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Professor & HoD Biochemistry, Project Director, Obesity Study Center, Guntur Medical College, Guntur, AP India
Tirumalasetty RangaRao MD,
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 HDLcholesterol, 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.
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 South Asian Europid Chinese Japanese Men >90 cm (35.4 in) >94 cm (37.0 in) >90 cm (35.4 in) >85 cm (33.5 in) Women >80 cm (31.5 in) >80 cm (31.5 in) >80 cm (31.5 in) >90 cm (35.4 in)
Plus any two of 2. Triglycerides (≥ 1.7 mmol/L [150 mg/dL]) 3. HDL cholesterol a. Men b. Women < 1.0 mmol/L (40 mg/dL) < 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 % MetS34.6 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) <2 3 4 5 R* 0 <2 3 4 5 R* 9 3 0 0 1:3 0 10 4 2 0 1:1.7 19 3 1 0 1:4.8 0 11 5 1 0 1:1.8
R*= Ratio of MetS : Pre-MetS
0 5 1
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 (PreMetS). 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.
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
. 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 Creactive 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.
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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