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Snapshot of India

India feels the burden of metabolic syndrome

In this issue, our ‘Snapshot’ features Mumbai in India, and a recent report examined the prevalence of metabolic syndrome in the city. In India, epidemiologists and international agencies have been sounding an alarm on the rapidly rising burden of cardiovascular disease (CVD) for the past 15 years. It is estimated that by 2020, CVD will be the largest cause of disability and death in India, with 2.6 million Indians predicted to die due to CVD.

Photo: Flickr/jonrawlinson

According to the authors, metabolic syndrome (MS) is a complex web of metabolic factors that are associated with a two-fold risk of CVD and a five-fold risk of diabetes. Individuals with MS have a 30%–40% probability of developing diabetes and/or CVD within 20 years, depending on the number of components present. MS consists of an atherogenic dyslipidemia (ie elevated triglycerides and apolipoprotein B (apo-B) and low high-density lipoprotein cholesterol (HDL-C)), elevation of blood pressure and glucose, pro-thrombotic and pro-inflammatory states. 

The aim of their report was to assess the prevalence of MS as defined by NCEP ATP III guidelines with a modification to the value for BMI that is more applicable to the Asian Indian population, and to look for the differences between the various components constituting MS. Along with the prevalence of MS, the investigators from Research Laboratories, PD Hinduja National Hospital & Medical Research Centre, Mumbai, also studied the prevalence of various risk factors leading to atherosclerotic CVD.

A total of 560 subjects, who attended the free CARDIAC evaluation camp arranged by PD Hinduja National Hospital and Medical Research Centre by general advertising, were recruited in the study. Among the 560 subjects, 548 (302 males and 246 females) who had all the required data for the analysis formed the study group.

Each participant was interviewed by a group of research students and completed a standardized questionnaire containing information on demographics, anthropometric profile, individual characteristics associated with the major risk factors of CVD, past medical history, and biochemical parameters. Prevalence of diabetes and hypertension was ascertained based on self-report of the physician’s diagnosis and/or use of prescription medications along with medical records of therapeutics. Blood samples were collected and analysis was performed via an automated clinical chemistry analyser. The prevalence of MS was calculated using the prevalence rate formula: number of patients per total number of all subjects at the time of study multiplied by 100. 

A total of five hundred and forty eight subjects participated in the study. On applying modified NCEP ATP III, consensus guidelines for defining obesity in Asian Indians and ADA, we found out that nearly 95% of the subjects had at least one abnormal parameter. 

Demographic characteristics

The gender distribution was 56.75% males and 46.71% females and the age of the subjects ranged from 20 to 90 years, with a mean age in males of 54.28 years and in females of 52.67 years. Of these, 18.65% males and 16.02% females were in 20–40 age group, 47.91% males and 57.42% females were in 41–60 age group, and 33.44% males and 26.56% females were >60 years old.

Results

The results showed a mean BMI of 25.68 in males and 26.95 in females, which clearly shows that the prevalence of BMI ≥23 kg/m2 was significant in females than in males (p=0.008). Both in males and females, the prevalence of overweight BMI (≥23 kg/m2) shows linear increase with age and was found to be more in males than females. The overall prevalence of BMI (≥23 kg/m2) was 79.01%. The prevalence of obesity was high in 41–60 age group females than 20–40 age group and >60 age group. The prevalence of obesity is almost the same in 20–40 and 41–60 age group males but drops down as age advances. The incidence of abdominal obesity observed was 70.9% and waist to hip ratio was 73.76%.

It was found in the current study that history of hypertension and diabetes increases as age advances both in males and females. Prevalence of history of diabetes was significant in males than in females (p=0.015). Prevalence of history of hypertension in both males and females was highly significant in 41–60 age groups (p=0.001). History of diabetes in 41–60 age group males was highly significant (p=0.001). Prevalence of family history of cardiovascular diseases was observed in 27.76% subjects.

Increased fasting blood glucose, hypertriglyceridemia and decreased levels of HDL-C were found to be more in males with high TG and low HDL-C to be highly significant (p=0.001). Hypercholesterolemia was highly significant in females as compared to males. Both males and females in 41–60 age groups showed significantly high levels of impaired glucose levels (p=0.001). On further comparing age wise, prevalence of low HDL-C in 20–40 age group males was 64.91% which is very high as compared to other age groups both in males and females. In males, the prevalence of hypercholesterolemia, and hypertriglyceridemia was found to be more in 41–60 age group. In females, fasting blood glucose, hypertriglyceridemia and hypercholesterolemia showed a linear increase with age.

The overall prevalence of MS having ≥3 components was 19.52% by modified NCEP ATP III criteria. The prevalence of MS in males was almost double (25.16%) than females (12.6%), and this was highly significant (p=0.008). For age, the distribution of prevalence of MS was found to be the same in 20–40 and 41–60 age groups (20.61% and 20.76%), respectively, whereas >60 age group showed a marginal decrease in the prevalence (16.66%). The prevalence of individual components of MS is reported in Figure 1. 

 

The prevalence of major risk factors of atherosclerotic CVD was 45.25% overweight, 33.75% obese, 39.96% having impaired blood glucose levels, 39.96% subjects with hypercholesterolemia, 38.13% with hypertriglyceridemia, and 47.97% with low HDL-C. The prevalence of elevated cardiac markers was 2.18% with high APO B, 1.82% with increased APO A, 30.65% and 8.39% with elevated levels of Lp(a) and hsCRP, respectively. The gender-specific prevalence of different atherosclerotic risk factors is reported in Figure 2.

The development of obesity, or more specifically an increase in abdominal fat, is thought to be the primary event in the progression of MS. A tendency to gain fat in the abdominal area, as opposed to the hip, buttock, and limb areas, is linked to a rise in fatty acids in the blood, which is thought to lead to insulin resistance, high blood pressure, abdominal blood lipids, and eventually diabetes. Asian Indians tend to develop central obesity rather than generalised obesity. About three fourth of the subjects participated in study were overweight/obese (BMI≥ 23kg/m2), being a prime determinant of MS prevalence. Of these around one third of overweight/obese subjects had impaired glucose tolerance and many exhibit features of MS. Obesity reduces HDL-C levels, and obese patients with MS and atherogenic dyslipidemia almost always have low HDL-C levels. This study shows that around 35% of subjects had low HDL-C were either overweight or obese.

Conclusion

The prevalence of MS varies amongst ethnic groups. Indians are high at risk for CVD and their predispositions. The prevalence of MS was double in males as compared to females and this study revealed the increased prevalence of MS to be more prevalent in 41–60 years, suggesting that this group is at increased risk of developing CAD. The investigators also reported that the high percentage prevalence of overweight and obesity was one of the major driving forces in the development of MS. Therefore, they concluded that an early identification of the metabolic abnormalities and appropriate intervention may be of primary importance in similar populations.

Source: Prevalence of Metabolic Syndrome in Urban India