Rapid urbanisation, modernisation and population growing in developing states has led to an rush of non-communicable diseases which are associated with important morbidity and mortality. Metabolic Syndrome besides described as “ Deadly Quartet ” and X syndrome ( 2, 3 ) is one of these disease entities defined by bunch of cardiovascular hazard factors which to a greater extent is influenced by ethnicity/race. This encompasses atherogenic dyslipidemia, high blood pressure, dysglycemia and splanchnic fleshiness and pro coagulator province. Apart from increasing prevalence, the age of oncoming is besides worsening among South Asiatic ( SA ) population due to familial sensitivity, ingestion of easy available energy dense nutrients from an early age. This tendency has got major wellness deductions since South Asians constitute one fifth of population all over the universe ( 4 ) and the wellness attention system is non really fit to cover with this medical crisis. Evidence suggests that it non merely amplifies the hazard of coronary bosom disease ( 5 ) but besides gives rise to cerebrovascular diseases.
Five diagnostic standards have been put frontward since the origin of this syndrome which has created perplexity among practicians. In 1998, World Health Organization ( WHO ) ab initio proposed a definition for metabolic syndrome ( 6 ) with chief accent on gluco-centricity. In 1999, the European Group for the survey of Insulin Resistance ( EGIR ) recommended more or less similar standards with lower cut offs for high blood pressure ( 7 ) .
Thereafter in 2001, National Cholesterol Education Program Adult Treatment Panel III ( NCEP ATP III ) proposed another definition for the diagnosing of metabolic syndrome with less focal point on insulin opposition as compared to WHO standards but non turn toing separate cut off points of waist perimeter for Asiatic population ab initio ( 8 ) . In 2003, American Association of Clinical Endocrinologist ( AACE ) proposed another set of standards for the diagnosing of metabolic syndrome. The chief restriction of the above mentioned standards is that the diagnosing is based on clinical judgement alternatively of presence of specific figure of hazard factors ( 9 ) .
Sing that SA have a higher per centum of organic structure fat chiefly in the signifier of abdominal adiposeness at a lower BMI in comparing with other population, International Diabetes Federation ( IDF ) in 2005 suggested separate cutoff points of waist perimeter for Asiatic population and defined cardinal fleshiness as waist perimeter of more than 80 centimeter for adult females and 90 centimeter in work forces based on local statistics from the corresponding country ( 10 ) . The revised NCEP ATPIII modified for South Asiatic population incorporated the same cut off points for Asiatic population as given by IDF ( Table 1 ) . Apart from the cut off differences, NCEP ATP III gives equal weight to each constituent of metabolic syndrome as compared to IDF for which abdominal fleshiness remains a requirement for the diagnosing ( 10 ) . Furthermore, microalbuminuria which is a controversial variable of WHO criteria is non included in other definitions. Among these definitions, WHO, NCEP ATPIII & A ; IDF have been the chief 1s which are used most widely ( Table 1 ) .
Type 2 diabetes is besides emerging as a planetary epidemic with increasing prevalence in developing states. Pakistan is among top 10 states estimated to hold the highest figure of diabetics busying 6th place on the diabetes prevalence naming presently ( 11 ) and it is estimated that prevalence would be doubled by 2025. Metabolic syndrome in combination with diabetes increases the hazard of both macro vascular, micro vascular complications and coronary artery disease patterned advance due to associated high blood pressure, lipoprotein abnormalcies and splanchnic fleshiness ( 12 ) .
There are surveies that have looked into the differences in most widely used definitions of metabolic syndrome in general ( 13-17 ) , but merely few surveies have compared these definitions in the diabetic population ( 18-20 ) . Therefore we decided to find the frequence of metabolic syndrome in Type 2 diabetics harmonizing to NCEP ATPIII, IDF and WHO definitions and so to compare and contrast these traits within Pakistani population.
This survey was conducted at the out-patient clinics of one of the big third attention infirmaries at Karachi, Pakistan. Data was collected retrospectively of type 2 diabetic patients sing clinics between June till November 2008 by utilizing a questionnaire which included demographic features and single constituents of metabolic syndrome i.e. weight, tallness, waist perimeter and BMI etc. Both hip and waist perimeter were recorded in centimetres and waist/hip perimeter was calculated ( WHR ) . BMI was calculated as a ratio of weight in kilogram to height in metres squared.
All the research lab trials which are routinely done for patients with type 2 diabetes including triglycerides and high denseness lipoprotein ( HDL-C ) were recorded. Patients already on anti hypertensive and anti lipid medicines specifically in the signifier of fibric acid derived functions and nicotinic acids were taken as instances of high blood pressure and hypertriglyceridimia severally irrespective of their blood force per unit area and lipid degrees. Since all the patients in the survey were diabetics, insulin degrees were non taken into history.
The information was analyzed individually harmonizing to NCEP ATP III, IDF and WHO definitions and the consequences were so compared. The frequence of Metabolic syndrome was calculated with 95 % CI based on three different standards ‘s. The informations were presented as the mean A± SD or per centum ; uninterrupted variables were compared by agencies of independent sample t-test and categorical variables were compared by chi-square. All analyses were conducted by utilizing the statistical bundle for societal scientific disciplines SPSS 14. A kappa trial was done to find the concurrency between three definitions. In univariate analyses, comparing between metabolic syndrome and without metabolic syndrome was done for each variable of involvement. Multivariable logistic arrested development analysis was conducted to place the factors associated with metabolic syndrome. All P values were two tailed and considered statistically important ifA a‰¤ 0.05.
Out of entire 210 type 2 diabetic patients, 112 ( 53.3 % ) were males and 98 ( 46.7 % ) were females. Their average age ( standard divergence ) was 53.35 A± 11.46 old ages. The mean ( SD ) continuance of diabetes mellitus was 8.48 A± 7.18 old ages. One hundred and ninety three ( 91.9 % ) were found to hold metabolic syndrome harmonizing to NCEP ATP III in comparing to 182 ( 86.7 % ) based on IDF standards. Lower frequence was documented with WHO standards of 171 ( 81.4 % ) . The frequence increased to 179 ( 85.2 % ) by WHO by utilizing the new cut offs for specifying corpulence ( BMI of 23 vs. 30 ) .
The grade of understanding ( kappa statistic ) between WHO and ATP III and WHO and IDF definitions were 0.436 95 % CI 0.26-0.60 and 0.417 95 % CI 0.25-0.57respectively. In contrast kappa statistic between IDF and ATP III definitions was found to be 0.728 95 % CI 0.57-0.87.The overall understanding between three definitions was 0.37 ( 95 % CI 0.26-0.51 ) .The cardinal fleshiness was present in 162 patients ( 77 % ) by WHO followed by 197 ( 90.5 % ) based on IDF & A ; NCEP ATP III. Hypertension was found in 116 patients ( 55.2 % ) harmonizing to WHO in comparing to 147 ( 70 % ) by NCEP & A ; IDF cut off of blood force per unit area. Presence of low HDL cholesterin once more differed being present in 77 ( 36.7 % ) when WHO definition was applied and 144 ( 68.6 % ) by ATP III and IDF.
Furthermore, gender wise dislocation of frequence of metabolic syndrome by WHO showed that 84 ( 85.7 % ) of females suffered from metabolic syndrome as compared to 87 ( 77.7 % ) in males a difference non statistically
important ( p=0.13 ) . However, by all other standards metabolic syndrome was significantly more common among females as compared to males, 95.9 % vs. 88.4 % ( p=0.04 ) by ATP III & A ; 95.9 % vs. 78.6 % ( p & lt ; 0.001 ) by IDF.
For prevalence of hypertriglyceridemia, no statistically important difference between both genders was found. However, for low HDL cholesterin, prevalence was higher in males 44 ( 57.14 % ) than in females 33 ( 43 % ) by WHO standards ( P & lt ; 0.001 ) . In contrast on the footing of ATP III and IDF definitions, prevalence of low HDL cholesterin degrees was higher ( p=0.009 ) in females 77 ( 57.46 % ) than in males 57 ( 42.53 % ) . Likewise, cardinal fleshiness was found to be more common among female patients based on IDF & A ; NCEP ( ATPIII ) cutoffs 64.8 % females vs. 35.2 % ( & lt ; 0.001 ) but demoing rearward form with WHO criteria,57.14 % males vs. 43 % females ( p-value & lt ; 0.001 ) .
Our survey showed a high frequence of metabolic syndrome in type 2 diabetics based on NECP ( ATPIII ) and IDF standards. This frequence was rather high ( 91.9 % ) as compared to 46 % found in another infirmary based survey from Pakistan ( 21 ) . This difference could non be merely attributed to the different waist cutoffs used based on modified NCEP ( ATPIII ) in our survey because even comparing with WHO categorization revealed important difference between two surveies from the same part. This difference in frequence is really interesting maintaining in position that both of these surveies were done in the same part but different vicinities. The disparity could be due to low frequence of fleshiness found in the old survey ( 30 % ) in comparing to our survey ( 90.5 % ) . It is speculated that this intra regional difference could be due to the fact that certain communities have high inclination to develop fleshiness and metabolic syndrome despite of belonging to the same state due to differences in life manner, eating wonts and degree of physical activity. On the other manus, another infirmary based survey another metropolis revealed comparable frequence of metabolic syndrome harmonizing to NCEP standards ( 22 ) .
In infirmary based survey from Iran the prevalence in type 2 diabetics on footing of NCEP ( ATPIII ) standards utilizing BMI alternatively of waist perimeter was found to be 65 % ( 23 ) .This difference highlights the importance of abdominal adiposeness which is a better marker of metabolic syndrome as compared to BMI. A multicenter infirmary based survey in Brazil showed instead close frequence ( 85 % ) in type 2 diabetics ( 24 ) although the survey population was rather different being white people of European descent. Likewise, in Finnish survey prevalence was found to be 91.5 % in diabetic work forces and 82.7 % in adult females ( 25 ) . Our information was besides consistent with Indian survey demoing prevalence of 91.1 % ( 16 ) utilizing the same NCEP ( ATPIII ) definition. However, separate constituents of metabolic syndrome were found to be more common in our population as compared to South Indians ( 16 ) . The higher frequence of metabolic syndrome in diabetic population found in our survey is a beginning of major concern since diabetes itself is an of import hazard factor for atherosclerotic cardiovascular disease ( ASCVD ) and presence of metabolic syndrome in combination plants as a two border blade.
Evidence suggests that combination of the constituents of the metabolic syndrome is associated with both micro and macro vascular complications and distal neuropathy in patients with type 2 diabetes mellitus ( 24 ) . In position of the high frequence, type 2 diabetic patients should non merely be screened for this deathly syndrome but besides offered intensive direction in order to avoid complications.
Similarly highly high frequence of cardinal fleshiness ( 90.5 % ) in our diabetic population is besides unreassuring since there is ample grounds associating cardinal fleshiness with coronary bosom disease ( 26 ) and insulin opposition is besides significantly associated with waist girth ( 27 ) .
The higher frequence of metabolic syndrome in adult females harmonizing to all standards besides consistent with other surveies from South Asiatic states ( 28 ) could be attributed to less physical activity in adult females due to cultural and cultural limitations on out-of-door activities. This besides highlights the importance of instruction of our adult females in footings of bar of the development of metabolic syndrome with life manner intercession which would indirectly act upon life manner and eating wonts of whole household.
The presence of multiple definitions of metabolic syndrome has been really confusing and argument ever exist which standards should be used in footings of diagnosing of metabolic syndrome particularly in diabetic patients.
The somewhat higher prevalence of metabolic syndrome by ATP III definition in comparing to IDF ( 91.9 % vs. 86.7 % ) was likely due to the comparative flexibleness of the ATP III definition in footings of non taking abdominal fleshiness as a requirement for the diagnosing.
Except for this difference the ATP III and IDF definitions are basically indistinguishable reflected in the grade of understanding ( kappa statistic ) between the two definitions which was in a good scope at 0.728. Harmonizing to this, NCEP ( ATPIII ) and IDF are the most dependable standards ‘s for naming metabolic syndrome in type 2 diabetic patients, with NECP capturing more patients in comparing with IDF definition. In contrast WHO showed lower frequence of metabolic syndrome due to different cutoffs used for HDL degrees and fleshiness. This difference remained important even after seting it with BMI cutoffs for Asiatic population of 23 vs.30 endorsed by WHO expert audience every bit good ( 29, 30 ) pointing towards the fact that waist perimeter or cardinal fleshiness is more valuable tool for sensing of metabolic syndrome in Asiatic population.
On the footing of these findings NCEP ( ATPIII ) modified standards should be sooner used in Pakistani population since doing waist perimeter as an obligatory standard would still lose out 5.2 % of the instances of metabolic syndrome harmonizing to our survey. But to farther validate these recommendations we need surveies to gauge the prognostic power for micro vascular and macro vascular complications to set up the most appropriate definition of metabolic syndrome to be used in South Asiatic population with a diagnosing of type 2 diabetes. The alarmingly high frequence of metabolic syndrome in type 2 diabetes found in our survey points towards the fact that our wellness attention system needs to take emergent stairss in bar of this syndrome through life manner intercession plans.