CC BY
4Received by the Editor 10.11.2020
IRSTI 76.75.29+76.29.37
UDC616-06.616.1
INFLUENCE OF DEFINITIONS, SOCIO-DEMOGRAPHIC FACTORS AND COMORBIDITY ON THE PREVALENCE OF METABOLIC SYNDROME
D. Kozhakhmetova, A. Nurtazina, A. Shakhanova, N. Dyusekenova
«Semey Medical University», non-commercial joint-stock company, Semey city, Kazakhstan
The widespread prevalence of metabolic syndrome in the population, its contribution to the development of fatal complications in patients with cardiovascular diseases, the ambiguity of the criteria used for the diagnosis of MS served as the basis for searching for relevant information on the problem of MS in available sources.
The purpose of the review is to study the prevalence of MS depending on the location of the study, the sex and age characteristics of its participants, the method of data collection and the diagnostic tool used. Criteria for including the source in the review: publication years 2000-2020; English, Kazakh and Russian languages of publication; epidemiological studies, systematic reviews and meta-analyzes; full-text articles and conference materials. Exclusion criteria: experimental studies, case description or case series description, interventional studies, literature reviews, other languages of publication
Conclusion.A review of available sources showed that even in one population, the prevalence of MS can vary significantly when using different diagnostic criteria (NCEP: ATP III, IDF, adaptation for Asian regions, criteria of the All-Russian Scientific Society of Cardiology). The prevalence of MS is also dependent on demographic, social and economic factors, and this fact should be taken into account when interpreting epidemiological indicators.
Keywords: metabolic syndrome (MS), epidemiology, prevalence, incidence, risk factors.
ВЛИЯНИЕ ДЕФИНИЦИЙ, СОЦИАЛЬНО-ДЕМОГРАФИЧЕСКИХ ФАКТОРОВ И КОМОРБИДНОСТЕЙ НА РАСПРОСТРАНЕННОСТЬ МЕТАБОЛИЧЕСКОГО СИНДРОМА
Д.К. Кожахметова, А.У. Нуртазина, А.Т. Шаханова, Н.Ж. Дюсекенова
НАО «Медицинский университет Семей», Семей, Казахстан
Широкая распространенность метаболического синдрома в популяции, его вклад в развитие фатальных осложнений у больных с заболеваниями кардиоваскулярной системы, неоднозначность используемых критериев диагностики послужили основой для проведения поиска актуальной информации по проблеме МС в доступных источниках.
Цель обзора - изучение распространенности МС в зависимости от локации исследования, половозрастных характеристик его участников, способа сбора данных и примененного диагностического инструмента. Критерии включения источника в обзор: годы публикации 2000-2020; английский, казахский и русский языки публикации; эпидемиологические исследования, систематические обзоры и мета-анализы; полнотекстовые статьи и материалы конференций. Критерии исключения: экспериментальные исследования, описание случая или серии случаев, интервенционные исследования, литературные обзоры, иные языки публикации
Заключение. Обзор доступных источников показал, что даже в одной популяции показатель распространенности МС может сильно варьировать при использовании разных критериев диагностики (NCEP:ATPIII, IDF, адаптации для азиатских регионов, критерии ВНОК). Показатель также зависим от демографических, социальных и экономических факторов, что должно учитываться при интерпретации эпидемиологических показателей.
Ключевые слова: метаболический синдром (МС), эпидемиология, распространенность, заболеваемость, факторы риска.
МЕТАБОЛИКАЛЬЩ СИНДРОМНЬЩ ТАРАЛУЫНА АНЬЩТАМАЛАРДЬЩ, ЭЛЕУМЕТТШ-ДЕМОГРАФИЯЛЬЩ ФАКТОРЛАРДЬЩ ЖЭНЕ ЦАТАР ЖYРЕТIН АУРУЛАРДЬЩ ЭСЕР1
Д.К. Цожахметова, А.У. Нуртазина, А.Т. Шаханова, Н.Ж. Дюсекенова
«Семей медицина университета КеА^, Семей к;., ^азакстан
Метаболикальщ синдромньщ кен таралуы, журек-кантам^1рлар жуйеа аурулары кезiнде аскынулардын дамуына коскан Yлесi, колданылатын диагностикалык критерийлердiн аньщ eMecTiri кол жетiмдi сенiмдi дереккездерден МС проблемасы туралы тиicтi акпаратты iздeугe нeгiз болды.
Шолудьщ максаты:зерттеудщ еткiзiлгeн жeрiнe, катысушылардын жасы жэне жыныстык eрeкшeлiктeрiнe, мэлiмeттeрдi жинау эдюше жэне колданылатын диагностикалык к¥ралга байланысты МС таралуын зерттеу. Дeрeккездi шолуга косу критeрийлeрi: басылып шыккан жылы 2000-2020 жж аралыгында; агылшын, казак жэне орыс тiлдeрiндe жариялау; эпидемиологиялык зерттеулер, жYЙeлi шолулар жэне мета -анализдер; толык мэтiндi макалалар мен конференция материалдары. Шеттету критерийлерг экcпeримeнттiк зерттеулер, кейс немесе кейстер сериясынын сипаттамасы, интервенциялык зерттеулер, эдеби шолулар, басылымнын баска тiлдeрi.
^орытынды. Цол жeтiмдi дереккездерге шолу керсеткендей, бiр популяциянын езiндe МС таралуы эр тYрлi диагностикалык критeрийлeрдi колданганда (NCEP: ATP III, IDF, Азия аймактарына бeйiмдeлу, БYкiлрeceйлiк гылыми кардиологтар когамы) айтарлыктай езгeруi мYмкiн. МС таралу керceткiшi демографиялык, элeумeттiк жэне экономикалык факторларга да тэуeлдi, сондыктан эпидемиологиялык керceткiштeрдi талдау кeзiндe айтылган мэлiмeттi ескеру кажет.
ТYЙiндi сездер: метаболикалык синдром (МС), эпидемиология, таралуы, аурушандык, кауiп факторлары.
Introduction
Metabolic syndrome (MS) is a cluster of clinical, metabolic and biochemical disorders that significantly increase the risk of diseases such as type 2 diabetes mellitus, coronary heart disease and stroke [1]. The first definition of MS was given by WHO in 1998. Since then, continuous work has been carried out on the concept of the definition of MS and its diagnostic criteria. Thus, until 2005, several international professional associations (American Association of Clinical Endocrinologists, European Group for the Study of Insulin Resistance, WHO) defined insulin resistance as a main criterion for diagnosing MS. Later the International Federation of Diabetes (IFD) gave another definition of MS; according to this definition, the fundamental sign of MS is the patient's waist circumference. The combination of several parameters (waist circumference, triglyceride and high-density lipoprotein levels, blood pressure (BP) and fasting glucose) became a logical outcome of this divergence of opinion [2]. Even with this unified approach to the definition of MC, each professional association uses different reference values for the same parameter. For example, the criteria for MS, established by the WHO (1999), imply the presence of MS with a BMI> 30.0 kg/m2, while the American Association of Clinical Endocrinologists has adopted a BMI> 25,0 kg/m2 as a threshold value. According to the International Diabetes Federation (2005), signs of abdominal obesity should correlate with the ethnic specifics of the general population [3]. Nevertheless, the use of proven diagnostic methods makes it possible to conduct studies on the epidemiology of MS that are sufficiently reliable from a methodological point of view, as well as to summarize their results in systematic reviews and meta-analyzes [4-6].
A variety of diagnostic criteria affects the reliability of the MS prevalence indicator. Epidemiology of MS can be dependent on socio-demographic and regional features. The prevalence of MS is growing steadily; however, there is a significant correlation with rising epidemiological rates of obesity [7].
The purpose of this review is to study the prevalence of MS depending on the location of the study, the age and sex characteristics of its participants, the method of data collection and the diagnostic tool that was applied. We also tried to assess the relationship of the epidemiological parameters of MS with arterial hypertension, one of the main components of the studied phenomenon.
Search strategy
The review includes articles describing the epidemiological indicators (prevalence and/or frequency) of MS in terms of the application of diagnostic criteria, gender, age, level of socioeconomic development of the country. The search depth was 20 years; the search was carried out in the following databases: Pubmed, Google Academy, Research Gate. Russian-language articles were selected from the following sources - Cyberleninka and e-Library. Database selection criteria: free access, the ability to download full-text articles.
The following terms were used as keywords: metabolic syndrome (MS), epidemiology, prevalence, incidence, risk factors. The inclusion criteria for the review were: publication years from 2000 to 2020, publications in English, Kazakh and Russian, epidemiological studies, systematic reviews and meta-analyzes, full-text articles and conference proceedings. Exclusion criteria: pilot studies, case or case series description, interventional studies, literature reviews, other languages of publication.
MS prevalence using different MS criteria. A large number of studies on the prevalence of MS are carried out in highly developed countries, where national health systems have data arrays in the form of registers or databases. Thus, the presence of the NHANES (National Health and Nutrition Examination Survey) register allowed American researchers to compare data for 1988-1994 (n = 6423) with data for 1999-2006 (n = 6962). For the diagnosis of MS the criteria adopted by the third group of experts from the US National Cholesterol Education Program were used (NCEP: ATP III). The authors found that the prevalence of MS according to the second period was statistically significantly higher compared to the first period (34,1 ± 0,8% versus 27,9 ± 1,1, respectively; p <0,001 using Student's t-test) [8]. The results of another American study analyzing data from 3423 adults included in the cohort of the previously mentioned NHANES database in the period 2003-2006 showed differences in epidemiological indicators depending on the criteria for diagnosing MS. So, when using the NCEP: ATP III tool, the prevalence of MS was 34,5 ± 0,9%, and the use of IFD criteria allowed them to obtain other figures - 39.0 ± 1.1% [9]. The divergence between the results of epidemiological studies due to the use of different criteria for determining MS is confirmed by European publications too. In an Irish population-based study, 1716 participants aged 32-78 years took part; the authors used similar diagnostic tools for MS. The prevalence of MS according to the results of the application of the NCEP: ATPIII criteria was 13,2%, while the IDF criteria already identified 21.4% of adult participants with MS [10]. A study by Tauler et al. (2014) showed that the prevalence of MS among the adult working population 20-65 years old in Spain is higher when using the IDF criteria compared with the NCEP: ATPIII tool (16,46% versus 12,39%, respectively). This cross-sectional study was quite extensive, the sample included 25 529 men and 18 736 women who underwent an annual preventive medical examination in the period from 2008 to 2010 [11].
The study of the epidemiological aspects of MS in Asian countries has its own characteristics, which associated, first of all, with different anthropometric indicators for identifying overweight and obesity. In 2000 WHO recommended the use of special criteria for the diagnosis of obesity and approaches to its treatment for the Asian race. According to these criteria, overweight for Asians can be determined with a BMI 23,0 to 24,9 kg/m2, respectively, obesity of the first degree is diagnosed with a BMI 25.0 to 29,9 kg/m2 [12]. This kind of "shifts" in the WHO body mass index classification requires a specialized approach in elaboration of MS criteria for Asians. Thus, in a cohort study, Y. Zhao et al. (2014), conducted with the participation of 2990 residents of the north-eastern provinces of China at the age of 18-80, compared the capabilities of three scales - IDF, NCEP: ATPIII and NCEP: ATPIII, modified for the Asian population. It was found that a differentiated approach, taking into account the anthropometric data of the studied population, increases the probability of detecting MS. If the prevalence of MS according to IDF and NCEP: ATPIII was 10.8% and 7.9%, respectively, then the criteria of the modified criteria NCEP: ATPIII made it possible to diagnose MS in 15.1% of the study participants [13]. Another large study, conducted among 40 968 Seoul residents who received an annual medical check-up at a university hospital in 2001, also demonstrates the great potential of the criteria for determining MS, modified for Asians. The prevalence of MS according to the ATP III criteria in the study sample was 6.8%, and the application of the criteria for determining obesity for the Asia-Pacific region revealed an increased rate - 10,9% [14].
The wide geography of the Asian region, its ethnic diversity, different levels of socio-economic and industrial development in Asian countries make it very interesting to evaluate the results of secondary studies on the epidemiology of MS. Thus, the results of a recent meta-analysis of 18 observational studies showed that the prevalence of MS in the Asia-Pacific region ranged from 11,9% in the Philippines to 49.0% in Pakistan [15,16]. For comparison, we can cite a study led by Ansarimoghaddam (2018), which conducted a meta-analysis of the results of 59 publications
containing epidemiological data on MS in another Asian subregion - the Middle East. The lowest prevalence of MS was 2,2% in Turkey, and the highest was 63,7% in Pakistan, while the overall odds ratio was 0,27 (95% CI: 0,24-0,30) [17]. The spread of epidemiological indicators in the overwhelming majority of cases is associated with a high degree of heterogeneity in the publications included in the review due to a wide range of MS criteria, differences in the ratio of urban to rural residents, study design and sample size [16,17]. The reason for this heterogeneity may be also different methodology for collecting anthropometric or clinical and laboratory data.
J.V. Van Vliet-Ostaptchouk et al. [18] presents synthesized data from 10 cohort studies from seven European countries. The authors, after analyzing the epidemiological parameters of 163 517 participants, found that the prevalence of MS among men varied from 42,7% in Italy to 78,2% in Finland, and among women - from 24,0 to 64,8% in the same countries, respectively. If the processes of sampling, analysis and interpretation of laboratory parameters (including the lipid spectrum and hyperglycemia) in the countries of the European Union are sufficiently standardized, the measurement of blood pressure and BMI indicators can be carried out both by the patient himself and by nurses or doctors.
Researchers from the Novosibirsk Scientific Center for Clinical and Experimental Medicine conducted an epidemiological study using the protocol of the WHO, Regional Office for Europe. The prevalence of MS was studied in three population samples among workers of the West Yakutsk industrial region - people who underwent preventive examinations in 1991 (n = 790), in 2000 (n = 1012) and in 2007 (n = 417). As a screening tool, the authors used the criteria for determining MC NCEP: ATP III. The prevalence of MS in the studied sample over the specified period of time increased both among men - from 6.3% to 23.0%, and among women - from 9,2% to 34,2% [19]. Other Russian researchers have chosen a cross-sectional study design to study the prevalence of MS among residents of Moscow, St. Petersburg, Kursk and Kaliningrad. The sample is represented by 1046 participants aged 25 to 74 years. The use of the ATP III tool made it possible to identify the presence of MS signs in the range of 35,3% - 43,0%, and the use of the IDF criteria gave higher rates of MS prevalence - from 40,3% to 50,5%. The highest prevalence values for MS were obtained by use the JIS 2009 Joint Preliminary Statement criteria: the rate in these cities ranged from 48,1% to 53,1% [20]. In a population study led by r. CHMOHOBaugp.[21]the prevalence of MS among residents of Novosibirsk at the age of 45-69 years was determined using the NCEP criteria: ATP III, IDF, All-Russian Scientific Society of Cardiology (ARSSC 2009) and amounted to 25,7%, 38,5% and 45,1 % respectively.
Influence of gender, age and socio-economic parameters on the prevalence of MS.
A review of publications on the epidemiology of MS shows that the prevalence of this pathological condition has age-related features. Analysis of data from the United States NHANES (National Health and Nutrition Examination Survey) database (n = 51 371), collected from 19882007, demonstrated the existence of an associative relationship between the prevalence of MS and age. The conducted logistic regression showed that age is a variable that increases the likelihood of MS in the studied sample (OR = 1,73; 95% CI 1,67-1,80), along with a low level of education (OR = 1,56; 95% CI 1,32-1,84) [22]. A number of studies previously included in the review demonstrate that the peak prevalence of MS occurs in the 50-59 age groups [3,5,11,17,19]. Other authors report higher prevalence of metabolic syndrome in the age groups defined by WHO as elderly and old-aged people [10,15].
According to foreign and domestic sources, it is not possible to identify a clear relationship between the prevalence of MS and gender. Some studies show that the percentage of people with MS among male and female participants is almost the same. For example, A. Mozumdar, G.Liguori [9] based on the results of the analysis of the NHANES database for 1999-2006 (n = 6423), determined the presence of MS using the NCEP criteria in 34.2% of men (n = 3 059) and 34.1% of women (n = 3 364). In a previous American study based on NHANES data for 1999-2002 (n = 3601), the prevalence of MS using the NCEP criteria among men (n = 1 825) was 33,7%, and among women (n = 1 776) - 35,4 % [10]. However, a similar gender balance is observed in few studies, some authors indicate a high prevalence of MS among women [3,5,18,21].
Even within the same country, gender bias in epidemiological indicators may be due to other factors. So, according to C.K. Chou et al. [23], the prevalence of MS among men living in the Indian rural region of Andhra Pradesh with a total sample size of 4 535 participants over 30 years old was 26,9%, while among women it was 18,4% (p = 0,03 using the chi-square test). Another Indian study involving 2 225 adults in the Indian city of Chandigarh showed that 43.2% of women had MS using the NCEP: ATP III criteria, while in men the prevalence was 27,7% [24].
The most obvious socioeconomic factors that can potentially affect the epidemiology of MS are the financial status and educational level of the sample participants. A recent German study revealed statistically significant associations between the prevalence of MS and some psychosocial and economic parameters [25]. The authors performed a regression analysis of data from the German Health Interview and Examination Survey for Adults database, which was collected with the participation of 7 987 participants aged 18-79 years from 2008 to 2011. By selecting 6 866 participants with one or more MS criteria, the researchers determined the prevalence of MS in this sample - 20,13% (n = 1382). Variables such as high levels of education and income, high job position acted as factors that statistically significantly reduce the likelihood of MS developing [25]. It can be assumed that the listed factors are universal in their influence on the epidemiology of MS S. Kerie et al. [26] published the results of a cross-sectional study involving 534 respondents from the city of Mizan Aman in south-eastern Ethiopia. In the studied population, illiteracy (inability to read and write) was statistically significantly associated with the risk of developing MS (OR 0,15 (95% CI 0,04 - 0,53); p <0,01 using logistic regression).
In the study of the epidemiology of MS, a Kazakh study conducted by Tursynbekova et al. in 2018 also deserves attention. The authors compared the incidence of MS in two groups: civil servants aged 35-70 years (n = 750) and patients who attended multidisciplinary clinics (n = 750), comparable in gender and age with the main group. In almost all age groups stratified with a five-year step (3540 years old, 40-45 years old, etc.), the prevalence of MS among civil servants was higher both among men and women. The researchers noted that such an epidemiological situation could have developed due to the specific working conditions of this population category - irregular working hours, the inability of rational nutrition, psychoemotional stress [27].
Association of MS with diseases of the cardiovascular system. Diseases of the cardiovascular system cause 17 million deaths worldwide annually, including 9,4 million deaths associated with complications of arterial hypertension (AH) [28]. AH plays a key role in the development of cardio-metabolic disorders, has rather high association with insulin resistance, obesity and dyslipidemia. Body mass index exceeding the norm is a risk factor for high blood pressure and it is a link between obesity and hypertension [29,30]. On the other hand, the presence of arterial hypertension as a pathogenetic component of MS can aggravate the course of atherosclerosis due to the escalation of dyslipidemia, prothrombotic activity, and endothelial dysfunction [31].
Among patients with MS, arterial hypertension is a common disease, because high blood pressure is one of the criteria for MS. On the other hand, among patients with hypertension, the prevalence of MS is higher than in the general population; in almost every third patient with hypertension, MS can be determined according to one or another criterion [32]. These indicators may fluctuate depending on the location of the study (inpatient or outpatient department), criteria for determining MS, age and gender and clinical and anamnestic characteristics of patients with hypertension included in the study. Thus, in the study by G. Leoncini et al. [33] enrolled 354 outpatients with hypertension who did not have diabetes mellitus at the time of examination and who had not received anti-hypertensive drugs in the previous six months. The prevalence of MS using the ATP III criteria in the studied sample (mean age 47,0 ± 9 years) was 25,0%. According to Andreadis et al. (2007), the prevalence of MS among patients with hypertension can reach 42.1% using the ATP III criteria. Here it is necessary to take into account the conditions of the study: the authors included in the sample of patients who visited the Blood Pressure Center of one of the Athenian hospitals in the period from 1992 to 2005. During this period, it was possible to select 1007 patients with hypertension, whose mean age was 59,3 ± 12,4 years [34].
The results of the wide-scale observational cross-sectional study GOOD (The Global Cardiometabolic Risk Profile in Patients with hypertension disease) showed that clinical variants of hypertension itself can affect the prevalence of MS. The authors analyzed data from 3370 hypertensive patients collected in 12 European countries at 305 medical institutions. It was found that the prevalence of MS among patients with controlled hypertension was statistically significantly lower than in the group of patients with uncontrolled hypertension (35,5% versus 66,5%; p <0,001 using the chi-square test) [35]. In another large study, KNHANES (Korean National Health and Nutrition Examination Survey), conducted in 1998-2008, the authors also found a high prevalence of MS among people with hypertension (60% versus 27% in the general population). Multivariate logistic regression of data from 2940 participants revealed that obesity, menopause, smoking and daily alcohol consumption are independent factors in the development of MS in patients with hypertension [36].
Conclusion
Analysis of literature sources in English and Russian has shown that the prevalence of MS remains high - in some regions the indicator includes from one third to half of the adult population. It is impossible to identify certain patterns in the distribution of the maximum and minimum values of epidemiological indicators depending on the geographical location, because even within the same population, the prevalence of MS varies greatly when different criteria for determining MS are applied [37-40]. In addition, the prevalence of MS is influenced by a variety of demographic, social and economic parameters that should be taken into account when interpreting epidemiological indicators in the context of the studied sample. MS and arterial hypertension have complementary pathogenetic relationships, which determines rather high epidemiological indicators of MS among this category of patients. At the same time, there are many risk and protective factors that can influence the prevalence of MS among patients with hypertension.
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Corresponding author: Kozhakhmetova Dana Kenzhebaevna - Chief Specialist of the Education Quality Control Department, Semey Medical University, dana_ken@mail.ru
