|Year : 2018 | Volume
| Issue : 1 | Page : 20-24
Metabolic syndrome among patients who had acute stroke in Hadramout, Republic of Yemen
Rasheed M Bamekhlah, Hussain S Alghazali, Adnan A Bakarman, Abdulraheem A Bahishwan, Abdullah S Bin-Nabhan
Department of Medicine, College of Medicine and Medical Sciences (HUCOM), Hadramout University, Mukalla, Hadramout, Republic of Yemen
|Date of Submission||01-Jan-2018|
|Date of Decision||05-Apr-2018|
|Date of Acceptance||05-May-2018|
|Date of Web Publication||13-Mar-2020|
Dr. Rasheed M Bamekhlah
P.O. Box No. 8892, Mukalla, Hadramout
Republic of Yemen
Source of Support: None, Conflict of Interest: None
Background and Objectives: Stroke is a major community problem with a high incidence, causing major neurological disability. Among the related risk factors, metabolic syndrome (MetS) is gaining a concern. Its relation to stroke has been suggested. We measured its frequency and described its following components among patients who had acute stroke: hypertension (HTN), diabetes mellitus (DM), waist circumference (WC), raised levels of serum triglycerides (TGs), and low levels of serum high-density lipoproteins. Materials and Methods: A prospective hospital-based case series study was conducted from October 2014 to April 2015. A total of 130 patients who had acute stroke, admitted in the medical department at Ibnseena Hospital, were recruited to this study. Clinical data, the results of investigations, and final diagnosis were collected. The patients were considered positive for MetS when they had ≥3 of the components according to the Adult Treatment Panel III. Results: The MetS frequency was 46.9% among all patients who had stroke, and 52.3% when restricted to patients who had ischemic stroke only. There were neither significant age nor gender differences. HTN was the most common component of the syndrome (98.4% of MetS among patients who had stroke), but without significant difference between patients with MetS and those who were non-MetS [OR 3.69 (95%CI 0.4–33.97), P = 0.22], followed by significantly higher WC measurements and levels of TGs among patients with MetS (77% each) than in those who were non-MetS [OR 112.5 (95%CI 24.41–518.5), P < 0.0001 and OR 29.73 (95%CI 11.12–79.5), P < 0.0001, respectively]. Forty-four percent of the patients with MetS had three MetS components, 31.1% had four, and 24.6% had all the five MetS components. Conclusion: MetS was present in a considerable percentage of patients who had stroke; it was more related to ischemic stroke. HTN was the most prevalent MetS components. There was a high frequency of patients having all the five MetS components.
Keywords: Hadramout, metabolic syndrome, stroke, Yemen
|How to cite this article:|
Bamekhlah RM, Alghazali HS, Bakarman AA, Bahishwan AA, Bin-Nabhan AS. Metabolic syndrome among patients who had acute stroke in Hadramout, Republic of Yemen. Saudi J Obesity 2018;6:20-4
|How to cite this URL:|
Bamekhlah RM, Alghazali HS, Bakarman AA, Bahishwan AA, Bin-Nabhan AS. Metabolic syndrome among patients who had acute stroke in Hadramout, Republic of Yemen. Saudi J Obesity [serial online] 2018 [cited 2020 Jun 4];6:20-4. Available from: http://www.saudijobesity.com/text.asp?2018/6/1/20/280259
| Introduction|| |
Stroke is the second leading cause of death worldwide and the leading cause of acquired disability in adults in most regions., Low- and middle-income countries have the largest burden of stroke, accounting for more than 85% of stroke mortality worldwide. However, less reliable data are available to identify risk factors for stroke in most of these regions, and particularly for hemorrhagic stroke (HS).,,,
Previous studies have divided risk factors for stroke and stroke recurrence into the following three categories: the first category is comprises immutable risk factors including age, gender, race, and heredity; the second category includes risk factors that can be intervened, such as hypertension (HTN), diabetes mellitus (DM), smoking, and atrial fibrillation;,,, the third category consists of newly discovered risk factors that differ from traditional risk factors and include elevated homocysteine levels, hypercoagulable states, and metabolic syndrome (MetS).
The incidence of MetS is rising worldwide. This is partly due to significant increase in the prevalence of obesity. The etiology of the MetS is multifactorial such as the high prevalence of excess body fat, abnormal body fat distribution, hypertriglyceridemia, and insulin resistance; these risk factors might begin at a young age. International data indicates that the epidemic of MetS is not merely confined to the western world but is in fact a global health problem. Cross-sectional studies and demographic health surveys from the Middle East showed that the prevalence of obesity increases from an average of 6% in healthy children to 20% in adolescent males and to a further 23% among the elderly patients.
The syndrome is a collection of different cardiovascular risk factors including obesity, insulin resistance, DM, HTN, and dyslipidemia. In the Middle East, extensive studies with regard to MetS were performed. In Yemen, studies conducted were few, and in Hadramout, our previous work about MetS among patients with diabetics was the only one. Because this study was within our trend, to know the frequency of MetS in different medical diseases, we studied the frequency of the syndrome and its components among the patients in Hadramout who had stroke.
| Materials and methods|| |
Study area and population
The study was conducted among all patients who had acute stroke, except excluded patients. All selected patients were admitted to the medical department of Ibnseena Teaching Hospital, Mukalla, Hadramout, Republic of Yemen within 6 months (October 2014–April 2015). The hospital is a tertiary referral and is the biggest hospital in the Hadramout region, in which medical and health institute students get their training. Further, the hospital serves about 4,000,000 people who are living in the Hadramout province, which includes Hadramout, Shabwah, Al-Mahrah, and Soqotra Governorates.
It is a prospective hospital-based case series study.
Patients who refused consent, those who had Type 1 DM, secondary DM, or HTN, any evidence of nondiabetic or nonhypertensive renal disease, severe renal disease, severe heart failure (New York Heart Association class III or more), liver disease, or pregnancy.
Stroke and metabolic syndrome definitions
Stroke was diagnosed according to criteria of the World Health Organization, and Ischemic stroke (IS) and HS were diagnosed based on computed tomography (CT) neuroimaging.
MetS was diagnosed according to the Adult Treatment Panel III in patients fulfilling three or more of the following:
- Abdominal obesity [waist circumference (WC) >102 cm in men and >88 cm in women].
- Triglycerides (TGs) >1.7 mmol/L (150 mg/dL).
- High-density lipoprotein (HDL) <1.04 mmol/L [40 mg/dL] for men and <1.30 mmol/L [50 mg/dL] for women.
- High levels of fasting plasma glucose (FPG) at ≥6.1 mmol/L [≥110 mg/dL] or taking antihyperglycemic drugs.
- High blood pressure (systolic blood pressure 130 mmHg or diastolic blood pressure 85 mmHg) or taking antihypertensive drugs.
All patients underwent detailed history taking and clinical examination, including the measurements of height, weight, WC, and blood pressure. Fasting venous blood was sampled from an antecubital vein for all patients for the measurement of FPG, HDL, TG, urea, and creatinine levels. CT was performed for all patients. A structured questionnaire was used to collect information.
Ethical clearance was obtained from the college ethical committee. Thereafter, a written consent from each patient or his/her guardian was obtained as an agreement to participate in the study.
Data were processed by the Statistical Package for Social Sciences software version 20.0 (IBM Corporation, Armonk, NY, USA). The paired "t" test was applied to compare means and Pearson’s chi-square test to compare gender and MetS components. In addition, we estimated odds ratio (OR) and the resulting confidence interval (95%CI) for all categorical variables. All statistical hypothesis tests were two-sided, and P values <0.05 were considered statistically significant. Microsoft Office Excel 2010 spreadsheet was used to structure the figure.
| Results|| |
Over a period of 6 months, 167 patients who had stroke were admitted to the Ibnseena Teaching Hospital. Among them, 130 of them were eligible to be recruited in the study. The hospital is considered as a tertiary-level hospital providing medical care to all patients in Hadramout region (Hadramout, Shabwah, Al-Mahrah, and Soqotra Governorates). The age range of the included patients was 40–89 years with a mean of 62.9 ± 9.7 years. Males were more in number than females (76, 58.5% vs. 54, 41.5%, respectively). The number of patients who had MetS was 61 out of 130 patients (46.9%), with a mean age of 62.8 ± 8.3 years, which was nearly equal to that of patients who were non-MetS (62.9 ± 10.9 years) (P = 0.94). With regard to gender, there was no significant difference between patients with MetS and those who were non-MetS [OR 0.36 (95%CI 0.31–1.27), P = 0.19]. IS was strongly associated with MetS than HS (52.3% vs. 19% of the stroke type, respectively) [OR 5.02 (95%CI 1.75–14.35), P = 0.19] [Table 1].
All the means of MetS components were statistically highly significant in patients with MetS compared to those who were non-MetS, except the systolic and diastolic blood pressures, which were nonsignificant [Table 2].
HTN was the most frequent MetS component among the patients with MetS who had a stroke (98.4%), but with no significant difference between patients with MetS and those who were non-MetS [OR 3.69 (95%CI 0.4–33.97), P = 0.22]. The next most frequent components were high WC measurements and levels of TGs (77% each), both of which were highly significant among patients with MetS in comparison to those who were non-MetS [OR 112.5 (95%CI 24.41–518.5), P < 0.0001 and OR 29.73 (95%CI 11.12–79.5), P < 0.0001, respectively]. The following component was low HDL levels (73.8%), which was also highly significant among patients with MetS in comparison to those who were non-MetS [OR 13.36 (95%CI 5.74–31.08), P < 0.0001]. DM was the least frequent MetS component in patients with MetS (65.5%) but was still highly significant among patients with MetS in comparison to those who were non-MetS [OR 9.05 (95%CI 4—20.47), P ˂ 0.0001] [Table 3].
Twenty-seven of the patients with MetS (44.3%) had three of the MetS components, 19 (31.1%) had four components, and only 15 (24.6%) were with the all five components [Figure 1].
| Discussion|| |
A number of studies examined the association between MetS and cardiovascular disease with conflicting findings., In 2005, the American Diabetes Association and the European Association for the Study of Diabetes issued a joint statement summarizing the issues surrounding MetS. They underscored the need to quantify the cardiovascular risk associated with MetS. A meta-analysis review from 16 studies conducted across USA, Europe, and Asia reported that the prevalence of MetS among patients who had stroke ranged from 9 to 51.8%. A prospective hospital-based study in Saudi Arabia, involving 60 patients diagnosed to have had acute stroke, showed a comparatively higher frequency (57%). This study was conducted in Ibnseena Teaching hospital, Hadramout, Republic of Yemen, and revealed that MetS frequency among stroke patients was 46.9%. The wide difference may be attributed to genetic, racial, socioeconomic, and dietary factors.
The syndrome is associated with intracranial and extracranial atherosclerotic diseases. Individuals with MetS have an increased prevalence of carotid intima–media thickness and asymptomatic carotid atherosclerosis; it was more prevalent during intracranial atherosclerosis rather than extracranial atherosclerosis.
This study showed that MetS has a significant stronger association with IS compared to HS, and the prevalence of MetS increased from 46.9% among all patients who had stroke to 57% when calculations were restricted to patients who had IS only. This finding was supported by the study of Reffat et al., which reported increment from 57 to 64%.
Although our work did not find any significant difference in age between patients who had stroke with MetS and those who were non-MetS and had stroke, including the fact that a nonsignificant higher frequency of females were noted to have MetS rather than non-MetS, MetS tended to be more common among those who were older. However, inconsistent findings regarding gender were reported in other studies.,The frequency of MetS components is inconsistent, because this study showed that HTN was the most prevalent MetS component, which agreed with only some studies., We reported that the frequency of HTN was followed by high WC measurement, whereas in other studies, it was followed by diabetes or high levels of TGs. Some revealed that a high level of TGs was the most frequent MetS component, whereas others showed that central obesity (high WC) was the most frequent component.
In this study, 44.3% of the patients who had stroke with MetS had three components of the syndrome, 31.1% had four, and 24.6% of them had all the five components. This sequence was comparable with other studies, but with lesser frequencies of patients having all the components, with 0% in Saudi Arabia and 8.9% in Taiwan. This seems to suggest that our people have a higher risk for coronary artery diseases and stroke; therefore, primary and secondary prevention must be more effective.
| Conclusion|| |
MetS was present in a considerable percentage of in patients who had stroke; it was significantly related to IS. HTN and high WC measurements were the most frequent components of the syndrome. Due to a high frequency of patients having all the five components, more efforts must be employed to prevent and treat the syndrome and its components.
We thank the workers of the Department of Medicine in Ibnseena Teaching Hospital for their help in obtaining the data of patients and workers of the Central Medical Laboratory Mukalla, Hadramout (Governmental), for processing and performing the investigation.
Financial support and sponsorship
Conflicts of interest
The Central Medical Laboratory Mukalla, Hadramout (Governmental) processed and gave the investigation results without charge.
| References|| |
Feigin VL. Stroke in developing countries: Can the epidemic be stopped and outcomes improved? Lancet Neurol 2007;6:94-7.
Strong K, Mathers C, Bonita R. Preventing stroke: Saving lives around the world. Lancet Neurol 2007;6:182-7.
O’Donnell M, Yusuf S. Tackling the global burden of stroke: The need for large-scale international studies. Lancet Neurol 2009;8:306-7.
Donnan GA, Hankey GJ, Davis SM. Intracerebral haemorrhage: A need for more data and new research directions. Lancet Neurol 2010;9:133-4.
El-Tallawy HN, Farghaly WM, Hamdy NA, Shehata GA, Rageh TA, Metwally NA et al.
Epidemiology and clinical presentation of stroke in Upper Egypt (desert area). Neuropsychiatr Dis Treat 2015;11:2177-83.
Rathore JA, Kango ZA, Nazir M, Mehraj A. Risk factors for stroke: A prospective hospital based study. J Ayub Med Coll Abottabad 2013;25:19-22.
Siddique A, Nur Z, Mahbub S, Alam B, Miah T. Clinical presentation and epidemiology of stroke: A study of 100 cases. J Med 2009;10:86-9.
Abdulsalam AM, Ezz Alarab MM, Afifi KK, Al-Hussian YF, Al-Sulaiman WA, Al-Sayyed AS. Clinical profiling of stroke. Bahrain Med Bull 2017;39:162-4.
Boysen G, Brander T, Christensen H, Gideon R, Truelsen T. Homocysteine and risk of recurrent stroke. Stroke 2003;34:1258-61.
Liou CW, Tan TY, Lin TK, Wang PW, Yip HK. Metabolic syndrome and three of its components as risk factors for recurrent ischaemic stroke as large-vessel infarction. Eur J Neurol 2008;15:802-9.
Cortez-Dias N, Martins S, Belo A, Fiuza M. Comparison of definitions of metabolic syndrome in relation to risk for coronary artery disease and stroke. Rev Port Cardiol 2011;30:139-69.
Stein CJ, Colditz GA. The epidemic of obesity. J Clin Endocrinol Metab 2004;89:2522-5.
Misra A, Vikram NK. Insulin resistance syndrome (metabolic syndrome) and obesity in Asian Indians: Evidence and implications. Nutrition 2004;20:482-91.
Elabbassi WN, Haddad HA. The epidemic of metabolic syndrome. Saudi Med J 2005;26:373-5.
Duc Son LN, Kunii D, Hung NT, Sakai T, Yamamoto S. The metabolic syndrome: Prevalence and risk factors in the urban population of Ho Chi Minh city. Diabetes Res Clin Pract 2005;67:243-50.
Ansarimoghaddam A, Adineh HA, Zareban I, Iranpour S, HosseinZadeh A, Kh F. Prevalence of metabolic syndrome in Middle-East countries: Meta-analysis of cross-sectional studies. Diabetes Metab Syndr 2018;12:195-201. doi: 10.1016/j.dsx.2017.11.004.
Bamekhlah RM, Bin-Nabhan AS, Alghazali HS, Albousi SA. Metabolic syndrome in Type 2 diabetic patients in Hadhramout province, Republic of Yemen. Al-Azhar Assiut Med J 2011;9:103-44.
The World Health Organization MONICA Project (monitoring trends and determinants in cardiovascular disease): A major international collaboration. WHO MONICA Project Principal Investigators. J Clin Epidemiol 1988;41:105-14.
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.
Garg PK, Biggs ML, Carnethon M, Ix JH, Criqui MH, Britton KA et al.
Metabolic syndrome and risk of incident peripheral vascular disease: The cardiovascular health study. Hypertension 2014;63:413-9.
Motillo S, Filicon KB, Genest J, Joseph L, Pilote L, Poirier P. The metabolic syndrome and cardiovascular risk a systemic review and meta-analysis. J Am Coll 2010;56:1113-32.
Kahn R, Burse J, Ferrannini E, Stern M. The metabolic syndrome: Time for a critical appraisal: Joint statement from the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 2005;28:2289-304.
Li X, Li X, Lin X, Li M, Zeng X, Gao Q. Metabolic syndrome and stroke: A meta-analysis of prospective cohort studies. J Clin Neurosci 2017;40:34-8.
Reffat S, Sheikh B, Fath-El-Bab M, Gabal AM, Ibrahim M, Hassan A et al.
Metabolic syndrome in acute stroke patients in Al-Madinah Al-Munawarah Kingdom of Saudi Arabia. J Med Biomed Sci 2010;8:10-5.
Park J, Kwon HM, Roh JK. Metabolic syndrome is more associated with intracranial atherosclerosis than extracranial atherosclerosis. Eur J Neurol 2007;14:379-88.
Dekker JM, Girman C, Rhodes T, Nijpels G, Stehouwer CD, Bouter LM et al.
Metabolic syndrome and 10-year cardiovascular disease risk in the Hoorn study. Circulation 2005;112:666-73.
Chen YC, Sun CA, Yang T, Chu CH, Bai CH, You SL et al.
The impact of metabolic syndrome on incident stroke subtypes: A Chinese cohort study. J Hum Hypertens 2014;28:689-93.
Brola W, Sobolewski P, Fudala M, Goral A, Kasprzyk M, Szczuchniak W et al.
Metabolic syndrome in polish ischemic stroke patients. J Stroke Cerebrovasc Dis 2015;24:2167-72.
Sarrafzadegan N, Gharipour M, Sadeghi M, Nezafati P, Talaie M, Oveisgharan S et al.
Metabolic syndrome and the risk of ischemic stroke. J Stroke Cerebrovasc Dis 2017;26:286-94.
[Table 1], [Table 2], [Table 3]