Comment www.thelancet.com Vol 371 June 7, 2008 1893 More than a decade since its formal introduction and thousands of papers later, these six propositions— promulgated by the proponents of the syndrome— remain no more than intriguing thoughts. However, the last argument—ie, metabolic syndrome is valuable for risk assessment and therefore its identification will improve patients’ outcomes—is often considered as the syndrome’s greatest strength. That people with metabolic syndrome are at increased risk of cardiovascular disease events or diabetes does not mean that the construct is useful for risk prediction in itself or compared with other approaches. First, as reviewed by Pepe and colleagues, 11 odds ratios or relative risks regarded as giving strong associations in observational studies (eg, odds ratios of 1·2–2·5) are inadequate to distinguish between people who do (will) or do not ( will not) have the outcome of interest. Much stronger associations are needed (eg, ≥4·0). Second, many reports compare metabolic syndrome with much simpler risk-assessment tests for cardiovascular disease, and those risk-assessment tests are significantly better. 2,6,7 Additionally, a simple fasting plasma glucose measurement is a much better predictor of future diabetes than the expense and inconvenience necessary to diagnose the syndrome. 2,10 What seems to make most sense is for clinicians to focus on global risk assessment that takes into account all the well-established cardiometabolic risk factors (figure), 13 and then to treat each abnormality appropriately. Also, more research is needed to understand the cause of risk-factor clustering and the pathogenesis of insulin resistance. Both actions would better serve the health of those at risk of diabetes and cardiovascular disease than seeking a diagnosis of the metabolic syndrome. Richard Kahn American Diabetes Association, Alexandria, VA 22307, USA rkahn@diabetes.org I declare that I have no conflict of interest. 1 Sattar N, McConnachie A, Shaper G, et al. Can metabolic syndromes usefully predict cardiovascular disease and diabetes? Outcome data from two prospective studies. Lancet 2008; published online May 22. DOI:10.1016/S0140-6736(08)60602-9. 2 Kahn R, Buse J, Ferrannini E, Stern M. The metabolic syndrome: time for a critical appraisal. Joint statement from the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 2005; 28: 2289–304. 3 Grundy SM. Does a diagnosis of the metabolic syndrome have value in clinical medicine? Am J Clin Nutr 2006; 83: 1248–51. 4 Grundy SM. Metabolic syndrome: a multiplex cardiovascular risk factor. J Clin Endocrinol Metab 2007; 92: 399–404. 5 Greenland P. Critical questions about the metabolic syndrome. Circulation 2005; 112: 3675–76. 6 Reaven GM. The metabolic syndrome: is this diagnosis necessary? Am J Clin Nutr 2006; 83: 1237–47. 7 Wilson PWF, D’Agostino RB, Parise H, Sullivan L, Meigs JB. Metabolic syndrome as a precursor of cardiovascular disease and type 2 diabetes mellitus. Circulation 2005; 112: 3066–72. 8 Iribarren C, Go AS, Husson G, et al. Metabolic syndrome and early-onset coronary disease: is the whole greater than the sum of its parts? Am Coll Cardiol 2006; 48: 1800–07. 9 Gami AS, Witt BJ, Howard DE, et al. Metabolic syndrome and risk of incident cardiovascular events and death: a systematic review and meta-analysis of longitudinal studies. J Am Coll Cardiol 2007; 49: 403–14. 10 Cull CA, Jensen CC, Retnakaran R, Holman RR. Impact of the metabolic syndrome on macrovascular and microvascular outcomes in type 2 diabetes mellitus: United Kingdom Prospective Study 78. Circulation 2007; 116: 2119–26. 11 Pepe MS, Janes H, Longton G, Leisenring W, Newcomb P. Limitations of the odds ratio in gauging the performance of a diagnostic, prognostic, or screening marker. Am J Epidemiol 2004; 159: 882–90. 12 Brunzell JD, Davidson M, Furberg CD, et al. Lipoprotein management in patients with cardiometabolic risk: consensus statement from the American Diabetes Association and the American College of Cardiology. Diabetes Care 2008; 31: 811–22. 13 Eckel RH, Kahn R, Robertson RM, Rizza RA. Preventing cardiovascular disease and diabetes: a call to action from the American Diabetes Association and the American Heart Association. Diabetes Care 2006; 29: 1697–99. Neonatal mortality—4 million reasons for progress By far the most dangerous time to be alive is during the first few days of life—especially if you are one of the 60 million children delivered worldwide without the benefit of a skilled attendant. 1 Most of the 4 million children who die within the first month of life are born into poverty and many remain unnamed and unrecorded. 2 This silent toll of neonatal death is in contrast to the decrease in deaths of children aged 2–59 months by a third over the past 25 years. 3 Although some progress has been made in improving late neonatal death, early mortality in the first week of life has remained unchanged. 4 Any progress towards the Millennium Development Goal target of a decrease in worldwide infant mortality by two-thirds by 2015 will be impos- sible without substantial decreases in early neonatal mortality. Two conditions—birth asphyxia and sepsis with pneumonia—cause nearly 60% of these deaths worldwide. 5 However, the biggest issue is restricted access to qualified health-care professionals. About 30–40% of neonatal deaths are associated with bacterial infection, 6 which often progresses rapidly and See Articles page 1936