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Evaluation of Anthropometric Indices for Metabolic Syndrome and their Association with Metabolic Risk Factors among Healthy Individuals in New Belgrade

Evaluation of Anthropometric Indices for Metabolic Syndrome and their Association with Metabolic... ACTA FACULTATIS MEDICAE NAISSENSIS DOI: 10.2478/v10283-012-0032-4 UDC: 616-008.9-084 Scientific Journal of the Faculty of Medicine in Nis 2013;30(1):21-30 Original article Evaluation of Anthropometric Indices for Metabolic Syndrome and their Association with Metabolic Risk Factors among Healthy Individuals in New Belgrade Veroslava Stankovi1, Svetlana Stojanovi1, Naa Vasiljevi2 Higher Education School of Professional Health Studies in Belgrade, Serbia University of Belgrade, Faculty of Medicine, Serbia SUMMARY People with metabolic syndrome (MetSy) are about twice as likely to develop cardiovascular disease and over four times as likely to develop type 2 diabetes compared to subjects without metabolic syndrome. Waist circumferences () and index () are useful screening tools for making the diagnosis. MetSy has increased the health risk in primary care. The aim of the study was to evaluate the anthropometric indices for MetSy and determine which of simple anthropometric measurements is most closely associated with metabolic risk factors. The research included 264 individuals, of which 132 men with mean age (±SD) of 44.73 ±9.37 years and 132 women with mean age (±SD) of 46.67±8.44 years. Antropometric indicators were measured using standard protocols, without shoes and outerwear. was calculated as weight/height2(kg/m2) ratio, as recommended by the World Health Organization (WHO). Blood pressure measurements were obtained with the subject in a seated position by using a standard mercury sphygmomanometer. Blood samples were obtained after a minimum of 12-h fast; the metabolic parameters (high-density lipoprotein-cholesterol, low-density lipoprotein-cholesterol, , blood glucose) were analyzed by standard procedures. Analysis of the examinees' medical records was also performed. Metabolic syndrome was diagnosed using the International Diabetes Federation (IDF) criteria. The analysis of the research results were performed using the Statistical Package for Social Science version 10.0 (SPSS 10.0 for Windows). The prevalence of the metabolic syndrome was 44.7% in men and 43.2% in women. Normal-weight subjects of both sexes were significantly younger and had significantly lower blood glucose, total cholesterol, LDL and than overweight and obese subjects. Systolic and diastolic blood pressure values were significantly increased in parallel with increasing of . For the whole sample, both anthropometric indices had significant associations with the other five components of MetSy. Waist circumference is a simple measure of adiposity most strongly associated with metabolic abnormalities. The results obtained in this study indicate that is a good indicator of health risk in women but not in men. Measurement of by categories may indicate a person with an increased risk of development of chronic diseases. Key words: waist circumference, index, metabolic syndrome, health risk appraisal Corresponding author: Veroslava Stankovi · phone: 062 250 675· e-mail: dr_vera@verat.net · 21 INTRODUCTION The prevalence of metabolic syndrome (MetSy) has dramatically increased with the rapid development of economy and society. Changed lifestyle, dietary pattern and low regular physical activity have also shown to be the major risk factors for cardiovascular disease (CVD), diabetes, and other chronic diseases (1, 2). It has been estimated that 17-25% of the world population have MetSy, and the importance of the metabolic syndrome lies largely in the development of cardiovascular diseases and type 2 diabetes mellitus (3). Genetic factors, aging, hormonal factors and proinflammatory conditions may affect the occurrence of MetSy (4, 5). In 1999, the WHO criteria for MetSy and were considered to be among the optional criteria. As for the development of the MetSy definitions, waist circumference () has been an optional component of MetSy, according to the Adult Treatment Panel III (ATPIII) Guideline (6). In the International Diabetes Federation (IDF) criteria (2005), central obesity is the major driver of MetSy developments (5, 6). and are useful screening tools for identifying obesity. Each index has different associations with obesity-related physiological and pathological processes (1, 3). Of many ways of measuring body fat and its distributions, anthropometric measurements still play an important role in clinical practice (7, 8). cut-off points may vary with age, gender, and menopausal status because of variation in body composition. While is a convenient marker of the overall adiposity, it does not distinguish between fat and lean , or between central adiposity, a better correlate of insulin resistance (IR) and peripheral adiposity. Compared to , is a better measurement of abdominal fat accumulation. It is unclear if direct measures of adiposity add further information about the link between adiposity and MetSy components in lean populations beyond and (9). The aim of the study was to evaluate the anthropometric indices for metabolic syndrome (MetSy), to determine which of these adiposity measures are the best predictors of metabolic risk factors and assess whether the combination of and is a better indicator of metabolic risk. EXAMINEES AND METHODS The study included 264 examinees (132 men, mean age 44.73±9.37 years and 132 women, mean age 44.73±9.37 years), who were on a regular systematic review in the Preventive center "Novi Beograd", in the period September-October, 2007. After the analysis of subjects'medical records, we excluded individuals with diabetes and CVD. In the study groups, clinical examinations were performed including blood pressure measurement, as well as blood biochemistry, and evaluation of anthro22 pometric parameters, nutritional status and metabolic risk factors. Participants attended the survey site early in the morning (6:30-9:30 A.M.) after 12 hours fasting. Anthropometric measurements were performed with subjects in light clothing and barefooted, and under standard procedures (10). Body weight was measured to the nearest 0.1 kg using a digital scale (SECAW, Columbia, USA), and height to the nearest centimetre using a wall stadiometer (SECAW, Hamburg, Germany). From these values, was calculated as recommended by the World Health Organization (WHO) - weight in kilograms divided by the square of height in meter (10). According to the nutritional status, the subjects were divided into three groups: group 1 - normal-weight (=18.5 to 24.99 kg/m2), group 2 - overweight (=25.00 to 29.99 kg/m2); group 3 - obese (30kg/m2). Waist circumference was measured with subject wearing light clothing (underwear) at a level midway between the lower rib margin and iliac crest to the nearest centimeter using a plastic, nonstretchable tailor's measuring tape. The measurements were recorded in centimeters. Blood pressure was measured to the nearest 2 mmHg on the right arm with subjects seated, after at least 10 min of rest, using a standard mercury sphygmomanometer. The mean of the two readings was taken as each individual's blood pressure. Evaluation of metabolic risk factors included the determination of blood glucose, total cholesterol, HDLC, low density lipoprotein (LDL-C) and . Two sets of fasting blood samples were collected from each subject in sodiumfluoride potassium oxalate tubes (for glucose) and lithium heparin vacuum tubes (for lipids). Blood glucose concentration was determined by the oxidation of glucose (glucose analyzer Beckman Coulter). Total cholesterol, HDL, LDL and were determined by chromatography (accessories Boeringher Mannheim). Reference values for serum lipid profile and fasting glucose were determined on the basis of The International Diabetes Federation (IDF) diagnstic criteria for MetSy (4). IDF diagnostic criteria for metabolic syndrome (5) are listed as following: equal or greater than 80 cm in women or equal or greater than 94 cm in men plus 2 or more of the following: · Low HDL cholesterol with values equaling or lower than 1.03 mmol/L for men and 1.29 mmol/L for women. · Hypertriglyceridemia with values higher than 1.7 mmol/L or under treatment. · Arterial hypertension with values equaling or higher than 130/85 mmHg, or under treatment; · Fasting hyperglycemia with values equaling or higher than 5.6 mmol/L , or under treatment. All data were expressed as mean value ± standard deviation (SD) unless other indicated. Descriptive analyses were performed for all s, and analyses of variance were used to assess differences among groups for the continuous s. Partial correlation coefficients were conducted to estimate the relationships between obesity indicators and metabolic risk factors. All statistical analyses were performed using the Statistical Package for Social Science version 10.0 (SPSS for Windows). All P values were based on two-sided tests with a significance level of 0.05. In addition to waist circumference (p<0.001), normal-weight men had significantly lower serum glucose level (p<0.05) and compared to overweight and obese men, and higher HDL cholesterol compared to obese subjects (Table 5). Normal-weight women were significantly younger than obese and overweight (p<0.001). All valuable and laboratory parameters were significantly increased with increasing . HDL cholesterol in normal weight women was significantly higher than in other subjects (Table 6). RESULTS Characteristics of subjects Of 264 subjects, there were 132 men with mean age (±SD) 44.73±9.37 years and 132 women with mean age (±SD) 46.67±8.44 years. Characteristics of study subjects and the level of metabolic risk components are shown in Table 1. Among the examinees, according to the criteria of IDF, MetSy was found in 44.7% of men and 43.2% of women. No statistically significant difference was found between the prevalence of MetSy in males and females (Table 2). Among subjects with normal , only 5 men had 94cm, and 19 women had 80cm (Table 3). Normal-weight subjects of both sexes were significantly younger and had significantly lower blood glucose, total cholesterol, LDL and than overweight and obese subjects. Systolic and diastolic blood pressure values were significantly increased in parallel with increasing (p<0.001) (Table 4). Relationship between anthropometric indices and metabolic risk factors Table 7 shows correlations between anthropometric indices and nonadipose components of MetSy for the whole sample, according to the criteria of IDF. For the whole sample, both anthropometric indices had significant associations with the five nonadipose components of MetSy. In men, was positively related to , blood pressure, blood glucose and triglyceride levels, while negatively correlated with HDL cholesterol. values in men were significantly associated only with the values of (r=0.58, p<0.01) and (r= 0.78, p<0.01) (Table 8). In women, values show a significant correlation with all parameters and values of body weight, and were significantly associated with all indicators, except (Table 9). Table 1. Characteristics of subjects (Mean±SD) Age (years) Waist circumference(cm) index (kg/m2) Systolic blood pressure(mmHg) Diastolic blood pressure(mmHg) Blood glucosa(mmol/l) Total cholesterol(mmol/l) LDL cholesterol(mmol/l) HDL cholesterol(mmol/l) (mmol/L) Male (n=132) 44.73±9.37 101.43±12.38 27.79±3.63 131.25±15.79 85.00±11.41 5.64±1.36 5.61±0.87 2.83±0.84 1.40±0.32 2.30±1.20 Female (n=132) 46.67±8.44 84.07±14.30 24.60±4.45 122.16±15.25 77.58±10.44 5.37±0.65 5.33±0.64 2.49±0.52 1.24±0.19 1.62±0.96 Table 2. Number and percentage of subjects with abnormal value <25 kg/m2 =25-29.9 kg/m2 30 kg/m2 94 cm (m); 80 cm (f) 130 mmHg 85 mmHg Blood glucose5.6 mmol/L Total cholesterol5.2 mmol/L LDL cholesterol2.6 mmol/L HDL cholesterol<1.04 mmol/L (m); 1.29 (f) 1.7mmol/L METABOLIC SYNDROME Male (n=132) 21 (15.9%) 76 (57.6%) 35 (26.5%) 91 (68.9%) 73 (55.3%) 72 (54.5%) 43 (32.6%) 67 (50.8%) 62 (47.0%) 6 (4.5%) 73 (55.3%) 59 (44.7%) Female (n=132) 74 (56.1%) 40 (30.3%) 18 (13.6%) 74 (56.1%) 53 (40.2%) 41 (31.1%) 57 (43.2%) 48 (36.4%) 44 (33.3%) 19 (14.4%) 41 (31.1%) 57 (43.2%) Statistical significance 2=83.89:p<0.001 2=19.85;p<0.001 2=6.80; p=0.009 2=4.65; p=0.031 2=6.05; p=0.014 2=14.87;p<0.001 ns =5.56 i p=0.018 2=5.11 i p=0.024 2=7.47 i p=0.006 2=15.81;p<0.001 ns Mantel-Haenszel chi square test (2 value) ns - no significant difference Table 3. Number and percentage of subjects with MetSy and abnormal value of according to category Normal weight Overweight (n=21) (n=76) 5 (23.8%) 1 (4.8%) Obesity (n=35) Statistical significance (Mantel-Haenszel2 or Fisher's test) A,B, C A, B 94cm (m) METABOLIC SYNDROME 52 (68.4%) 34 (97.1%) 35 (46.1%) 23 (65.7%) Obesity (n=18) Normal weight Overweight (n=74) (n=40) 80cm (f) METABOLIC SYNDROME 19 (25.7%) 15 (20.3%) 37 (92.5%) 18 (100.0%) 29 (72.5%) 13 (72.2%) B A, B A - optimal weight vs overweight; B - optimal weight vs obese; C - overweight vs obese; * - p<0.05; p<0.01; - p<0.001; ns - no significant difference Table 4. Average values of age, , BP, glycemia, cholesterol and of the whole sample according to category Ages (years) Waist circumference (cm) Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg) Blood glucosa (mmol/l) Total cholesterol (mmol/l) LDL cholesterol (mmol/l) HDL cholesterol (mmol/l) (mmol/L) Normal weight (n=95) 42.96±8.68 78.06±9.71 119.95±16.33 76.11±11.09 5.20±0.60 5.11±0.71 2.40±0.69 1.38±0.29 1.52±1.12 Overweight (n=116) 47.09±8.75 95.83±8.84 128.49±14.69 82.63±10.50 5.61±1.12 5.65±0.75 2.82±0.75 1.30±0.29 2.16±1.05 Obesity (n=53) 47.57±8.85 112.34±11.59 134.91±14.16 87.64±10.59 5.82±1.44 5.73±0.71 2.78±0.57 1.28±0.21 2.31±1.12 ANOVA i Dunnet's test) A, B A, B, C A, B, C* A, B, C* A, B* A, B A, B ns A, B Table 5. Average values of ages, , BP, glycemia, cholesterol and of men according to category Ages (years) Waist circumference (cm) Sistolic blood pressure (mmHg) Diastolic blood pressure (mmHg) Blood glucosa (mmol/l) Total cholesterol (mmol/l) LDL cholesterol (mmol/l) HDL cholesterol (mmol/l) (mmol/L) Normal weight (n=21) 40.95±9.80 89.33±5.77 127.86±23.00 82.14±13.47 5.14±0.38 5.33±1.21 2.74±1.12 1.59±0.41 1.65±0.81 Overweight (n=76) 45.64±9.41 98.87±8.41 130.33±13.74 84.67±10.56 5.64±1.32 5.65±0.80 2.90±0.85 1.39±0.32 2.38±1.20 Obesity (n=35) 45.00±8.69 114.26±11.86 135.29±14.40 87.43±11.72 5.94±1.71 5.67±0.76 2.75±0.58 1.33±0.23 2.50±1.30 ANOVA i Dunnet's test) ns A, B, C ns ns A*, B* ns ns B* A, B* Table 6. Average values of ages, , BP, glycemia, cholesterol and of women according to category <25 kg/m2(n=74) 43.53±8.32 74.86±8.08 117.70±13.25 74.39±9.76 5.22±0.65 5.04±0.48 2.31±0.46 1.31±0.21 1.48±1.19 =2529.9kg/m2 (n=40) 49.85±6.62 90.05±6.51 125.00±15.93 78.75±9.32 5.56±0.58 5.65±0.65 2.68±0.47 1.13±0.12 1.73±0.41 30kg/m2(n=18) 52.56±6.96 108.61±10.34 134.17±14.06 88.06±8.25 5.60±0.68 5.83±0.59 2.83±0.56 1.18±0.10 1.96±0.50 ANOVA i Dunnet's test) A, B A, B, C A*, B A*, B, C A*, B* A, B A, B A, B B* Ages (years) Waist circumference (cm) Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg) Blood glucosa (mmol/l) Total cholesterol (mmol/l) LDL cholesterol (mmol/l) HDL cholesterol (mmol/l) (mmol/L) Table 7. Correlation coefficients between anthropometric indices and other components for MetSy Total cholesterol Blood glucose LDL-C HDL-C Ages Blood glucose Total cholesterol LDL-C HDL-C -0.06 -0.03 0.17 0.21 0.13* 0.13* 0.25 0.18 0.01 0.07 0.06 0.03 0.01 0.06 0.07 0.78 0.85 0.36 0.40 0.24 0.22 0.87 0.32 0.35 0.22 0.35 0.35 0.38 0.28 0.32 0.84 0.14* 0.15* 0.14* 0.19 0.12 0.02 0.02 0.31 0.30 0.28 0.32 0.36 0.15* 0.25 0.26 0.13* Table 8. Correlation coefficients between anthropometric indices and other components for MetSy-men Total cholesterol Blood glucose LDL-C HDL-C Ages Blood glucose Total cholesterol LDL-C Ages -0.39 -0.12 0.17 0.05 -0.01 0.29 0.21* 0.08 0.12 0.01 0.22* 0.57 -0.07 0.07 0.01 -0.24 -0.30 -0.08 0.11 0.11 0.09 0.04 0.10 0.09 0.06 0.05 0.08 0.06 -0.17 -0.05 -0.13 -0.06 0.58 0.83 0.19* 0.23* 0.20* -0.02 0.78 0.03 0.19* 0.20* 0.26 0.80 0.08 0.07 -0.15 -0.25 0.24 -0.01 -0.25 0.26 0.85 -0.26 0.19* -0.20* 0.13 -0.24 Table 9. Correlation coefficients between anthropometric indices and other components for MetSy-women Total cholesterol Blood glucosa LDL-C HDL-C Ages Blood glucosa Total cholesterol LDL-C Ages -0.06 0.27 0.38 0.42 0.31 0.41 0.25 0.20* 0.22* -0.24 -0.07 -0.11 -0.08 0.03 0.01 -0.15 -0.09 -0.08 0.10 0.76 0.89 0.31 0.33 0.25 0.40 0.33 -0.32 0.35 0.39 0.31 0.49 0.37 -0.40 0.84 0.19* 0.19* 0.12 0.18 -0.23* 0.09 -0.04 0.05 0.13 0.20* 0.91 0.35 0.41 0.35 0.54 0.44 -0.47 0.21* 0.21* 0.21* 0.22* -0.27 0.26 0.19* -0.37 0.21* 0.71 -0.48 0.23* -0.46 0.35 -0.21* DISCUSSION The prevalence of dyslipidemia, angina pectoris and myocardial infarction, as well as the lethal outcome, is higher in overweight patients (11). Not only but also the distribution of body fat has a direct impact on the occurrence of metabolic disorders that lead to the metabolic syndrome (7, 8). The study included 264 examinees (132 men, mean age 44.73±9.37 years and 132 women, mean age 44.73±9.37 years), who were on a regular systematic check-up with no history of diabetes or cardiovascular disease. Our participants performed an easy physical work and lead a sedentary lifestyle. In our study, metabolic syndrome was diagnosed in 59 men (44.7%) and 57 females (43.2%). It has been estimated that 17-25% of the world population has MetSy, and in people with DM the reported prevalence rates range from 59% to 61% (3). The authors who have studied this problem found different data. Ardern et al. (8) showed that 17% of men and 13.2% of women in Canada have MetSy, while the prevalence of MetSy among U.S. adults was 24,0% in men and 23.4% in women (12). According to the literature, the MetSy frequency ranges from 9% to 32% depending on the ethnic background of the examined population and the definition of the metabolic syndrome, which is used for establishing the diagnosis (5, 8). As can be seen from the data, the frequency of MetSy depends on gender, ethnicity, and is directly related to age. In the western populations, the MetSy frequency is higher and more common in men, while the Chinese and Arabs MetSy is more common in women. The prevalence of MetSy in the European population by IDF classification was 35.9% in men and 34.1% in women (5). Studies have shown that MetSy is related to obesity. However, some studies have shown that there is a subgroup of obese, which is metabolically normal (13). Our research showed that MetSy is reported in 65.7% of obese men and in 72.2% of obese women, while in the category of normal weight subjects the syndrome occurs in 4.8% of men and 20.3% women. According to the NHANES (1988-1994), in normal weight individuals MetSy was reported in 4.6% of men, in 22.4% in the overweight group, and in 59.6% in obese group; similar distribution was observed in women, and even then Insulin Resistance Atherosclerosis Study suggested that waist circumference was introduced as a measure of obesity to predict the incidence of MetSy (5). Recent studies have shown that only about 7% of normal weight males, 30% of overweight males and 65% of obese males had MetSy. Slightly more than 9% of normal weight females, 33% of overweight females, and 56% of obese females had MetSy (13). In people who are normally-nourished and obese, the prevalence of metabolic syndrome increases with increasing of waist circumference. If 30 kg/m2, it points to the existence of central obesity (8). The preva28 lence of abdominal obesity in our study was 68.9% in men and 56.1% in women. In the group of normal-weight men and women, the prevalence of abdominal obesity was 23.8% and 25.7%, respectively. In the overweight group, 68.4% of men and 92.7% of women had increased , while in the obese group abdominal obesity occurs in 97.1% of men and 100% of women. In a study conducted by Ardren et al. (8), 65% of obese men and 80% of women had values higher than the limit values; in the group of overweight people, 13% of men and 27% of women had high levels of . Janssen et al. (14) have obtained similar findings: increased levels of had in the normal-weight category 1.0% of men and 13.7% of women, in the overweight group 27.6% of men and 71.6% of women, while the prevalence of abdominal obesity in the obese group was 84.8% of men and 97.6% of women. These data confirm previous studies that show that there is abdominal obesity if 30kg/m2, in the case of which does not have to be measured (8). Studies have shown that there were differences in the prevalence of each of the individual risk factors by sex. Males had a higher prevalence of hypertriglyceridemia, hypertension, and hyperglycemia than females, but females had a higher prevalence of abdominal obesity and low HDL cholesterol than males (13). In the examined male elements, that are commonly associated with the development MetSy, were elevated serum (55.3%) and the presence of hypertension and impaired glycemic control (32.6%), while the and low HDL cholesterol were less important. In groups of women the most common elements of the metabolic syndrome were waist circumferences (56.1%), impaired glycemic control (43.2%) and elevated serum (31%). Analysis of the data confirmed a significant positive correlation between and other parameters, and values of body weight and waist circumference were significantly positively interdependent with all indicators, except for HDL cholesterol. This indicates that both anthropometric factors correlated with risk factors for cardiovascular disease. In the examined men, showed a significant correlation with all factors: is significantly positively correlated with the values of , , blood pressure, blood glucose and triglyceride levels, while negatively correlated with HDL cholesterol. In men, values are positively related only with the values of body weight and . In the examined women, values show a significant correlation with all measured parameters, and values of body weight and are not correlated only with . In many studies, as in our study, it was shown that abdominal obesity in women is associated with metabolic syndrome and the presence of risk factors for cardiovascular disease, while the health risks associated with high are limited only to overweight men (15). However, studies have shown that both factors correla- ted with all 10 risk factors for cardiovascular disease in young adults of both sexes, and in the elderly these anthropometric factors are correlated with 8 of 10 risk factors (14). is increasingly being proposed as a better predictor of cardiovascular risk than . However, few direct comparisons exist between and as predictors of metabolic abnormalities in the elderly, and evidence tends to come from studies with a wide population range. In the third National Health and Nutrition Examination Study and in population studies from Canada, Hong Kong, and Japan, was more closely related to metabolic risk factors than was (7). The limitation of the study is the small sample size, so the results cannot be applied to the urban population in Serbia. Since the sample is small and we excluded examinees with diabetes and CVD, there is a possibility that among subjects not diagnosed with diabetes the frequency of MetSy and individual metabolic factors are higher than in similar studies. However, as in many studies, in our study the males had higher prevalence of hypertriglyceridemia, hypertension, and hyperglycemia than females, but females had higher prevalence of abdominal obesity and low HDL cholesterol compared to males. Therefore, the relationships between adiposity measures and MetSy in this report are the same as in many similar studies. CONCLUSION Results of our study indicate that MetSy is present in a high percentage in healthy individuals in Belgrade, which refers to both males and females. Determination of waist circumference is a quick and simple method for the assessment of central obesity. Anthropometric indices ( and ) are useful screening tools for obesity, MetSy or its components, and CVD risk factors. The results obtained in this study indicate that is a good indicator of health risk in women but not in men. Measurement of by categories may indicate a person with an increased risk of development of chronic diseases. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Acta Facultatis Medicae Naissensis de Gruyter

Evaluation of Anthropometric Indices for Metabolic Syndrome and their Association with Metabolic Risk Factors among Healthy Individuals in New Belgrade

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10.2478/v10283-012-0032-4
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Abstract

ACTA FACULTATIS MEDICAE NAISSENSIS DOI: 10.2478/v10283-012-0032-4 UDC: 616-008.9-084 Scientific Journal of the Faculty of Medicine in Nis 2013;30(1):21-30 Original article Evaluation of Anthropometric Indices for Metabolic Syndrome and their Association with Metabolic Risk Factors among Healthy Individuals in New Belgrade Veroslava Stankovi1, Svetlana Stojanovi1, Naa Vasiljevi2 Higher Education School of Professional Health Studies in Belgrade, Serbia University of Belgrade, Faculty of Medicine, Serbia SUMMARY People with metabolic syndrome (MetSy) are about twice as likely to develop cardiovascular disease and over four times as likely to develop type 2 diabetes compared to subjects without metabolic syndrome. Waist circumferences () and index () are useful screening tools for making the diagnosis. MetSy has increased the health risk in primary care. The aim of the study was to evaluate the anthropometric indices for MetSy and determine which of simple anthropometric measurements is most closely associated with metabolic risk factors. The research included 264 individuals, of which 132 men with mean age (±SD) of 44.73 ±9.37 years and 132 women with mean age (±SD) of 46.67±8.44 years. Antropometric indicators were measured using standard protocols, without shoes and outerwear. was calculated as weight/height2(kg/m2) ratio, as recommended by the World Health Organization (WHO). Blood pressure measurements were obtained with the subject in a seated position by using a standard mercury sphygmomanometer. Blood samples were obtained after a minimum of 12-h fast; the metabolic parameters (high-density lipoprotein-cholesterol, low-density lipoprotein-cholesterol, , blood glucose) were analyzed by standard procedures. Analysis of the examinees' medical records was also performed. Metabolic syndrome was diagnosed using the International Diabetes Federation (IDF) criteria. The analysis of the research results were performed using the Statistical Package for Social Science version 10.0 (SPSS 10.0 for Windows). The prevalence of the metabolic syndrome was 44.7% in men and 43.2% in women. Normal-weight subjects of both sexes were significantly younger and had significantly lower blood glucose, total cholesterol, LDL and than overweight and obese subjects. Systolic and diastolic blood pressure values were significantly increased in parallel with increasing of . For the whole sample, both anthropometric indices had significant associations with the other five components of MetSy. Waist circumference is a simple measure of adiposity most strongly associated with metabolic abnormalities. The results obtained in this study indicate that is a good indicator of health risk in women but not in men. Measurement of by categories may indicate a person with an increased risk of development of chronic diseases. Key words: waist circumference, index, metabolic syndrome, health risk appraisal Corresponding author: Veroslava Stankovi · phone: 062 250 675· e-mail: dr_vera@verat.net · 21 INTRODUCTION The prevalence of metabolic syndrome (MetSy) has dramatically increased with the rapid development of economy and society. Changed lifestyle, dietary pattern and low regular physical activity have also shown to be the major risk factors for cardiovascular disease (CVD), diabetes, and other chronic diseases (1, 2). It has been estimated that 17-25% of the world population have MetSy, and the importance of the metabolic syndrome lies largely in the development of cardiovascular diseases and type 2 diabetes mellitus (3). Genetic factors, aging, hormonal factors and proinflammatory conditions may affect the occurrence of MetSy (4, 5). In 1999, the WHO criteria for MetSy and were considered to be among the optional criteria. As for the development of the MetSy definitions, waist circumference () has been an optional component of MetSy, according to the Adult Treatment Panel III (ATPIII) Guideline (6). In the International Diabetes Federation (IDF) criteria (2005), central obesity is the major driver of MetSy developments (5, 6). and are useful screening tools for identifying obesity. Each index has different associations with obesity-related physiological and pathological processes (1, 3). Of many ways of measuring body fat and its distributions, anthropometric measurements still play an important role in clinical practice (7, 8). cut-off points may vary with age, gender, and menopausal status because of variation in body composition. While is a convenient marker of the overall adiposity, it does not distinguish between fat and lean , or between central adiposity, a better correlate of insulin resistance (IR) and peripheral adiposity. Compared to , is a better measurement of abdominal fat accumulation. It is unclear if direct measures of adiposity add further information about the link between adiposity and MetSy components in lean populations beyond and (9). The aim of the study was to evaluate the anthropometric indices for metabolic syndrome (MetSy), to determine which of these adiposity measures are the best predictors of metabolic risk factors and assess whether the combination of and is a better indicator of metabolic risk. EXAMINEES AND METHODS The study included 264 examinees (132 men, mean age 44.73±9.37 years and 132 women, mean age 44.73±9.37 years), who were on a regular systematic review in the Preventive center "Novi Beograd", in the period September-October, 2007. After the analysis of subjects'medical records, we excluded individuals with diabetes and CVD. In the study groups, clinical examinations were performed including blood pressure measurement, as well as blood biochemistry, and evaluation of anthro22 pometric parameters, nutritional status and metabolic risk factors. Participants attended the survey site early in the morning (6:30-9:30 A.M.) after 12 hours fasting. Anthropometric measurements were performed with subjects in light clothing and barefooted, and under standard procedures (10). Body weight was measured to the nearest 0.1 kg using a digital scale (SECAW, Columbia, USA), and height to the nearest centimetre using a wall stadiometer (SECAW, Hamburg, Germany). From these values, was calculated as recommended by the World Health Organization (WHO) - weight in kilograms divided by the square of height in meter (10). According to the nutritional status, the subjects were divided into three groups: group 1 - normal-weight (=18.5 to 24.99 kg/m2), group 2 - overweight (=25.00 to 29.99 kg/m2); group 3 - obese (30kg/m2). Waist circumference was measured with subject wearing light clothing (underwear) at a level midway between the lower rib margin and iliac crest to the nearest centimeter using a plastic, nonstretchable tailor's measuring tape. The measurements were recorded in centimeters. Blood pressure was measured to the nearest 2 mmHg on the right arm with subjects seated, after at least 10 min of rest, using a standard mercury sphygmomanometer. The mean of the two readings was taken as each individual's blood pressure. Evaluation of metabolic risk factors included the determination of blood glucose, total cholesterol, HDLC, low density lipoprotein (LDL-C) and . Two sets of fasting blood samples were collected from each subject in sodiumfluoride potassium oxalate tubes (for glucose) and lithium heparin vacuum tubes (for lipids). Blood glucose concentration was determined by the oxidation of glucose (glucose analyzer Beckman Coulter). Total cholesterol, HDL, LDL and were determined by chromatography (accessories Boeringher Mannheim). Reference values for serum lipid profile and fasting glucose were determined on the basis of The International Diabetes Federation (IDF) diagnstic criteria for MetSy (4). IDF diagnostic criteria for metabolic syndrome (5) are listed as following: equal or greater than 80 cm in women or equal or greater than 94 cm in men plus 2 or more of the following: · Low HDL cholesterol with values equaling or lower than 1.03 mmol/L for men and 1.29 mmol/L for women. · Hypertriglyceridemia with values higher than 1.7 mmol/L or under treatment. · Arterial hypertension with values equaling or higher than 130/85 mmHg, or under treatment; · Fasting hyperglycemia with values equaling or higher than 5.6 mmol/L , or under treatment. All data were expressed as mean value ± standard deviation (SD) unless other indicated. Descriptive analyses were performed for all s, and analyses of variance were used to assess differences among groups for the continuous s. Partial correlation coefficients were conducted to estimate the relationships between obesity indicators and metabolic risk factors. All statistical analyses were performed using the Statistical Package for Social Science version 10.0 (SPSS for Windows). All P values were based on two-sided tests with a significance level of 0.05. In addition to waist circumference (p<0.001), normal-weight men had significantly lower serum glucose level (p<0.05) and compared to overweight and obese men, and higher HDL cholesterol compared to obese subjects (Table 5). Normal-weight women were significantly younger than obese and overweight (p<0.001). All valuable and laboratory parameters were significantly increased with increasing . HDL cholesterol in normal weight women was significantly higher than in other subjects (Table 6). RESULTS Characteristics of subjects Of 264 subjects, there were 132 men with mean age (±SD) 44.73±9.37 years and 132 women with mean age (±SD) 46.67±8.44 years. Characteristics of study subjects and the level of metabolic risk components are shown in Table 1. Among the examinees, according to the criteria of IDF, MetSy was found in 44.7% of men and 43.2% of women. No statistically significant difference was found between the prevalence of MetSy in males and females (Table 2). Among subjects with normal , only 5 men had 94cm, and 19 women had 80cm (Table 3). Normal-weight subjects of both sexes were significantly younger and had significantly lower blood glucose, total cholesterol, LDL and than overweight and obese subjects. Systolic and diastolic blood pressure values were significantly increased in parallel with increasing (p<0.001) (Table 4). Relationship between anthropometric indices and metabolic risk factors Table 7 shows correlations between anthropometric indices and nonadipose components of MetSy for the whole sample, according to the criteria of IDF. For the whole sample, both anthropometric indices had significant associations with the five nonadipose components of MetSy. In men, was positively related to , blood pressure, blood glucose and triglyceride levels, while negatively correlated with HDL cholesterol. values in men were significantly associated only with the values of (r=0.58, p<0.01) and (r= 0.78, p<0.01) (Table 8). In women, values show a significant correlation with all parameters and values of body weight, and were significantly associated with all indicators, except (Table 9). Table 1. Characteristics of subjects (Mean±SD) Age (years) Waist circumference(cm) index (kg/m2) Systolic blood pressure(mmHg) Diastolic blood pressure(mmHg) Blood glucosa(mmol/l) Total cholesterol(mmol/l) LDL cholesterol(mmol/l) HDL cholesterol(mmol/l) (mmol/L) Male (n=132) 44.73±9.37 101.43±12.38 27.79±3.63 131.25±15.79 85.00±11.41 5.64±1.36 5.61±0.87 2.83±0.84 1.40±0.32 2.30±1.20 Female (n=132) 46.67±8.44 84.07±14.30 24.60±4.45 122.16±15.25 77.58±10.44 5.37±0.65 5.33±0.64 2.49±0.52 1.24±0.19 1.62±0.96 Table 2. Number and percentage of subjects with abnormal value <25 kg/m2 =25-29.9 kg/m2 30 kg/m2 94 cm (m); 80 cm (f) 130 mmHg 85 mmHg Blood glucose5.6 mmol/L Total cholesterol5.2 mmol/L LDL cholesterol2.6 mmol/L HDL cholesterol<1.04 mmol/L (m); 1.29 (f) 1.7mmol/L METABOLIC SYNDROME Male (n=132) 21 (15.9%) 76 (57.6%) 35 (26.5%) 91 (68.9%) 73 (55.3%) 72 (54.5%) 43 (32.6%) 67 (50.8%) 62 (47.0%) 6 (4.5%) 73 (55.3%) 59 (44.7%) Female (n=132) 74 (56.1%) 40 (30.3%) 18 (13.6%) 74 (56.1%) 53 (40.2%) 41 (31.1%) 57 (43.2%) 48 (36.4%) 44 (33.3%) 19 (14.4%) 41 (31.1%) 57 (43.2%) Statistical significance 2=83.89:p<0.001 2=19.85;p<0.001 2=6.80; p=0.009 2=4.65; p=0.031 2=6.05; p=0.014 2=14.87;p<0.001 ns =5.56 i p=0.018 2=5.11 i p=0.024 2=7.47 i p=0.006 2=15.81;p<0.001 ns Mantel-Haenszel chi square test (2 value) ns - no significant difference Table 3. Number and percentage of subjects with MetSy and abnormal value of according to category Normal weight Overweight (n=21) (n=76) 5 (23.8%) 1 (4.8%) Obesity (n=35) Statistical significance (Mantel-Haenszel2 or Fisher's test) A,B, C A, B 94cm (m) METABOLIC SYNDROME 52 (68.4%) 34 (97.1%) 35 (46.1%) 23 (65.7%) Obesity (n=18) Normal weight Overweight (n=74) (n=40) 80cm (f) METABOLIC SYNDROME 19 (25.7%) 15 (20.3%) 37 (92.5%) 18 (100.0%) 29 (72.5%) 13 (72.2%) B A, B A - optimal weight vs overweight; B - optimal weight vs obese; C - overweight vs obese; * - p<0.05; p<0.01; - p<0.001; ns - no significant difference Table 4. Average values of age, , BP, glycemia, cholesterol and of the whole sample according to category Ages (years) Waist circumference (cm) Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg) Blood glucosa (mmol/l) Total cholesterol (mmol/l) LDL cholesterol (mmol/l) HDL cholesterol (mmol/l) (mmol/L) Normal weight (n=95) 42.96±8.68 78.06±9.71 119.95±16.33 76.11±11.09 5.20±0.60 5.11±0.71 2.40±0.69 1.38±0.29 1.52±1.12 Overweight (n=116) 47.09±8.75 95.83±8.84 128.49±14.69 82.63±10.50 5.61±1.12 5.65±0.75 2.82±0.75 1.30±0.29 2.16±1.05 Obesity (n=53) 47.57±8.85 112.34±11.59 134.91±14.16 87.64±10.59 5.82±1.44 5.73±0.71 2.78±0.57 1.28±0.21 2.31±1.12 ANOVA i Dunnet's test) A, B A, B, C A, B, C* A, B, C* A, B* A, B A, B ns A, B Table 5. Average values of ages, , BP, glycemia, cholesterol and of men according to category Ages (years) Waist circumference (cm) Sistolic blood pressure (mmHg) Diastolic blood pressure (mmHg) Blood glucosa (mmol/l) Total cholesterol (mmol/l) LDL cholesterol (mmol/l) HDL cholesterol (mmol/l) (mmol/L) Normal weight (n=21) 40.95±9.80 89.33±5.77 127.86±23.00 82.14±13.47 5.14±0.38 5.33±1.21 2.74±1.12 1.59±0.41 1.65±0.81 Overweight (n=76) 45.64±9.41 98.87±8.41 130.33±13.74 84.67±10.56 5.64±1.32 5.65±0.80 2.90±0.85 1.39±0.32 2.38±1.20 Obesity (n=35) 45.00±8.69 114.26±11.86 135.29±14.40 87.43±11.72 5.94±1.71 5.67±0.76 2.75±0.58 1.33±0.23 2.50±1.30 ANOVA i Dunnet's test) ns A, B, C ns ns A*, B* ns ns B* A, B* Table 6. Average values of ages, , BP, glycemia, cholesterol and of women according to category <25 kg/m2(n=74) 43.53±8.32 74.86±8.08 117.70±13.25 74.39±9.76 5.22±0.65 5.04±0.48 2.31±0.46 1.31±0.21 1.48±1.19 =2529.9kg/m2 (n=40) 49.85±6.62 90.05±6.51 125.00±15.93 78.75±9.32 5.56±0.58 5.65±0.65 2.68±0.47 1.13±0.12 1.73±0.41 30kg/m2(n=18) 52.56±6.96 108.61±10.34 134.17±14.06 88.06±8.25 5.60±0.68 5.83±0.59 2.83±0.56 1.18±0.10 1.96±0.50 ANOVA i Dunnet's test) A, B A, B, C A*, B A*, B, C A*, B* A, B A, B A, B B* Ages (years) Waist circumference (cm) Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg) Blood glucosa (mmol/l) Total cholesterol (mmol/l) LDL cholesterol (mmol/l) HDL cholesterol (mmol/l) (mmol/L) Table 7. Correlation coefficients between anthropometric indices and other components for MetSy Total cholesterol Blood glucose LDL-C HDL-C Ages Blood glucose Total cholesterol LDL-C HDL-C -0.06 -0.03 0.17 0.21 0.13* 0.13* 0.25 0.18 0.01 0.07 0.06 0.03 0.01 0.06 0.07 0.78 0.85 0.36 0.40 0.24 0.22 0.87 0.32 0.35 0.22 0.35 0.35 0.38 0.28 0.32 0.84 0.14* 0.15* 0.14* 0.19 0.12 0.02 0.02 0.31 0.30 0.28 0.32 0.36 0.15* 0.25 0.26 0.13* Table 8. Correlation coefficients between anthropometric indices and other components for MetSy-men Total cholesterol Blood glucose LDL-C HDL-C Ages Blood glucose Total cholesterol LDL-C Ages -0.39 -0.12 0.17 0.05 -0.01 0.29 0.21* 0.08 0.12 0.01 0.22* 0.57 -0.07 0.07 0.01 -0.24 -0.30 -0.08 0.11 0.11 0.09 0.04 0.10 0.09 0.06 0.05 0.08 0.06 -0.17 -0.05 -0.13 -0.06 0.58 0.83 0.19* 0.23* 0.20* -0.02 0.78 0.03 0.19* 0.20* 0.26 0.80 0.08 0.07 -0.15 -0.25 0.24 -0.01 -0.25 0.26 0.85 -0.26 0.19* -0.20* 0.13 -0.24 Table 9. Correlation coefficients between anthropometric indices and other components for MetSy-women Total cholesterol Blood glucosa LDL-C HDL-C Ages Blood glucosa Total cholesterol LDL-C Ages -0.06 0.27 0.38 0.42 0.31 0.41 0.25 0.20* 0.22* -0.24 -0.07 -0.11 -0.08 0.03 0.01 -0.15 -0.09 -0.08 0.10 0.76 0.89 0.31 0.33 0.25 0.40 0.33 -0.32 0.35 0.39 0.31 0.49 0.37 -0.40 0.84 0.19* 0.19* 0.12 0.18 -0.23* 0.09 -0.04 0.05 0.13 0.20* 0.91 0.35 0.41 0.35 0.54 0.44 -0.47 0.21* 0.21* 0.21* 0.22* -0.27 0.26 0.19* -0.37 0.21* 0.71 -0.48 0.23* -0.46 0.35 -0.21* DISCUSSION The prevalence of dyslipidemia, angina pectoris and myocardial infarction, as well as the lethal outcome, is higher in overweight patients (11). Not only but also the distribution of body fat has a direct impact on the occurrence of metabolic disorders that lead to the metabolic syndrome (7, 8). The study included 264 examinees (132 men, mean age 44.73±9.37 years and 132 women, mean age 44.73±9.37 years), who were on a regular systematic check-up with no history of diabetes or cardiovascular disease. Our participants performed an easy physical work and lead a sedentary lifestyle. In our study, metabolic syndrome was diagnosed in 59 men (44.7%) and 57 females (43.2%). It has been estimated that 17-25% of the world population has MetSy, and in people with DM the reported prevalence rates range from 59% to 61% (3). The authors who have studied this problem found different data. Ardern et al. (8) showed that 17% of men and 13.2% of women in Canada have MetSy, while the prevalence of MetSy among U.S. adults was 24,0% in men and 23.4% in women (12). According to the literature, the MetSy frequency ranges from 9% to 32% depending on the ethnic background of the examined population and the definition of the metabolic syndrome, which is used for establishing the diagnosis (5, 8). As can be seen from the data, the frequency of MetSy depends on gender, ethnicity, and is directly related to age. In the western populations, the MetSy frequency is higher and more common in men, while the Chinese and Arabs MetSy is more common in women. The prevalence of MetSy in the European population by IDF classification was 35.9% in men and 34.1% in women (5). Studies have shown that MetSy is related to obesity. However, some studies have shown that there is a subgroup of obese, which is metabolically normal (13). Our research showed that MetSy is reported in 65.7% of obese men and in 72.2% of obese women, while in the category of normal weight subjects the syndrome occurs in 4.8% of men and 20.3% women. According to the NHANES (1988-1994), in normal weight individuals MetSy was reported in 4.6% of men, in 22.4% in the overweight group, and in 59.6% in obese group; similar distribution was observed in women, and even then Insulin Resistance Atherosclerosis Study suggested that waist circumference was introduced as a measure of obesity to predict the incidence of MetSy (5). Recent studies have shown that only about 7% of normal weight males, 30% of overweight males and 65% of obese males had MetSy. Slightly more than 9% of normal weight females, 33% of overweight females, and 56% of obese females had MetSy (13). In people who are normally-nourished and obese, the prevalence of metabolic syndrome increases with increasing of waist circumference. If 30 kg/m2, it points to the existence of central obesity (8). The preva28 lence of abdominal obesity in our study was 68.9% in men and 56.1% in women. In the group of normal-weight men and women, the prevalence of abdominal obesity was 23.8% and 25.7%, respectively. In the overweight group, 68.4% of men and 92.7% of women had increased , while in the obese group abdominal obesity occurs in 97.1% of men and 100% of women. In a study conducted by Ardren et al. (8), 65% of obese men and 80% of women had values higher than the limit values; in the group of overweight people, 13% of men and 27% of women had high levels of . Janssen et al. (14) have obtained similar findings: increased levels of had in the normal-weight category 1.0% of men and 13.7% of women, in the overweight group 27.6% of men and 71.6% of women, while the prevalence of abdominal obesity in the obese group was 84.8% of men and 97.6% of women. These data confirm previous studies that show that there is abdominal obesity if 30kg/m2, in the case of which does not have to be measured (8). Studies have shown that there were differences in the prevalence of each of the individual risk factors by sex. Males had a higher prevalence of hypertriglyceridemia, hypertension, and hyperglycemia than females, but females had a higher prevalence of abdominal obesity and low HDL cholesterol than males (13). In the examined male elements, that are commonly associated with the development MetSy, were elevated serum (55.3%) and the presence of hypertension and impaired glycemic control (32.6%), while the and low HDL cholesterol were less important. In groups of women the most common elements of the metabolic syndrome were waist circumferences (56.1%), impaired glycemic control (43.2%) and elevated serum (31%). Analysis of the data confirmed a significant positive correlation between and other parameters, and values of body weight and waist circumference were significantly positively interdependent with all indicators, except for HDL cholesterol. This indicates that both anthropometric factors correlated with risk factors for cardiovascular disease. In the examined men, showed a significant correlation with all factors: is significantly positively correlated with the values of , , blood pressure, blood glucose and triglyceride levels, while negatively correlated with HDL cholesterol. In men, values are positively related only with the values of body weight and . In the examined women, values show a significant correlation with all measured parameters, and values of body weight and are not correlated only with . In many studies, as in our study, it was shown that abdominal obesity in women is associated with metabolic syndrome and the presence of risk factors for cardiovascular disease, while the health risks associated with high are limited only to overweight men (15). However, studies have shown that both factors correla- ted with all 10 risk factors for cardiovascular disease in young adults of both sexes, and in the elderly these anthropometric factors are correlated with 8 of 10 risk factors (14). is increasingly being proposed as a better predictor of cardiovascular risk than . However, few direct comparisons exist between and as predictors of metabolic abnormalities in the elderly, and evidence tends to come from studies with a wide population range. In the third National Health and Nutrition Examination Study and in population studies from Canada, Hong Kong, and Japan, was more closely related to metabolic risk factors than was (7). The limitation of the study is the small sample size, so the results cannot be applied to the urban population in Serbia. Since the sample is small and we excluded examinees with diabetes and CVD, there is a possibility that among subjects not diagnosed with diabetes the frequency of MetSy and individual metabolic factors are higher than in similar studies. However, as in many studies, in our study the males had higher prevalence of hypertriglyceridemia, hypertension, and hyperglycemia than females, but females had higher prevalence of abdominal obesity and low HDL cholesterol compared to males. Therefore, the relationships between adiposity measures and MetSy in this report are the same as in many similar studies. CONCLUSION Results of our study indicate that MetSy is present in a high percentage in healthy individuals in Belgrade, which refers to both males and females. Determination of waist circumference is a quick and simple method for the assessment of central obesity. Anthropometric indices ( and ) are useful screening tools for obesity, MetSy or its components, and CVD risk factors. The results obtained in this study indicate that is a good indicator of health risk in women but not in men. Measurement of by categories may indicate a person with an increased risk of development of chronic diseases.

Journal

Acta Facultatis Medicae Naissensisde Gruyter

Published: Mar 1, 2013

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