Prevalence of metabolic syndrome in an Indian urban population

International Journal of Cardiology 97 (2004) 257 – 261 www.elsevier.com/locate/ijcard

Prevalence of metabolic syndrome in an Indian urban population Rajeev Gupta a, Prakash C. Deedwania b, Arvind Gupta a,*, Shweta Rastogi a, Raja B. Panwar c, Kunal Kothari d a

Department of Medicine, Monilek Hospital and Research Centre, Jawahar Nagar, Jaipur 302004, India b University of California-San Francisco VA Medical Center, Fresno, CA, USA c SP Medical College and Associated Group of Hospitals, Bikaner 334001, India d SMS Medical College and Hospital, Jaipur 302004, India Received 24 October 2002; received in revised form 12 November 2003; accepted 17 November 2003

Abstract Objectives: To determine prevalence of the metabolic syndrome using United States Adult Treatment Panel-3 (ATP-3) guidelines in an urban Indian population. Methods: Randomly selected adults > 20 years were studied using stratified sampling. Target study sample was 1800 with population proportionate distribution (men 960, women 840). Evaluation of anthropometric variables, blood pressure, fasting blood glucose and lipids was performed. Subjects (1123; response 62.4%) were examined, fasting blood samples were available in 1091 (532 men, 559 women) and analysed for prevalence of metabolic syndrome. Atherosclerosis risk factors were determined using the current guidelines. Metabolic syndrome was diagnosed when any three of the following were present: central obesity, raised triglycerides z 150 mg/dl (z 1.7 mmol/l), low high-density lipoprotein (HDL) cholesterol, blood pressure z 130/ z 85 mm Hg, and diabetes or fasting glucose >110 mg/dl (>6.1 mmol/l). Intergroup comparisons were performed using t-test or chi-square test. Results: Metabolic syndrome was present in 345 (31.6%) subjects; prevalence was 122 (22.9%) in men and 223 (39.9%) in women ( p < 0.001); the age-adjusted prevalence was 24.9%, 18.4% in men and 30.9% in women. There was a significant age-related increase in its prevalence (Mantel – Haenzel v2 for trend p < 0.05). Prevalence of components of metabolic syndrome in men and women was: central obesity (waist, men >102 cm, women >88 cm) in 116 (25.6%) and 246 (44.0%); low HDL cholesterol (men < 40 mg/dl, < 1.0 mmol/l), women < 50 mg/dl, < 1.3 mmol/l) in 292 (54.9%) and 504 (90.2%); high triglycerides z 150 mg/dl (z 1.7 mmol/l) in 172 (32.3%) and 160 (28.6%); and impaired fasting glucose or diabetes in 90 (16.9%) and 90 (16.1%). The prevalence of physical inactivity, hypertension, hypercholesterolemia (z 200 mg/dl, z 5.2 mmol/l) and high LDL cholesterol (z 130 mg/dl, z 3.4 mmol/l) was greater in the metabolic syndrome group in both men and women ( p < 0.05). Conclusions: There is a high prevalence of metabolic syndrome in an urban Indian population. Focus of cardiovascular prevention should be at this high-risk group. D 2004 Elsevier Ireland Ltd. All rights reserved. Keywords: Prevalence; Metabolic syndrome; Indian population

1. Introduction Metabolic syndrome, also known as cardiovascular dysmetabolic syndrome, is a constellation of abnormalities characterized by central obesity, high triglycerides, hypertension or high normal blood pressure, low high-density lipoprotein (HDL) cholesterol and diabetes or high fasting glucose. Subjects with this condition are at increased risk for developing diabetes mellitus and cardiovascular disease as well as increased mortality from other causes [1,2]. After publication of the Third Report of United States (US) National Cholesterol Education Program (Adult Treatment * Corresponding author. Tel.: +91-141-653021; fax: +91-141-366328. E-mail address: [email protected] (A. Gupta). 0167-5273/$ - see front matter D 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2003.11.003

Panel-3 (ATP-3)) [3] data of the US Third National Health and Nutrition Survey (NHANES-3) were evaluated for prevalence of metabolic syndrome [4]. The age-adjusted prevalence in the US was reported as 23.7% with prevalence being similar for men (24.0%) and women (23.4%). An ethnic difference in its prevalence was reported with a greater prevalence among Mexican-Americans than other groups in the US [4]. India is a major contributor to the global cardiovascular mortality [5,6] and there is increasing trends in prevalence of various components of the metabolic syndrome [7– 9]. Deedwania and Gupta [10] have speculated that cardiovascular dysmetabolic syndrome is the most important cardiovascular risk factor in Asian Indians, more than in other ethnic groups. Therefore to determine the prevalence of

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Table 1 Clinical criteria for metabolic syndrome (ATP-3 guidelines) [2] Risk factor

Defining level

Abdominal obesity Men Women Triglycerides HDL cholesterol Men Women Blood pressure Fasting glucose

Waist circumference >102 cm (>40 in) >88 cm (>35 in) z 150 mg/dl (z 1.7 mmol/l) < 40 mg/dl (< 1.0 mmol/l) < 50 mg/dl (< 1.3 mmol/l) z 130/ z 85 mm Hg z 110 mg/dl (z 6.1 mmol/l)

metabolic syndrome in a representative Indian urban population using the ATP-3 guidelines we analysed data from an Indian urban epidemiological study.

2. Methods The study was approved by the institution ethics committee. Detailed protocol of the study has been reported [11]. Details of major cardiovascular risk factors such as smoking, alcohol intake, amount of physical activity, diabetes and hypertension were inquired. The physical examination emphasized measurement of height, weight, waist – hip ratio (WHR) and blood pressure. Height was measured in centimetres and weight in kilograms using calibrated springbalance. Supine waist girth was measured at the level of umbilicus with person breathing silently according to the WHO guidelines [12]. Blood pressure was measured using standard mercury manometer. At least two readings at 5-min intervals were recorded and if a high blood pressure (z 140/ 90) was noted a third reading was taken after 30 min. The lowest of the three readings was taken as blood pressure. Fasting blood sample was obtained from all the individuals for estimation of glucose, total, HDL and LDL cholesterol and triglycerides using previously standardised techniques [13]. The study was designed to investigate people at random and to cover large and varied areas of Jaipur with a view to include persons from all walks of urban life. Randomly chosen wards from different regions of the city were identified so as to cover different socioeconomic groups. Details of the population in these wards were available from the Voters’ Lists. We randomly selected population proportionate sample of 300 persons (160 males, 140 females) from each locality. The total study sample was 1800 (960 males, 840 females) who were invited for participation. This sample size was considered adequate for identification of major coronary risk factors. The formulae for calculation of the sample size have been reported [14]. The study was preceded by meetings with local leaders who cooperated in identifying and ensuring participation of selected subjects. The diagnostic criteria for risk factors have been reported [11]. Smokers in India consume tobacco in various forms; therefore, users of all types of tobacco products and present

and past smokers were included in smoker category. Physical activity was measured by asking about both work-related and leisure-time activities [11]. Hypertension was diagnosed when systolic blood pressure z 140 mm Hg and/or diastolic blood pressure z 90 mm Hg or a person was a known hypertensive. Body mass index (BMI) (weight in kg/height in metres2) was calculated and overweight and obesity defined as BMI z 25 kg/m2. Truncal obesity was diagnosed when waist was more than 102 cm in men and >88 cm in women according to the ATP-3 [3]. Diabetes was diagnosed when history of diagnosis was present or fasting blood glucose was z 126 mg/dl (z 7.0 mmol/l). Dyslipidaemia was defined by the presence of high total cholesterol (z 200 mg/dl, z 5.2 mol/l), high LDL cholesterol (z 130 mg/dl, z 3.4 mmol/l), low HDL cholesterol (men < 40 mg/dl, < 1.0 mmol/l; women < 50 mg/dl, < 1.3 mmol/l) or high triglycerides (z 150 mg/dl, z 1.7 mmol/l) according to ATP-3 [2]. Metabolic syndrome was defined when any three of the five diagnostic criteria were present (Table 1). 2.1. Statistical analysis Continuous variables are reported as mean F 1 S.D. The prevalence rates are given in percent. Age-related trends have been examined by Mantel – Haenzel v2 for trend. Variables have been compared using either t-test or v2 test as appropriate. P values < 0.05 were considered significant. Direct method of age-adjustment standardised to the local population was used.

3. Results The response rates have been reported [11]. The overall response rate was 62.4% and 1123 of 1800 eligible subjects were examined. The response rate in males was 550/960 (57.3%) and in females 573/840 (68.2%). Response rates for lipid estimation in males was 523/550 (95.1%) and in females 559/573 (97.6%) and these subjects have been evaluated for presence of the metabolic syndrome. Metabolic syndrome diagnosed according to the ATP-3 guidelines was present in 345 (31.6%) subjects; prevalence

Table 2 Prevalence of the metabolic syndrome Age groups

Men

Women

Total

Total Prevalence Total Prevalence Total Prevalence (%) (%) (%)

20 – 29 98 30 – 39 147 40 – 49 111 50 – 59 89 60 + 78 Total 532 Age-adjusted

9 (9.2) 26 (17.7) 27 (24.3) 38 (38.8) 22 (28.2) 122 (22.9) 18.4%

89 143 127 113 87 559

Numbers in parentheses are percent.

13 (13.3) 38 (26.6) 49 (38.6) 67 (59.3) 56 (64.4) 223 (39.9) 30.9%

187 22 (11.8) 290 64 (22.1) 238 76 (31.9) 211 105 (49.9) 165 78 (47.3) 1091 345 (31.6) 24.9%

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Table 3 Prevalence of individual abnormalities of the metabolic syndrome Age group

Fasting glucose z 110 mg/dl (>6.1 mmol/l) or diabetes

Triglycerides z 150 mg/dl (z 1.7 mmol/l)

HDL cholesterol < 40 mg/dl (< 1.0 mmol/l) men; < 50 mg/dl (< 1.3 mmol/l) women

Central obesity waist >102 cm men; >88 cm women

Hypertension z 130/ z 85

4 (4.1) 24 (16.3) 32 (28.8) 36 (36.7) 20 (25.6) 116 (21.8)

24 47 48 55 46 292

27 53 59 66 41 246

11 (12.4) 36 (25.2) 51 (40.2) 67 (59.3) 59 (67.8) 224 (40.0)

Men (n = 532) 20 – 29 6 30 – 39 13 40 – 49 18 50 – 59 33 60 + 20 Total 90

(6.1) (8.8) (16.2) (33.7) (25.6) (16.9)

21 61 37 38 15 172

(21.4) (41.5) (33.3) (38.8) (19.2) (32.3)

48 82 68 51 43 292

Women (n = 559) 20 – 29 2 30 – 39 9 40 – 49 15 50 – 59 34 60 + 30 Total 90

(2.2) (6.3) (11.8) (30.1) (34.5) (16.1)

17 36 34 42 31 160

(19.1) (25.2) (26.8) (37.2) (35.6) (28.6)

80 (89.9) 132 (92.3) 116 (91.3) 97 (85.8) 79 (90.8) 504 (90.2)

(49.0) (55.8) (61.3) (52.0) (55.1) (54.9)

(30.3) (37.1) (46.5) (58.4) (47.1) (44.0)

(24.5) (32.0) (43.2) (56.1) (59.0) (41.4)

Numbers in parentheses are percent.

was 122 (22.9%) in men and 223 (39.9%) in women ( p < 0.001) (Table 2). The age-adjusted prevalence was 24.9% (271 subjects), 18.4% (98) in men and 30.9% (173) in women. There was a significant age-related increase in its prevalence (Mantel – Haenzel v2 for trend p < 0.05). Age-specific prevalence of individual components of the metabolic syndrome is reported in Table 3. In men and women, respectively, central obesity was in 116 (25.6%) and 246 (44.0%); low HDL cholesterol (men < 40 mg/dl, < 1.0 mmol/l; women < 50 mg/dl, < 1.3 mmol/l) in 292 (54.9%) and 504 (90.2%); high triglycerides in 172 (32.3%) and 160 (28.6%); and impaired fasting glucose or diabetes in 90 (16.9%) and 90 (16.1%). Prevalence of other atherosclerosis risk factors in men and women, respectively, was: smoking or tobacco use in 201 (36.5%) and 67 (11.7%); sedentariness, either workrelated or leisure time, in 157 (28.5%) and 130 (22.7%); hypertension (known or blood pressure z 140 and/or 90 mm Hg) in 200 (36.4%) and 215 (37.5%); obesity, body mass index z 25 kg/m2, in 135 (24.5%) and 173 (30.2%);

diabetes (known or fasting glucose z 126 mg/dl) in 70 (13.2%) and 64 (11.4%); high total cholesterol z 200 mg/dl ( z 5.2 mmol/l) in 199 (37.4%) and 241 (43.1%); and high LDL cholesterol z 130 mg/dl ( z 3.4 mmol/l) in 197 (37.0%) and 252 (45.8%). Table 4 shows the prevalence of standard coronary risk factors in subjects with metabolic syndrome as compared to those without. The prevalence of smoking or tobacco use is not different in the two groups but the prevalence of physical inactivity is greater among the metabolic syndrome group in both men and women. Hypertension ( z 140/ z 90) as well as high total and LDL cholesterol, which are not part of the metabolic syndrome, are also more prevalent among men and women with this condition.

4. Discussion This study shows a high prevalence of the metabolic syndrome in an urban Indian population. Grundy [15]

Table 4 Prevalence of other atherosclerosis risk factors in metabolic syndrome Variable

Smoking/tobacco Sedentary lifestyle Hypertension z 140/ z 90 Obesity BMI z 25 kg/m2 Central obesity waist, men >102 cm women >88 cm Cholesterol z 200mg/dl (z 5.2 mmol/l) LDL z 130 mg/dl (z 3.4 mmol/l) Triglycerides z 150 mg/dl (z 1.7 mmol/l) Low HDL men < 40 mg/dl (< 1.0 mmol/l), women < 50 mg/dl (< 1.3 mmol/l)

Men (n = 532)

Women (n = 539)

Normal (n = 410)

Metabolic syndrome (n = 122)

z-test ( p value)

Normal (n = 316)

Metabolic syndrome (n = 223)

z-test ( p value)

162 (39.5) 101 (24.6) 109 (26.6) 110 (26.8) 36 (8.8) 137 (33.4) 139 (33.9) 97 (23.7) 191 (46.6)

38 44 88 91 80 62 58 75 101

1.57 2.39 9.03 9.45 13.21 3.38 2.62 7.72 6.95

37 (11.7) 48 (21.5) 49 (15.5) 109 (34.5) 68 (21.5) 119 (37.7) 131 (41.5) 60 (19.0) 286 (90.5)

28 48 161 172 178 122 121 100 218

0.18 0.42 13.21 9.66 13.30 3.82 2.85 6.36 3.21

(31.1) (36.1) (72.1) (74.6) (65.6) (50.8) (47.5) (61.5) (82.8)

BMI, body mass index; LDL, low density lipoprotein; HDL, high density lipoprotein.

(0.115) (0.017) (< 0.001) (< 0.001) (< 0.001) (< 0.001) (0.009) (< 0.001) (< 0.001)

(12.6) (21.5) (72.2) (77.1) (79.8) (54.7) (54.3) (44.8) (97.8)

(0.856) (0.678) (< 0.001) (< 0.001) (< 0.001) (< 0.001) (0.004) (< 0.001) (0.001)

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initially defined the metabolic syndrome to denote a constellation of physiological and biochemical abnormalities also called the syndrome of multiple metabolic risk factors. The component risk factors identified were atherogenic dyslipidaemia (borderline high-risk LDL cholesterol, raised triglycerides, small LDL particles and low HDL cholesterol) hypertension, insulin resistance F non-insulin dependent diabetes mellitus and a procoagulant state. Multiple eponyms of this syndrome existed before guidelines of ATP-3 regarding the clinical diagnosis of this condition (Table 1). The contributing causes of metabolic syndrome have been reported as obesity (especially truncal obesity), physical inactivity, cholesterol-raising nutrients, aging and genetic factors [15]. The present study also shows that the prevalence of metabolic syndrome increases with age and there is greater prevalence of physical inactivity, obesity, and hypercholesterolemia in this group (Table 4). Thus the contributing causes of this syndrome are similar everywhere. In the US population, the age-adjusted prevalence of metabolic syndrome has been reported as 23.7% [4]. This is similar to the age-adjusted prevalence in the present study (24.9%). However, the prevalence was similar in men and women in the US study whereas in the present study women have a significantly greater prevalence of metabolic syndrome. This appears to be due to a disproportionately high prevalence of low HDL cholesterol in Indian women (90.2%) as compared to US women (39.3%). High prevalence of low HDL cholesterol has been previously reported from India by Reddy et al. [16] from Delhi (North India) and Krishnaswami [17] from Vellore (South India). Reddy et al. [16] reported HDL cholesterol < 40 mg/dl (< 1.0 mmol/l) in 60% urban men and 40% urban women. In men, the present study shows a similar prevalence of low HDL cholesterol (54.9%) but in women as the cutoff of < 50 mg/dl (< 1.3 mmol/l) was not used we cannot compare our results. Krishnaswamy [17] reported mean HDL cholesterol of 36.6 F 11.8 mg/dl (0.95 F 0.3 mmol/l) in urban men and 39.1 F 11.9 mg/dl (1.01 F 0.3 mmol/l) in rural women in a South Indian urban population, this is similar to the mean HDL cholesterol of 39.5 F 8 mg/dl (1.02 + 0.2 mmol/l) in men and 39.0 F 9 mg/dl (1.01 F 0.2 mmol/l) in women in the present cohort. This could be due to a high prevalence of hypoalphalipoproteinemia in the Indian population and needs to be confirmed in larger prospective studies. Prevalence of other components of metabolic syndrome in Indian and US subjects was not much different. In the US subjects, abdominal obesity was present in 38.6% (men 29.8, women 46.3), high triglycerides in 30.0% (men 35.1, women 24.7), low HDL cholesterol in 37.1% (men 35.2, women 39.3), high normal blood pressure and hypertension in 34.0% (men 38.2, women 29.3), and high fasting glucose or diabetes in 12.6% (men 15.6, women 10.0) [4]. The present study results are not comparable with any previous Indian study as metabolic syndrome is a new entity. McKeigue et al. [18] observed a high prevalence of insulin resistance, diabetes and truncal obesity in South

Asians in Britain and speculated that this constellation was an important coronary risk factor in this group. These findings were confirmed in a larger prospective study among the same group [19]. Greater degree of insulin resistance was observed in South Asian children in Britain [20]. Recent studies in India have reported increasing multiple metabolic abnormalities in the general population, more in urban than in the rural [6 – 10,21 – 23]. Malhora et al. [21] studied 2964 subjects aged 16– 70 years in a rural north Indian population. Insulin resistance was determined in 68 newly detected hypertensives, 82 matched controls and 58 family controls. Analysis showed that fasting and post-glucose load serum insulin was significantly associated with hypertension. Mishra et al. [22] studied 532 subjects (170 men, 362 women) in an urban north Indian slum. Insulin resistance was determined in 80 women and was present in 18.5 – 22.5%. There was a significant correlation of insulin resistance with body fat, central obesity, hypertension and hypercholesterolemia. Deepa et al. [23] determined prevalence of insulin resistance syndrome in a selected south Indian population using the fasting insulin levels. The overall prevalence of insulin resistance was 11.2% among the 1070 subjects evaluated and this syndrome correlated significantly with age, body mass index, central obesity, cholesterol, triglycerides and physical inactivity. A high prevalence of multiple metabolic risk factors was thus seen in all these Indian studies. Similar trends have been reported from other regions of South Asia [24]. There is a need to develop therapeutic strategies that would modify the metabolic syndrome as a whole. The possibility of discovering new drugs that can strike to the heart of the metabolic syndrome has been proposed but this approach is in infancy. From a public health perspective, the major causes of the metabolic syndrome are unhealthy life habits; thus, for the general public the best approach to favourably modify the whole syndrome is through weight control, increased physical activity, and decreased intake of LDL-raising nutrients [10]. Larger prospective studies in India and other developing countries are required to clarify the importance of this syndrome among these populations. References [1] Godsland IF, Stevenson JC. Insulin resistance: syndrome or tendency? Lancet 1995;346:100 – 3. [2] Fagan TC, Deedwania PC. The cardiovascular dysmetabolic syndrome. Am J Med 1998;105:77S – 82S. [3] National Cholesterol Education Program. Executive summary of the third report of the National Cholesterol Education Program Expert Panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel-III). JAMA 2001;285:2486 – 97. [4] Ford ES, Giles WH, Dietz WH. Prevalence of metabolic syndrome among US adults: findings from the Third National Health and Nutrition Examination Survey. JAMA 2002;287:356 – 9. [5] Murray CJL, Lopez AD. Mortality by cause for eight regions of the world: global burden of disease study. Lancet 1997;349:1269 – 76. [6] Reddy KS, Yusuf S. Emerging epidemic of cardiovascular disease in developing countries. Circulation 1998;97:596 – 601.

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