Diabetes & Metabolic Syndrome: Clinical Research & Reviews
Original articleThe effect of age, gender, TG/HDL-C ratio and behavioral lifestyles on the metabolic syndrome in the high risk Mediterranean Island population of Malta
Introduction
The metabolic syndrome (MetS) is a public health concern with an estimated quarter of the world’s adults suffering from this condition with European adults being no exception [1], [2]. The prevalence varies considerably and depends on the environment, region, gender, age, race and ethnicity of the studied population [3]. The MetS is composed of a cluster of risk factors including central obesity, insulin resistance, hypertension and dyslipidemia, which predispose towards the development of cardiovascular disease and diabetes mellitus type 2 [4]. Family and twin studies exhibit a heritability element to the development of MetS [5]. The presence of MetS increases the individual risk to develop cardiovascular disease by threefold and diabetes mellitus type 2 by fivefold [4]. Globally, the prevalence of MetS is higher in females, except in Eastern populations. However, European studies report little gender differences in the prevalence of MetS [6], [7], [8]. European studies overall reported little gender disparity [8].
Central obesity and insulin resistance are the underlying causes for the development of MetS and have been related to low physical activity levels, aging, polycystic ovarian syndrome and a high dietary intake of fats and carbohydrates [6], [9]. Increased added sugar in food and beverages (during processing and preparation) is also an independent risk factor for MetS [10].
Insulin resistance is a crucial risk factor for MetS. The identification of a predictive marker for insulin resistance could enable professionals to preemptively assess the risk of MetS development. Considering that waist circumference is not a routine measurement by physicians but that a lipid profile is more often performed, a lipid-derived ratio may be suggested [11]. The triglyceride to high-density lipoprotein (TG/HDL-C) ratio is an easy, non-invasive test that has been considered an independent marker for insulin resistance [12], [13]. Epidemiological studies have also shown an association of high TG/HDL-C ratio with increased cardiovascular disease risk [13]. A limited number of studies have investigated this ratio as a metabolic syndrome indicator for particular populations [14], [15].
The Maltese Islands within the Mediterranean Sea, positioned at the crossroads between the European and African continents, are a high-risk population for the metabolic syndrome [16]. A recent study reported that 69.75% of the Maltese adult population is either overweight or obese [18]. This corroborates with previously reported data that the Mediterranean populations have a heavy overweight-obese burden, linked to cardiovascular disease [18]. Considering that the Maltese archipelago amounts to an area of 316 km2, with a total population of 425,384 inhabitants, it presents itself as an ideal location for epidemiological representative population studies to be conducted. Such studies provide essential findings that could enable other Mediterranean countries to relate to. An exploration of such risk factors for MetS in the adult population of Malta was the main aim of this study.
The objectives were to; (a) determine the prevalence of the metabolic syndrome within the Maltese Islands, (b) examine the sex differences in the prevalence of the metabolic syndrome and its components, (c) determine the age effect on the prevalence of metabolic syndrome and its components by gender, (d) identify the effect, if any, of triglyceride/high-density lipoprotein ratio (TG/HDL-C ratio) on the prediction of the metabolic syndrome within the Maltese population, (e) determine whether behavioral lifestyles in this population had an effect on the metabolic syndrome, (f) determine the effect of diabetes mellitus on the metabolic syndrome and (e) determine the predictors for the development of MetS within the Maltese population. This study will serve as a fundamental basis for understanding metabolic syndrome risk factors for neighbouring Mediterranean countries.
Section snippets
Subjects, materials and methods
A nation-wide cross-sectional survey under the auspices of the University of Malta with the name “SAHHTEK” (your health) was conducted from November 2014 to January 2016 in Malta. A population of 4060 adults was recruited from the national registry after randomization, stratification by age (18–70 years) and gender from every town. The detailed protocol of this survey has been published elsewhere [19]. This survey consisted of a validated questionnaire as well as a health examination, including
Results
The data obtained from SAHHTEK study was statistically weighted by age, gender and locality to compensate for the non-responders (50%). The final weighted representative population of 3947 (1998 male) was obtained.
The prevalence of MetS within the entire adult population of SAHHTEK study was of 26.30% (CI 95%: 24.95–27.69) (n = 1038). On incorporating this prevalence to the demographic population data of the total adult Maltese population (18–70 years), it was estimated that 80,788
Discussions
Southern European countries tend to exhibit higher overweight populations and hypertension than the Northern counterparts, predisposing these populations to greater risk for MetS development [22], [23]. Malta is a Southern European country with the adult MetS prevalence found to be higher than several other Mediterranean countries, notably Italy and Greece [24], [25]. In Europe, only a small gender difference has been exhibited in MetS prevalence rates distribution [23]. A Portuguese study
Conclusions
The Maltese male population exhibited the highest MetS prevalence and predictive risk for MetS when compared to females. The presence of an increased waist circumference and 2 other MetS risk factors exhibited the highest risk of developing MetS. The development of MetS is further increased by the presence of alcohol consumption and if the individual suffered from diabetes mellitus type 2. Even though this study found no direct relationship between a sedentary lifestyle and the development of
Study limitations
There are various definitions for the metabolic syndrome in the literature and the prevalence rate may be subject to the definition used. The different metabolic components measurements were recorded by trained skilled fieldworkers but still could have been subject to human error. The study population included 1038 participants suffering from MetS, which may have had an effect on the power of the study’s results. In particular, certain subgroups such as those adults regularly exercising might
Funding
Funding was obtained from the University of Malta, Alfred Mizzi Foundation and Atlas Insurance (Malta). Funding had no role in the design of the study, analysis, and interpretation of data and in writing the manuscript.
Disclosure statement
The authors declare that they have no conflict of interest. The funding body had no influence on the protocol of the survey or on the data analysis. No author received any personal funding.
Author’s contributions
S.C., J.V., N.C., N.P. and J.M. were responsible for the design of the cross-sectional protocol. S.C. was responsible for the data collection and analysis, data interpretation and manuscript writing. J.V., N.C., N.P. and J.M. were responsible for the reviewing of the article including data analysis.
Acknowledgements
The authors are extremely grateful for the strong support forthcoming from the University of Malta (through the Medical School and Research Innovative Development Trust department) and from the Alfred Mizzi Foundation as major sponsors, as well as that of a host of others, including Atlas Health Insurance (Malta). The in-kind support and encouragement of the Parliamentary Secretariat for Health of the Government of Malta is also gratefully acknowledged.
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