|Year : 2019 | Volume
| Issue : 3 | Page : 95-101
Metabolic syndrome and its associated factors among apparently “healthy” adults residing in rural settlements in Dutse, Northwestern Nigeria: A community-based study
Salisu B Muazu1, Rifkatu Mshelia2, Hauwa Bako3, Mohammad B Ahmad4, Tasiu Mohammed5, Innocent O Okpe5, Adamu G Bakari5
1 Department of Medicine, Rasheed Shekoni Specialist Hospital, Dutse, Jigawa State, Nigeria; Department of Medicine, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State, Nigeria
2 Department of Medicine, College of Health Sciences, University of Abuja Teaching Hospital, Abuja, Nigeria
3 Department of Chemical Pathology, College of Health Sciences, Ahmadu Bello University, Zaria, Kaduna State, Nigeria
4 Department of Chemical Pathology, Faculty of Allied Health Sciences, College of Health Sciences, Bayero University, Kano, Nigeria
5 Department of Medicine, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State, Nigeria
|Date of Submission||14-Jun-2019|
|Date of Acceptance||15-Jul-2019|
|Date of Web Publication||27-Nov-2019|
Dr. Salisu B Muazu
Consultant Physician and Endocrinologist Department of Medicine, Rasheed Shekoni Specialist, Dutse Jigawa State and Visiting Lecturer, Ahmadu Bello University, Zaria.
Source of Support: None, Conflict of Interest: None
Background: Metabolic syndrome (MS) is a cluster of the most dangerous risk factors for heart attack, is associated with unhealthy lifestyle practices brought about by modernization of societies, and is thought to be uncommon in developing nations, especially in rural setting, hence we intend to document its prevalence and associated factors. Materials and Methods: A cross-sectional community-based study involved 362 apparently healthy consenting adults, aged 18–72 years (males, 197 and females, 165) who met the inclusion criteria. Structured questionnaire was used to generate data and physicals were carried out, including anthropometry using the World Health Organization Stepwise protocol. Fasting blood sample was taken for determination of serum lipid profiles and glucose. International Diabetes Federation ethnic-specific criteria for the diagnosis of MS were used. The Statistical Package for the Social Sciences (SPSS) (version 23) software was used for the analysis with P < 0.05. Results: The mean age was 30.2 (9.4) years. A prevalence of MS was found to be 8.8%. Female/male ratio was 15.1%:3.6%, P = 0.003, 40–49 years age group (37.5%) was the most common age group, and 19.8% of all subjects were overweight. The most common recurring components in the diagnosis of MS were reduced high-density lipoprotein cholesterol (HDL-C) (87.5%), raised fasting blood glucose (56.3%), and high systolic blood pressure (46.9%). Regression analysis revealed that being diabetic/hypertensive, family history of hypertension/diabetes mellitus, total cholesterol, and increasing age were found to be associated with MS. Conclusion: The prevalence of MS in this community was 8.8%, more common in females and 40–49 years age group, and was largely determined by the contribution of low levels of HDL-C but not hypertriglyceridemia. Independent predictors of MS were found to be family history of hypertension, raised total cholesterol, and increasing age.
Keywords: Community-based, Low high-density lipoprotein, Metabolic syndrome, Nigeria
|How to cite this article:|
Muazu SB, Mshelia R, Bako H, Ahmad MB, Mohammed T, Okpe IO, Bakari AG. Metabolic syndrome and its associated factors among apparently “healthy” adults residing in rural settlements in Dutse, Northwestern Nigeria: A community-based study. J Health Res Rev 2019;6:95-101
|How to cite this URL:|
Muazu SB, Mshelia R, Bako H, Ahmad MB, Mohammed T, Okpe IO, Bakari AG. Metabolic syndrome and its associated factors among apparently “healthy” adults residing in rural settlements in Dutse, Northwestern Nigeria: A community-based study. J Health Res Rev [serial online] 2019 [cited 2020 Sep 25];6:95-101. Available from: http://www.jhrr.org/text.asp?2019/6/3/95/271840
| Introduction|| |
Metabolic syndrome (MS) is defined as a cluster of the most dangerous heart attack risk factors including raised fasting plasma glucose, abdominal obesity, high density cholesterol, and high blood pressure, which predisposes one to adverse cardiovascular event and/or type 2 diabetes mellitus (T2DM). It was designed as a mathematical construct (three of the five factors) with the intent of achieving early detection of T2DM and cardiovascular disease.
The condition, which is also known as insulin resistance syndrome or Syndrome X, was first described in 1988. It is estimated to affect around 20%–25% of the world’s adult population and they are twice as likely to die from and three times as likely to have a heart attack or stroke compared to people without the syndrome. In addition, people with MS have a fivefold greater risk of developing T2DM.
MS like most noncommunicable diseases (NCDs) is associated with global modernization witnessed in recent times. The urbanized societies bring with them, the increasing changing dietary patterns, sedentary lifestyle, and increased consumption of alcohol and tobacco smoking.
In contrast to the urbanized societies, which are characterized by affluence and overnutrition, the less privileged societies show perinatal undernutrition, which leads to compensatory childhood catch-up obesity and subsequent increase in the incidence of MS.
Both insulin resistance and central obesity are considered central in the pathogenesis of MS. The genetic composition, sex, age, and pro-inflammatory state all may play a role in the pathogenesis,, and triggers of MS, especially when there is negative environmental influence in a predetermined or susceptible population.,,,
The rural population in sub-Saharan Africa, which is characterized with less affluence, is becoming more urbanized so is the increase in bad cultural practices, including changing food habits, drinking of alcohol, smoking, and sedentary lifestyle. Consequently, this will lead to rise in the potential of MS among the populace. The readily available and accessible technological advances in the recent times have permeated to the rural areas with the potential to change the lifestyle of the rural populations. MS and other NCDs are relatively unexplored in Nigeria and there is paucity of data in this region of the country, hence the need to estimate the prevalence and associated risk factors among the inhabitants of this rural settlement in northern Nigeria.
| Materials and Methods|| |
The Ethics Committee of State ministry of health and the hospitalapproved the study with Ethical committee clearance number MOH/REV/RSSH//2016/OPR/003 dated Monday January 18th, 2016. The participants gave informed consent before recruitment into the survey. A community-based cross-sectional study was conducted in rural settlements located near Dutse in northwestern Nigeria during the months of June to November 2016. The area is located in the Sudan Savannah belt of the sub-Saharan Africa, an area with moderate annual rainfall and patchy vegetation that supports a peasantry farming and animal husbandry. The communities have homogenous population characteristics with Hausa-Fulani being the dominant tribe, and the staple food is mainly cereals. The subjects comprise artisans, housewives, peasant farmers, and lower cadre public servants.
Four hundred and fifty-seven (457) people were initially recruited through simple random sampling technique during an awareness campaign on NCD, which involves screening, examination, and blood sample collection. Three hundred and sixty-two (362) apparently healthy subjects comprising 197 males and 165 females agreed to fast for 8–12h and came on the appointed date for the sample collection. Patients with known diabetes or hypertension on medications, any diagnosed chronic medical condition, and/or people on long-term medications that may interfere with the lipid parameters were excluded.
At first visit, all subjects were informed on the NCD campaign and the mission of the study. Their personal and medical histories were recorded in a structured questionnaire and anthropometric measurements including height measured to the nearest 0.1 m and weight in kilogram to the nearest 0.1kg. The body mass index (BMI) was derived from dividing the weight (in kg) by height (in meter square). The waist circumference (WC) was measured to the nearest whole centimeters, with subjects standing with arms at the side, according to the World Health Organization Stepwise protocol (at the approximate midpoint between the lower margin of the last palpable rib and the top of the iliac crest). The hip circumference (HC) measurement was taken around the widest portion of the buttocks, whereas waist/hip ratio (WHR) was derived by dividing the WC by HC to the nearest 0.01.
Subsequently, subjects were asked to fast on the day the team would make the next visit, and venous blood sample was collected from the antecubital vein for the determination of blood glucose and lipids. The blood glucose was immediately determined using a point of care device (Accu-chek glucometre, Roche Diabtes care GmbH, Mannheim, Germany), and the remaining blood was separated for lipid profile determination using enzymatic method (ELISA Kits, Monobind Illinious, USA).
Diagnosis of metabolic syndrome
International Diabetes Federation (IDF) ethnic-specific criteria for the diagnosis of MS were used., The sub-Saharan African is lacking of agreed criteria and it is thought that the metabolic indices of the population are closer to that of the Europeans, hence the choice of IDF (Europid) criteria as follows:
- Central obesity defined by WC in centimeters, >94cm in male or >80cm in female subjects plus any two of the following confirms diagnosis of MS.
- Triglyceride (TGD) ≥150mg/dL (1.7 mmol/L)
- High-density lipoprotein cholesterol (HDL-C) ≤40mg/dL (1.03 mmol/L) in males or ≤50mg/dL (1.29 mmol/L) in females
- Hypertension (systolic blood pressure [SBP]/diastolic blood pressure [DBP]) ≥130/85mm Hg
- Fasting blood glucose (FBG) ≥100mg/dL (5.6 mmol/L)
The data were collated and analyzed using the Statistical Package for the Social Sciences (SPSS, version 23) software (IBM Chicago, USA). Student’s t-test for paired data set and regression analysis to find associations were used at significance level of P < 0.05.
| Results|| |
A total of 362 subjects were screened, mean age was 30.2 (9.4) years, comprising 197 males and 165 females. [Figure 1] shows the prevalence of MS of 8.8% with higher rate among the females (15.1%) than that among the males (3.6%), P = 0.003. [Table 1] shows the mean values of WC, WHR, SBP, DBP, FBG, glycated hemoglobin A (HBA1c), total cholesterol (TC), and low-density lipoprotein cholesterol (LDL-C), which were found to be significantly higher among those with MS than those in normal group, (P < 0.05). The mean values of TGD were higher in MS than those in normal group >0.05.
|Figure 1: Pie chart showing the proportion of metabolic syndrome among the study population|
Click here to view
|Table 1: Comparison of the clinical and biochemical characteristics between the metabolic syndrome and the control groups|
Click here to view
[Figure 2] shows the distribution of metabolic risk factors among the study population with reduced HDL-C of 34.3% as the highest, whereas only 8.0% of the study subjects showed high TGD as lowest proportion. The females have higher proportion of risk factors in general.
|Figure 2: Bar chart showing the percent distribution of metabolic risk factors by sex. SBP = systolic blood pressure, HDL = high-density lipoprotein, TGD = triglyceride, FBG = fasting blood glucose, WC = waist circumference|
Click here to view
[Table 2] shows the percentage contribution of each component toward making the diagnosis of MS. In male patients, systolic hypertension contributed in all cases, followed by reduced HDL-C (85.7%) and raised TGD (57.1%) toward the diagnosis of MS, whereas in females, reduced HDL-C, raised blood glucose, and SBP contributed to the diagnosis of MS by 88.0%, 68.0%, and 33.3%, respectively. Overall reduced HDL-C contributed more (87.5%), with least from raised TGD (37.5%), toward the diagnosis of MS among the study population.
|Table 2: Percentage contribution of each component toward the diagnosis of metabolic syndrome|
Click here to view
[Table 3] shows the distribution of MS according to the age group of the study population. The largest proportion of MS (>60%) occurs in the young adults and early middle age. The incidence of MS rises with age as the percentage increases from 25% in 20–29 years age group to 37.5% in 40–49 years age group of the study population. [Table 4] shows the proportion of the BMI by sex of the study population. The female group has 24.2% and 22.4% of overweight and obesity compared to the male group with 16.7% and 3.6%, respectively, P < 0.05.
|Table 3: Proportion of metabolic syndrome in various age groups among the study population|
Click here to view
Multiple regression analysis reveals that history of diabetes and hypertension in the subject, family history of hypertension or diabetes, total cholesterol, and increasing age were associated with MS [Table 5].
|Table 5: Odds for the risk factors for the determination of metabolic syndrome|
Click here to view
| Discussion|| |
The prevalence of MS among this rural community was found to be 8.8% with more female preponderance and was associated with a family history of hypertension, raised total cholesterol, and increasing age. This rate may look low but considering the rural setting of this community and knowing fully that the rate of MS, among West Africans, shows a near-absolute proportionality with the presence and quantum of cardiometabolic risk factors, it may portend a potential dangerous situation.
This was lower than the findings in the semi-urban southeast Nigeria (10%), and what was documented by Peer et al. (31.7%) among blacks in urban South Africa, and that of Ofori-Asenso et al. (21.2%) in a meta-analysis on MS among healthy Ghanaian adults.
The difference between these findings may be related to the different lifestyles and dietary practices in the rural and urban areas.
The prevalence rate is lower when compared to that of Caucasians (31.7%), this may be attributed to the relative absence of hypertriglyceridemia seen among the people of West African ancestry, hence the lower rate.,,
The findings in this study show more females (15.1%) than males (3.6%) have MS, which is consistent with other studies reported among Africans,, Asian Indians, Chinese, and Americans. This gender preponderance can be linked to the known fact that women tend to be more obese, enjoy sedentary lifestyle, and perhaps with increased genetic predisposition accentuate the risk factors present.
The prevalence of MS was found to be higher among the young adults and early middle-aged groups with less among the younger age groups, this is in consonance with the findings by Ford et al., which showed increasing age as a risk factor and more recently by Li et al., where they found more MS in the middle-aged and the elderly aged groups.
Low HDL cholesterol is the most common risk factor in this rural population contributing (87.5%) toward the diagnosis of MS. This pattern of low lipid profiles, particularly triglycerides, among the Hausa tribe of northern Nigeria was earlier reported by Bakari et al. In contrast to our findings, Ford et al. and Alberti et al., in a similar surveys reported hypertriglyceridemia among apparently healthy Caucasians.
Other metabolic risk factors found among the study group are obesity (27.8%), high blood pressure (21%), glucose intolerance (11.1%), and TGD (8.0%) with female preponderance. And about one-fifth (1/5) of all the subjects had two of the five diagnostic risk factors making them more susceptible to develop cardiometabolic morbidities in a very near future. This pattern of cardiometabolic risk factor may be explained due to excess adipose tissue associated with central obesity, which enhances secretion of cytokines that alter the insulin signaling cascade with resultant insulin resistance as reported by Hu et al. in the Diabetes epidemiology: collaborative analysis of diagnostic criteria in Europe (DECODE) study and the study by Ismail et al. In this study, it was found that >25% of the subjects are either overweight or obese.
The cardiometabolic risk factors that mostly contribute toward making the diagnosis of MS were low HDL-C, hypertension, and glucose intolerance with female subjects having more of low HDL-C as against hypertension in males. This is in concordance with other findings among the West Africans as reported by Summer et al., and Li et al. in China.
In Caucasians with MS, low HDL-C and raised TGD levels usually occur together;, however, in this study, we reported low HDL-C and low TGD levels in overwhelming majority of the subjects with MS. A similar study by Summer et al., among the people of West Africa ancestry showed low HDL-C and normal TGD pattern. Similarly, Ukegbu et al. documented among the African immigrants to have a worse metabolic profile than African Americans but a similar or less prevalence of MS.
Therefore, low prevalence of MS among the West Africans, based on the IDF criteria, especially with regard to HDL-C and TGD levels, may not really suggest the presence neither will it predict metabolic risk in them. To further buttress the existence of this peculiar lipid profile pattern, Muazu et al. reported low HDL-C and normal or reduced TGD among T2DM in the same region of Nigeria, and Isezou who also documented similar lipid values pattern, questioned the usefulness of HDL-C in the diagnosis of MS among black people with T2DM.
This pattern of lipid profiles may explain the existing racial differences seen with regard to prevalence of MS between people of West African ancestry and Caucasians. Therefore, the cutoff values of lipid profiles and perhaps the diagnostic criteria for MS use for West African subjects may begin to be questioned of its desirability or otherwise. In this study, we found that the history of hypertension and diabetes mellitus, family history of hypertension, serum total cholesterol, and advancing age were associated with MS. These findings are in keeping with the theory of insulin resistance, which is known to run in families and is more common with advancing age, which serves as the foundation of cardiometabolic risk factor. Similar studies have shown that the occurrence of MS, hypertension, diabetes, and dyslipidemia was higher in first-degree relatives of those with diabetes than those without.,,,
Raised total serum cholesterol was found to be significantly associated with MS. It is a product of increased very low-density lipoprotein (VLDL) production, which is known to be the most important risk factor for atherosclerosis and also leads to raised TGD and decrease HDL-C. Recent studies have shown that a fundamental defect in MS is the hepatic overproduction of VLDL particles, which initiates a sequence of lipoprotein changes that lead to raised LDL-C and TGD and decreased HDL-C levels.,
The study may be limited by the relatively small sample size carried among one ethnic group of population and in a particular region; as such, the results cannot be generalized. The strength of the study lies on its design, content, and being the first community-based study carried out among the population and the region.
| Conclusion|| |
We recorded a prevalence of MS of 8.8% more common in females (15.1% vs. 3.6%) P = 0.003, 40–49 years age group, and greatly driven by reduced serum HDL-C levels. Overall, the components that contributed most to the diagnosis of MS in females were low HDL and glucose intolerance, whereas hypertension and low HDL-C were more in the males.
MS was found to be associated with family history of hypertension, serum total cholesterol, and advancing age.
Considering the documented rate of 8.8%, the presence of at least two risk factors in one-fifth of this naive population with a quarter of them who have been either obese or overweight, this is alarming and prelude to a potential epidemic of cardiometabolic morbidities in a setting already bedeviled with the scourge of communicable diseases. This will require concerted effort, from both the community and authorities, toward providing the population with necessary health education that will promote healthy lifestyle through reorientation, training, and skills acquisition on best practices to prevent this gloomy scenario.
The little contribution of hypertriglyceridemia toward the diagnosis of MS in this study in contrast to other studies, especially the Caucasians, needs to be further explored on whether the lipid’s cutoff values, used in the diagnosis of MS among the West Africans, are appropriate and can predict metabolic risk as in other race and/or populations.
Ethical approval and informed consent policy
Ethical clearance was sought and given by the states’ “Operational Research Ethics Committee” (Ref no: MOH/REV/RSSH/2016/OPR/003 dated Monday, January 18, 2016). Informed consent was also obtained from all the participants after explanation of purpose of study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Alberti KG, Zimmet P, Shaw J. Metabolic syndrome—A new world-wide definition. A consensus statement from the international diabetes federation. Diabet Med 2006;23:469-80.
International Diabetes Federation. Available from: www.idf.org/metabolic_syndrome. [Last accessed on 2018 Jun 30].
Stern M, Williams K, González-Villalpando C, Hunt KJ, Haffner SM. Does the metabolic syndrome improve identification of individuals at risk of type 2 diabetes and/or cardiovascular disease? Diabetes Care 2004;27:2676-81.
Hu G, Qiao Q, Tuomilehto J, Eliasson M, Feskens EJ, Pyorala K. Plasma insulin and cardiovascular mortality in non-diabetic European men and women: A meta-analysis of data from eleven prospective studies. The DECODE Insulin Study Group. Diabetologia 2004;47:1245-56.
Anderson PJ, Critchley JAJH, Chan JCN, Cockram CS, Lee ZS, Thomas GS, et al
. Factor analysis of the metabolic syndrome: Obesity vs. insulin resistance as the central abnormality. Int J Obes Relat Metab Disord 2001;25:1782-8.
Saad MF, Lillioja S, Nyomba BL, Castillo C, Ferraro R, De Gregorio M, et al
. Racial differences in the relationship between blood pressure and insulin resistance. N Eng J Med 1991;324:733-9.
Sattar N, Gaw A, Scherbakova O,Ford I, O’Reilly DS, Haffner SM, et al
. Metabolic syndrome with and without C-reactive protein as a predictor of coronary heart disease and diabetes in the west of Scotland coronary prevention study. Circulation 2003;108:414-9.
Golden SH, Folsom AR, Coresh J, Sharrett AR, Szklo M, Brancati F. Risk factor groupings related to insulin resistance and their synergistic effects on subclinical atherosclerosis: The atherosclerosis risk in communities study. Diabetes 2002;51:3069-76.
Summer AE, Jie Zhou MS, Ayo D, Imoisili OE, Amoah A, Acheampong A, et al
. Low HDL-C with normal triglyceride levels is the most common lipid pattern in the West Africans and African Americans with metabolic syndrome: Implications for cardiovascular disease prevention. CVD Prev Control 2010;5:75-80.
Gaillard T, Schuster D, Osei K. Metabolic syndrome in black people of the African diaspora: The paradox of current classification, definition and criteria. Ethn Dis 2009;19:S2-1-7.
Osei K. Metabolic syndrome in blacks: Are the criteria right? Curr Diab Rep 2010;10:199-208.
World Health Organization. Waist circumference and waist-hip ratio. In: Report of a WHO expert consultation. Geneva, Switzerland: WHO; 2008.
Ulasi II, Ijoma CK, Onodugo OD. A community-based study of hypertension and cardio-metabolic syndrome in semi-urban and rural communities in Nigeria. BMC Health Serv Res 2010;10:71.
Peer N, Lombard C, Steyn K, Levitt N. High prevalence of metabolic syndrome in the black population of Cape Town: The cardiovascular risk in black South Africans (CRIBSA) study. Eur J Prev Cardiol 2015;22:1036-42.
Ofori-Asenso R, Agyeman AA, Laar A. Metabolic syndrome in apparently “healthy” Ghanaians adults: A systematic review and meta-analysis. Int J Chronic Dis 2017;2017:2562374.
Ajayi EA, Ajayi OA, Adeoti OA. Metabolic syndrome: Prevalence and association with electrocardiographic abnormalities in Nigerian hypertensive patients. Metab Syndr Relat Disord 2014;12:437-42.
Ravikiran M, Bhansali A, Ravikumar P, Bhansali S, Dutta P, Thakur JS, et al
. Prevalence and risk factors of metabolic syndrome among Asian Indians: A community survey. Diabetes Res Clin Pract 2010;89:181-8.
Song QB, Zhao Y, Liu YQ, Zhang J, Xin SJ, Dong GH. Sex difference in the prevalence of metabolic syndrome and cardiovascular-related risk factors in urban adults from 33 communities of China: The CHPSNE study. Diab Vasc Dis Res 2015;12:189-98.
Park YW, Zhu S, Palaniappan L, Heshka S, Carnethon MR, Heymsfield SB. The metabolic syndrome: Prevalence and associated risk factor findings in the US population from the Third National Health and Nutrition Examination Survey, 1988-1994. Arch Intern Med 2003;163:427-36.
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.
Li Y, Yu D, Wang Z, Ding G. Metabolic syndrome prevalence and its risk factors among adults in China: A nationally representative cross-sectional study. PLoS One. 2018;13:e0199293.
Bakari AG, Onyemelukwe GC. Indices of obesity among type 2 diabetes mellitus Hausa-Fulani Nigerians. Int J Diabetes Metab 2005;13:28-9.
Ismail IM, Azeez K, Antomy A, Sobhith VK. Metabolic syndrome and its associated factors among the adult population residing in Kannavam tribal area of Kannur District Kerala. Trop J Med Res 2016;19:36-41. [Full text]
Li R, Li W, Lun Z, Zhang H, Sun Z, Kanu JS, et al
. Prevalence of metabolic syndrome in main land China: A meta-analysis of published studies. BMC Public Health 2016;16:296.
Ukegbu UJ, Castillo DC, Knight MG, Ricks M, Miller BV 3rd, Onumah BM, et al
. Metabolic syndrome does not detect metabolic risk in African men living in the U.S. Diabetes Care 2011;34:2297-9.
Muazu BS, Okpe IO, Anumah F, Bakari AG. The components of metabolic syndrome among type two diabetes mellitus patients attending a tertiary health facility in Northern Nigeria. Int Inv J Med Med Sci 2016;3:238-44.
Isezou SA. Is high density lipoprotein cholesterol useful in diagnosis of metabolic syndrome in native Africans with type 2 diabetes? Ethn Dis 2005;15:6-10.
Chakraborty SN, Roy SK, Rahaman MA. Epidemiological predictors of metabolic syndrome in urban West Bengal, India. J Family Med Prim Care 2015;4:535-8.
] [Full text]
Osuji CU, Nzerem BA, Dioka CE, Onwubuya EI. Metabolic syndrome in newly diagnosed type 2 diabetes mellitus using NCEP-ATP III, the Nnewi experience. Niger J Clin Pract 2012;15:475-80. [Full text]
Adiels M, Olofsson SO, Taskinen MR, Borén J. Overproduction of very low-density lipoproteins is the hallmark of the dyslipidemia in the metabolic syndrome. Arterioscler Thromb Vasc Biol 2008;28:1225-36.
Ginsberg HN, Zhang YL, Hernandez-Ono A. Metabolic syndrome: Focus on dyslipidemia. Obesity (Silver Spring) 2006;14:41-9S.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]