Using the Framingham Offspring cohort study, these researchers investigated trends in the diagnosis of the metabolic syndrome (MetS), its individual components, and the relationship between different combinations of these risk factors and subsequent cardiovascular events. There were four main findings of this investigation. First, the prevalence of Met S essentially doubled over the 10 years of follow-up (23.5% to 40.6%), consistent with what has been demonstrated in other studies. Second, of the components of Met S, the incidence of increased waist circumference and hyperglycemia demonstrated the greatest increase over 10 years. Third, of the components of MetS, the presence of increased waist circumference at baseline was most predictive of subsequent development of MetS. Fourth, subjects who developed MetS with a combination of central obesity, hyperglycemia, and high blood pressure had the greatest risk of developing subsequent cardiovascular events (236% increased risk compared to no MetS) and mortality (309% increased risk compared to no MetS). One potential limitation of this study is that the cohort was nearly universally non-Hispanic Caucasians; whether these findings are relevant to other racial and ethnic groups remains under-studied. Nonetheless, these data have important clinical implications. Clinicians need to alert patients with increased waist circumference that even if they do not have MetS currently, they are at high risk of developing MetS in the future. And, perhaps we need to pay particular attention to cardiovascular risk reduction, including aggressive lipid lowering therapy, blood pressure control and anti-platelet therapy, in the subset of MetS patients who present with central obesity, increased blood pressure and hyperglycemia as their first components of MetS. Michael J. Bloch, M.D.