The metabolic syndrome in type 2 diabetic subjects in Gorgan, Iran

Abstract

To assess the prevalence of the metabolic syndrome in subjects diagnosed with Type 2 diabetes in Gorgan, Iran.
Data were collected from 200 subjects with Type 2 diabetes mellitus and they were categorized as with or without the metabolic syndrome. Metabolic syndrome was diagnosed using Adult Treatment Panel-III (ATP-III) guidelines.
The overall metabolic syndrome prevalence was 51.50%. The mean age of all the subjects was 53.65 +/- 9.50 years. There were 122 females and 78 males of whom 65 females and 38 males had the metabolic syndrome. The mean duration of diabetes was 7.70 +/- 1.29 years. Mean triglycerides were 185.15 +/- 56.63 mg/dl, and fasting blood glucose 153 +/- 19.6 mg/dl. These levels were significantly higher in the subjects with type-2 diabetes with metabolic syndrome, but the mean HDL-cholesterol was 37.96 +/- 5.09 mg/dl and this was lower (p < 0.001). Female and male subjects with metabolic syndrome had significantly longer (except HDL-cholesterol) duration of diabetes, higher Triglyceride, and fasting blood glucose levels (p < 0.001, p < 0.05).
This study showed a high prevalence of the metabolic syndrome in subjects with type 2 diabetes. Females were more affected than males.

Full text

Introduction
Diabetes is a major public health problem that is
approaching epidemic proportions globally. This metabolic
disease is one of the most common endocrine disorders
affecting an almost 6% of the world's population.1The
prevalence of Type 2 diabetes mellitus ranges from 1.2% to
14.6% in Asia, 4.6% to 40% in the Middle East, and 1.3% to
14.5 % in Iran.2,3 The number of people affected by Type 2
diabetes is projected to increase sharply from the current
estimate of 125 million globally to 221 million by 2010, and
to 300 million by 2025.4In Asia, the increase in Type 2
diabetes prevalence is even more alarming with the main
increase occurring in young adults.5,6
The metabolic syndrome (MetS) is described by the
clustering of several risk factors for cardiovascular disease
(CVD) such as hypertension, dyslipidaemia, obesity
(particularly central obesity), insulin resistance and high
fasting plasma glucose.7
Metabolic syndrome was initially observed in 1923 by
Kyln,8who described the clustering of hypertension,
hyperglycaemia and gout as the syndrome. Subsequently,
several other metabolic abnormalities have been associated
with this syndrome, including obesity, microalbuminuria, and
abnormalities in fibrinolysis and coagulation.9In 1988,
Gerald Reaven reintroduced the concept of Syndrome X for
the clustering of cardiovascular risk factors like hypertension,
glucose intolerance, high triglycerides and low high density
lipoprotein (HDL) concentration.10 The syndrome has been
given several names, including the 'metabolic syndrome', the
'insulin resistance syndrome', the 'plurimetabolic syndrome',
and the 'deadly quartet'.10 In 1998, world health organization
(WHO) proposed a unifying definition for the syndrome and
chose to call it the 'metabolic syndrome' rather than the
'insulin resistance syndrome'.11 This name was selected
primarily because it was the cause of all the components of
the syndrome.
In 2001, The Third Report of National Cholesterol
Education Program Expert Panel on Detection, Evaluation,
and Treatment of High Blood Cholesterol in Adults (Adult
Treatment Panel III) (ATP III) emphasized the importance of
the metabolic syndrome and provided a working definition of
this syndrome for the first time.12 Most of the data on
metabolic syndromes are based on the studies from Western
countries. Differences in genetic background, diet, levels of
physical activity, age and sex structure all influence the
prevalence of both metabolic syndrome and its components.13
The prevalence of metabolic syndrome in adult population
worldwide varies from 8 to 24.2%14,15 in males and from 7 to
46.5%16,17 in females. The importance of the metabolic
syndrome in general populations as a predictor of vascular
disease has been confirmed by a number of large prospective
epidemiologic studies.18-20 In our area, we do not have enough
data on the metabolic syndrome. The present study aimed to
Vol. 61, No. 5, May 2011 458
Original Article
The metabolic syndrome in type 2 diabetic subjects in Gorgan, Iran
Abdoljalal Marjani,1Mohammad Mojerloo2
Department of Biochemistry and Biophysics, Biochemistry and Metabolic Disorder Research Center,1
Department of Internal Medicine,2Gorgan Faculty of Medicine, Golestan University of Medical Sciences, Iran.
Abstract
Objective: To assess the prevalence of the metabolic syndrome in subjects diagnosed with Type 2 diabetes in
Gorgan, Iran.
Methods: Data were collected from 200 subjects with Type 2 diabetes mellitus and they were categorized as
with or without the metabolic syndrome. Metabolic syndrome was diagnosed using Adult Treatment Panel-III
(ATP-III) guidelines.
Results: The overall metabolic syndrome prevalence was 51.50%. The mean age of all the subjects was
53.65±9.50 years. There were 122 females and 78 males of whom 65 females and 38 males had the metabolic
syndrome. The mean duration of diabetes was 7.70±1.29 years. Mean triglycerides were 185.15±56.63 mg/dl,
and fasting blood glucose 153 ±19.6 mg/dl. These levels were significantly higher in the subjects with type-2
diabetes with metabolic syndrome, but the mean HDL-cholesterol was 37.96±5.09 mg/dl and this was lower (p<
0.001). Female and male subjects with metabolic syndrome had significantly longer (except HDL-cholesterol)
duration of diabetes, higher Triglyceride, and fasting blood glucose levels (p < 0.001, p < 0.05).
Conclusion: This study showed a high prevalence of the metabolic syndrome in subjects with type 2 diabetes.
Females were more affected than males.
Keywords: Gorgan, Metabolic syndrome, Type 2 diabetes (JPMA 61:458; 2011).

assess the metabolic syndrome in patients diagnosed with
Type 2 diabetes in Gorgan (South East of Caspian Sea), Iran.
Subjects and Methods
This study was performed in the Biochemistry and
Metabolic Disorder Research Center of Gorgan, Golestan
province (South East of Caspian Sea), Iran in 2010. The study
group included 200 subjects with type-2 diabetes mellitus
who were referred to the Diabetes Center in 5th Azar
Hospital, Golestan University of Medical Sciences. All the
included subjects provided an informed consent. There were
122 females and 78 males included. At the point of study
entry, all study participants were subjected to clinical and
biochemical investigations. Data were collected by trained
interviewers. The exclusion criterion was the coexistence of
any other serious illness. Type-2 diabetes mellitus was
defined as nonketosis diabetes by medical history and current
treatment with oral hypoglycaemic agents. None of the
subjects had micro vascular complications (diabetic
nephropathy or retinopathy). Administration of insulin for
glycaemic control was considered an exclusion criterion. A
venous blood sample was collected from all the subjects who
came after a 12-hours overnight fast. The samples were
centrifuged for 10 minutes at 3000 rpm. The serum was used
for estimating fasting blood glucose, triglycerides and HDL-
cholesterol concentration, by biochemical kit using
spectrophotometer techniques (Model JENWAY 6105 UV /
VIS) in the Biochemistry and Metabolic Disorder Research
Center (Faculty of Medicine). Waist circumference was
measured at the point halfway between the lower border of
ribs and the iliac crest in a horizontal plane . Subjects with
Type 2 diabetes were considered to have metabolic syndrome
if they had any three or more of the following, according to
the ATP III Criteria:12
A) Abdominal obesity: WC >102 cm in men and >88 cm in
women.
B) Hypertriglyceridaemia: serum triglycerides level > 150
mg/dl (1.69 m mol/l).
C) Low HDL-cholesterol: < 40 mg/dl (1.04 m mol/l) in men
and < 50 mg/dl (1.29 m mol/l) in women.
D) High blood pressure: SBP > 130 mmHg and/or DBP > 85
mmHg or on treatment for hypertension.
E) High fasting glucose: serum glucose level > 110 mg/dl (6.1
m mol/l) or on treatment for diabetes.
In subjects with type 2 diabetes, metabolic syndrome
was based on the presence of three or more factors (large WC,
high fasting glucose, high triglyceride and low HDL-
cholesterol) of the metabolic syndrome definition. The results
were reported as percentages and mean ± SD. The statistical
analysis was done with SPSS- 11.5 version software. The
results were evaluated by using student't' test and Chi-squared
test. Statistical significance was considered at P < 0.05.
Results
A total of two hundred subjects with Type-2 diabetes
were studied. The mean age of the subjects was 53.65±9.50
years (range 30-60 years), consisting of 78 (39%) males and
122 (61%) females. The mean duration of diabetes was
5.96±2.20 years.
Table-1 shows the baseline data of the subjects
with and without the metabolic syndrome. The mean
duration of disease, triglyceride, and fasting blood
glucose levels were significantly higher in the Type-2
diabetes with metabolic syndrome, but the mean HDL-
cholesterol was lower (p< 0.001).
There were no significant differences in the waist
circumferences of subjects with type 2 diabetes with or
without the metabolic syndrome.
The baseline data of the female and male subjects
with and without metabolic syndrome are presented in Table-
2. Female and male patients with metabolic syndrome had
significantly higher (except HDL-cholesterol) duration of
disease, Triglyceride, and fasting blood glucose (p < 0.001, p
< 0.05). There were no significant differences in the waist
circumference of subjects with Type 2 diabetes, both male
and female, with and without metabolic syndrome.
There were more females than males in the total study
population, (122 females' vs.78 males). Female subjects with
diabetes had a significantly higher prevalence of the
459 J Pak Med Assoc
Table-1: Clinical characteristic of subjects with type 2 diabetes (Total subjects, subjects with and without metabolic syndrome).
Parameters Total number of subjects Subjects with Type 2 diabetes Subjects with Type Type 2 diabetes P-value
with type 2 diabetes & metabolic syndrome without metabolic syndrome
Number of patients (%) 200 (100%) 103(51.50%) 97(39%) >0.05
Age (years) 53.65±9.50 53.33±9.81 53.98±9.20 >0.05
Duration of diabetes (years) 5.96±2.20 7.70±1.29 4.11±1.26 <0.001
Waist Circumference (cm)(WC>102 for
males and WC>88 for females) (%) 145(72.50%) 86(59.31%) 59(40.68%) >0.05
Triglyceride (mg/dl) 153.94±56.01 185.15±56.63 120.80±30.69 <0.001
HDL-cholesterol (mg/dl) 40.72±5.02 37.96±5.09 43.66±2.79 <0.001
Fasting blood sugar (mg/dl) 131.58±21.78 146.7±19.6 115.74±8.82 <0.001

metabolic syndrome (p < 0.001).
Discussion
The present study aimed to assess the prevalence of
the metabolic syndrome in subjects with Type 2 diabetes.
Although, many studies have been done to determine the
prevalence of diabetes mellitus worldwide and few have been
performed to determine the prevalence of metabolic
syndrome, but there are no studies on this aspect in this
region. People with Type 2 diabetes have a 2-6 times higher
risk of death from cardiovascular causes compared to the
healthy population.21 People with the metabolic syndrome are
at an increased risk for developing diabetes mellitus and
cardiovascular disease, and have a higher mortality from
cardiovascular disease. Because the implications of
metabolic syndrome for healthcare are substantial, it is
essential to establish the prevalence of the metabolic
syndrome in all cities of Iran. In our study, there were more
female than male participants (122 females, 78 males). This
could be due to the high rate of referrals of females with
diabetes to Diabetes centers.
The present study showed the prevalence of metabolic
syndrome in type 2 diabetes subjects to be 51.50% in Gorgan,
which is appreciably higher than many other countries. It was
also observed that females (53.27%) were more affected than
males (48.71%). The prevalence of metabolic syndrome
(using the WHO definition) in Ireland was 21 % with more
males (24.6%) than females (17.8%).15 From the available
data from "the Botnia study" (using the WHO definition) and
involving families of Finland and Sweden descent, the
prevalence was 84% and 78% in male and female subjects
with type-2 diabetes, respectively.9
In the United States, the prevalence of metabolic
syndrome was 21.8% using the ATP III definition.15 Mexican
Americans had the highest prevalence of metabolic syndrome
(31.9%). with similar figures for males (24.0%) and females
(23.4%).22 The prevalence in Isfahan (Iran) was 65.0% with
a higher rate in females than males (71.7% female and 55.8%
male).23 The prevalence in Karachi (Pakistan) was 79.7% in
people with type 2 diabetes, (45.5% females and 34.3%
males).24 The overall prevalence of metabolic syndrome in
Japanese subjects with type 2 diabetes was 168 out of 637
(26.37%) persons with type 2 diabetes. The figure was higher
in males (45.9%) than females (28.0%).25 In an another
Korean study the estimated overall prevalence was 32.6%.
There were 46.9% males and 65.1% females.26 The overall
prevalence among Saudis with type 2 diabetes was 22.64%
(19.49% male, 25.17% female).27 Our results were
significantly different from the results of some international
studies conducted in different parts of the world. Our figures
were lower than those of Isfahan (Iran) and Karachi
(Pakistan), but higher than the results of the studies done in
Ireland, United States, Mexico, Japan, Korea and Saudi
Arabia. Thus our results are in agreement with the studies of
Iran and Korea showing metabolic syndrome to be higher in
females with type 2 diabetes. The female preponderance
could be due to the specific characteristics in the lifestyle
changes between females and males with diabetes among the
Gorgan inhabitants. Females were less educated in
comparison to males and majority of females with the
metabolic syndrome were housewives. They were also
performing less physical activity at home.
Conclusion
The prevalence of the Metabolic Syndrome according
to the ATP111 criteria in Gorgan was high and more so in
comparision to other countries. It is therefore advisable that
Vol. 61, No. 5, May 2011 460
Table-2: Clinical characteristic of female and males type 2 diabetic subjects (Total subjects, subjects with and without metabolic syndrome).
Total number of type 2 Type 2 diabetic with Type 2 diabetic without P-value
diabetic patients metabolic syndrome metabolic syndrome
Females
Number of patients (%) 122 (100%) 65 (53.27%) 57 (46.71%) >0.05
Age (years) 53.74±9.54 53.50±9.80 54.01±9.32 >0.05
Duration of diabetes (years) 6.02±2.16 7.59±1.40 4.22±1.29 0.05>
Waist Circumference (WC>88)(%) 101(82.78%) 60(49.18%) 41(33.60%) >0.05
Triglyceride (mg/dl) 154.94±54.33 178.69±55.82 127.85±37.63 <0.001
HDL-cholesterol (mg/dl) 40.55±5.41 37.56±5.25 43.96±3.09 <0.001
Fasting blood sugar ( mg /dl) 129.96±2.34 145.8±20.88 112.14±8.46 <0.001
Males
Number of patients (%) 78 (100%) 38 (48.71%) 40 (51.28%) >0.05
Age (years) 53.95±9.15 53.05±9.94 53.95±9.15 >0.05
Duration of diabetes (years) 3.95±1.21 7.89±1.07 3.95±1.21 <0.001
Waist Circumference (WC>102)(%) 44(56.41%) 26(59.09%) 18(40.90%) >0.05
Triglyceride (mg/dl) 110.75±10.43 196.21±57.02 110.75±10.43 <0.001
HDL-cholesterol (mg/dl) 43.23±2.28 38.63±4.79 43.23±2.28 <0.05
Fasting blood sugar ( mg/dl) 120.78±6.84 148.32±17.46 120.78±6.84 <0.001

clinicians should seriously consider screening all obese
people regardless of age, for abnormalities in glucose levels.
Early treatment in obese people with abnormal glucose level
constitutes a strategy of preventing type 2 diabetes mellitus
and the metabolic syndrome.
References
1. Adeghate E, Schattner P, Dunn E. An update on the etiology and epidemiology
of diabetes mellitus. Ann N Y Acad Sci 2006; 1084: 1-29.
2. Azizi F, Guoya MM, Vazirian P, Dolatshati P, Habbibian S. Screening for type
2 diabetes in the Iranian national programme: a preliminary report. East
Mediterr Health J 2003; 9: 1122-7.
3. Azizi F, Gouya MM, Vazirian P, Dolatshahi P, Habibian S. The diabetes
prevention and control programme of the Islamic Republic of Iran. East
Mediterr Health J 2003; 9: 1114-21.
4. King H, Aubert RE, Herman WH. Global burden of diabetes, 1995-2025:
prevalence, numerical estimates and projections. Diabetes Care 1998; 21: 1414-31.
5. Zimmet P, Alberti KG, Shaw J. Global and societal implications of the diabetes
epidemic. Nature 2001; 414: 782-7.
6. Chan JC, Cockram CS. Diabetes mellitus in Chinese and its implications on
health care. Diabetes Care 1997; 20: 1785-90.
7. Miranda PJ, DeFronzo RA, Califf RM, Guyton JR. Metabolic syndrome:
definition, pathophysiology, and mechanisms. Am Heart J 2005; 149: 33-45.
8. Kylin E. Studien ueber das Hypertonie-Hyperglyk amie -
Hyperurikamiesyndrom. Zentrallblatt fuer Innere Medizin 1923; 44: 105-27.
9. Isomaa B, Almgren P, Tuomi T, Forsen B, Lahti K, Nissen M, et al.
Cardiovascular morbidity and mortal ity asso ciated with the met abolic
syndrome. Diabetes Care 2001; 24: 683-9.
10. Reaven GM. Banting Lecture 1988. Role of insulin resistance in human disease.
Diabetes 1988; 37: 1595-607.
11. Alberti KG, Zimmet PZ. Definition, diagnosis and classification of diabetes
mellitus and its complications. Part I: diagnosis and classification of
diabetes mellitus, provisional report of a WHO Co nsultation. Diabet Med
1998; 15: 539-53.
12. Expert Panel on Detection, Evaluation, and Treatment of High Blood
Cholesterol in Adults. Executive Summary of The Third Report of The National
Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation,
and Treatment of High Blood Cholesterol in Adults Adult Treatment Panel III).
JAMA 2001; 285: 2486-97.
13. Cameron AJ, Shaw JE, Zimmet PZ. The metabolic syndrome: prevalence in
worldwide populations. Endocrinol Metab Clin N Am 2004; 33: 351-75.
14. Gupta A, Gupta R, Sarna M, Rastogi S, Grupta VP, Kothari K. Prevalence of
diabetes, impaired fasting glucose and insulin resistance syndrome in an urban
Indian population. Diabetes Res Clin Pract 2003; 61: 69-76.
15. Ford ES, Giles WH, Dietz WH. Prevalence of the metabolic syndrome among
US adults: findings from the Third National Health and Nutrition Examination
Survey. JAMA 2002; 287: 356-9.
16. Balkau B, Vernay M, Mhamdi L, Novak M, Arondel D, Vol S, et al. The
D.E.S.I.R Study Group. The incidence and persistence of the NCEP (National
Cholesterol Education Program) metabolic syndrome. The French D.E.S.I.R.
study. Diabetes Metab 2003; 29: 526-32.
17. Ramachandran A, Snehalatha C, Satyavani K, Sivasankari S, Vijay V. Metabolic
syndrome in urban Asian Indian Adults-a population study using modified ATP
III criteria. Diabetes Res Clin Pract 2003; 60: 199-204.
18. Shepherd J, Cobbe SM, Ford I, Isles CG, Lorimer AR, Mac Farlane PW, et al.
Prevention of coronary heart disease wi th pravastatin in men with
hypercholesterolemia. West of Scotland Coronary Prevention Study Group. N
Engl J Med 1995; 333: 1301-7.
19. Downs JR, Clearfield M, Weis S, Whitney E, Shapiro DR, Beerc PA, et al.
Primary prevention of acute coronary events with lovastatin in men and women
with average cholesterol levels: results of AFCAPS/ TexCAPS. Air Force/Texas
Coronary Atherosclerosis Prevention Study. JAMA 1998; 279: 1615-22.
20. Ballantyne CM, Olsson AG, Cook TJ, Mercuri MF, Pedersen TR, Kjekshus J.
Influence of low high-density lipoprotein cholesterol and elevated triglyceride
on coronary heart disease events and response to simvastatin therapy in 4S.
Circulation 2001; 104: 3046-51.
21. Dalton M, Cameron AJ, Zimmet PZ, Shaw JE, Jolley D, Dunstan DW, et al.
AusDiab Steering Committee. Waist circumference, waist-hip ratio and body
mass index and their correlation with cardiovascular disease risk factors in
Australian adults. J Intern Med 2003; 254: 555-63.
22. Kannel WB, McGee DL. Diabetes and cardiovascular disease. The Framingham
study. JAMA 1979; 241: 2035-8.
23. Janghorbani M, Amini M. Metabolic syndrome in type 2 diabetes mellitus in
isfahan, iran: prevalence and risk factors. Metab Syndr Relat Disord 2007; 5:
243-54.
24. Imam SK, Shahid SK, Hassan A, Alvi Z. Frequency of the metabolic syndrome
in type 2 diabetic subjects attending the diabetes clinic of a tertiary care hospital
J Pak Med Assoc 2007; 57: 239-42.
25. Shimajiri Y, Tsunoda K, Furuta M, Kadoya Y, Yamada S, Nanjo K, et al.
Prevalence of metabolic syndrome in Japanese type 2 diabetic patients and its
significance for chronic vascular complications Diabetes Res Clin Pract 2008;
79: 310-7.
26. Kim WY, Kim JE, Choi YJ, Huh KB. Nutritional risk and metabolic syndrome
in Korean type 2 diabetes mellitus. Asia Pac J Clin Nutr 2008; 17: 47-51.
27. Ahmed AA. The Prevalence of Metabolic Syndrome Among Type 2 Saudi
Diabetic Patients: A particular View in Gurayat Province. Middle East J Fam
Med 2008; 6: 3-7.
461 J Pak Med Assoc