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AGREEMENT BETWEEN METABOLIC SYNDROME DIAGNOSTIC CRITERIA AMONG TYPE 2

DIABETES MELLITUS PATIENTS
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1. PHRC Research Centre, Muhammad Adnan1, Tayyaba Rahat2, Naheed Hashmat3, Zahra Ali4
Fatima Jinnah Medical University/ Sir
Ganga Ram Hospital, Lahore, Pakistan,
Postal Code: 54000.
2. PHRC Research Centre,
ABSTRACT… Background: Metabolic syndrome and diabetes mellitus are the modifiable risk factors of
Fatima Jinnah Medical University/ Sir cardiovascular diseases that double the chance of illness when occur together. Little work has been
Ganga Ram Hospital, Lahore, Pakistan, reported on the superlative criteria to diagnose metabolic syndrome among diabetics from the country.
Postal Code: 54000. Therefore, the study was aimed to find the agreement between metabolic syndrome diagnostic criteria
3. Department of Medicine, Sir Ganga among type 2 diabetics. Methods: The retrospective data of 373 known type 2 diabetics who had
Ram Hospital, Lahore, Pakistan,
Postal Code: 54000. reported history of taking antidiabetic medicines was analyzed. The new International Diabetes
4. PHRC Research Centre, Federation definition, the World Health Organization criteria and the NCEP Adult Treatment Panel III
Fatima Jinnah Medical University/ Sir criteria were used to diagnose metabolic syndrome. Data was analyzed by using Statistical Package for
Ganga Ram Hospital, Lahore, Pakistan, Social Sciences version 21. Results: Mean age of 373 diabetics was 49±10 years. Participants included
Postal Code: 54000.
36.5% males and 63.5% females. Mean BMI, WC and BP were high in females; while HDL-C was low in
Correspondence Address: males (p <0.05). The frequency of MS by ATP III, IDF and WHO criteria were 88.2%; 87.4%; and 86.3%,
Muhammad Adnan, respectively. Significant association was present between femininity, higher socioeconomic status and
Research Officer, MS (p <0.05). ATP III criteria diagnosed the maximum number of MS followed by IDF and WHO criteria.
PHRC Research Centre, OPD Block, 2nd
Floor, Sir Ganga Ram Hospital, Lahore,
The highest agreement was found between ATP III and IDF criteria (k 0.487). More than 85.0% diabetics
Pakistan, Postal Code 54000. were diagnosed as true positive and true negative on all three criteria. The disagreement between the
adnanpmrc@gmail.com studied criteria ranged from 5.1% to 8.0%. Conclusion: The ATP III, IDF and WHO criteria can equally be
used to diagnose metabolic syndrome among type 2 diabetics in the settings. However, ATP III and IDF
Article received on: 16/09/2016
Accepted for publication: criteria have an edge over WHO criteria. Increased rate of metabolic syndrome among diabetics have

METABOLIC SYNDROME
The Professional
05/02/2017 Received after proof Medical need
Journalof serious attention to reduce the risk of cardiovascular events.
www.theprofesional.com
reading: 06/04/2017
ORIGINAL PROF-3631
Key words: Diabetes Mellitus Type 2, Metabolic Syndrome X, Obesity, Body Mass Index, Waist
DOI: 10.17957/TPMJ/17.3631 Circumference, Blood Pressure, Hypertriglyceridemia, Prevalence.
INTRODUCTION
METABOLIC Article Citation: Adnan M, Rahat T, Hashmat N, Ali Z. Metabolic syndrome; agreement between

SYNDROME; diagnostic criteria among type 2 diabetes mellitus patients. Professional Med J
2017;24(4):539-544. DOI: 10.17957/TPMJ/17.3631
AGREEMENT BETWEEN
METABOLIC SYNDROME Numbers of criteria for the diagnosis of MS are
DIAGNOSTIC CRITERIA
AMONG TYPE 2 DIABETES
MELLITUS PATIENTS
Metabolic syndrome (MS) is a group of disorders that in practice worldwide. According to the new
includes abdominal obesity, dyslipidemia, insulin International Diabetes Federation (IDF) definition, a
resistance and hypertension (HTN). Though all these person presenting MS must have central obesity
components act as independent risk factors for (waist circumference with ethnicity specific values)
cardiovascular diseases (CVD), but collectively these plus any two or more components. 3 Similarly World
factors compound the risk to the higher level. Health Organization (WHO) criteria also have a
Therefore diagnosing MS is necessary for its prerequisite i.e. Insulin Resistance/ Diabetes Mellitus
treatment and to prevent or delay CVD.1 Type 2 plus any two or more of remaining components. 4
diabetics have higher prevalence of MS than While the National Cholesterol Education Program -
apparently healthy subjects; also diabetics with MS Adult Treatment Panel III (NCEP ATP III) criteria do
have increased risk of CVD than the diabetics without not have a prerequisite and suggest a person with
MS. Thus measuring prevalence of MS among T2DM MS who have any three of the five components.5
patients is very crucial.2

Professional Med J 2017;24(4):539-544. www.theprofesional.com 539

METABOLIC SYNDROME 2

Depending on the criteria used, these differences Treatment Panel III (NCEP ATP III) criteria 5 were used
may result in different prevalence rates of MS. to diagnose metabolic syndrome. Detailed
MS and DM are the modifiable risk factors of CVD description of the criteria used in the study shown in
that double the chance of illness when occur Table-I.
together. In Pakistan, several studies have measured
frequency of MS among diabetics by using a single STATISTICAL ANALYSIS
diagnostic criterion of their own choice.6-10 And Data was analyzed by using Statistical Package for
unfortunately, a little has been reported on the Social Sciences (SPSS) version 21. Qualitative
superlative criteria to diagnose MS among diabetics. variables were presented as number (percentage)
Therefore, the study was designed with the and quantitative variables as mean (standard
hypothesis that new IDF definition is the better deviation). Chi Square and Student’s t-test were used
criterion than the WHO and ATP III criteria to for the comparison of qualitative and quantitative
diagnose MS among type 2 diabetics in the setting. variables, respectively. Cross tabulation and kappa
statistics were used to find agreement between
METHODS Study type & Ethical approval diagnostic criteria for MS. P value <0.05 was
Ethical approval of this retrospective cross sectional considered significant.
study was obtained by the Institutional Ethical
Review Board, Fatima Jinnah Medical University/ Sir RESULTS
Ganga Ram Hospital, Lahore on 5 th January 2016 Demographic Characteristics Mean age of 373 type 2
(No.26/ResProj/IERB). diabetics was 49±10 years. Patients included 36.5%
males; 63.5% females; 54.4% illiterate; and 10.5%
Study population, Setting, Duration cigarette smokers. Monthly income of 59.5% patients
The data of 373 known T2DM patients who had was less than 100 USD. Mean duration of diabetes
reported history of taking antidiabetic medicines and was 08±06 years. No relationship was found between
visited PHRC Research Centre specialized for MS and the variables age, education, cigarette
Metabolic Diseases at Fatima Jinnah Medical smoking and duration of diabetes. However,
University Lahore during the year 2012-13 was significant association was present between MS and
analyzed. the variables gender female and higher
socioeconomic status (p <0.05).
Metabolic Syndrome Diagnostic Criteria The new
International Diabetes Federation (IDF) definition3, Anthropometry & Biochemical Assay
the World Health Organization (WHO) criteria4 & the Mean BMI, waist circumference and blood pressure
National Cholesterol Education Program - Adult levels were significantly higher in females (p <0.05).

IDFa Criteria WHOb Criteria ATPc III Criteria

Central Obesity plus Any other two Diabetes Mellitus plus Any other
MSd or more components two or more components Any three or more components

WCe WHRf WC
Obesity (cm) Men ≥90 Men ≥0.90 Men ≥102
Women ≥80 Women ≥0.85 Women ≥88
DM (mg/dl)
g
Rx or ≥100 (FPG )
h
Rx or ≥110 (FPG) Rx or ≥100 (FPG)
HTN (mm/Hg)
i
Rx or ≥130/85 Rx or ≥140/90 Rx or ≥130/85
Men <40 Men <35 Men <40
HDL-Cj (mg/dl)
Women <50 Women <39 Women <50
HTG (mg/dl)
k
≥150 ≥150 ≥150

Table-I. Description of Criteria Used to Diagnose Metabolic Syndrome

IDF: International Diabetes Federation; bWHO: World Health Organization; cATP III: National Cholesterol Education
a

Professional
Program Med J 2017;24(4):539-544.
- Adult Treatment Panel III; dMS: Metabolic Syndrome; www.theprofesional.com
e
WC: Waist Circumference; fWHR: Waist-to-hip ratio; gDM: Diabetes
Mellitus; hFPG: Fasting Plasma Glucose; iHTN: Hypertension; jHDL-C: Low HDL-Cholesterol; kHTG: Hypertriglyceridemia.

540
METABOLIC SYNDROME 3

Mean HDL-C levels were significantly low in males (p difference was observed for HTN except in WHO
<0.001). Mean triglycerides levels were raised among criteria (p <0.001). Hypertriglyceridemia was the least
both genders (p 0.953) Table-II. prevalent component by all three criteria and was
equally present among both genders Table-III.
MS Prevalence Rate
The rates obtained by ATP III, IDF and WHO criteria Agreement Analysis
were 88.2%; 87.4%; and 86.3%, respectively. It was The highest agreement was achieved between IDF &
seen that ATP III criteria identified the maximum ATP III criteria (k 0.487; p <0.001). Overall 89.0%
number of diabetics with MS, while WHO criteria patients were identified on both criteria; 82.3%
identified the minimum. According to IDF and ATP III diabetics with MS and 6.7% without MS. A moderate
criteria, gender female had significantly higher MS agreement was estimated between IDF & WHO
prevalence rate than males (p <0.001), but it was criteria (k 0.366; p <0.001). Total patients identified
insignificant when WHO criteria was used (p 0.091). on both criteria were 85.5%; of which 79.6%
When compared to other two criteria, it was the diabetics were with MS and 5.9% without MS. The
WHO criteria that reported the highest MS rate lowest agreement was evaluated between ATP III &
(82.4%) among males; and the lowest rate (88.6%) WHO criteria (k 0.361; p <0.001) and total 85.8%
among females Table-III. patients were recognized on both criteria; There
were 80.2% diabetics with MS; and 5.6% without MS.
MS Components Overall more than 85.0% diabetics were screened as
Obesity was the most prevalent MS component true positive and true negative on all three criteria.
especially in females. It was found in more than 90% The disagreement between the studied criteria
patients by IDF & WHO criteria. But its occurrence ranged from 5.1% to 8.0%. It was the lowest between
was reduced upto 67% patients by ATP III criteria. A ATP III & IDF criteria; and the highest between ATP III
large number of males evaluated as obese by IDF & & WHO criteria Table-IV.
WHO criteria were normal on ATP III criteria. The
second most prevalent component was low HDL-C.
Its incidence rate was significantly higher in females.
The frequency of low HDL-C (34.3%) by WHO criteria
was less than half of the frequencies determined by
IDF & ATP III criteria. The prevalence of HTN was
ranked at number three among MS components. The
prevalence of HTN by WHO criteria (57.4%) was the
lowest frequency when compared to the frequencies
determined by other two studied criteria. No gender

All Male (n=136) Female (n=237)

P value
(n=373)
Age (years) 49±10 52±10 47±09 <0.001
Weight (Kg) 70±13 72±11 69±14 0.030
Height (cm) 158±12 168±08 152±11 <0.001
Body Mass Index 28±07 25±04 30±07 <0.001
Waist Circumference (cm) 101±13 97±11 104±13 <0.001
Hip Circumference (cm) 102±11 98±09 105±12 <0.001
Waist-to-hip ratio 0.99±0.07 0.99±0.06 0.99±0.08 0.414
Glucose Fasting (mg/dl) 176±78 167±71 180±82 0.111
HDL-Cholesterol (mg/dl) 40±07 38±06 42±08 <0.001
Triglycerides (mg/dl) 213±131 212±127 213±134 0.953
Systolic Blood Pressure (mm/Hg) 135±18 131±17 136±18 0.008
Professional MedPressure
Diastolic Blood J 2017;24(4):539-544.
(mm/Hg) www.theprofesional.com
84±11 82±11 85±11 0.036
Table-II. Comparison of anthropometric measurements and biochemical assays
541
METABOLIC SYNDROME 4

IDFa ATP IIIb WHOc

All 326(87.4%) 329(88.2%) 322(86.3%)
Male 103(75.7%) 106(77.9%) 112(82.4%)
MSd
Female 223(94.0%) 223(94.0%) 210(88.6%)
P value <0.001 <0.001 0.091
All 337(90.3%) 252(67.6%) 351(94.1%)
Male 108(79.4%) 36(26.5%) 123(90.4%)
Obesity
Female 229(96.6%) 216(91.1%) 228(96.2%)
P value <0.001 <0.001 0.023
All 287(76.9%) 287(76.9%) 128(34.3%)
Male 83(61.0%) 83(61.0%) 37(27.2%)
HDL-Ce
Female 204(86.1%) 204(86.1%) 91(38.4%)
P value <0.001 <0.001 0.028
All 263(70.5%) 263(70.5%) 214(57.4%)
Male 94(69.1%) 94(69.1%) 61(44.9%)
HTNf
Female 169(71.3%) 169(71.3%) 153(64.6%)
P value 0.655 0.655 <0.001
All 249(66.8%) 249(66.8%) 249(66.8%)
Male 90(66.2%) 90(66.2%) 90(66.2%)
HTGg
Female 159(67.1%) 159(67.1%) 159(67.1%)
P value 0.857 0.857 0.857
Table-III. Frequency distribution of metabolic syndrome and its components
a
IDF: International Diabetes Federation; bATP III: National Cholesterol Education Program - Adult Treatment Panel III; cWHO: World
Health Organization; dMS: Metabolic Syndrome; eHDL-C: Low HDL-Cholesterol; fHTN: Hypertension; gHTG: Hypertriglyceridemia.

ATP IIIc
MS Non- MS
MSb 307(82.3%) 19(5.1%) 326(87.4%)
IDFa <0.001
Non- MS 22(5.9%) 25(6.7%) 47(12.6%)
(Kappa=0.487)
Total 329(88.2%) 44(11.8%) 373(100%)
WHOd
MS Non- MS
MS 297(79.6%) 29(7.8%) 326(87.4%)
IDF <0.001
Non- MS 25(6.7%) 22(5.9%) 47(12.6%)
(Kappa=0.366)
Total 322(86.3%) 51(13.7%) 373(100%)
WHO
MS Non- MS
MS 299(80.2%) 30(8.0%) 329(88.2%)
ATP III <0.001
Non- MS 23(6.2%) 21(5.6%) 44(11.8%)
(Kappa=0.361)
Total 322(86.3%) 51(13.7%) 373(100%)
Table-IV. Agreement analysis between MS diagnostic criteria
IDF: International Diabetes Federation; bMS: Metabolic Syndrome; cATP III: National Cholesterol Education Program - Adult Treatment
a

Panel III; dWHO: World Health Organization.

Professional Med J 2017;24(4):539-544. www.theprofesional.com

METABOLIC SYNDROME 5

DISCUSSION recommend ethnic specific values for waist

Diabetics with MS have increased risk of CVD than circumference.5 Hypertension was the second least
the diabetics without MS. For the reason, it was prevalent component in the study. Approximately
important to determine MS prevalence rate among similar ranking was achieved by Pokharel et al. 12 who
T2DM patients. Asma et al.11 used ATP III, IDF and found it the least prevalent component. Oppositely,
WHO criteria to determine the prevalence rates of Alebiosu et al.14 found it as the most prevalent MS
MS among Pakistani diabetics, and found pretty component.
similar rates as obtained in the study. By using same
three diagnostic criteria, Pokharel et al.12 yielded The frequencies of MS (88.2%, 87.4%, and 86.3%)
frequencies among Nepali diabetics were slightly obtained in the study were slightly increased but
lower. In contrast to the above findings, Yadav et al. 13 comparable to other frequencies ranging 70.0% to
reported percentages 91.9% reported from Pakistan7-10; however greatly
differed with the frequencies reported from India,
542
Ghana and Nigeria.13-15 It was established that ATP III
criteria identified the maximum number of diabetics
among Indian diabetics were nearly half. Gender was with MS, while WHO criteria identified the minimum.
significantly associated with MS and females had Similarly, the highest rates of MS by ATP III criteria
higher prevalence rate of MS than males. 11-13 Same and the lowest by WHO criteria were reported by
significant association and high prevalence rate was other studies from Pakistan.7-11 But studies from
achieved in present study. Turkey2, India13, Iran16, and Africa17 showed that it was
the IDF criteria that reported the highest rate
Several studies had used a single criterion to followed by ATP III criteria. The studies had reported
diagnose MS among diabetics. The MS rates the highest degree of agreement between IDF & ATP
calculated in the study were a little higher but III criteria; and the lowest between IDF & WHO
comparable to the other rates reported from Pakistan criteria.11-13 Similar highest agreement for the same
i.e. 85.8% (ATP III) by Mohsin et al. 7; 77.0% (ATP III) by two criteria was obtained in the present study. But
Tariq et al.8; 76.0% (IDF) by Ahmed et al.9; and 70.0% the lowest agreement was observed between ATP III
(WHO) by Khuwaja et al.10 However rates 25.2% & WHO criteria.
(WHO) from Nigeria14; and 24.0% (IDF) from Ghana15
were amazingly low. These rates were about 3 times The ATP III, IDF and WHO criteria determined nearly
lesser than the MS rates reported among Pakistani equivalent frequencies and propose that these
diabetics. Few studies had used ATP III & IDF criteria criteria can equally be used to measure frequency of
to diagnose MS among diabetics. The prevalence MS in type 2 diabetics. However, the highest
rates (ATP=85.1%; IDF=87.2%) among Turkish agreement was found between ATP III and IDF
diabetics2 were same as of present study. However, criteria; and had an edge over WHO criteria. By using
rates (ATP=75.4%; IDF=76.8%) from Iran16; and ethnic specific values for waist circumference, ATP III
(ATP=60.4%; IDF=71.7%) from criteria can further improve its agreement with IDF
Africa17 were comparatively smaller. definition. The rates obtained in the studied
population were very high and have need of serious
Obesity was the most prevalent MS component attention by the physicians to screen diabetics for MS
especially in females. Likewise present study, other to reduce the risk of cardiovascular events.
studies also reported obesity as the most frequently
occurring MS component with gender association. 10,12 Conflicts of Interest
Obesity was found in more than 90% patients by IDF It is stated that all the authors meet authorship
& WHO criteria; but was markedly reduced upto 67% criteria; assure you that the manuscript contains an
patients by ATP III criteria. This significant difference original data of T2DM patients; is neither published
seems because of ATP III criteria that do not nor under consideration for publication in any other

Professional Med J 2017;24(4):539-544. www.theprofesional.com

METABOLIC SYNDROME 6

journal; and there are no conflicts of interest. Also, all 8. Tariq M, Hadi A, Rahman S. Metabolic syndrome in type-2
the authors have read and approved the manuscript. diabetics: an update on the silent epidemic. Rawal Med J
2010; 35:1-9.
Copyright© 05 Feb, 2017.
9. Ahmed N, Ahmad T, Hussain SJ, Javed M. Frequency of
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IDF definitions. Bratisl Lek Listy 2011; 112: 253-259. ATP III, IDF and Harmonized criteria. Journal of Diabetes &
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consensus group. The metabolic syndrome: a new 13. Yadav et al. Prevalence of metabolic syndrome in type 2
worldwide definition. Lancet 2005; 366:10591062. diabetes mellitus using NCEP-ATPIII, IDF and WHO
definition and its agreement in Gwalior Chambal region of
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with type 2 diabetes mellitus. JNMA 2004; 96:817-821.
5. Expert Panel on Detection, Evaluation and Treatment of
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16. Marjani A, Shirafkan A. The metabolic syndrome in type 2
6. Ahmed S, Ahmed SA, Ali N. Frequency of metabolic
diabetic patients in Gorgan: according to NCEP ATP III and
syndrome in type 2 diabetes and its relationship with
IDF definitions. Advances in Biological Research 2011; 5:200-
insulin resistance. JAMC 2010; 22:22-27.
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7. Mohsin et al. Frequency of the metabolic syndrome in adult
17. Kengne et al. Metabolic syndrome in type 2 diabetes:
type2 diabetics presenting to Pakistan Institute of Medical
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METABOLIC SYNDROME 7

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Literature review, Manuscript
writing
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