Korean Circulation Journal

The Korean Society of Cardiology (대한심장학회)
권호 표지
DOI QR코드

DOI QR Code

Lifestyle Modification in the Management of Metabolic Syndrome: Statement From Korean Society of CardioMetabolic Syndrome (KSCMS)

  • Hack-Lyoung Kim (Division of Cardiology, Department of Internal Medicine, Boramae Medical Center, Seoul National University College of Medicine) ;
  • Jaehoon Chung (Division of Cardiology, Department of Internal Medicine, National Medical Center) ;
  • Kyung-Jin Kim (Division of Cardiology, Department of Internal Medicine, Ewha Womans University Medical Center, Ewha Womans University School of Medicine) ;
  • Hyun-Jin Kim (Department of Cardiology in Internal Medicine, Hanyang University Guri Hospital) ;
  • Won-Woo Seo (Division of Cardiology, Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine) ;
  • Ki-Hyun Jeon (Division of Cardiology, Department of Internal Medicine, Cardiovascular Center, Seoul National University Bundang Hospital) ;
  • Iksung Cho (Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine) ;
  • Jin Joo Park (Division of Cardiology, Department of Internal Medicine, Cardiovascular Center, Seoul National University Bundang Hospital) ;
  • Min-Ho Lee (Division of Cardiology, Department of Internal Medicine, Soon Chun Hyang University Seoul Hospital) ;
  • Jon Suh (Division of Cardiology, Department of Internal Medicine, Soon Chun Hyang Bucheon Hospital, Soon Chun Hyang University College of Medicine) ;
  • Sang-Yup Lim (Departments of Internal Medicine, Korea University Ansan Hospital) ;
  • Seonghoon Choi (Division of Cardiology, Department of Internal Medicine, Hallym University College of Medicine) ;
  • Sang-Hyun Kim (Division of Cardiology, Department of Internal Medicine, Boramae Medical Center, Seoul National University College of Medicine)
  • Received : 2021.09.28
  • Accepted : 2021.12.01
  • Published : 2022.02.01
Download PDF
⟨ Previous Next ⟩

Abstract

With the recent rapid increase in obesity worldwide, metabolic syndrome (MetS) has gained significant importance. MetS is a cluster of obesity-related cardiovascular risk factors including abdominal obesity, atherogenic dyslipidemia, high blood pressure and impaired glucose tolerance. MetS is highly prevalent and strongly associated with an increased risk of developing diabetes and cardiovascular disease, putting a great burden on human society. Therefore, it is very important to reduce MetS risk, which can improve patients' cardiovascular prognosis. The primary and most effective strategy to control each component of MetS is lifestyle change such as losing body weight, keeping regular exercise, adopting a healthy diet, quitting smoking and alcohol drinking in moderation. Many studies have shown that lifestyle modification has improved all components of MetS, and reduces the incidence of diabetes and cardiovascular disease. Here, the Korean Society of CardioMetabolic Syndrome has summarized specific and practical methods of lifestyle modification in the management of MetS in the healthcare field.

Keywords

Acknowledgement

The final version of manuscript was endorsed by Korean Society of Cardiology, Korean Society of Lipid and Atherosclerosis, Korean Association of Clinical Cardiology, Korean Society of Hypertension, Korean Society of Heart Failure, Korean Society of Echocardiography, Korean Society of Interventional Cardiology, and Korean Heart Rhythm Society.

References

  1. Eckel RH, Grundy SM, Zimmet PZ. The metabolic syndrome. Lancet 2005;365:1415-28.
  2. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the third report of the national cholesterol education program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III). JAMA 2001;285:2486-97.
  3. Nam GE, Kim YH, Han K, et al. Obesity fact sheet in Korea, 2018: data focusing on waist circumference and obesity-related comorbidities. J Obes Metab Syndr 2019;28:236-45.
  4. Huh JH, Kang DR, Jang JY, et al. Metabolic syndrome epidemic among Korean adults: Korean survey of Cardiometabolic Syndrome (2018). Atherosclerosis 2018;277:47-52.
  5. Saklayen MG. The global epidemic of the metabolic syndrome. Curr Hypertens Rep 2018;20:12.
  6. Swinburn BA, Sacks G, Hall KD, et al. The global obesity pandemic: shaped by global drivers and local environments. Lancet 2011;378:804-14.
  7. Hirode G, Wong RJ. Trends in the Prevalence of metabolic syndrome in the United States, 2011-2016. JAMA 2020;323:2526-8.
  8. Huh JH, Kim JY, Koh KK. Metabolic syndrome fact sheet 2021: executive report. Cardiometab Syndr J 2021;1:125-34.
  9. Sperling LS, Mechanick JI, Neeland IJ, et al. The cardiometabolic health alliance: working toward a new care model for the metabolic syndrome. J Am Coll Cardiol 2015;66:1050-67.
  10. Galassi A, Reynolds K, He J. Metabolic syndrome and risk of cardiovascular disease: a meta-analysis. Am J Med 2006;119:812-9.
  11. Isomaa B, Almgren P, Tuomi T, et al. Cardiovascular morbidity and mortality associated with the metabolic syndrome. Diabetes Care 2001;24:683-9.
  12. Lakka HM, Laaksonen DE, Lakka TA, et al. The metabolic syndrome and total and cardiovascular disease mortality in middle-aged men. JAMA 2002;288:2709-16.
  13. Malik S, Wong ND, Franklin SS, et al. Impact of the metabolic syndrome on mortality from coronary heart disease, cardiovascular disease, and all causes in United States adults. Circulation 2004;110:1245-50.
  14. Del Brutto OH, Zambrano M, Penaherrera E, Montalvan M, Pow-Chon-Long F, Tettamanti D. Prevalence of the metabolic syndrome and its correlation with the cardiovascular health status in stroke- and ischemic heart disease-free Ecuadorian natives/mestizos aged ≥40 years living in Atahualpa: a population-based study. Diabetes Metab Syndr 2013;7:218-22.
  15. Dragsbaek K, Neergaard JS, Laursen JM, et al. Metabolic syndrome and subsequent risk of type 2 diabetes and cardiovascular disease in elderly women: challenging the current definition. Medicine (Baltimore) 2016;95:e4806.
  16. Guembe MJ, Fernandez-Lazaro CI, Sayon-Orea C, Toledo E, Moreno-Iribas C; RIVANA Study Investigators. Risk for cardiovascular disease associated with metabolic syndrome and its components: a 13-year prospective study in the RIVANA cohort. Cardiovasc Diabetol 2020;19:195.
  17. Hanson RL, Imperatore G, Bennett PH, Knowler WC. Components of the "metabolic syndrome" and incidence of type 2 diabetes. Diabetes 2002;51:3120-7.
  18. Laaksonen DE, Lakka HM, Niskanen LK, Kaplan GA, Salonen JT, Lakka TA. Metabolic syndrome and development of diabetes mellitus: application and validation of recently suggested definitions of the metabolic syndrome in a prospective cohort study. Am J Epidemiol 2002;156:1070-7.
  19. Mottillo S, Filion KB, Genest J, et al. The metabolic syndrome and cardiovascular risk a systematic review and meta-analysis. J Am Coll Cardiol 2010;56:1113-32.
  20. Despres JP, Lemieux I, Bergeron J, et al. Abdominal obesity and the metabolic syndrome: contribution to global cardiometabolic risk. Arterioscler Thromb Vasc Biol 2008;28:1039-49.
  21. Park YW, Zhu S, Palaniappan L, Heshka S, Carnethon MR, Heymsfield SB. The metabolic syndrome: prevalence and associated risk factor findings in the US population from the Third National Health and Nutrition Examination Survey, 1988-1994. Arch Intern Med 2003;163:427-36.
  22. Wilson PW, Kannel WB, Silbershatz H, D'Agostino RB. Clustering of metabolic factors and coronary heart disease. Arch Intern Med 1999;159:1104-9.
  23. Palaniappan L, Carnethon MR, Wang Y, et al. Predictors of the incident metabolic syndrome in adults: the Insulin Resistance Atherosclerosis Study. Diabetes Care 2004;27:788-93.
  24. Lloyd-Jones DM, Liu K, Colangelo LA, et al. Consistently stable or decreased body mass index in young adulthood and longitudinal changes in metabolic syndrome components: the Coronary Artery Risk Development in Young Adults Study. Circulation 2007;115:1004-11.
  25. Case CC, Jones PH, Nelson K, O'Brian Smith E, Ballantyne CM. Impact of weight loss on the metabolic syndrome. Diabetes Obes Metab 2002;4:407-14.
  26. Phelan S, Wadden TA, Berkowitz RI, et al. Impact of weight loss on the metabolic syndrome. Int J Obes 2007;31:1442-8.
  27. Ferland A, Eckel RH. Does sustained weight loss reverse the metabolic syndrome? Curr Hypertens Rep 2011;13:456-64.
  28. Grundy SM, Hansen B, Smith SC Jr, Cleeman JI, Kahn RA; American Heart Association; National Heart, Lung, and Blood Institute; American Diabetes Association. Clinical management of metabolic syndrome: report of the American Heart Association/National Heart, Lung, and Blood Institute/American Diabetes Association conference on scientific issues related to management. Circulation 2004;109:551-6.
  29. Korean Statistical Information Service. Daejeon: Statistics Korea; 2021 [cited 2021 July 26]. Available from: https://kosis.kr/index/index.do.
  30. Ambrose JA, Barua RS. The pathophysiology of cigarette smoking and cardiovascular disease: an update. J Am Coll Cardiol 2004;43:1731-7.
  31. Harris KK, Zopey M, Friedman TC. Metabolic effects of smoking cessation. Nat Rev Endocrinol 2016;12:684.
  32. Ishizaka N, Ishizaka Y, Toda E, Hashimoto H, Nagai R, Yamakado M. Association between cigarette smoking, metabolic syndrome, and carotid arteriosclerosis in Japanese individuals. Atherosclerosis 2005;181:381-8.
  33. Oh SW, Yoon YS, Lee ES, et al. Association between cigarette smoking and metabolic syndrome: the Korea National Health and Nutrition Examination Survey. Diabetes Care 2005;28:2064-6.
  34. Sun K, Liu J, Ning G. Active smoking and risk of metabolic syndrome: a meta-analysis of prospective studies. PLoS One 2012;7:e47791.
  35. Cryer PE, Haymond MW, Santiago JV, Shah SD. Norepinephrine and epinephrine release and adrenergic mediation of smoking-associated hemodynamic and metabolic events. N Engl J Med 1976;295:573-7.
  36. Kong C, Nimmo L, Elatrozy T, et al. Smoking is associated with increased hepatic lipase activity, insulin resistance, dyslipidaemia and early atherosclerosis in Type 2 diabetes. Atherosclerosis 2001;156:373-8.
  37. Facchini FS, Hollenbeck CB, Jeppesen J, Chen YD, Reaven GM. Insulin resistance and cigarette smoking. Lancet 1992;339:1128-30.
  38. Kawachi I, Colditz GA, Stampfer MJ, et al. Smoking cessation and time course of decreased risks of coronary heart disease in middle-aged women. Arch Intern Med 1994;154:169-75.
  39. Rigotti NA, Clair C. Managing tobacco use: the neglected cardiovascular disease risk factor. Eur Heart J 2013;34:3259-67.
  40. Kim BJ, Kim BS, Sung KC, Kang JH, Lee MH, Park JR. Association of smoking status, weight change, and incident metabolic syndrome in men: a 3-year follow-up study. Diabetes Care 2009;32:1314-6.
  41. Benowitz NL, Fraiman JB. Cardiovascular effects of electronic cigarettes. Nat Rev Cardiol 2017;14:447-56.
  42. Dunbar A, Gotsis W, Frishman W. Second-hand tobacco smoke and cardiovascular disease risk: an epidemiological review. Cardiol Rev 2013;21:94-100.
  43. Morris PB, Ference BA, Jahangir E, et al. Cardiovascular effects of exposure to cigarette smoke and electronic cigarettes: clinical perspectives from the prevention of cardiovascular disease section leadership council and early career councils of the American College of Cardiology. J Am Coll Cardiol 2015;66:1378-91.
  44. Lancaster T, Stead L. Physician advice for smoking cessation. Cochrane Database Syst Rev 2004:CD000165.
  45. Barua RS, Rigotti NA, Benowitz NL, et al. 2018 ACC expert consensus decision pathway on tobacco cessation treatment: a report of the American College of Cardiology task force on clinical expert consensus documents. J Am Coll Cardiol 2018;72:3332-65.
  46. Lindson-Hawley N, Thompson TP, Begh R. Motivational interviewing for smoking cessation. Cochrane Database Syst Rev 2015:CD006936.
  47. Marcus BH, Albrecht AE, King TK, et al. The efficacy of exercise as an aid for smoking cessation in women: a randomized controlled trial. Arch Intern Med 1999;159:1229-34.
  48. Parsons AC, Shraim M, Inglis J, Aveyard P, Hajek P. Interventions for preventing weight gain after smoking cessation. Cochrane Database Syst Rev 2009:CD006219.
  49. Filozof C, Fernandez Pinilla MC, Fernandez-Cruz A. Smoking cessation and weight gain. Obes Rev 2004;5:95-103.
  50. Vergnaud AC, Norat T, Romaguera D, et al. Fruit and vegetable consumption and prospective weight change in participants of the European Prospective Investigation into cancer and nutrition-physical activity, nutrition, alcohol, cessation of smoking, eating out of home, and obesity study. Am J Clin Nutr 2012;95:184-93.
  51. Koppes LL, Dekker JM, Hendriks HF, Bouter LM, Heine RJ. Moderate alcohol consumption lowers the risk of type 2 diabetes: a meta-analysis of prospective observational studies. Diabetes Care 2005;28:719-25.
  52. Thun MJ, Peto R, Lopez AD, et al. Alcohol consumption and mortality among middle-aged and elderly U.S. adults. N Engl J Med 1997;337:1705-14.
  53. Yoon YS, Oh SW, Baik HW, Park HS, Kim WY. Alcohol consumption and the metabolic syndrome in Korean adults: the 1998 Korean National Health and Nutrition Examination Survey. Am J Clin Nutr 2004;80:217-24.
  54. Jeon YJ, Pyo J, Park YK, Ock M. Health behaviors in major chronic diseases patients: trends and regional variations analysis, 2008-2017, Korea. BMC Public Health 2020;20:1813.
  55. Choi J, Choi JY, Shin A, et al. Trends and correlates of high-risk alcohol consumption and types of alcoholic beverages in middle-aged Korean adults: results from the HEXA-G study. J Epidemiol 2019;29:125-32.
  56. Alkerwi A, Boutsen M, Vaillant M, et al. Alcohol consumption and the prevalence of metabolic syndrome: a meta-analysis of observational studies. Atherosclerosis 2009;204:624-35.
  57. Sun K, Ren M, Liu D, Wang C, Yang C, Yan L. Alcohol consumption and risk of metabolic syndrome: a meta-analysis of prospective studies. Clin Nutr 2014;33:596-602.
  58. Vieira BA, Luft VC, Schmidt MI, et al. Timing and type of alcohol consumption and the metabolic syndrome - ELSA-Brasil. PLoS One 2016;11:e0163044.
  59. Beilin LJ, Puddey IB. Alcohol and hypertension: an update. Hypertension 2006;47:1035-8.
  60. De Oliveira E Silva ER, Foster D, McGee Harper M, et al. Alcohol consumption raises HDL cholesterol levels by increasing the transport rate of apolipoproteins A-I and A-II. Circulation 2000;102:2347-52.
  61. Vu KN, Ballantyne CM, Hoogeveen RC, et al. Causal role of alcohol consumption in an improved lipid profile: the atherosclerosis risk in communities (ARIC) study. PLoS One 2016;11:e0148765.
  62. van de Wiel A. Diabetes mellitus and alcohol. Diabetes Metab Res Rev 2004;20:263-7.
  63. Rehm J. The risks associated with alcohol use and alcoholism. Alcohol Res Health 2011;34:135-43.
  64. Jakobsen MU, O'Reilly EJ, Heitmann BL, et al. Major types of dietary fat and risk of coronary heart disease: a pooled analysis of 11 cohort studies. Am J Clin Nutr 2009;89:1425-32.
  65. Mozaffarian D, Katan MB, Ascherio A, Stampfer MJ, Willett WC. Trans fatty acids and cardiovascular disease. N Engl J Med 2006;354:1601-13.
  66. Carnethon MR, Loria CM, Hill JO, Sidney S, Savage PJ, Liu K; Coronary Artery Risk Development in Young Adults study. Risk factors for the metabolic syndrome: the Coronary Artery Risk Development in Young Adults (CARDIA) study, 1985-2001. Diabetes Care 2004;27:2707-15.
  67. Mirmiran P, Noori N, Azizi F. A prospective study of determinants of the metabolic syndrome in adults. Nutr Metab Cardiovasc Dis 2008;18:567-73.
  68. Ha K, Kim K, Chun OK, Joung H, Song Y. Differential association of dietary carbohydrate intake with metabolic syndrome in the US and Korean adults: data from the 2007-2012 NHANES and KNHANES. Eur J Clin Nutr 2018;72:848-60.
  69. Kim BK, Lim YH, Kim SG, Kim YM, Shin J. Relationship between sodium intake and blood pressure according to metabolic syndrome status in the Korean National Health and Nutrition Examination Survey. Blood Press Monit 2012;17:120-7.
  70. He FJ, MacGregor GA. Effect of modest salt reduction on blood pressure: a meta-analysis of randomized trials. Implications for public health. J Hum Hypertens 2002;16:761-70.
  71. Vivekananthan DP, Penn MS, Sapp SK, Hsu A, Topol EJ. Use of antioxidant vitamins for the prevention of cardiovascular disease: meta-analysis of randomised trials. Lancet 2003;361:2017-23.
  72. Weickert MO, Pfeiffer AF. Metabolic effects of dietary fiber consumption and prevention of diabetes. J Nutr 2008;138:439-42.
  73. Azadbakht L, Mirmiran P, Esmaillzadeh A, Azizi T, Azizi F. Beneficial effects of a Dietary Approaches to Stop Hypertension eating plan on features of the metabolic syndrome. Diabetes Care 2005;28:2823-31.
  74. McTiernan A, Sorensen B, Irwin ML, et al. Exercise effect on weight and body fat in men and women. Obesity (Silver Spring) 2007;15:1496-512.
  75. Lavie CJ, Ozemek C, Carbone S, Katzmarzyk PT, Blair SN. Sedentary behavior, exercise, and cardiovascular health. Circ Res 2019;124:799-815.
  76. Nocon M, Hiemann T, Muller-Riemenschneider F, Thalau F, Roll S, Willich SN. Association of physical activity with all-cause and cardiovascular mortality: a systematic review and meta-analysis. Eur J Cardiovasc Prev Rehabil 2008;15:239-46.
  77. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. Circulation 2019;140:e596-646.
  78. Bertrais S, Beyeme-Ondoua JP, Czernichow S, Galan P, Hercberg S, Oppert JM. Sedentary behaviors, physical activity, and metabolic syndrome in middle-aged French subjects. Obes Res 2005;13:936-44.
  79. Ford ES, Kohl HW 3rd, Mokdad AH, Ajani UA. Sedentary behavior, physical activity, and the metabolic syndrome among U.S. adults. Obes Res 2005;13:608-14.
  80. Pattyn N, Cornelissen VA, Eshghi SR, Vanhees L. The effect of exercise on the cardiovascular risk factors constituting the metabolic syndrome: a meta-analysis of controlled trials. Sports Med 2013;43:121-33.
  81. Saris WH, Blair SN, van Baak MA, et al. How much physical activity is enough to prevent unhealthy weight gain? Outcome of the IASO 1st Stock Conference and consensus statement. Obes Rev 2003;4:101-14.
  82. Swift DL, Johannsen NM, Lavie CJ, Earnest CP, Church TS. The role of exercise and physical activity in weight loss and maintenance. Prog Cardiovasc Dis 2014;56:441-7.
  83. Donnelly JE, Blair SN, Jakicic JM, Manore MM, Rankin JW, Smith BK; American College of Sports Medicine. American College of Sports Medicine Position Stand. Appropriate physical activity intervention strategies for weight loss and prevention of weight regain for adults. Med Sci Sports Exerc 2009;41:459-71.
  84. Church TS, Blair SN, Cocreham S, et al. Effects of aerobic and resistance training on hemoglobin A1c levels in patients with type 2 diabetes: a randomized controlled trial. JAMA 2010;304:2253-62.
  85. Dunkley AJ, Charles K, Gray LJ, Camosso-Stefinovic J, Davies MJ, Khunti K. Effectiveness of interventions for reducing diabetes and cardiovascular disease risk in people with metabolic syndrome: systematic review and mixed treatment comparison meta-analysis. Diabetes Obes Metab 2012;14:616-25.
  86. Mekary RA, Feskanich D, Hu FB, Willett WC, Field AE. Physical activity in relation to long-term weight maintenance after intentional weight loss in premenopausal women. Obesity (Silver Spring) 2010;18:167-74.
  87. Armstrong MJ, Mottershead TA, Ronksley PE, Sigal RJ, Campbell TS, Hemmelgarn BR. Motivational interviewing to improve weight loss in overweight and/or obese patients: a systematic review and meta-analysis of randomized controlled trials. Obes Rev 2011;12:709-23.
  88. Rubak S, Sandbaek A, Lauritzen T, Christensen B. Motivational interviewing: a systematic review and meta-analysis. Br J Gen Pract 2005;55:305-12.
  89. Rodriguez-Gutierrez R, Gionfriddo MR, Ospina NS, et al. Shared decision making in endocrinology: present and future directions. Lancet Diabetes Endocrinol 2016;4:706-16.
  90. Ockene IS, Hebert JR, Ockene JK, et al. Effect of physician-delivered nutrition counseling training and an office-support program on saturated fat intake, weight, and serum lipid measurements in a hyperlipidemic population: Worcester Area Trial for Counseling in Hyperlipidemia (WATCH). Arch Intern Med 1999;159:725-31.
  91. Murray CJ, Aravkin AY, Zheng P, et al. Global burden of 87 risk factors in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet 2020;396:1223-49.
  92. Kim HC, Cho SM, Lee H, et al. Korea hypertension fact sheet 2020: analysis of nationwide population-based data. Clin Hypertens 2021;27:8.
  93. Appel LJ, Champagne CM, Harsha DW, et al. Effects of comprehensive lifestyle modification on blood pressure control: main results of the PREMIER clinical trial. JAMA 2003;289:2083-93.
  94. Kim HC, Ihm SH, Kim GH, et al. 2018 Korean Society of Hypertension guidelines for the management of hypertension: part I-epidemiology of hypertension. Clin Hypertens 2019;25:16.
  95. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. Circulation 2018;138:e484-594.
  96. Williams B, Mancia G, Spiering W, et al. 2018 ESC/ESH guidelines for the management of arterial hypertension. Eur Heart J 2018;39:3021-104.
  97. He FJ, Li J, Macgregor GA. Effect of longer-term modest salt reduction on blood pressure. Cochrane Database Syst Rev 2013:CD004937.
  98. Neter JE, Stam BE, Kok FJ, Grobbee DE, Geleijnse JM. Influence of weight reduction on blood pressure: a meta-analysis of randomized controlled trials. Hypertension 2003;42:878-84.
  99. Virdis A, Giannarelli C, Neves MF, Taddei S, Ghiadoni L. Cigarette smoking and hypertension. Curr Pharm Des 2010;16:2518-25.
  100. Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: a report of the American College of Cardiology/American Heart Association TASK FORCE ON CLINICAL PRACTICE GUIDELINES. J Am Coll Cardiol 2019;73:e285-350.
  101. Mach F, Baigent C, Catapano AL, et al. 2019 ESC/EAS guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk. Eur Heart J 2020;41:111-88.
  102. Rhee EJ, Kim HC, Kim JH, et al. 2018 guidelines for the management of dyslipidemia. Korean J Intern Med 2019;34:723-71.
  103. Mensink RP, Zock PL, Kester AD, Katan MB. Effects of dietary fatty acids and carbohydrates on the ratio of serum total to HDL cholesterol and on serum lipids and apolipoproteins: a meta-analysis of 60 controlled trials. Am J Clin Nutr 2003;77:1146-55.
  104. Brown L, Rosner B, Willett WW, Sacks FM. Cholesterol-lowering effects of dietary fiber: a meta-analysis. Am J Clin Nutr 1999;69:30-42.
  105. Griswold MG, Fullman N, Hawley C, et al. Alcohol use and burden for 195 countries and territories, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet 2018;392:1015-35.
  106. Razay G, Heaton KW, Bolton CH, Hughes AO. Alcohol consumption and its relation to cardiovascular risk factors in British women. BMJ 1992;304:80-3.
  107. Kraus WE, Houmard JA, Duscha BD, et al. Effects of the amount and intensity of exercise on plasma lipoproteins. N Engl J Med 2002;347:1483-92.
  108. Haskell WL, Lee IM, Pate RR, et al. Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Circulation 2007;116:1081-93.
  109. Hellerstein MK, Benowitz NL, Neese RA, et al. Effects of cigarette smoking and its cessation on lipid metabolism and energy expenditure in heavy smokers. J Clin Invest 1994;93:265-72.
  110. Craig WY, Palomaki GE, Haddow JE. Cigarette smoking and serum lipid and lipoprotein concentrations: an analysis of published data. BMJ 1989;298:784-8.
  111. Maeda K, Noguchi Y, Fukui T. The effects of cessation from cigarette smoking on the lipid and lipoprotein profiles: a meta-analysis. Prev Med 2003;37:283-90. 
  112. Imperatore G, Cheng YJ, Williams DE, Fulton J, Gregg EW. Physical activity, cardiovascular fitness, and insulin sensitivity among U.S. adolescents: the National Health and Nutrition Examination Survey, 1999-2002. Diabetes Care 2006;29:1567-72.
  113. Young DR, Hivert MF, Alhassan S, et al. Sedentary behavior and cardiovascular morbidity and mortality: a science advisory from the American Heart Association. Circulation 2016;134:e262-79.
  114. Pan XR, Li GW, Hu YH, et al. Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance. The Da Qing IGT and Diabetes Study. Diabetes Care 1997;20:537-44.
  115. Sigal RJ, Kenny GP, Wasserman DH, Castaneda-Sceppa C, White RD. Physical activity/exercise and type 2 diabetes: a consensus statement from the American Diabetes Association. Diabetes Care 2006;29:1433-8.
  116. Orchard TJ, Temprosa M, Goldberg R, et al. The effect of metformin and intensive lifestyle intervention on the metabolic syndrome: the diabetes prevention program randomized trial. Ann Intern Med 2005;142:611-9.
  117. American Diabetes Association. 5. Facilitating behavior change and well-being to improve health outcomes: standards of medical care in diabetes-2021. Diabetes Care 2021;44 Suppl 1:S53-72.
  118. Vessby B, Uusitupa M, Hermansen K, et al. Substituting dietary saturated for monounsaturated fat impairs insulin sensitivity in healthy men and women: the KANWU Study. Diabetologia 2001;44:312-9.
  119. Kastorini CM, Milionis HJ, Esposito K, Giugliano D, Goudevenos JA, Panagiotakos DB. The effect of Mediterranean diet on metabolic syndrome and its components: a meta-analysis of 50 studies and 534,906 individuals. J Am Coll Cardiol 2011;57:1299-313.
  120. Martinez-Gonzalez MA, Salas-Salvado J, Estruch R, Corella D, Fito M, Ros E; PREDIMED INVESTIGATORS. Benefits of the mediterranean diet: insights from the PREDIMED Study. Prog Cardiovasc Dis 2015;58:50-60.
  121. Shai I, Schwarzfuchs D, Henkin Y, et al. Weight loss with a low-carbohydrate, Mediterranean, or low-fat diet. N Engl J Med 2008;359:229-41.
  122. Venn BJ, Mann JI. Cereal grains, legumes and diabetes. Eur J Clin Nutr 2004;58:1443-61.
  123. Papathanasopoulos A, Camilleri M. Dietary fiber supplements: effects in obesity and metabolic syndrome and relationship to gastrointestinal functions. Gastroenterology 2010;138:65-72.e1.
  124. Blesso CN, Andersen CJ, Barona J, Volek JS, Fernandez ML. Whole egg consumption improves lipoprotein profiles and insulin sensitivity to a greater extent than yolk-free egg substitute in individuals with metabolic syndrome. Metabolism 2013;62:400-10.
  125. Akter S, Kurotani K, Nanri A, et al. Dairy consumption is associated with decreased insulin resistance among the Japanese. Nutr Res 2013;33:286-92.