Metabolic Syndrome among Yemeni Physicians in Sana'a

Suez Canal Univ Med J
Vol. 11, No, 1 , March, 2008
31 - 34
Metabolic Syndrome among Yemeni Physicians in Sana'a
Abdullah A Almikhlajy™, Fathi A Mak!ady(2),
Sobhy A Sobhyl3>, Enas 1 Elsheikh1", Ahmed K Alansi<4>
Departments of Community Medicine 0,3 ' and Cardiology12-4', Science and Technology University, Yemen1",
Suez Canal University, Egypt*2-3' and Sana'a University, Yemen1'"
Abstract
Objective: To assess the prevalence of metabolic syndrome among Yemeni physicians in Sana'a,
Yemen
Methodology: Data were collected on 332 Yemeni physicians in Sana'a (224 males and 108 females)
aged 25 years and over. Metabolic syndrome was diagnosed according to ATP-ill criteria.
Results: The prevalence of metabolic syndrome in the study population was 23.8% (25.4% among
males and 20.4% among females). All the components of the metabolic syndrome were significantly more
common in males, except low HDL-cholesterol level. Low HDL-C was the most common metabolic
abnonnality in both sexes.
Conclusion: Metabolic syndrome is prevalent among Yemeni physicians in figures comparable to
western populations. Low HDL was the most prevalent component.
Keywords: Prevalence, Metabolic Syndrome, Yemeni, Physicians.
association with obesity especially its central or
visceral component'7'.
Introduction
Metabolic syndrome is a collection of major
and emerging risk factors for atherosclerosis that
tend to occur together 0 '. This syndrome has gone
by various names, including Reaven's syndrome,
the deadly quartet, syndrome X, insulin resistance
syndrome, as well as metabolic syndrome'1,2'. It
was found that the prevalence of CHD, myocardial
infarction and stroke were approximately 3-fold
higher in individuals with the metabolic syndrome
compared with those without the syndrome'3'.
Subjects and Methods
This is a descriptive cross-sectional .study on Yemeni
physicians in Sana'a capital city, According to the Health
Office in Sana'a, they were 1083. Sample size was
calculated by using the following formula'*': n=NZ2pq/d2
(N-l) f-Z2pq. The calculated number-"249. To adjust the
sample size estimate for non response, 10% was added
to the calculated size. Then the tolal sample size = 249
+ 25 = 274.
The major characteristics of metabolic syndrome
include insulin resistance, abdominal obesity,
elevated blood pressure, and lipid abnormalities
(i.e., elevated levels of triglycerides and low levels
of high-density lipoprotein [HDL] cholesterol)'4'.
Initially defined by an expert panel of the World
Health Organization in 1998'51, the ATP III has
created an operational definition of metabolic
syndrome: the co-occurrence of any three of the
abnormalities mentioned above'2'.
Many investigators place a greater priority on
insulin resistance than on obesity in pathogenesis
of metabolic syndrome'6'. They argue that insulin
resistance, or its accomplice, hyperinsulinemia,
directly causes other metabolic risk factors.
Identifying a unique role for insulin resistance is
complicated by the fact that it is linked to obesity.
Insulin resistance is the link between the different
components of metabolic syndrome. It has strong
The subjects were taken from the main hospitals in
Sana'a (Allhawra, Aljomhori, and Alsabeen). Response
rate was 71.2% among females, and 54.3% among male
physicians.
Data collection included filling out a questionnaire,
measurement ofBP, taking anlhropomelric measurements.
In addition, fasting blood samples were taken for
measuring lipids profile and glucose. The questionnaire
was developed, pre-tested, and validated in a pilot study.
It included basic demographic and socio-economic data,
family and medical history as well as drug intake.
Before measuring theblood pressure, it was confirmed
thai the participant had not consumed tea or coffee,
engaged in physical activity, or smoked one hour before,
and had an empty bladder.
Participants were initially told to rest for 5 minutes.
Then blood pressure was measured twice in a seated
position after one more measurement for determining
11
32
Almikhlafy et al.
peak inflation level using a standard mercury
sphygmomanometer (Reister, Germany). An appropriate
cuff was chosen. There was at least a 30 second interval
between the two separate measurements. Thereafter,
the mean of two measurements was considered as
the participant's blood pressure. The systolic blood
pressure was defined as the appearance of the first sound
(Korotkoff phase 1), and the diastolic blood pressure was
defined as the point before the disappearance of the sound
(Korotkoff phase 5) during deflation of the cuff at a 2-3
mm per second decrement rate of mercury column'9*.
Waist was defined as the midpoint between the lower
rib and the upper margin of the iliac crest. It was measured
using a tape.
A sample of 10 ml of venous blood was taken from
participants after overnight fasting for 8 hours at least.
Blood samples were drawn in a sitting position and the
participant remained in sitting position at least for 5
minutes prior to blood collection. Blood was drawn from
the left arm. Blood samples were taken from the vein in
the antecubita! fossa. Tubes were labeled with the subject
identification code. The blood samples were allowed
to clot at the room temperature. The clotting time was
minimally 30 minutes and maximally 45 minutes. After
that samples were centrifuged at a temperature 15-24°C.
Blood spun for 10 minutes at 1500 g. After centrifugation,
the serum promptly separated from clot or cells and
transferred to a clean tube. After serum separating lo
proper tubes the lubes were carefully marked with slicker
with identification code. The Hitachi 912 chemistry autoanalyzer (Roche/Hitachi) was used.
The metabolic syndrome was defined according lo
Third Report of the Expert Panel on detection, evaluation,
and treatment of high blood cholesterol in adults(2). It
defined metabolic syndrome as presence of any 3 of the
following 5 diagnostic criteria: Waist Circumference
>102 cm in men or > 88 in women; blood pressure (BP)
>130/85 mm Hg; HDL cholesterol <40 mg/dL in men or
<50 mg/dL in women; triglycerides >150 mg/dL; fasting
blood glucose >110 mg/dL, or receiving anti-diabetic
treatment, or the presence of previously diagnosed
diabetes mellitus.
Data were analyzed using the SPSS 11.5 (SPSS Inc.,
Chicago 1L, USA). The prevalence rate was given as
percentages. Relations among the categorical parameters
were investigated by "Chi-square test". P value < 0.05
was considered significant. Informed consent was taken
from those who agreed to participate in the study. The
obtained data was confidential. No one exposed to
participants personal data except the research group.
Results
Table (I) shows the prevalence of metabolic
syndrome among physicians. As shown in the table,
about fifth of males (25.4%) and fourth of females
(20.4) had metabolic syndrome. The difference
was not significant (X2 = 1.04, p = 0.304). Table
(11) shows the prevalence of each components of
metabolic syndrome according to ATP III. Of all
the components of the metabolic syndrome, low
HDL-C was the most common abnormality in both
sexes. It was more statistically prevalent among
female participants with prevalence rate of 65.7%
compared with 50.9% among males (X2 = 6.51,,
p = 0.011). Hypertriglyceridemia rank second in
contributing to MS among males and females.
It was more statistically prevalent among male
participants with prevalence rate of 46.9% compared
with 28.7% among males (X2=9.95, p=0.01). High
blood pressure was found in about third of male
physicians (34.4%) and 27.8% of females without
significant difference between them. On the other
hand, central obesity was found in 18.7% of
participants with predominant prevalence among
female physicians with prevalence rate of 23.1%
among them compared to 16.5% among males. But
the difference was not significant. Prevalence of
high blood glucose was similar among both sexes
with prevalence rate of 19.2 % among male and
16.7% among female physicians
Table (I): Prevalence of metabolic syndrome among male and female physicians
Male (n = 224)
N
%
Female (n = 108)
N
%
Total
N
%
Present
57
25.4
22
20.4
79
23.8
Absent
167
74.6
86
79.6
253
76.2
X2
P
1.04
0.304
Table (11): Prevalence of each component of the metabolic syndrome among male and female physicians
Male (n : = 224)
Female (n = 108)
Total
- X2
N
%
%
N
%
N
25
23.1
62
18.7
2.109
37
16.5
Abdominal obesity
114
50.9
71
65.7
188
56.6
6.51
Low HDL cholesterol
105
46.9
31
28.7
121
36.4
9.95
Hypertriglyceridemia
77
1.45
32.2
34.4
30
27.8
107
High BP or on medication
43
18.4
0.001
19.2
16.7
18
61
High FBG or on medication
*: Significant
P
0.15
0.011*
0.01*
0.23
0.97
33
Metabolic Syndrome among Yemeni Physicians
Discussion
It is well known that the metabolic syndrome
and its complications are hazardous due to the
combination of its components such as abdominal
obesity, high blood pressure, high fasting blood
sugar, high serum triglycerides level and low
HDL-cholesterol. Nevertheless, the prevalence
of metabolic syndrome has never been studied in
Yemen population so our comparisons will be
with studies in the other countries especially with
Arab ones. The Adult Treatment Panel III (ATPIII) criteria of the national Cholesterol Education
Program in the USA were used.
hypertriglyceridemia, obesity, and smoking. While
these factors might play an important role in the low
HDL-C level, previous family and twin studies have
suggested that genetic polymorphism accounts for
40-60% of the inter-individual variation in plasma
HDL-C level'13'. Some of the gene loci suggested
for such variations is the hepatic lipasc (LIPC)
and cholesteryl ester transfer protein (CETP)
loci. Several mutations at CETP locus, especially
common in Japanese population, have been
identified resulting in the absence of detectable
CETP mass and/or activity It has also been shown
that over expression of LIPC gene decreases plasma
HDL-C concentration"6'.
In this study, fifth of male (25.4%) and fourth
of female Yemeni physicians had metabolic
syndrome. The difference between both groups was
not significant. In other Arab countries, metabolic
syndrome was more prevalent among females. AlNozha et al.(10) reported prevalence rate of 40.9
among male and 42% among female adults in Saudi
Arabia. In Oman, metabolic syndrome was also
more prevalent among females than males with
prevalence rate of 23% and 19.5% respectively"!).
In these studies'101", women were more obese than
men. However, in our study there was no significant
difference between both groups. It is well known
that metabolic syndrome is more prevalent among
obese ones.
In addition another factor can explain why the
metabolic syndrome in our study is relatively more
prevalent among male physicians. It is the age;
siuce female physicians were younger than males.
Physical activity is another factor that can play a
role in the variation of distribution of metabolic
syndrome among males and females. However, in
the previous studies'10"', females were physically
inactive more than males, whereas in our study there
were no difference between both groups.
In this study, low HDL was the most common
component of MS in male and female physicians
with female predominance (50.9% vs. 65.7%,
respectively). Other studies in the region are in
agreement with these findings; 81% of women and
78.4% of men had low HDL-C"01, while in Oman,
it was 77.2% of women and 74.4% of men"". In
another Arab country, Palestine, low HDL was also
high1'2'. Conversely, it was more prevalent among
males (70%) than females (55.7%). In Iran, it was
reported that about three fourths (73%) of Iranian
women and 69% of men had low HDL-C l3 >. Similar
results were found in Turkey'M).
These findings are larger those reported from
western countries with the same criteria. For
instance, in USA, it was reported among 35.1%
of men and 39.1% of women"5'. In the light of
these findings it seems that low HDL-C is a
dilemma in our region. This could be attributed to
urbanization, modification of life style, unhealthy
diet, physical inactivity, increased prevalence of
The importance of the metabolic syndrome as a
predictor of atherosclerotic cardiovascular disease
is becoming established'l7). In our study, metabolic
syndrome was highly prevalent among those with
previous coronary heart disease (66%). In a recent
analysis of data from the third National Health
and Nutrition Examination Study (NHANES 111),
Ninomiyaandhiscolleagues"s,observed a significant
2-fold increase in the multivariatc likelihood oF
prevalent myocardial infarction and stroke among
individuals with the metabolic syndrome compared
with individuals without the metabolic syndrome.
When taking in consideration that 47% of
male and 38% of female physicians in our study
have overweight, it is likely that the prevalence of
metabolic syndrome will probably increase in [lie
coming years among Yemeni physicians with its
complications including CHD.
In conclusion, metabolic syndrome is prevalent
among Yemeni physicians in figures comparable
to western populations. Low HDL was [he mosL
prevalent component. Studies should be done to
assess the metabolic syndrome among Yemeni
population.
References
1. Dunbiir R and Szapary P. Metabolic syndrome: A new uirgel
of therapy? Am J Mcd Care; 2004, Supplement IV: SlS13.
2. National Institutes of Health (NIH). Third Repori of The
National Cholesterol Education Program Expert Panel
on Detection, Evaluation, and Treatment of High Blood
Cholesterol in Adults (Adult Treatment Panel III). National
Institutes of Health, Bcthcsda, MD, 2002; Publication No.
02-5215.
3.IsomaaB,AlmgrenP,TuorniTctaLCardiovascularmoibidily
and mortality associated with the metabolic syndrome.
Diabetes Care; 2001. 24(4):683-9.
4. Dccn D. Metabolic Syndrome: Time for Action. Am Fain
Phys; 2004, 69:2875-82,2887-8.
5. Alberti KG and Ziminet PZ. Definition, diagnosis and
classification of diabetes mcllitus and its complications.
Part I: Diagnosis and classification of diabetes mcllitus,
provisional report of a WHO consultation. Diabct Med;
1998, 15:539-53.
Almikhlafy et al.
34
6. Reaven G. Metabolic Syndrome: Pathophysiology and
Implications for Management of Cardiovascular Disease.
Circulation; 2002, 106:286-288.
7. Shanka R and Sundarka M. Metabolic Syndrome: Its
Pathogenesis and Management. J Ind Acad Clin Mcd; 2003,
4(4): 275-81.
S. Daniel WW. Biostatistics: A foundation for analysis in the
health sciences, 6th ed. Singapore, John Wiley and Sons,
1995.pl80
9. Chobanian AV, Bakris GL, Black HR. Joint National
Committee on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure. Seventh report of
the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure.
Hypertension; 2003, 42(6): 1206-52.
10. Al-Nozha M, Al-Khadra A, Arafah Mr ct al..Metabolic
syndrome in Saudi Arabia. Saudi Med J; 2005,26(12): 191825.
11. Al-Lawati JA, Mohammed AJ, Al-Hinai HQ, Jousilahti
P. Prevalence of the metabolic syndrome among Omani
adults. Diabetes Care; 2003,26(6): 1781 -5.
12. Abdul-Rahim HF, Husseini A, Bjertness E et al. The
metabolic syndrome in the West Bank population: an urbanrural comparison. Diabetes Care; 2001, 24(2):275-9.
13. Azizi F, Salehi P, Etemadi A et al. Prevalence of metabolic
syndrome in an urban population: Tehran Lipid and Glucose
Study. Diabetes Res Clin Pract; 2003, 6l(l):29-37.
14. Mahley L, Wyszynski DF, Watervvorth et al. Relation
between atherogenic dyslipidemia and the Adult Treatment
Program-Ill, definition of metabolic syndrome (Genetic
Epidemiology of Metabolic Syndrome Project). Am J
Cardiol; 2005, 95(2): 194-8.
15. Ford M and Giles A. A comparison of the prevalence of
the metabolic syndrome using two proposed definitions.
Diabetes Care; 2003, 26(3):575-81.
16. Santamarina-Fojo, Amar MJ, Dugi KA et al. Hepatic lipase
facilitates the selective uptake of cholesteryl esters from
remnant lipoproteins in apo E-deficient mice. J Lipid Res;
1998, 39(12):2436-42.
17. LaMonte MJ, Nichaman M2, Blair SN. Physical activity
and the metabolic syndrome association with myocardial
infarction and stroke. Circulation; 2004, 109(22):e314
18. Ninomiya JK, L'ltalien G, Criqui MH. Association of the
metabolic syndrome with history of myocardial infarction
and stroke in the Third National Health and Nutrition
Examination Survey. Circulation.; 2004, 109(l):42-6.
Correspondence to:
Dr Abdullah Abdu Almikhlafy,
Community Medicine Department,
Faculty of Medical Sciences,
University of Science and Technology,
Sana'a, Yemen P.O Box: 13064,
E-mail: mikhlafyab@yahoo.com
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