participants reported preferring to treat the individual components of MetSy due to ease of access to guidelines for the individual components	“It feels like I don’t have any patients who just have metabolic syndrome, where I’m just primarily treating that in isolation. I think the patients who I have with metabolic syndrome have either, hypertension, type two diabetes, obesity, or high cholesterol or high triglycerides. And I admit that I would target treating those things, because it seems easier” (GP02).
Lack of guidelines for MetSy	GP participants reported lack of guidelines dedicated to MetSy, which made managing MetSy difficult.	“So no, there’s no actual metabolic syndrome guidelines that I’d use, it would just be the individual condition ones” (GP06).
Patient education
Metsy as useful patient education tool	GP participants reported the concept of MetSy could be useful from an educational perspective depending on the patient to which it was being offered.	“I think it depends on the demographic. …. I think collectively the term is useful. Just use a slightly different way to describe it, depending on the patient” (GP10).

. Overall, there were differing views among the GPs interviewed regarding the utility of the MetSy label. Some GPs felt that MetSy could be useful as an entity that unites the component conditions of the syndrome under a single umbrella to help deliver holistic and integrated care, acknowledging the interplay between the component conditions and a shared underlying pathophysiology. However, many GPs did not use the label consciously or diagnose their patients with the syndrome. As well, while data were collected on the age, gender, practice ownership, and level of training level of the GP participants, these helped to show the diversity of participants in our study but did not identify any key differences around understanding and insights into MetSy between participants based on demographics in the relatively small sample.

4. Discussion

This study provides insights into clinicians’ perspectives on the utility of the concept of a metabolic syndrome, considering increasing understanding of metabolic health in recent years. We found that Australian GPs interviewed for this study were aware of the concept of MetSy, described it as a cluster of conditions increasing the risk of cardiovascular disease, and listed most of the individual components of the syndrome. However, many were unsure of the defining criteria of MetSy and mostly did not use the diagnosis in their clinics. As well, while many of the GPs identified the presence of insulin resistance as being the most likely key driver for MetSy, most could not explain the underlying pathophysiological link between the conditions comprising MetSy, as well as the links between the usual conditions associated with MetSy such as T2DM and CVD with other associated conditions such as polycystic ovary syndrome and fatty liver.

Most GPs, in fact, reported being unsure of the utility of the MetSy diagnosis in managing their patients in practice, preferring to treat the individual component conditions of MetSy such as obesity, hypertension, and elevated glucose and lipid levels separately based on clear available Australian management guidelines, rather than through a holistic approach addressing overall metabolic health. GPs noted that whereas significant resources were available for the management of these component conditions of MetSy, the lack of identified dedicated guidelines for management of MetSy holistically created a hindrance to managing the syndrome. Currently, Australia does not have published national guidelines for the management of MetSy, although there is guidance for obesity [44]. While the American Heart Association has published a set of guidelines in 2005 [24], which collates the management of the components of MetSy into a set of recommendations including care for obesity, these are not frequently referenced. Newer guidelines from Poland by Dobrowolski et al. 2022 added a graded protocol to managing the component conditions of MetSy [23], but GPs did not routinely reference these.

In addition, while some GPs used the concept of MetSy when educating their patients on their risk factors for cardiovascular disease to help patients understand links between obesity and the other component conditions of the syndrome, some considered it a challenging concept for their patients to understand. This was magnified by the widespread and comprehensive health information available for the individual conditions such as for hypertension and elevated lipids, but few addressing metabolic syndrome. Furthermore, some GPs commented that while they had learned about MetSy and its definition during their training programme, they had no further education unless they had a personal interest in the subject. This likely reduced the likelihood they could effectively convey the latest understanding of MetSy effectively to their patients. GPs described not having the necessary guidelines, resources, and knowledge to manage the metabolic health of their patients holistically and to educate them on the syndrome.

This study is limited by the inclusion of GPs from only one region of Australia, and these GPs may not reflect the diversity of GP experiences nationally. As a qualitative study, it is exploratory in nature. While there is a general understanding that the MetSy as a diagnosis is underutilised in primary care [8], we believe this to be a unique study in interviewing GPs on their perspectives on MetSy.

The metabolic syndrome is a clinical entity, which is difficult to measure and define across populations. Due to this, general practitioners interviewed have found it to be a difficult concept to apply in practice. However, MetSy as a diagnosis may have benefits over and above simply diagnosing the individual conditions of MetSy, since it unites the risk assessment for both CVD and T2DM and may additionally capture risk factors not accounted for in individual risk calculators for these conditions. Given this fact and its potential underlying pathophysiology of insulin resistance, which is receiving greater scientific attention, the clinical use of the concept of MetSy in clinical care could be indeed valuable. First of all, it could be of aid in patient education, helping patients’ understanding of the compounded health risks associated with its multiple interconnected conditions and used to demonstrate the connectivity between obesity, hypertension, dyslipidaemia, and impaired glucose tolerance and the accumulated excess risks of having more than one condition [17]. Secondly, using the concept of MetSy, clinicians, particularly GPs, could reinforce the utility of interventions which target MetSy as a whole and create a positive compound effect on health. Indeed, a focus on the management of insulin resistance itself may be a pathway forward, as trials such as IRIS [45] and PROactive [46], utilising Pioglitazone to improve insulin sensitivity, demonstrate reduced all-cause, myocardial infarction, and stroke mortality [45,46]. To date, there are no complex clinical trials addressing the benefits of holistic management of MetSy compared to the individual management strategies for CVD and T2DM in a primary care setting. Treating insulin resistance under a diagnosis of metabolic syndrome, whether through lifestyle or pharmacological means, may result in snowballing of health gains with significant reductions in cardiometabolic risk for patients with Metsy. The use of the concept of MetSy may also aid in discourses around obesity and specifically with discussions with patients around the topic of obesity. Qualitative studies on obesity management in primary care suggest that primary care practitioners find it difficult to approach patients on the topic of obesity due to body image and obesity-related stigma and the fear of causing psychological harm to patients and creating mistrust in the doctor–patient relationship [41,42]. Changing the conversation with patients surrounding obesity to one of metabolic health improvement may be a relatively easy way to overcome this challenging issue.

Considering the above factors, it may be time for GPs and primary care practitioners to again consider re-engaging with the diagnosis of metabolic syndrome for the benefit of their patients. While specific guidelines are not yet available and while research continues on the utility of Metsy and of holistic interventions to tackle the syndrome, it would be remiss not to ensure awareness around the condition for GPs and other primary care practitioners, especially in view of the growing interest by patients and the public with regard to metabolic health. The development and promotion of up-to-date guidelines for the diagnosis and management of MetSy, as well as dedicated educational programmes in and outside general practice and primary care on MetSy as a unifying concept to manage cardiometabolic risk could assist clinicians with educating and managing their patients to understand and address the underlying pathophysiology of the metabolic syndrome in order to achieve better health overall. Such programmes should provide the space for discussions around the ongoing debates around the utility of the metabolic syndrome as a concept, as well as its benefits. Furthermore, helping educate GPs to increase their confidence and ability to have discussions on weight and obesity centred around metabolic health may avoid the stigma attached to weight management, with education on MetSy being readily incorporated into obesity-related training and educational programmes. Multidisciplinary engagement and interaction between primary care and allied health professionals around metabolic health would be a further step in improving understanding and insights and best practices for improving metabolic health in patients.

5. Conclusions

Metabolic syndrome is a common condition with significant associated complications for the individual including cardiovascular disease, type 2 diabetes, and a range of other conditions potentially associated with insulin resistance. Based on those interviewed, Australian general practitioners, while familiar with the concepts of MetSy, did not routinely use the diagnosis clinically and frequently did not manage their patients’ metabolic syndrome holistically. MetSy can encompass the management of obesity in an integrated fashion and help alter the conversation to focus on improvements in metabolic health instead of body size issues. With increasing evidence around holistic management of metabolic health conditions, it seems timely for the further development and implementation of dedicated guidelines and concomitant increased education of GPs on metabolic syndrome—its diagnosis, complications, holistic management, and follow-up.