METABOLIC SYNDROME AND RELATED DISORDERS

Volume XX, Number XX, 2018

 Mary Ann Liebert, Inc.
Pp. 1–11
DOI: 10.1089/met.2017.0157

Prevalence of Metabolic Syndrome in Mexico:

A Systematic Review and Meta-Analysis

Ana Ligia Gutiérrez-Solis, PhD,1 Sudip Datta Banik, PhD,2 and Rosa Marı́a Méndez-González, MSc2

Abstract
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Background: Metabolic syndrome (MetS) is closely linked with type 2 diabetes mellitus (T2DM) and car-
diovascular diseases. The T2DM is one of the major causes of mortality and public health concern in Mexico.
Some studies reported MetS prevalence in different regions from Mexico. However, a systematic report or
meta-analysis on MetS prevalence is not available. The aim of this study was to estimate the pooled prevalence
of MetS among apparently healthy Mexican adults.
Methods: A systematic review was done of scientific articles published and available from different sources,
including MEDLINE/PubMed, Web of Science, Cochrane Library, LILACS, and SCIELO. The overall prevalence
of MetS and prevalence based on different diagnostic criteria [National Cholesterol Education Program-Adult
Treatment Panel III (NCEP-ATP III), International Diabetes Federation (IDF), American Heart Association/
National Heart, Lung, and Blood Institute (AHA/NHLBI), and World Health Organization (WHO)] were pooled
using a random-effects model, and the results were presented in a forest plot. The study was performed based on
the criteria of Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA).
Results: Altogether, 15 studies were included in the systematic meta-analysis. The estimated prevalence of
MetS, based on different criteria, was as follows: IDF 54% (95% CI 0.44–0.63), AHA/NHLBI 48% (95% CI
0.34–0.62), ATP III 36% (95% CI 0.30–0.42), and WHO 31% (95% CI 0.04–0.81). According to the Der
Simonian–Laird random-effects model, a pooled prevalence of MetS in Mexico was 41% (95% CI 0.34–0.47).
Conclusions: This study reported a high prevalence of MetS among healthy Mexican adults, in comparison
with reports from other countries, including United States and Latin America. An urgent need to control and
prevent MetS and its consequent health complications in Mexican populations is recommended.

Keywords: metabolic syndrome, prevalence, meta-analysis, Mexico

Introduction circumference, increased blood pressure, low high-density

lipoprotein-cholesterol (HDL-C), and elevated glucose and

M etabolic syndrome (MetS) was described by Re-

aven in 1998 for the first time as ‘‘Syndrome X’’; the
definition and diagnostic criteria of MetS had been adapted
thereafter by other authors.1 Currently, the most widely used
definitions of MetS are proposed by the Adult Treatment
Panel III (ATP III), the International Diabetes Federation
(IDF), American Heart Association/National Heart, Lung,
and Blood Institute (AHA/NHLBI), and the World Health
Organization (WHO) (Table 1).1,2 Despite some differences
found among the definitions, most of them agreed that MetS is
a condition that is characterized by a congregation of risk
factors, including abdominal obesity (AO), based on waist
triglyceride levels. The MetS is diagnosed when at least three
of the five conditions are found in patients.3
Diverse diseases have been linked to MetS, but cardio-
vascular diseases (CVDs) and type 2 diabetes mellitus
(T2DM) have been more widely studied and reported to be
associated with MetS.4 Some authors also related MetS to
chronic renal diseases, nonalcoholic fatty liver disease,
polycystic ovary syndrome, and cancer, among other non-
communicable diseases.5–8
The insulin resistance and abnormal regulation of lipid
metabolism are some of the several mechanisms involved in
the pathogenesis of MetS.9 Moreover, MetS is a multifactorial

1
Regional High Speciality Hospital of the Yucatan Peninsula, Mérida, Yucatan, Mexico.
2
Center for Research and Advanced Studies (CINVESTAV-IPN), Mérida, Yucatan, Mexico.

1
 2 GUTIÉRREZ-SOLIS ET AL.

Table 1. Diagnostic Criteria for Metabolic Syndrome, According to ATP III, WHO, IDF, and AHA/NHLBI
Risk factors ATP III WHO IDF AHA/NHLBI
Blood pressure ‡130/‡85 mmHg ‡140/‡90 mmHg ‡130/‡85 mmHg ‡130/‡85 mmHg
Glucose levels ‡100 mg/dL or T2DM IR ‡100 mg/dL or T2DM ‡100 mg/dL or T2DM
Triglyceride levels ‡150 mg/dL ‡150 mg/dL ‡150 mg/dL ‡150 mg/dL
HDL-C <40 mg/dL M, <35 mg/dL M, <40 mg/dL M, <40 mg/dL M,
<50 mg/dL W <39 mg/dL W <50 mg/dL W <50 mg/dL W
AO >102 cm M, >88 cm W Waist-to-hip ratio WC criteria dependent >102 cm M, >88 cm W
>0.90 cm M, or ethnicity
>0.80 cm W or
BMI >30 kg/m2
Microalbuminuria — <30 mg albumin/g — —
creatinine
MetS is diagnosed if: Any three risk factors IR and two or Increased WC and two Indicates risk factors
more risk factors or more risk factors
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AHA/NHLBI, American Heart Association/National Heart, Lung, and Blood Institute; AO, abdominal obesity based on WC; ATP III,
Adult Treatment Panel III; BMI, body mass index; HDL-C, high-density lipoprotein-cholesterol; IDF, International Diabetes Federation;
IR, insulin resistance; M, men; MetS, metabolic syndrome; T2DM, type 2 diabetes mellitus; W, women; WC, waist circumference; WHO,
World Health Organization.

disorder, and therefore age, body weight, socioeconomic
status, and other lifestyle factors are involved directly or in-
directly in the pathogenesis of the syndrome.10 Globally, the
estimated prevalence of MetS in the adult population that have
been reported was *20%–25%.11,12 The growing prevalence
of T2DM, hypertension, CVD, and obesity has been paral-
leled to the increasing prevalence of MetS.13 Especially, the
MetS prevalence is growing rapidly among children and
young adults worldwide.1 Despite the differences in the
standard criteria (ATP III, IDF, AHA/NHLBI, and WHO) to
diagnose MetS, it is well accepted that the prevalence of MetS
is increasing in low-, middle-, and high-income countries.14
In this study, we intend to access maximum possible re-
ports on the prevalence of MetS in Mexican healthy adult
populations. Therefore, estimation of MetS prevalence and
identification of the associated factors will enable us to
recommend policies for the prioritization and implementa-
tion of interventions through Mexican national and regional
health and welfare programs to combat and prevent MetS.
The present systematic review and meta-analysis summarize
the recent prevalence and trends of MetS among healthy
adults aged 18 years and above from Mexico.
Methods
Study design and search strategy of data sources
A systematic review and meta-analysis were performed
using published articles on the prevalence of MetS in
Mexican adults. The studies were identified through Internet
search using the sources of MEDLINE/PubMed, Web of
Science, Cochrane Library, LILACS, and SCIELO. The
search terms were taken from the Medical Subject Headings
library of PubMed. The following keywords were used in
combination: ‘‘metabolic syndrome X’’ (that includes other
terms: Insulin Resistance Syndrome X, Syndrome X, Insulin
Resistance, Reaven’s Syndrome X, and Metabolic Cardio-
vascular Syndrome), ‘‘prevalence,’’ and ‘‘Mexico.’’ The
search was also performed using the Spanish equivalents of
these terms. The search was done for titles and/or abstracts.
The search strategy for MEDLINE was developed first, and
then adapted for the remaining sources. The gray literature
was searched using Google Scholar. The searching of arti-
cles was carried out between March and July 2017.
Selection of studies
Studies were selected for the systematic review and meta-
analysis if they were conducted in Mexico and reported the
prevalence of MetS. A total of 192 relevant studies were
identified and exported to EndNote X5 (Philadelphia); du-
plicates were eliminated. Then, the following inclusion
criteria were applied: (1) cross-sectional studies; (2) studies
that were conducted among 18 years of age or older and
reportedly healthy individuals; and (3) to define MetS,
studies that used any defined criteria to determine the
prevalence of MetS.
The exclusion criteria for our study were as follows: (1)
the reviews and letters to the editors, (2) studies that used
animal models, (3) studies performed outside of Mexico, (4)
the study population comprising individuals who were re-
ported to have other health complications, (5) studies fo-
cusing on biological pathways, (6) studies with incomplete
information, and (7) no abstract (Fig. 1).
After preliminary screening of the titles of the studies, all
abstracts were evaluated for eligibility, based on the estab-
lished criteria. At this point, some studies were assessed in
full length. There was no restriction in the year of publi-
cation, recruitment period, or sample size.
Data extraction
This study has been performed based on the criteria of
Preferred Reporting Items for Systematic Reviews and
Meta-Analysis (PRISMA)15 (Fig. 1). Data from the se-
lected studies were extracted into a predefined form, such
as first author information, year of publication, study type
and location, sample size, age, and prevalence of MetS
(Table 2).
Statistical analysis
All statistical analyses were undertaken using the soft-
ware RStudio version 1.0.153. The prevalence of MetS re-
ported in the selected cross-sectional studies among healthy
 PREVALENCE OF METS IN MEXICO: META-ANALYSIS
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Mexican adult populations was analyzed based on different
diagnostic criteria used. Then, prevalence of MetS was
pooled using a random-effects model and afterward pre-
sented in a forest plot. Statistical heterogeneity was assessed
using the I2 index. The statistical program was also used to
determine the responsible factors for the observed hetero-
geneity through meta-regression.
Results
Identified studies
In total, 192 articles were identified. Altogether, 39 arti-
cles were eliminated due to duplications in the search. After
applying exclusion criteria, 119 articles were eliminated.
Altogether, 34 articles were reviewed in full text, and only
11 articles matched with the inclusion criteria; 4 articles
were found in the gray literature and fulfilled the inclusion
criteria. Finally, 15 studies were selected for the present
review and meta-analysis (Fig. 1).
Description of studies
Year of publication of the studies ranged from 2004 to
2016. Thirteen of 15 studies were carried out in urban areas
of Mexico. Only two studies16,17 estimated the prevalence of
MetS from Mexican rural communities showing a high
3
FIG. 1. Flow diagram of studies
included in the systematic review.
prevalence of 41.1% and 45.2%, respectively. The rest of
the studies were carried out in different cities of Mexico:
Mexico City, Guanajuato, Guadalajara, Merida, Puebla,
Baja California Norte, Morelos, and Queretaro.
Population backgrounds and the recruitment period of the
participants were different in the selected studies (Table 2).
Among the reports, del Pilar Cruz-Dominguez et al. ( January–
April 2014)18 and Denova-Gutiérrez et al. (March–April
2006)19 estimated MetS prevalence in samples drawn from
nurses, physicians, and academic staff. The study carried
out by Dı́az-Cisneros et al. (February 2000)20 estimated
MetS prevalence from teachers. Goodman et al. (October
2008)16 and Echavarrı́a-Pinto et al. (2004)17 conducted
studies in rural communities. Escobedo et al. (September
2003–August 2005)21 and Rojas et al. (October 2005–May
2006)22 reported data from big cross-sectional surveys,
including Cardiovascular Risk Factor Multiple Evaluation
in Latin America (CARMELA) and Mexican National
Survey of Health and Nutrition (ENSANUT in Spanish
acronym), respectively. The authors, Jiménez et al. ( June
2007–April 2008),23 Castro-Sansores et al. (September
2008–December 2009),24 and Gonzalez-Mejia et al.
(March 2012–February 2014),25 carried out studies among
hospitalized patients who had undergone treatments for
different diseases not including CVD. Authors such as
Garcı́a-Jiménez et al. (October 2007–April 2008),26
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Table 2. Characteristic of Studies on the Prevalence of Metabolic Syndrome

Overall prevalence
Overall prevalence of individual
Reference Study population/place Measurements of MetS (%) components of MetS (%)
18
del Pilar Cruz-Domı́nguez et al. (cross- 244 individuals, the median age AO: the lesser curvature, between the ATP III (36.6%) ATP III
sectional study) 30.6 years old; W: 76.2%, lower most rib and the iliac crest. AO: 44.1%
Overweight, obesity, MetS, and waist/ M: 23.8% G, TAG and HDL-C: fasting 8 hr. High G: 22.5%
height index in health staff Mexico city BP: one measurement HT: N/A
HTG: 40.4%
Low HDL-C: W: 51.4%
W, M: 66%
Denova-Gutiérrez et al.19 (cross-sectional 5240 individuals, 20–70 years old; AO: the lesser curvature, between the ATP III (26.6%) ATP III
study) W: 71.6%, M: 56.6% lower most rib and the iliac crest. AO: 38%
Sweetened beverage consumption and in- Morelos and Mexico city G, TAG, and HDL-C: fasting 8 hr. High G: 14.4%
creased risk of MetS in Mexican adults. BP: one measurement HT: 18.3%
HTG: 37.5%
Low HDL-C: 76.6%
Dı́az-Cisneros et al.20 (cross-sectional 477 individuals, 20–60 years old; AO: the lesser curvature, between the ATP III (29.6%) ATP III
study) W: 56.4%, M: 43.6% lower most rib and the iliac crest. AO: 43.4%
Prevalencia del sı́ndrome Guanajuato, Guanajuato G, TAG, and HDL-C: N/A High G: 7%
metabólico en profesores de BP: one measurement HT: D: 12.3%, S: 9.6%
Guanajuato, México HTG: 48.8%
Low HDL-C: 43%

4
Echavarrı́a-Pinto et al.17 (cross-sectional 73 individuals, 20–40 years old; AO: the lesser curvature, between the ATP III (45.2%) ATP III
study) W: 42.5%, M: 57.5% lower most rib and the iliac crest. AO: W: 83.3%, M: 16.1%
MetS in adults from 20 to 40 years Senegal de Palomas, San Juan del G, TAG, and HDL-C: fasting 9–12 hr. High G: 12.5%
old in a rural Mexican community Rı́o, Querétaro BP: two measurements HT: 27.3%
HTG: N/A
Low HDL-C: N/A
Escobedo et al.21 (cross-sectional study) 1720 individuals, 25–64 years old; AO: the lesser curvature, between the ATP III (27%) ATP III
Prevalence of the MetS in Latin America W: 56.4%, M: 43.6% lower most rib and the iliac crest. AO: W: 93.%, M: 72.7%
and its association with subclinical Mexico city G, TAG, and HDL-C: fasting 6 hr. High G: W: 35.2%, M: 30.4%
carotid BP: two measurements HT: W: 52.3%, M: 58.3%
atherosclerosis: the CARMELA HTG: W: 85.7%, M: 93%
cross-sectional study Low HDL-C: W: 77.7%, M: 78%
Jiménez et al.23 (cross-sectional Study) 770 individuals, 18–65 years old; AO: N/A ATP III (52.5%) ATP III
Prevalencia del sı́ndrome W: 59.7%, M: 40.3% G, TAG, and HDL-C: N/A AO: W: N/A, M: 83%
metabólico en relación con las Mexico city BP: N/A High G: N/A
concentraciones de ácido úrico HT: W: 32%, M: 48%
HTG: W: 43%, M: 41%
Low HDL-C: W: 69%, M: 58%
Gurrola-Dı́az et al.30 (cross-sectional 80 individuals, 40–78 years old; AO: between the lowest rib margin ATP III (31%) ATP III
study) Guadalajara and the iliac crest, at the end of a AO: N/A
Establishment of a cut-point gentle expiration. High G: N/A
value of serum TNF-a levels G, TAG, and HDL-C: fasting 12 hr. HT: N/A
in the MetS BP: one measurement HTG: N/A
Low HDL-C: N/A

(continued)
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Table 2. (Continued)
Overall prevalence
Overall prevalence of individual
Reference Study population/place Measurements of MetS (%) components of MetS (%)
Garcı́a-Jiménez et al.26 (cross-sectional 204 individuals, 21–55 years old; AO: between the lower rib ATP III (33.8%) ATP III
study) Morelos and the iliac crest, AO: 74%
Serum leptin is associated with metabolic G, TAG, and HDL-C: fasting 10 hr. High G: 7.4%
syndrome in obese Mexican subjects BP: two measurements HT: 34.3%
HTG: 16.7%
Low HDL-C: 17.2%
Castro-Sansores et al.24 (cross-sectional 204 individuals, 20–75 years old; AO: N/A IDF (49%) IDF
study) W: 68%, M: 32% G, TAG, and HDL-C: fasting 12 hr. AO: 59.8%
Prevalencia de Sı́ndrome Merida BP: N/A High G: 48%
Metabólico en sujetos adultos que viven HT: 50%
en Mérida, Yucatán, México HTG: 57.8%
Low HDL-C: N/A
Goodman et al.16 (cross-sectional study) 107 individuals, 18–80 years old; AO: N/A AHA/NHLBI (41.1%) AHA/NHLBI
Prevalence of diabetes and MetS in a W: 56%, M: 38.5% G, TAG, and HDL-C: fasting 8 hr AO: N/A
migrant Mixtec population, Baja, San Quintin, Baja California, BP: N/A High G: 45.8%
California, Mexico Mexico HT: 24.3%
HTG: 33.6%
Low HDL-C: 73.8%
Gonzalez-Mejia et al.25 (cross-sectional 270 individuals, 18–80 years old; AO: the lesser curvature, between the ATP III ATP III/IDF/WHO

5
study) W: 57.8%, M: 42.2% lower most rib and the iliac crest G, (56.3%) AO: N/A
C-peptide is a sensitive indicator for the Puebla TAG, and HDL-C: IDF High G: N/A
diagnosis of metabolic syndrome in fasting 10–12 hr (63.3%) HT: N/A
subjects from BP: two measurement WHO HTG: N/A
Central Mexico (56.3%) Low HDL-C: N/A
Rojas et al.22 6021 individuals, ‡20 years old AO: N/A ATP III ATP III
(cross-sectional study) Mexico G, TAG, and HDL-C: N/A (36.8%) AO: 42.7%
MetS in Mexican adults: results BP: N/A IDF High G: 21%
from the National Health and (49.8%) HT: 42.6%
Nutrition Survey 2006 AHA/NHLBI (41.6%) HTG: 31.4%
Low HDL-C: 76.3%
IDF
AO: 74.2%
High G: 33%
HT: 42.6%
HTG: 33%
Low HDL-C: 76.3%
AHA/NHLBI
AO: 43.7%
High G: 33%
HT: 42.6%
HTG: 33%
Low HDL-C: 76.3%

(continued)
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Table 2. (Continued)
Overall prevalence
Overall prevalence of individual
Reference Study population/place Measurements of MetS (%) components of MetS (%)
Aguilar-Salinas et al.27 (cross-sectional 2158 individuals, 20–69 years old AO: N/A ATP III ATP III
study) Mexico G, TAG, and HDL-C: fasting 12 hr (26.6%) AO: N/A
High prevalence of MetS in Mexico BP: N/A WHO High G: N/A
(13.6%) HT: 21.8%
HTG: N/A
Low HDL-C: N/A
WHO
AO: N/A
High G: N/A
HT: N/A
HTG: N/A
Low HDL-C: N/A

González-Chávez et al.28 (cross-sectional 189 individuals, ‡18 years old; AO: N/A ATP III ATP III
study) Mexico city G, TAG, and HDL-C: fasting 12 hr (46.5%) AO: 70.3%
Prevalencia del sı́ndrome metabólico entre BP: N/A IDF High G: N/A
adultos mexicanos no diabéticos, usan- (43.3%) HT: N/A
do las definiciones de la OMS, NCEP- WHO HTG: 52.3%
ATP IIIa e IDF (36.5%) Low HDL-C: 65.6%
IDF

6
AO: 70.3%
High G: N/A
HT: N/A
HTG: 44.4%
Low HDL-C: 54.4%
WHO
AO: N/A
High G: N/A
HT: 10.5%
HTG: 48.5%
Low HDL-C: N/A
Isordia-Salas et al.29 (cross-sectional 854 individuals, ‡20 years old; AO: the midpoint between the last rib IDF IDF
study) Mexico city and the iliac crest (68.7%) OA: W: 100%, M: 100%
Prevalence of MetS components in an G, TAG, and HDL-C: overnight AHA/NHLBI (59.7%) High G: W: 64.8%, M: 67.3%
urban Mexican sample: comparison fasting. HT: W: 46.1%, M: 54.7%
between two classifications BP: two measurements HTG: W: 73.8%, M: 74.7%
Low HDL-C: W: 93.2%, M: 90%
AHA/NHLBI
AO: W: 83%, M: 47%
High G: W: 70.4%, M: 73.5%
HT: W: 50.2%, M: 65.2%
HTG: W: 76%, M: 80%
Low HDL-C: W: 93.5%, M:
95.5%
BP, blood pressure; CARMELA, Cardiovascular Risk Factor Multiple Evaluation in Latin America; G, glucose; HT, hypertension; HTG, hypertriglyceridemia; N/A, not available; TAG,
triglyceride.
 PREVALENCE OF METS IN MEXICO: META-ANALYSIS
Aguilar-Salinas et al. (February 2000),27 González-Chávez
et al. (2008),28 Isordia-Salas et al. (May 2011),29 and
Gurrola-Dı́az et al. (no data)30 estimated MetS prevalence
from other Mexican communities (Table 2).
Prevalence of MetS was reported based on different cri-
teria and was also compared: Gonzalez-Mejia et al.25 stated
a MetS prevalence using ATP III, WHO, and IDF criteria,
and Rojas et al.22 used ATP III, IDF, and AHA/NHLBI
criteria. In addition, Isordia-Salas et al.29 evaluated the
prevalence of MetS according to IDF and AHA/NHLBI, and
Aguilar-Salinas et al.27 reported prevalence based on ATP
III and WHO criteria. In another study, González-Chávez
et al.28 described MetS prevalence using ATP III, IDF, and
WHO criteria (Table 2).
The overall prevalence of MetS was estimated from
pooled information of 15 selected studies. However, four
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subgroups were allocated based on different criteria: ATP
III subgroup was integrated by 12 studies, and WHO sub-
group consisted of 3 studies. Moreover, five studies were
allocated to IDF subgroup, and finally three studies were
classified in AHA/NHLBI subgroup (Table 2). It was in-
teresting to observe that in eight studies, proportion of
women was higher than men, and in six reports the pro-
portions of women and men were not described. Six studies
reported prevalence of MetS by sex.
Factors associated with MetS
The inter-relationships between different risk factors and
the presence of MetS were analyzed in 6 of 15 studies. The
risk of MetS increased significantly with the consumption of
sweetened beverages19 and alcohol.16 It was found that high
concentrations of C-peptide,25 TNF-a,30 leptin,26 and uric
acid23 were positively associated with MetS. Individuals who
consumed more than two servings of sweetened beverages
per day showed a greater risk of having MetS (two times).19
Goodman et al.16 revealed that drinking alcohol at least once
a week had a positive correlation with the MetS (P = 0.003).
In addition, Castro-Sansores et al.24 reported association of
MetS with degrees of hepatic fat infiltration, and del Pilar
FIG. 2. Forest plot of the studies of population using ATP III. ATP III, Adult Treatment Panel III.
7
Cruz-Dominguez et al.18 showed an association between
excess weight (overweight and obesity) and MetS.
Components of MetS in Mexico
The prevalence of the components of MetS was reported
in 12 studies; among these Escobedo et al.,21 Jiménez
et al.,23 and Isordia-Salas et al.29 reported the prevalence of
the components separately for men and women. The prev-
alence of AO was reported in 10 studies. The AO showed to
be more prevalent among urban individuals in the Mexico
City, based on IDF criteria (100%).29 Differences in the
prevalence of AO in adults varied *36%. The prevalence of
increased glucose levels was reported in 10 studies; based
on IDF criteria, Isordia-Salas et al.29 showed the highest
prevalence of increased glucose levels (67.3%) among men.
However, levels of increased glucose levels varied from
7%20 to 45.8%.16 The prevalence of hypertension was re-
ported in 11 studies; AHA/NHLBI criteria presented the
highest prevalence of hypertension with 50.2% for women
and 65.2% for men.29 However, del Pilar Cruz-Dominguez
et al.18 using the ATP III criteria showed the lowest prev-
alence of hypertension (2.2%) among healthy individuals
from Mexico City. Prevalence of increased levels of tri-
glycerides was reported in 10 studies; using the ATP III
criteria, Escobedo et al.21 showed the highest prevalence of
85.7% in women and 93% in men. Ten studies reported
prevalence of low HDL-C (Table 2).
Meta-analysis
Twelve studies presented a prevalence of MetS using the
ATP III criteria, five studies defined MetS according to IDF,
three studies used WHO criteria, and three studies defined
MetS according to AHA/NHLBI. The observed preva-
lence of MetS varied between 31% and 54% based on dif-
ferent criteria. The estimated prevalence of MetS for ATP
III subgroup was 36% (95% CI 0.30–0.42) (Fig. 2), and for
IDF subgroup it was 54% (95% CI 0.44–0.63) (Fig. 3); for
WHO subgroup, it was 31% (95% CI 0.04–0.69) (Fig. 4), and
 8 GUTIÉRREZ-SOLIS ET AL.

FIG. 3. Forest plot of the studies of population using IDF. IDF, International Diabetes Federation.
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FIG. 4. Forest plot of the studies of population using WHO. WHO, World Health Organization.

for AHA/NHLBI subgroup it was 48% (95% CI 0.34–0.62)
(Fig. 5). According to the Der Simonian–Laird random-effects
model, the pooled prevalence of MetS in healthy adult Mexi-
can populations was 41% (95% CI 0.34–0.47) (Fig. 6). The
results showed that studies using IDF criteria presented the
highest prevalence and WHO criteria reported the lowest
prevalence. Differences in the prevalence of MetS among
adults varied *23%. Furthermore, six studies reported
prevalence of MetS by sex; men showed a prevalence of
39% (95% CI 0.28–0.52) and women 38% (95% CI 0.28–
0.48) (Figs. 7 and 8).
A meta-regression analysis was performed to take the
different criteria into account. In the univariate meta-
regression analysis, only the variables of ATP III and IDF
criteria were found to be significantly associated with hete-
rogeneity (P = 0.0001, P = 0.0052, respectively) (Table 3).
Discussion
Several studies have reported the prevalence of MetS
representing different population characteristics, ethnic
backgrounds, locations, and so on. Consequently, studies
have shown a high degree of variability in MetS prevalence.
This variation could be affected by the different MetS cri-
teria, age, and sex or even by the sampling design used.
Differences in the criteria of MetS definition were observed
in the literature of MetS. For example, estimated prevalence
of MetS in African populations was reported to vary from as
low as 0% to as high as 50% or even higher, depending on
the population settings and the criteria of MetS definition
used.31 In Turkey, the MetS prevalence was found to be
36.6% according to ATP III and 44% according to IDF.32
Furthermore, in Spain, remarkable difference in the esti-
mated MetS prevalence was observed based on WHO
(17.9%) and ATP III (23.5%) criteria.33
This study found a combined MetS prevalence of 41%
among healthy Mexican adults (Fig. 6); the frequency ranged
from 31% to 54%, depending on the MetS definition used.
This pooled prevalence was higher than that reported in the
United States (34.2%)34 and in Latin America (24.9%).35
Based on the information obtained in this study from Mexico,
the prevalence of MetS following different criteria was 54%

FIG. 5. Forest plot of the studies of population using AHA/NHLBI. AHA/NHLBI, American Heart Association/National
Heart, Lung, and Blood Institute.
Downloaded by Karolinska Institutet University Library from www.liebertpub.com at 08/25/18. For personal use only.

FIG. 6. Forest plot of the pooled prevalence of the studies among healthy Mexicans.

FIG. 7. Forest plot of the studies of men population.

FIG. 8. Forest plot of the studies of women population.

9
 10
Table 3. Results of Meta-Regression for the Prevalence of Metabolic Syndrome Among Criteria
Variables Estimate SE
ATP III 0.6415 0.0394
IDF 0.2279 0.0816
WHO -0.0841 0.0962
AHA/NHLBI 0.1210 0.0824
Significant P values: 0***, 0.001**.
for IDF, 48% for AHA/NHLBI, 36% for ATP III, and 31%
for the WHO (Figs. 2–6). Therefore, it appears that some of
the differences in the reported prevalence were due to the
differential diagnostic criteria for MetS.
In our meta-analysis, according to the ATP III criteria,
low HDL-C was the most frequent component of MetS
Downloaded by Karolinska Institutet University Library from www.liebertpub.com at 08/25/18. For personal use only.
(53%) followed by AO (48%), which suggests an emergent
need for better monitoring after diagnosis (Table 2). In
Mexico, anthropometric measurements are not always part
of the routine medical evaluation; it is common to check
only the body mass index. However, evaluation of AO,
based on waist circumference measurement, is not frequent.
In a study from the United States, the most prevalent
component of MetS was AO, estimating frequency of
56.1%, and this trend was much higher among adult women
than men.36 In agreement with Murguı́a-Romero et al.,37
low HDL-C was found to be an important component to
estimate MetS prevalence among young Mexicans, showing
55% in women and 28.6% in men.
Difference between the estimated prevalence of MetS
using the IDF and AHA/NHLBI criteria was very small, but
the estimated values using ATP III and WHO criteria were
remarkably higher. The highest estimated MetS frequency
using WHO criteria might be explained by the fact of low
number of studies that followed the criteria. Both studies
presented big differences in the estimated MetS frequencies
(13.6% and 56.3%)25,27 (Table 2).
In our study, it was found that differences in the frequencies
of the components of MetS were even greater. This might be
explained, at least to some degree by the sociodemographic
backgrounds of the studied populations. Another compound-
ing factor was the difficulty in the comparability of the studies
that were mostly performed in urban areas, and only two
studies were carried out in rural areas. Eleven of 15 studies
were performed in the central region of Mexico; this leads to
an issue of unavailability of information from the other re-
gions of the country. Only two studies included samples from
the general population of Mexico.22,27 All studies included
apparently healthy individuals. No significant difference
(P > 0.05) in the prevalence of MetS was found among women
and men (38% and 39%, respectively).
Some of the limitations in our study are as follows: un-
availability of large-scale data from different Mexican
States, some studies were conducted in different population
backgrounds, for example, hospital workers (nurses and
physicians), and differences in the cutoff values to diagnose
MetS, based on standard criteria (ATP III, IDF, WHO, and
AHA/NHLBI).
Conclusion
To decrease the MetS prevalence in Mexico, early inter-
ventions in the lifestyle habits are needed and recommended.
GUTIÉRREZ-SOLIS ET AL.
Z 95% CI P
16.2691 0.56–0.71 <0.0001***
2.7930 0.06–0.38 <0.0052**
-0.8743 -0.27–0.10 0.3820
1.4682 -.0.04–0.28 0.1420
Therefore, the actions could help reducing and controlling the
complications due to MetS. Particularly, CVD and T2DM are
the main causes of mortality in Mexico. To the best of our
knowledge, this is the first published systematic review and
meta-analysis evaluating studies on the prevalence of MetS
and its components, at least from healthy Mexican adult
populations. This meta-analysis shows a high prevalence of
MetS in healthy Mexican adults, despite the use of different
criteria for MetS diagnosis. The lack of consensus on the
diagnostic criteria for MetS is an important issue in this area
of research. More information on the clinical criteria of the
MetS components and their inter-relationships will provide
greater insights into the problem, and contribute to the
planning and implementation of public health strategies.
Therefore, primary preventive care could be used to reduce
its prevalence and impacts on human health.
Acknowledgment
We are very grateful to Mr. Julio Vega for helping with
the statistical analysis.
Author Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Ana Ligia Gutiérerez-Solis, PhD
Departamento de Investigación Research Unit
Hospital Regional de Alta Especialidad
de la Penı́nsula de Yucatán
Calle 7
No. 433 por 20 y 22
Fraccionamiento Altabrisa
Mérida 97130
Yucatán
México
E-mail: ganaligia@gmail.com