- Email: [email protected]
High prevalence of obesity, dyslipidemia and metabolic syndrome in a rural area in Pakistan
Diabetes & Metabolic Syndrome: Clinical Research & Reviews (2008) 2, 13—19
http://diabetesindia.com/
High prevalence of obesity, dyslipidemia and metabolic syndrome in a rural area in Pakistan Naeem Zahid *, Bjørgulf Claussen, Akhtar Hussain Department of General Practice and Community Medicine, University of Oslo, Norway KEYWORDS Pakistan; Rural; Obesity; Dyslipidemia; Metabolic syndrome
Summary Aims: To determine the prevalence of metabolic syndrome, adiposity and dyslipidemia amongst subjects in a rural area of Pakistan. Methods: One thousand six hundred and fifty-eight rural individuals aged 20 years and above were randomly included in the study. Lipid profile, fasting plasma glucose (FPG), BMI, WHR, and body fat percentage (BF%) were recorded. The prevalence of metabolic syndrome was calculated. Results: High prevalence of obesity, dyslipidemia and metabolic syndrome were recorded. They were all more common in women than men. Conclusions: Obesity, dyslipidemia and metabolic syndrome are common. Preventive measures should be applied to reduce the prevalence of these potential cardiovascular risk factors. # 2007 Diabetes India. Published by Elsevier Ltd. All rights reserved.
Introduction High prevalence of metabolic syndrome and cardiovascular risk factors in South Asians has been regularly reported [1—5]. Jafar et al. showed that one out of four of a randomly sampled adult cohort in Pakistan’s largest city, Karachi, had coronary artery disease [3]. Even though more than one fifth of the world’s population lives in the South Asian subcontinent, very few studies on the metabolic syndrome have been conducted in this part of the world. Studies on metabolic syndrome and risk factors for cardio* Corresponding author at: Department of General Practice and Community Medicine, University of Oslo, Post Box 1130, Blindern, N-0318 Oslo, Norway. E-mail address: [email protected] (N. Zahid).
vascular disease are warranted in Asia because many Asian countries are making rapid socioeconomic and lifestyle changes. Parts of the populations in these countries are experiencing a shift in risk factors from those of under nutrition to over nutrition and overweight [6]. These changes seem in turn to dispose for cardiovascular disease and diabetes. Some studies have been conducted in India with prevalence rates of the metabolic syndrome ranging up to more than 40% of the population [2]. Generally, the components of the metabolic syndrome are unfortunately common amongst South Asians [7]. Very few studies have looked at the prevalence of metabolic syndrome in Pakistan. Looking at coronary heart disease patients and matched controls, on group found that about 44% of the entire cohort and 13% of the controls had metabolic syndrome [4]. They also showed that the
1871-4021/$ — see front matter # 2007 Diabetes India. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.dsx.2007.11.001
14 metabolic syndrome was associated with presence of CAD [8]. A study in Oslo showed that the prevalence of obesity amongst Pakistani-Norwegians was very high, both in terms of BMI and waist hip ratio [9]. Studies in Pakistan confirm the same trend [10]. To our knowledge, no study has looked at metabolic syndrome and dyslipidemia in rural Pakistan. We conducted a cross-sectional survey in a rural area in Pakistan, and have already presented data on the prevalence of diabetes, which was high (submitted). In this paper we look at the epidemiology of dyslipidemia, obesity and the metabolic syndrome.
Research design and methods The study was conducted during the months of March to July year 2006. Subjects were enrolled from 44 villages from an area called Kharian, about 150 km from the capital Islamabad. This is primarily an agricultural community, but has developed greatly in the recent decades due to emigration to Europe and America. All participants were above 20 years of age and met fasting for the examinations. Verbal information was given to all participants, and verbal consent was received. The methods of the survey are described in detail elsewhere (submitted). In short; age, name and gender were recorded. For measuring body weight a digital weight machine was used, using a foot-tofoot bio-impedance method it also showed body fat percentage (BF%). The weight machine was placed on a flat surface. The subjects were wearing light clothes but not shoes. Weight was taken to the nearest kilogram. Fat percentages were noted to the nearest whole number. Height was measured without shoes; the subjects standing upright against a wall with the heels, buttocks, shoulders and the back of the head touching a wall onto which a measuring tape was attached. BMI was calculated by dividing the weight in kilos on the square of the height in meters. Underweight was defined as BMI <18.5 kg/m2; normal weight 18.5—24.9 kg/m2, overweight was defined as BMI between 25 and 29.9 kg/m2, obesity was defined as a BMI 30 kg/ m2 [11]. Waist and hip were measured in centimetres with a non-elastic measuring tape. The waist measure was taken midway between the iliac crest and the lower border of the ribs. The hip girth was measured at the greatest circumference of the buttocks. Waist hip ratio (WHR) was calculated by dividing the waist on the hip girth. Blood pressure was measured with a regular sphygmomanometer; the cuff was placed on the upper arm, the bell on the brachial artery.
N. Zahid et al. Eight milliliters of blood was drawn for fasting plasma glucose (FPG) and lipid profile from a venous puncture. For the analyses of the lipid profile blood was collected in plain tubes, blood samples for plasma glucose was were collected in vials containing and anticoagulant and a glycolysis inhibitor. The blood was transported to the laboratory of the local hospital within 2 h of collection. Before transportation, the blood was stored in refrigerators. The lipid profile consisted of total cholesterol (TotChol), HDL and triglycerides. All blood samples were analyzed by an enzymatic colorimetric method. LDL was computed by Friedwhals formula. Total cholesterol levels higher than 5.0 mmol/L, LDL levels higher then 3.0 mmol/L and triglycerides higher then 1.7 mmol/L were considered high. HDL levels below 1.03 and 1.29 mmol for males and females, respectively, were regarded as low. The laboratory had daily controls and calibrations in addition to monthly inter-laboratory controls. The diagnosis of metabolic syndrome was made by both the ATP III and the newly proposed IDF criteria, South Asian cutoffs were used [12,13]. To meet the ATP III criteria three or more of the following five risk factors must be present: FPG 6.5 mmol/L, TG 1.7 mmol/L, HDL < 1.03 mmol/L for men and <1.29 mmol/L for women, waist >102 cm for men and >88 cm for women [12]. The revised criteria for the IDF definition was as follows: waist 90 cm for men and 80 cm for women and two of the following four: TG 1.7 mmol/L, HDL < 1.03 for men and <1.29 for women, systolic pressure 135 mmHg or diastolic pressure 85 mmHg and FPG 5.6 mmol/L [13]. A total of 2114 subjects were examined. Those who did not have complete values for height, weight, blood pressure, hip, waist, FPG, TotChol, HDL, and TG were also excluded. Complete data had been recorded for 1658 subjects.
Results Out of the 1658 subjects, 600 were males, 1058 were females. The mean age was 44 16.4 years. We found a high prevalence of diabetes, IFG, IGT and hypertension, these results are reported elsewhere (submitted).
Lipids The mean total cholesterol level, LDL and triglycerides levels were in mmol/L were high, HDL levels were low (Table 1). Females had statistically sig-
N
TotChol
LDL
HDL
TG
FPG
Weight
Waist
Waist/Hip
BMI
BF%
Mean
S.E.
Mean
S.E.
Mean
S.E.
Mean
S.E.
Mean
S.E
Mean
S.E.
Mean
S.E.
Mean
S.E.
Mean
S.E.
Mean
S.E.
262 188 150
4.3 4.5 4.6
0.06 0.07 0.08
2.8 2.8 2.9
0.04 0.05 0.05
1.0 1.1 1.0
0.03 0.04 0.03
1.3 1.4 1.4
0.03 0.05 0.04
4.7 5.2 5.0
0.04 0.14 0.13
62.2 68.6 61.7
0.72 1.05 0.94
78.3 89.4 86.4
0.65 0.95 0.97
0.88 0.93 0.93
0.00 0.00 0.01
20.9 23.5 21.9
0.23 0.34 0.33
21.7 30.4 31.8
0.52 0.75 0.93
Total
600
4.4
0.04
2.8
0.03
1.0
0.02
1.4
0.02
4.9
0.06
64.1
0.53
83.8
0.52
0.91
0.00
22.0
0.17
26.9
0.44
Female 20—40 41—60 61—99
512 378 168
4.4 4.8 5.1
0.04 0.05 0.09
2.8 3.0 3.2
0.03 0.03 0.05
1.0 1.1 1.2
0.01 0.02 0.04
1.4 1.6 1.6
0.03 0.04 0.05
4.8 5.5 5.7
0.05 0.12 0.20
59.9 65.6 57.4
0.66 0.72 0.90
84.1 93.3 90.7
0.61 0.62 0.83
0.84 0.87 0.88
0.00 0.00 0.01
24.3 26.7 24.0
0.26 0.28 0.36
37.7 43.2 41.4
0.40 0.39 0.62
Total
1058
4.7
0.03
3.0
0.02
1.0
0.01
1.5
0.02
5.2
0.06
61.5
0.44
88.4
0.41
0.85
0.00
25.1
0.18
40.3
0.27
Overall 20—40 41—60 61—99
774 566 318
4.4 4.7 4.8
0.03 0.04 0.06
2.8 3.0 3.0
0.02 0.03 0.04
1.0 1.1 1.1
0.01 0.02 0.02
1.4 1.5 1.5
0.02 0.03 0.03
4.7 5.4 5.4
0.04 0.09 0.12
60.7 66.6 59.4
0.50 0.60 0.66
82.2 92.0 88.7
0.47 0.53 0.65
0.85 0.89 0.90
0.00 0.00 0.00
23.1 25.6 23.0
0.20 0.23 0.25
32.3 39.0 36.9
0.42 0.44 0.61
Total
1658
4.6
0.03
2.9
0.02
1.0
0.01
1.4
0.02
5.1
0.04
62.5
0.34
86.8
0.33
0.87
0.00
24.0
0.13
35.4
0.28
Male 20—40 41—60 61—99
Prevalence of potential cardiovascular risk factors in Pakistan
Table 1 Mean values for total cholesterol, LDL, HDL triglycerides, weight, waist, waist/hip-ratio, BMI and body fat percentage by gender and age group with standard error of mean
N is 1646 for LDL because LDL was not calculated when TG was above 4.5 mmol/L.
15
16
N. Zahid et al.
Table 2 Percentage with high total cholesterol, LDL, triglycerides and FPG and low HDL with standard error N
TotChol
LDL
HDL
TG
FPG
%
S.E.
%
S.E.
%
S.E.
%
S.E.
%
S.E.
Male 20—40 41—60 61—99
262 188 150
19.8 28.2 28.0
2.47 3.29 3.68
29.4 36.2 42.7
2.82 3.54 4.05
78.6 67.6 69.3
2.54 3.42 3.78
18.7 30.9 26.0
2.41 3.38 3.59
9.2 21.3 16.0
1.79 2.99 3.00
Total
600
24.5
1.76
34.8
1.95
72.8
1.82
24.3
1.75
14.7
1.45
Female 20—40 41—60 61—99
512 378 168
25.2 39.9 47.6
1.92 2.52 3.86
36.0 50.8 58.1
2.13 2.59 3.83
89.8 79.4 72.6
1.34 2.08 3.45
26.2 35.4 43.5
1.94 2.46 3.84
12.3 27.0 30.4
1.45 2.29 3.56
Total
1058
34.0
1.46
44.8
1.54
83.4
1.15
32.2
1.44
20.4
1.24
Overall 20—40 41—60 61—99
774 566 318
23.4 36.0 38.4
1.52 2.02 2.73
33.8 46.0 50.8
1.71 2.11 2.81
86.0 75.4 71.1
1.25 1.81 2.55
23.6 33.9 35.2
1.53 1.99 2.68
11.2 25.1 23.6
1.14 1.82 2.38
Total
1658
30.6
1.13
41.2
1.21
79.6
0.99
29.4
1.12
18.3
0.95
N is 1646 for LDL because LDL was not calculated when TG was above 4.5 mmol/L.
nificant higher values ( p < 0.05) of total cholesterol, LDL and triglycerides. HDL levels were similar. All lipids except HDL increased with age. Almost one third of the sample had high total cholesterol (Table 2). Significantly higher percentage of women had higher total cholesterol compared with their male counterparts ( p < 0.05). More than 40% had high levels of LDL, women had higher percentage than males ( p < 0.05). Almost four out of five had low HDL, this was true for all age groups and both genders. One third had high levels of triglycerides, the percentage increased with age and was higher amongst women compared to males ( p < 0.05).
Adiposity The mean weight of the population was 62.5 kg (Table 1). Males had significantly higher body weight ( p < 0.05). In both genders it was highest amongst those who were between 20 and 60 years of age. The mean waist girth was 86.8 for the cohort, women having higher mean value than men ( p < 0.05). The highest mean waist girth was found in the age group 20—60. Waist hip ratio increased with age in both sexes. The mean BMI was 24.0, was highest in the middle age groups, and women had significantly higher ( p < 0.05). Even though women across the bar had higher BMI than men, they had lower body weight (Table 1). Women had significantly higher body fat percentages compared to males, 40.3 versus 26.9 ( p < 0.05). While almost four out of five men were either underweight or normal, 50% of the women were either overweight or obese (Fig. 1) About 70% of the males had less then 30% body fat, while less then one out of five of the women had the same (Fig. 2).
Metabolic syndrome
Fig. 1
Prevalence of overweight and obesity by gender.
As stated above, we used two definitions to diagnose metabolic syndrome. The IDF definition yielded higher prevalence compared to the ATP III definition (Fig. 3) 13 and 20% of the males met the definitions of metabolic syndrome, while 50 and 40% of the women met the definitions. In total 40% of the cohort met the IDF definition and 31% met the ATP III definition of the metabolic syndrome. There
Prevalence of potential cardiovascular risk factors in Pakistan
Fig. 2
17
Percentage distribution of subjects according to gender and to body fat.
Fig. 3 Prevalence of metabolic syndrome according to ATPIII and IDF definitions. Error bars show 95% confidence interval.
was fairly good agreement between the two definitions with a kappa value of 0.71 (Table 3).
Discussion This survey shows that a large proportion of the population in this area has high total cholesterol, LDL and triglycerides and low HDL. We also show Table 3 Agreement between ATP III and IDF definition of metabolic syndrome ATPIII definition Normal Mets Total Kappa
IDF definition Normal
Mets
Total
965 38
183 472
1148 510
655
1658
1003 0.71
that adiposity is common, especially amongst females. The prevalence of metabolic syndrome is very high, regardless of definition. Unfavourable levels of lipids in Pakistanis have been demonstrated earlier as well both in and out of Pakistan [4,14]. Similar results were also reported from an ethnically comparable population in India [1]. Adiposity is also consistently been reported in Pakistani populations. Kumar et al. showed that Pakistani-Norwegians had a mean BMI at 27.5 for men and 29.3 for women. Seventy-seven percent of the males were overweight and 22% obese. While applying the same cut values as we did, they found that 4 out of 10 females were obese and 8 out of 10 overweight [9]. This is considerably higher then the result we present. Our results are however in line with the findings of Shera et al., who showed that in a cohort of more than 5000 subjects the mean BMI was 22.6 for males and 25 for females [10]. The prevalence of over-
18 weight, with the same cutoff value as we used was also comparable, 26 and 36% for males and females. On the other hand, a large study in conducted in both rural and urban areas of all four provinces of Pakistan consisting of almost 10,000 subjects showed a noticeably lower prevalence of overweight and correspondingly low levels of BMI [15]. The mean BMI for males was 21 and 22 for females. Only 14% of the males and 20% of the females had BMI higher then 25. This study was however conducted more than 10 years ago. As stated above, a large proportion of the females in our study were overweight, and they also had a proportionally high body fat percentage. The body fat percentage distribution is clearly shifted to higher body fat content compared to men (Fig. 2). To our knowledge, no survey has reported such high body fat percentage. One study from northern India surveyed 123 healthy volunteers, and found that the mean body fat percentage in men was 21.3 while it was 35.4 in females [16]. We demonstrate alarmingly high levels of metabolic syndrome, regardless of definition. In a recently published paper, Jafar et al. show that 45.9% of the males and 57.2% of the females aged 40 and above meet the modified NCEP criteria [17]. Similarly high prevalence was also reported from India in a recently published article [1]. High prevalence has also been reported from an area called Bhutia in India [5]. Using the ATP III criteria, the authors found that half of the women and one third of the men had metabolic syndrome. The prevalence was slightly higher in urban dwellers compared rural. On the other hand, the same report showed that in a less urbanized area, namely Toto, only 8.7% of the males and 3.8% of the females had metabolic syndrome. The authors of this paper did point out that the Toto population was younger than the population in Bhutia. We suspect that the reason for the undesirable lipid profiles and obesity amongst women might be due to the fact that opportunities for exercise may be sparse for women in Muslim communities. Furthermore, we do not know what knowledge women in rural Pakistan possess about nutrition and exercise. It might be poor due to high levels of illiterateness. The findings in our survey may not be representative for the entire population of Pakistan and caution should be applied if trying to extrapolate the result to do so. The population of Pakistan is very heterogeneous and diverse. There are at least four large ethnic groups, we surveyed in an area that is dominated by the Punjabi people. It has been showed that there are marked differences between
N. Zahid et al. the ethnic groups of Pakistan regarding anthropometry [15]. We surveyed an area that has traditionally been dominated by agriculture and manual work. Due to migration from this area to Europe and USA during the last few decades the economy has improved quite rapidly. Fewer people are now engaged in agricultural work and many families receive remittance from abroad. The results do however point out the fact that the burden of obesity-related diseases and cardiovascular diseases might rise exponentially with the improvement of the living conditions in Pakistan. It is therefore of utmost importance that special care is given to pre-emptive measure aimed at tackling obesity and unfavourable lipid status [7].
References [1] Chow CK, Naidu S, Raju K, Raju R, Joshi R, Sullivan D, Celermajer DS, Neal BC. Significant lipid, adiposity and metabolic abnormalities amongst 4535 Indians from a developing region of rural Andhra Pradesh. Atherosclerosis 2007. [2] Ramachandran A, Snehalatha C, Satyavani K, Sivasankari S, Vijay V. Metabolic syndrome in urban Asian Indian adults–—a population study using modified ATP III criteria. Diab Res Clin Pract 2003;60:199—204. [3] Jafar TH, Jafary FH, Jessani S, Chaturvedi N. Heart disease epidemic in Pakistan: women and men at equal risk. Am Heart J 2005;150:221—6. [4] Wierzbicki AS, Nishtar S, Lumb PJ, Lambert-Hammill M, Turner CN, Crook MA, Marber MS, Gill J. Metabolic syndrome and risk of coronary heart disease in a Pakistani cohort. Heart 2005;91:1003—7. [5] Sarkar S, Das M, Mukhopadhyay B, Chakrabarti CS, Majumder PP. High prevalence of metabolic syndrome and its correlates in two tribal populations of India and the impact of urbanization. Indian J Med Res 2006;123:679—86. [6] WHO. The world health report 2002: reducing risks, promoting healthy life. Geneva: WHO; 2002. [7] Misra A, Misra R, Wijesuriya M, Banerjee D. The metabolic syndrome in South Asians: continuing escalation & possible solutions. Indian J Med Res 2007;125:345—54. [8] Wierzbicki AS, Nishtar S, Lumb PJ, Lambert-Hammill M, Crook MA, Marber MS, Gill J. Waist circumference, metabolic syndrome and coronary artery disease in a Pakistani cohort. Int J Cardiol 2007. [9] Kumar BN, Meyer HE, Wandel M, Dalen I, Holmboe-Ottesen G. Ethnic differences in obesity among immigrants from developing countries, in Oslo, Norway. Int J Obes (Lond) 2006;30:684—90. [10] Shera AS, Jawad F, Maqsood A. Prevalence of diabetes in Pakistan. Diab Res Clin Pract 2006. [11] WHO. Physical status: the use and interpretation of anthropometry. Report of a WHO Expert committee. Geneva: WHO; 1995. [12] 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 285:2001;2486—97. [13] Alberti KG, Zimmet P, Shaw J. Metabolic syndrome–—a new world-wide definition. A consensus statement from the
Prevalence of potential cardiovascular risk factors in Pakistan International Diabetes Federation. Diab Med 2006;23: 469— 80. [14] Jenum AK, Anderssen SA, Birkeland KI, Holme I, Graff-Iversen S, Lorentzen C, Ommundsen Y, Raastad T, Odegaard AK, Bahr R. Promoting physical activity in a low-income multiethnic district: effects of a community intervention study to reduce risk factors for type 2 diabetes and cardiovascular disease: a community intervention reducing inactivity. Diab Care 2006;29: 1605—12.
19
[15] Jafar TH, Levey AS, White FM, Gul A, Jessani S, Khan AQ, Jafary FH, Schmid CH, Chaturvedi N. Ethnic differences and determinants of diabetes and central obesity among South Asians of Pakistan. Diab Med 2004;21:716—23. [16] Dudeja V, Misra A, Pandey RM, Devina G, Kumar G, Vikram NK. BMI does not accurately predict overweight in Asian Indians in northern India. Br J Nutr 2001;86:105—12. [17] Jafar TH, Qadri Z, Chaturvedi N. Coronary artery disease epidemic in Pakistan–—more electrocardiographic evidence of ischemia in women than in men. Heart 2007.
Available online at www.sciencedirect.com
http://diabetesindia.com/
High prevalence of obesity, dyslipidemia and metabolic syndrome in a rural area in Pakistan Naeem Zahid *, Bjørgulf Claussen, Akhtar Hussain Department of General Practice and Community Medicine, University of Oslo, Norway KEYWORDS Pakistan; Rural; Obesity; Dyslipidemia; Metabolic syndrome
Summary Aims: To determine the prevalence of metabolic syndrome, adiposity and dyslipidemia amongst subjects in a rural area of Pakistan. Methods: One thousand six hundred and fifty-eight rural individuals aged 20 years and above were randomly included in the study. Lipid profile, fasting plasma glucose (FPG), BMI, WHR, and body fat percentage (BF%) were recorded. The prevalence of metabolic syndrome was calculated. Results: High prevalence of obesity, dyslipidemia and metabolic syndrome were recorded. They were all more common in women than men. Conclusions: Obesity, dyslipidemia and metabolic syndrome are common. Preventive measures should be applied to reduce the prevalence of these potential cardiovascular risk factors. # 2007 Diabetes India. Published by Elsevier Ltd. All rights reserved.
Introduction High prevalence of metabolic syndrome and cardiovascular risk factors in South Asians has been regularly reported [1—5]. Jafar et al. showed that one out of four of a randomly sampled adult cohort in Pakistan’s largest city, Karachi, had coronary artery disease [3]. Even though more than one fifth of the world’s population lives in the South Asian subcontinent, very few studies on the metabolic syndrome have been conducted in this part of the world. Studies on metabolic syndrome and risk factors for cardio* Corresponding author at: Department of General Practice and Community Medicine, University of Oslo, Post Box 1130, Blindern, N-0318 Oslo, Norway. E-mail address: [email protected] (N. Zahid).
vascular disease are warranted in Asia because many Asian countries are making rapid socioeconomic and lifestyle changes. Parts of the populations in these countries are experiencing a shift in risk factors from those of under nutrition to over nutrition and overweight [6]. These changes seem in turn to dispose for cardiovascular disease and diabetes. Some studies have been conducted in India with prevalence rates of the metabolic syndrome ranging up to more than 40% of the population [2]. Generally, the components of the metabolic syndrome are unfortunately common amongst South Asians [7]. Very few studies have looked at the prevalence of metabolic syndrome in Pakistan. Looking at coronary heart disease patients and matched controls, on group found that about 44% of the entire cohort and 13% of the controls had metabolic syndrome [4]. They also showed that the
1871-4021/$ — see front matter # 2007 Diabetes India. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.dsx.2007.11.001
14 metabolic syndrome was associated with presence of CAD [8]. A study in Oslo showed that the prevalence of obesity amongst Pakistani-Norwegians was very high, both in terms of BMI and waist hip ratio [9]. Studies in Pakistan confirm the same trend [10]. To our knowledge, no study has looked at metabolic syndrome and dyslipidemia in rural Pakistan. We conducted a cross-sectional survey in a rural area in Pakistan, and have already presented data on the prevalence of diabetes, which was high (submitted). In this paper we look at the epidemiology of dyslipidemia, obesity and the metabolic syndrome.
Research design and methods The study was conducted during the months of March to July year 2006. Subjects were enrolled from 44 villages from an area called Kharian, about 150 km from the capital Islamabad. This is primarily an agricultural community, but has developed greatly in the recent decades due to emigration to Europe and America. All participants were above 20 years of age and met fasting for the examinations. Verbal information was given to all participants, and verbal consent was received. The methods of the survey are described in detail elsewhere (submitted). In short; age, name and gender were recorded. For measuring body weight a digital weight machine was used, using a foot-tofoot bio-impedance method it also showed body fat percentage (BF%). The weight machine was placed on a flat surface. The subjects were wearing light clothes but not shoes. Weight was taken to the nearest kilogram. Fat percentages were noted to the nearest whole number. Height was measured without shoes; the subjects standing upright against a wall with the heels, buttocks, shoulders and the back of the head touching a wall onto which a measuring tape was attached. BMI was calculated by dividing the weight in kilos on the square of the height in meters. Underweight was defined as BMI <18.5 kg/m2; normal weight 18.5—24.9 kg/m2, overweight was defined as BMI between 25 and 29.9 kg/m2, obesity was defined as a BMI 30 kg/ m2 [11]. Waist and hip were measured in centimetres with a non-elastic measuring tape. The waist measure was taken midway between the iliac crest and the lower border of the ribs. The hip girth was measured at the greatest circumference of the buttocks. Waist hip ratio (WHR) was calculated by dividing the waist on the hip girth. Blood pressure was measured with a regular sphygmomanometer; the cuff was placed on the upper arm, the bell on the brachial artery.
N. Zahid et al. Eight milliliters of blood was drawn for fasting plasma glucose (FPG) and lipid profile from a venous puncture. For the analyses of the lipid profile blood was collected in plain tubes, blood samples for plasma glucose was were collected in vials containing and anticoagulant and a glycolysis inhibitor. The blood was transported to the laboratory of the local hospital within 2 h of collection. Before transportation, the blood was stored in refrigerators. The lipid profile consisted of total cholesterol (TotChol), HDL and triglycerides. All blood samples were analyzed by an enzymatic colorimetric method. LDL was computed by Friedwhals formula. Total cholesterol levels higher than 5.0 mmol/L, LDL levels higher then 3.0 mmol/L and triglycerides higher then 1.7 mmol/L were considered high. HDL levels below 1.03 and 1.29 mmol for males and females, respectively, were regarded as low. The laboratory had daily controls and calibrations in addition to monthly inter-laboratory controls. The diagnosis of metabolic syndrome was made by both the ATP III and the newly proposed IDF criteria, South Asian cutoffs were used [12,13]. To meet the ATP III criteria three or more of the following five risk factors must be present: FPG 6.5 mmol/L, TG 1.7 mmol/L, HDL < 1.03 mmol/L for men and <1.29 mmol/L for women, waist >102 cm for men and >88 cm for women [12]. The revised criteria for the IDF definition was as follows: waist 90 cm for men and 80 cm for women and two of the following four: TG 1.7 mmol/L, HDL < 1.03 for men and <1.29 for women, systolic pressure 135 mmHg or diastolic pressure 85 mmHg and FPG 5.6 mmol/L [13]. A total of 2114 subjects were examined. Those who did not have complete values for height, weight, blood pressure, hip, waist, FPG, TotChol, HDL, and TG were also excluded. Complete data had been recorded for 1658 subjects.
Results Out of the 1658 subjects, 600 were males, 1058 were females. The mean age was 44 16.4 years. We found a high prevalence of diabetes, IFG, IGT and hypertension, these results are reported elsewhere (submitted).
Lipids The mean total cholesterol level, LDL and triglycerides levels were in mmol/L were high, HDL levels were low (Table 1). Females had statistically sig-
N
TotChol
LDL
HDL
TG
FPG
Weight
Waist
Waist/Hip
BMI
BF%
Mean
S.E.
Mean
S.E.
Mean
S.E.
Mean
S.E.
Mean
S.E
Mean
S.E.
Mean
S.E.
Mean
S.E.
Mean
S.E.
Mean
S.E.
262 188 150
4.3 4.5 4.6
0.06 0.07 0.08
2.8 2.8 2.9
0.04 0.05 0.05
1.0 1.1 1.0
0.03 0.04 0.03
1.3 1.4 1.4
0.03 0.05 0.04
4.7 5.2 5.0
0.04 0.14 0.13
62.2 68.6 61.7
0.72 1.05 0.94
78.3 89.4 86.4
0.65 0.95 0.97
0.88 0.93 0.93
0.00 0.00 0.01
20.9 23.5 21.9
0.23 0.34 0.33
21.7 30.4 31.8
0.52 0.75 0.93
Total
600
4.4
0.04
2.8
0.03
1.0
0.02
1.4
0.02
4.9
0.06
64.1
0.53
83.8
0.52
0.91
0.00
22.0
0.17
26.9
0.44
Female 20—40 41—60 61—99
512 378 168
4.4 4.8 5.1
0.04 0.05 0.09
2.8 3.0 3.2
0.03 0.03 0.05
1.0 1.1 1.2
0.01 0.02 0.04
1.4 1.6 1.6
0.03 0.04 0.05
4.8 5.5 5.7
0.05 0.12 0.20
59.9 65.6 57.4
0.66 0.72 0.90
84.1 93.3 90.7
0.61 0.62 0.83
0.84 0.87 0.88
0.00 0.00 0.01
24.3 26.7 24.0
0.26 0.28 0.36
37.7 43.2 41.4
0.40 0.39 0.62
Total
1058
4.7
0.03
3.0
0.02
1.0
0.01
1.5
0.02
5.2
0.06
61.5
0.44
88.4
0.41
0.85
0.00
25.1
0.18
40.3
0.27
Overall 20—40 41—60 61—99
774 566 318
4.4 4.7 4.8
0.03 0.04 0.06
2.8 3.0 3.0
0.02 0.03 0.04
1.0 1.1 1.1
0.01 0.02 0.02
1.4 1.5 1.5
0.02 0.03 0.03
4.7 5.4 5.4
0.04 0.09 0.12
60.7 66.6 59.4
0.50 0.60 0.66
82.2 92.0 88.7
0.47 0.53 0.65
0.85 0.89 0.90
0.00 0.00 0.00
23.1 25.6 23.0
0.20 0.23 0.25
32.3 39.0 36.9
0.42 0.44 0.61
Total
1658
4.6
0.03
2.9
0.02
1.0
0.01
1.4
0.02
5.1
0.04
62.5
0.34
86.8
0.33
0.87
0.00
24.0
0.13
35.4
0.28
Male 20—40 41—60 61—99
Prevalence of potential cardiovascular risk factors in Pakistan
Table 1 Mean values for total cholesterol, LDL, HDL triglycerides, weight, waist, waist/hip-ratio, BMI and body fat percentage by gender and age group with standard error of mean
N is 1646 for LDL because LDL was not calculated when TG was above 4.5 mmol/L.
15
16
N. Zahid et al.
Table 2 Percentage with high total cholesterol, LDL, triglycerides and FPG and low HDL with standard error N
TotChol
LDL
HDL
TG
FPG
%
S.E.
%
S.E.
%
S.E.
%
S.E.
%
S.E.
Male 20—40 41—60 61—99
262 188 150
19.8 28.2 28.0
2.47 3.29 3.68
29.4 36.2 42.7
2.82 3.54 4.05
78.6 67.6 69.3
2.54 3.42 3.78
18.7 30.9 26.0
2.41 3.38 3.59
9.2 21.3 16.0
1.79 2.99 3.00
Total
600
24.5
1.76
34.8
1.95
72.8
1.82
24.3
1.75
14.7
1.45
Female 20—40 41—60 61—99
512 378 168
25.2 39.9 47.6
1.92 2.52 3.86
36.0 50.8 58.1
2.13 2.59 3.83
89.8 79.4 72.6
1.34 2.08 3.45
26.2 35.4 43.5
1.94 2.46 3.84
12.3 27.0 30.4
1.45 2.29 3.56
Total
1058
34.0
1.46
44.8
1.54
83.4
1.15
32.2
1.44
20.4
1.24
Overall 20—40 41—60 61—99
774 566 318
23.4 36.0 38.4
1.52 2.02 2.73
33.8 46.0 50.8
1.71 2.11 2.81
86.0 75.4 71.1
1.25 1.81 2.55
23.6 33.9 35.2
1.53 1.99 2.68
11.2 25.1 23.6
1.14 1.82 2.38
Total
1658
30.6
1.13
41.2
1.21
79.6
0.99
29.4
1.12
18.3
0.95
N is 1646 for LDL because LDL was not calculated when TG was above 4.5 mmol/L.
nificant higher values ( p < 0.05) of total cholesterol, LDL and triglycerides. HDL levels were similar. All lipids except HDL increased with age. Almost one third of the sample had high total cholesterol (Table 2). Significantly higher percentage of women had higher total cholesterol compared with their male counterparts ( p < 0.05). More than 40% had high levels of LDL, women had higher percentage than males ( p < 0.05). Almost four out of five had low HDL, this was true for all age groups and both genders. One third had high levels of triglycerides, the percentage increased with age and was higher amongst women compared to males ( p < 0.05).
Adiposity The mean weight of the population was 62.5 kg (Table 1). Males had significantly higher body weight ( p < 0.05). In both genders it was highest amongst those who were between 20 and 60 years of age. The mean waist girth was 86.8 for the cohort, women having higher mean value than men ( p < 0.05). The highest mean waist girth was found in the age group 20—60. Waist hip ratio increased with age in both sexes. The mean BMI was 24.0, was highest in the middle age groups, and women had significantly higher ( p < 0.05). Even though women across the bar had higher BMI than men, they had lower body weight (Table 1). Women had significantly higher body fat percentages compared to males, 40.3 versus 26.9 ( p < 0.05). While almost four out of five men were either underweight or normal, 50% of the women were either overweight or obese (Fig. 1) About 70% of the males had less then 30% body fat, while less then one out of five of the women had the same (Fig. 2).
Metabolic syndrome
Fig. 1
Prevalence of overweight and obesity by gender.
As stated above, we used two definitions to diagnose metabolic syndrome. The IDF definition yielded higher prevalence compared to the ATP III definition (Fig. 3) 13 and 20% of the males met the definitions of metabolic syndrome, while 50 and 40% of the women met the definitions. In total 40% of the cohort met the IDF definition and 31% met the ATP III definition of the metabolic syndrome. There
Prevalence of potential cardiovascular risk factors in Pakistan
Fig. 2
17
Percentage distribution of subjects according to gender and to body fat.
Fig. 3 Prevalence of metabolic syndrome according to ATPIII and IDF definitions. Error bars show 95% confidence interval.
was fairly good agreement between the two definitions with a kappa value of 0.71 (Table 3).
Discussion This survey shows that a large proportion of the population in this area has high total cholesterol, LDL and triglycerides and low HDL. We also show Table 3 Agreement between ATP III and IDF definition of metabolic syndrome ATPIII definition Normal Mets Total Kappa
IDF definition Normal
Mets
Total
965 38
183 472
1148 510
655
1658
1003 0.71
that adiposity is common, especially amongst females. The prevalence of metabolic syndrome is very high, regardless of definition. Unfavourable levels of lipids in Pakistanis have been demonstrated earlier as well both in and out of Pakistan [4,14]. Similar results were also reported from an ethnically comparable population in India [1]. Adiposity is also consistently been reported in Pakistani populations. Kumar et al. showed that Pakistani-Norwegians had a mean BMI at 27.5 for men and 29.3 for women. Seventy-seven percent of the males were overweight and 22% obese. While applying the same cut values as we did, they found that 4 out of 10 females were obese and 8 out of 10 overweight [9]. This is considerably higher then the result we present. Our results are however in line with the findings of Shera et al., who showed that in a cohort of more than 5000 subjects the mean BMI was 22.6 for males and 25 for females [10]. The prevalence of over-
18 weight, with the same cutoff value as we used was also comparable, 26 and 36% for males and females. On the other hand, a large study in conducted in both rural and urban areas of all four provinces of Pakistan consisting of almost 10,000 subjects showed a noticeably lower prevalence of overweight and correspondingly low levels of BMI [15]. The mean BMI for males was 21 and 22 for females. Only 14% of the males and 20% of the females had BMI higher then 25. This study was however conducted more than 10 years ago. As stated above, a large proportion of the females in our study were overweight, and they also had a proportionally high body fat percentage. The body fat percentage distribution is clearly shifted to higher body fat content compared to men (Fig. 2). To our knowledge, no survey has reported such high body fat percentage. One study from northern India surveyed 123 healthy volunteers, and found that the mean body fat percentage in men was 21.3 while it was 35.4 in females [16]. We demonstrate alarmingly high levels of metabolic syndrome, regardless of definition. In a recently published paper, Jafar et al. show that 45.9% of the males and 57.2% of the females aged 40 and above meet the modified NCEP criteria [17]. Similarly high prevalence was also reported from India in a recently published article [1]. High prevalence has also been reported from an area called Bhutia in India [5]. Using the ATP III criteria, the authors found that half of the women and one third of the men had metabolic syndrome. The prevalence was slightly higher in urban dwellers compared rural. On the other hand, the same report showed that in a less urbanized area, namely Toto, only 8.7% of the males and 3.8% of the females had metabolic syndrome. The authors of this paper did point out that the Toto population was younger than the population in Bhutia. We suspect that the reason for the undesirable lipid profiles and obesity amongst women might be due to the fact that opportunities for exercise may be sparse for women in Muslim communities. Furthermore, we do not know what knowledge women in rural Pakistan possess about nutrition and exercise. It might be poor due to high levels of illiterateness. The findings in our survey may not be representative for the entire population of Pakistan and caution should be applied if trying to extrapolate the result to do so. The population of Pakistan is very heterogeneous and diverse. There are at least four large ethnic groups, we surveyed in an area that is dominated by the Punjabi people. It has been showed that there are marked differences between
N. Zahid et al. the ethnic groups of Pakistan regarding anthropometry [15]. We surveyed an area that has traditionally been dominated by agriculture and manual work. Due to migration from this area to Europe and USA during the last few decades the economy has improved quite rapidly. Fewer people are now engaged in agricultural work and many families receive remittance from abroad. The results do however point out the fact that the burden of obesity-related diseases and cardiovascular diseases might rise exponentially with the improvement of the living conditions in Pakistan. It is therefore of utmost importance that special care is given to pre-emptive measure aimed at tackling obesity and unfavourable lipid status [7].
References [1] Chow CK, Naidu S, Raju K, Raju R, Joshi R, Sullivan D, Celermajer DS, Neal BC. Significant lipid, adiposity and metabolic abnormalities amongst 4535 Indians from a developing region of rural Andhra Pradesh. Atherosclerosis 2007. [2] Ramachandran A, Snehalatha C, Satyavani K, Sivasankari S, Vijay V. Metabolic syndrome in urban Asian Indian adults–—a population study using modified ATP III criteria. Diab Res Clin Pract 2003;60:199—204. [3] Jafar TH, Jafary FH, Jessani S, Chaturvedi N. Heart disease epidemic in Pakistan: women and men at equal risk. Am Heart J 2005;150:221—6. [4] Wierzbicki AS, Nishtar S, Lumb PJ, Lambert-Hammill M, Turner CN, Crook MA, Marber MS, Gill J. Metabolic syndrome and risk of coronary heart disease in a Pakistani cohort. Heart 2005;91:1003—7. [5] Sarkar S, Das M, Mukhopadhyay B, Chakrabarti CS, Majumder PP. High prevalence of metabolic syndrome and its correlates in two tribal populations of India and the impact of urbanization. Indian J Med Res 2006;123:679—86. [6] WHO. The world health report 2002: reducing risks, promoting healthy life. Geneva: WHO; 2002. [7] Misra A, Misra R, Wijesuriya M, Banerjee D. The metabolic syndrome in South Asians: continuing escalation & possible solutions. Indian J Med Res 2007;125:345—54. [8] Wierzbicki AS, Nishtar S, Lumb PJ, Lambert-Hammill M, Crook MA, Marber MS, Gill J. Waist circumference, metabolic syndrome and coronary artery disease in a Pakistani cohort. Int J Cardiol 2007. [9] Kumar BN, Meyer HE, Wandel M, Dalen I, Holmboe-Ottesen G. Ethnic differences in obesity among immigrants from developing countries, in Oslo, Norway. Int J Obes (Lond) 2006;30:684—90. [10] Shera AS, Jawad F, Maqsood A. Prevalence of diabetes in Pakistan. Diab Res Clin Pract 2006. [11] WHO. Physical status: the use and interpretation of anthropometry. Report of a WHO Expert committee. Geneva: WHO; 1995. [12] 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 285:2001;2486—97. [13] Alberti KG, Zimmet P, Shaw J. Metabolic syndrome–—a new world-wide definition. A consensus statement from the
Prevalence of potential cardiovascular risk factors in Pakistan International Diabetes Federation. Diab Med 2006;23: 469— 80. [14] Jenum AK, Anderssen SA, Birkeland KI, Holme I, Graff-Iversen S, Lorentzen C, Ommundsen Y, Raastad T, Odegaard AK, Bahr R. Promoting physical activity in a low-income multiethnic district: effects of a community intervention study to reduce risk factors for type 2 diabetes and cardiovascular disease: a community intervention reducing inactivity. Diab Care 2006;29: 1605—12.
19
[15] Jafar TH, Levey AS, White FM, Gul A, Jessani S, Khan AQ, Jafary FH, Schmid CH, Chaturvedi N. Ethnic differences and determinants of diabetes and central obesity among South Asians of Pakistan. Diab Med 2004;21:716—23. [16] Dudeja V, Misra A, Pandey RM, Devina G, Kumar G, Vikram NK. BMI does not accurately predict overweight in Asian Indians in northern India. Br J Nutr 2001;86:105—12. [17] Jafar TH, Qadri Z, Chaturvedi N. Coronary artery disease epidemic in Pakistan–—more electrocardiographic evidence of ischemia in women than in men. Heart 2007.
Available online at www.sciencedirect.com