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Prevelence of Metabolic Syndrome (MetS) in young

and Middle aged with Central Obesity in


Vinukonda, Andhra Pradesh, India

Tirumalasetty RangaRao MD,


Professor & HoD Biochemistry,
Project Director, Obesity Study Center,
Guntur Medical College, Guntur, AP India

Aknowledgement

This work was conducted with the support of Dr Achyut Rao, The Principal, Guntur Medical College, Guntur , AP;
DFID Program under National Rural Health Mission

The author extend his sincere thanks to Dr Suresh Kumar, DMHO Guntur, Dr Giri Kumar Dy DMHO, Guntur
Dr A Satyanarayana Vinukonda Nursing Home, Vinukonda; Doctors of PHCs Public Leaders and people of Vinukonda
area and also Staff and Post Graduates of Department of Biochemistry for their cooperation
Prevelence of Metabolic Syndrome (MetS) in young
and Middle aged with Central Obesity in Vinukonda
Andhra Pradesh, India
Tirumalasetty RangaRao MD,
Professor & HoD Biochemistry,
Project Director, Obesity Study Center,
Guntur Medical College, Guntur, AP India

It is clear that in vivo insulin resistance is a key abnormality associated with an


atherogenic, prothrombotic, and inflammatory profile which has been named by some
the "Metabolic Syndrome"(MetS) or by others "Syndrome X" or "Insulin Resistance
Syndrome", it is more and more recognized that the most prevalent form of this
constellation of metabolic abnormalities linked to insulin resistance is found in patients
with abdominal obesity, especially with an excess of intra-abdominal or visceral adipose
tissue. Visceral obesity may partly be a marker of a dysmetabolic state and partly a
cause of the MetS.

In his 1988 Banting award lecture, Reaven1 proposed that insulin resistance was
a fundamental "disorder" associated with a set of metabolic abnormalities which not only
increased the risk of type 2 diabetes but also contributed to the development of
cardiovascular disease (CVD) before the appearance of hyperglycemia. It is also
relevant to mention that as Reaven found insulin resistant individuals who were not
obese, he did not include obesity as a feature of the insulin resistance syndrome.

Since the introduction of the syndrome X concept, a plethora of studies2–6 have


shown that insulin resistance assessed by various methods is indeed a key factor
associated with clustering atherogenic abnormalities which include a typical atherogenic
dyslipidemic state (high triglyceride and apolipoprotein B concentrations, an increased
proportion of small dense LDL particles and a reduced concentration of HDL-
cholesterol, HDL particles also being smaller in size), a prothrombotic profile, and a
state of inflammation. Furthermore, insulin resistance could also contribute to an
elevated blood pressure7–10 and to dysglycemia,5,11–13 eventually leading, among
genetically susceptible individuals, to systemic hypertension and type 2 diabetes.

Study Design
The project was designed in population who are obese, clinically healthy without
known Diabetes and Hypertention of ages between 18 to 45 years in a primary care
setup of Vinukonda area constitute of Primary Health Centers of Enugupalem, Ipur,
Nuzendla, Bollepalli, Savalyapuram 90 Kms away from Guntur. The individual blood
samples were screened in fasting state for Glucose and Lipid profile. Their BP, Height,
Weight and Waist Circumference was recorded.
Results

Among 61 male and 62 female individuals screened 39 male and 46 female are
with central obesity (increased Waist Circumference) as per International Diabetes
Federation (IDF) criteria14 between ages of 18 to 45.

The diagnosis of MetS

There are three currently recognized criteria


The existence of several diagnostic criteria for the syndrome and the use of different
outcomes can lead to difficulty when comparing data from separate studies. Although
the World Health Organization (WHO) criteria15 are more widely accepted and used in
Europe, the National Cholesterol Education Program Adult Treatment Panel III (NCEP
ATP-III) criteria for the MetS are viewed as simpler and are more commonly used in the
United States16. In most long-term follow- up studies, either the NCEP ATP-III definition
or the WHO criteria were used. The International Diabetes Federation (IDF) criteria14
were defined more recently, and there have been fewer studies testing its predictive
value for CVD compared with other criteria. In the current study IDF criteria is used for
detection of MetS.

IDF criteria14

MetS can be detected when more three of following measures are abnormal
1. High waist circumference (Central Obesity)
waist circumference measurements may need modification for use in different
population groups. The new IDF criteria of the metabolic syndrome have addressed
this issue.
Table 1 – Showing risk levels of Waist Circumference as per IDF criteria
Population group Men Women
South Asian >90 cm (35.4 in) >80 cm (31.5 in)
Europid >94 cm (37.0 in) >80 cm (31.5 in)
Chinese >90 cm (35.4 in) >80 cm (31.5 in)
Japanese >85 cm (33.5 in) >90 cm (35.4 in)
Plus any two of
2. Triglycerides (≥ 1.7 mmol/L [150 mg/dL])
3. HDL cholesterol
a. Men < 1.0 mmol/L (40 mg/dL)
b. Women < 1.3 mmol/L (50 mg/dL)
4. Blood pressure ≥ 130 / >85 mm Hg
5. FPG ≥ 5.6 mmol/L [100 mg/dL], or diabetes

Central obesity is required for diagnosing the metabolic syndrome. The new criteria
of the metabolic syndrome from the IDF requires the presence of high waist
circumference, along with two other cardiovascular risk factors. The IDF criteria are
generally reminiscent of the current NCEP ATP-III criteria, except that the diagnostic
cut-offs for abdominal obesity from 102 to 90cm in males; from 88 to 80cm in south
asian population and FPG 110 to 100mg% in the new IDF criteria.

The Individuals are made into two groups based on age as group-I young (18 to
35 yrs) and group-II middle aged (36 to 45 yrs).
Risk Factor Analysis

Table-2 – Showing prevalence of MetS men and women in Vinukonda


Male Group I Male Group II Female Group I Female Group II
Total Screened 20 25 26 26
Central Obesity 14 24 22 26
HTN, DM* -- 02 -- --
HTN* 03 04 01 04
DM* -- 03 01 05
Study Target 11 15 20 17
MetS 03 06 04 06
% MetS 27.3 40 20 35.3
% MetS- 34.6 27
Genderwise
*New cases of DM and / or HTN detected who are unaware of disease and not under treatment

In Male Group-I three(3) individuals having hypertension. In Male Group-II, two


(2) having DM with Hypertension; Four (4) having Hypertension; Three (3) having DM.
In Female Group-I one women having hypertension other women having DM. In
Female Group-II, four (4) having Hypertension; five (5) having DM.
On excluding the cases of newly diagnosed Hypertension & DM and both, the
final preventable group of MetS (focus of current study) is obtained. In this study the
prevalence of preventable cases of MetS are distributed about 1 in 3 men and 1 in 4
women aged between 18 and 45 years. In both sexes the prevelance is increasing with
age. The prevalence of MetS is higher in middle aged than young. MetS is more
prevalent in middle aged women than young women ie. 35.3% in middle aged to 20% in
young women and that in men it is still higher with 40% in middle aged to 27.3 in young.
However these finding are to be consolidated with large sample size.

Table 3 showing ratio MetS with pre-MetS


Group I (Young) Group II (Middle Aged)
Risk Level (>3 MetS) Risk Level (>3 MetS)
0 <2 3 4 5 R* 0 <2 3 4 5 R*
Male 5 9 3 0 0 1:3 0 10 4 2 0 1:1.7
Female 1 19 3 1 0 1:4.8 0 11 5 1 0 1:1.8
R*= Ratio of MetS : Pre-MetS

In Male Group_I (aged between 18 and 35) 20 people were studied. Three were
diagnosed as hypertensives; three with MetS; Nine with Risk level less than 2 (Pre-
MetS). The ratio of MetS to pre-MetS in young male is 1:3

In Male Group_II (aged between 36 and 45) 25 people were studied. Nine were
diagnosed as Diabetes/hypertensives; Six with MetS; Ten with Risk level less than 2
(Pre-MetS). The ratio of MetS to pre-MetS in young male is 1:1.7 The prevalence is
MetS is almost doubled from young to middle aged.

In Female Group_I (aged between 18 and 35) 26 women were studied. One
woman was diagnosed as Diabetic and other was diagnosed as hypertensive; Four with
MetS; Ninteen with Risk level less than 2 (Pre-MetS). The ratio of MetS to pre-MetS in
young female is 1:4.8 The prevalence is MetS in young women is less than young men.

In Female Group_II (aged between 36 and 45) 26 women were studied. Nine
were diagnosed as Diabetes/hypertensives; Six with MetS; Eleven with Risk level less
than 2 (Pre-MetS). The ratio of MetS to pre-MetS in young male is 1:1.8 The prevalence
is MetS is more than two times from young to middle aged.

The prevalence is almost same in middle aged men and women. The number of
risk factors are increasing with increasing age in both men and women which may be a
reason for an increased risk of CVD with increasing age.
Discussion

Cardiovascular disease (CVD), particularly coronary heart disease


(CHD), remains a major health concern worldwide. More than 15 million adults have
CHD in the United States, and it kills one out of every five people17. In 2004,
approximately one third of deaths from CVD occurred prematurely, and over 147,000
americans killed by CVD were under age 65. Despite the advances in both reperfusion
therapy and post myocardial infarction (MI) management, approximately 38% of the
people who experience a coronary event in a given year will die from it. Primary
prevention is obligatory; it is the most affordable and feasible strategy currently
available to us worldwide.
The metabolic syndrome (MetS) refers to a constellation of interrelated cardiac
risk factors that appear to directly promote development of atherosclerotic
cardiovascular disease (ASCVD)14,16,18-19. It receives widespread attention as obesity
becomes a crisis of epidemic proportions in the India as in the world. Escalating rates of
both obesity and diabetes among the younger population, caused by discernible
changes in lifestyle particularly negative attitude, diet, and environment, continue to fuel
the cardiovascular epidemic. There is lot of support that MetS actually reflects a unique
underlying pathological process.

Metabolic risk factors and cardiovascular disease

Central obesity and insulin resistance are the common underlying denominators
of MetS, and are thought to manifest as several metabolic risk factors, including
atherogenic dyslipidemia, elevated plasma glucose, elevated blood pressure,
proinflammatory state, and prothrombotic state 14,16,18-19,21
. These metabolic risk factors
are believed to have a direct effect on atherosclerotic disease.

Dyslipidemia
The dyslipidemia found in individuals who have the MetS consists of an
aggregate of lipoprotein abnormalities that include: elevated serum triglyceride and
apolipoprotein B (Apo B), low concentration of high-density lipoprotein (HDL)
cholesterol, and increased number of small dense low-density lipoprotein (LDL)
particles and small HDL particles. All of these abnormalities are independently
atherogenic16,22–24.

Inflammation and prothrombotic markers

Individuals who have characteristics of MetS commonly manifest a


proinflammatory and prothrombotic state. This is evidence by elevated levels of C-
reactive protein25, interleukin-6, and plasminogen activator inhibitor-1 (PAI-1)26. Studies
have shown a linear relation between the number of the MetS components and the level
of C-reactive protein20. Inflammatory and prothrombotic markers are known to be
associated with an increased risk of subsequent CVD27.

Risk assessment for future development of atherosclerotic cardiovascular


disease (ASCVD) in individuals who have the metabolic syndrome

To reduce the lifetime risk of ASCVD, all individuals found to have the MetS
deserve a comprehensive global risk assessment and long-term monitoring18.
Individuals who have clinical ASCVD (eg, CHD, stroke, or peripheral artery disease
[PAD]) or who have diabetes belong in a high-risk category and should be treated more
aggressively with risk factor-targeted pharmacotherapy, in addition to lifestyle
intervention to significantly reduce morbidity and mortality. Recommendations from
ATP-III and the 2006 American College of Cardiology (ACC)/American Heart
Association (AHA) guidelines on secondary prevention should be followed in this risk
Category19,28-29.

Clinical implications of diagnosing the metabolic syndrome

Any single risk factor can produce cumulative damage and increase morbidity
and mortality if left untreated for long-term, however, the MetS carries an increased
relative risk for CVD in the short and long term. A diagnosis of the MetS emphasizes the
importance of risk factor modification through lifestyle changes. These interventions
should focus on weight reduction, increased physical activity, an anti-atherogenic diet,
and smoking cessation. Unfortunately, lifestyle intervention is often neglected in daily
practice. Studies demonstrated that increased obesity reduces the beneficial effect of
other risk-reduction strategies30. Institution of lifestyle interventions helps to lessen the
impact of each metabolic risk factor on an individual at every stage, but particularly in
early phases, and slows the subsequent development of CVD. As stated earlier,
identification of individuals who have the MetS is aimed at long-term risk reduction
primarily through lifestyle modification. Incorporating the diagnosis of the MetS into
routine clinical practice may serve as a ‘‘teachable moment,’’ in which health care
providers can help patients understand their true lifetime risk profile, and motivate them
to adopt lifestyle changes that promote health and longevity.

Summary
CVD remains the most widespread health care problem of the world. Recently,
the MetS has received an increasing amount of attention because of the growing
prevalence of obesity and its association with heart disease. Longitudinal observational
studies have confirmed that the MetS is a risk factor for the subsequent development of
CVD and mortality. Identifying patients who have MetS may enhance the clinical
management of individuals who have various risk factors.

Although the scientific basis for the MetS is still debated, its clinical value in
identifying individuals who have a compilation of risk factors who are at an increased
risk for CVD is undisputed. The patients who have the MetS, longterm management of
each risk factor is essential. The lifetime risk for CVD with MetS is higher than expected
in untreated patients. Lifestyle intervention is fundamental and should be introduced,
maintained, and reinforced in all individuals. Pharmacotherapy, targeting individual risk
factors, should be guided by global risk assessment and accepted treatment guidelines.

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