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Metabolic Syndrome 2.5 X more likely if less than 25 ng of vitamin D – Oct 2018

The relationship between hypovitaminosis D and metabolic syndrome: a cross sectional study among employees of a private university in Lebanon

BMC Nutrition 20184:36; https://doi.org/10.1186/s40795-018-0243-x
Rachelle Ghadieh, Jocelyne Mattar Bou Mosleh, Sibelle Al Hayek, Samar Merhi and Jessy El Hayek Fares

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The prevalence of low vitamin D status and metabolic syndrome is increasing globally and in Lebanon. The objectives of this study are to assess the prevalence of metabolic syndrome (MetS) and its components (elevated triglycerides, low HDL, abdominal obesity defined by high waist circumference, hypertension, impaired fasting blood glucose) and investigate the association between serum 25-hydroxyvitamin D (25(OH)D) concentrations and MetS and its components among a sample of Lebanese adults.

A cross-sectional study was carried out on Notre Dame University employees. A background questionnaire, a short-form of the International Physical Activity Questionnaire and a food frequency questionnaire were administered. Participants were invited to the nutrition laboratory to gather data on anthropometric (height, waist circumference, weight, body composition and body mass index) and biochemical measurements (serum vitamin D, triglycerides, HDL and fasting blood glucose). Vitamin D status was assessed according to the Institute of Medicine cut-offs (inadequate or adequate: 25(OH)D < or ≥ 50 nmol/L).The definition of the Third Report of the National Cholesterol Education Program was used to identify individuals who had MetS. The data were analyzed using the SPSS version 22. P < 0.05 was considered statistically significant.

A total of 344 participants (age range of 20 to 74 years) were included in the study. The prevalence of MetS was 23.5%. Among MetS components, central obesity was the most prevalent condition (50.6%), while the least prevalent was impaired fasting blood glucose (20.3%). The odds of having MetS were found to be 2.5 (95% CI 1.3–4.7) higher among those with inadequate vitamin D status, than among those with adequate vitamin D status while controlling for important confounders (age, marital status, education level, income, medical morbidity, smoking and percent body fat and gender). Among the components of MetS, only hypertriglyceridemia (OR: 2.4, 95%CI: 1.3–4.2) and low HDL (OR: 1.8, 95% CI: 1.0–3.0) were associated with inadequate vitamin D status while controlling for important confounders.

Early identification and control of risk factors for cardiovascular diseases in the primary care level is needed, particularly among adults who have low vitamin D status, are obese, and have low income level.

Discussion (from PDF)

This study found that 23.5% of Lebanese adults in a private university had MetS. All the components of MetS, except for risky WC and low HDL, were more common in men than women. The factors that were associated with MetS included low vitamin D status, older age, low income and high body fat. The odds of having MetS were approximately 2.5 higher among those with inadequate vitamin D status compared to those with adequate status after controlling for important confounders.
The prevalence of MetS (23.5%) reported in the current study was similar to that reported by another study among a national sample of Lebanese adults of 25.4% [33]. Our study findings indicated a prevalence of MetS comparable to that reported in the US of 23.7% [11] and in line with rates reported in the Middle East such as in Oman (21.0%) [34], Turkey (33.4%) [35] and Iran (33.7%) [36]. Similar to Sibai et al., 2008, our study reported a higher prevalence of MetS in men compared to women. In contrast, Erem et al., 2008 reported a higher prevalence of MetS among Turkish women compared to men and Delavari et al., 2009 reported a similar trend among Iranian adults [37, 38]. These gender differences could be attributed to different obesity rates between men and women. For instance, in our study, higher prevalence of overweight and obesity was observed among Lebanese men compared to women and also in the general Lebanese population [39], while in Turkey and in Iran more women were overweight and obese compared to men [10]. It is well-known in the literature that obesity is an important component for MetS [40, 41]. Our results support this assumption as the prevalence of MetS was significantly higher among participants who were overweight or obese compared to normal weight participants. The prevalence of MetS increased across increasing BMI categories, which is coherent with the literature [42]. As BMI and adiposity increase, the adipocytes secrete pro-inflammatory cytokines and chemokines which enhance the inflamed state of the tissues, increase insulin resistance and hence increase the risk of MetS [42]. Further, the concentration of HDL-cholesterol is adversely altered in obesity, with HDL-cholesterol levels associated with both the degree and distribution of obesity [43].
The most prevalent component of MetS was risky WC in both men and women. These results are concordant with the literature in Lebanon and in neighboring countries [10, 33], as obesity has been on the rise in the Middle Eastern region across all age and gender groups [10].
In bivariable and multivariable analyses, our findings showed that age was positively correlated with MetS among both genders, which is in line with previous studies [3, 44, 45]. Several population studies have reported an increase in the prevalence of MetS with age regardless of the definition used [11, 46-48]. It can be inferred that, with age, blood vessels gradually lose elasticity and gain resistance, slowing blood flow. Moreover, with poor circulation, fat is prone to accumulate in the abdomen and release free fatty acids into the serum, leading to higher insulin resistance, elevated serum Tg levels, increased low density lipoprotein- cholesterol (LDL-C) levels, and, consequently, a greater risk of MetS [45].
The prevalence of MetS was inversely associated with income and education, which is in line with the literature in different ethnic and gender groups [49-51]. It is well known in the literature that education and income are strong predictors of health since they may affect lifestyle behaviors and accessibility to healthcare services [51, 52]. This observation was also supported by our results since further data analyses showed that among individuals with low income and education, the prevalence of overweight and obesity and the prevalence of smoking were higher compared to individuals with higher income and education, which would likely increase the risk of MetS. Further, other studies have reported that individuals having low socio-economic background tend to select low-cost, energy-dense food and practice less leisure time activities, which would favor the development of insulin resistance, hypertriglyceridemia, and body weight gain resulting in a higher risk of MetS [53].
In the current study, smoking was associated with MetS in all participants and specifically in men. Previous studies have shown conflicting results regarding the influence of smoking on the prevalence of MetS [54, 55]. Some studies have reported that exposure to tobacco smoke in all forms has been associated with MetS [56, 57]. Smoking has been found to play a causal role in the emergence of core components of MetS. Smoking could increase the risk of abdominal obesity, insulin resistance, leptin resistance, low-grade systemic inflammation, endothelial dysfunction, autonomic dysfunction [58], BP and reduce HDL [57].
Our results showed that a higher percentage of those who had MetS had inadequate vitamin D status compared to those who did not have MetS in the total sample and in women only. However, using the multivariable logistic regression, having inadequate vitamin D status increased the odds of having MetS by 2.5 times. Our results are in line with the literature, for instance Ford et al. showed that the odds of having MetS decreased progressively across increasing quintiles of concentration of 25(OH)D [59]. Previous studies showed that lower serum levels of 25(OH)D were associated with a statistically significant increase in the prevalence of the components of MetS, i.e., elevated BP, elevated Tgs, reduced HDL-C and increased WC [12, 58-61]. In the current study, only hypertriglyceridemia and low HDL were associated with inadequate vitamin D status, while hypertension, risky WC and impaired fasting glucose were not associated with vitamin D status. On the other hand, few studies failed to observe the association between vitamin D status and MetS [3, 14, 15]. It is very likely that the studies that did not observe an association between MetS and vitamin D status were conducted on either high or low risk populations. For instance, Rueda et al. 2008 and Hjelmesaeth et al. 2009 examined this association in morbidly obese individuals reporting very high rates of MetS and other co-morbidities (diabetes type II, hypertension and heart disease), while Gannage-Yared et al., 2009 recruited a sample of young Lebanese adults with healthy weights and low prevalence of MetS [3, 14, 15].
The association between vitamin D status and MetS could be explained by the fact that vitamin D receptors are distributed on vascular smooth muscle, endothelium and cardiomyocytes. Activated 1,25-dihydroxyvitamin D suppresses renin gene expression, regulating the growth and proliferation of vascular smooth muscle cells, cardio- myocytes, and inhibiting cytokine release from lymphocytes. Therefore, the absence of vitamin D receptor activation leads to tonic upregulation of the renin-angiotensin system, eventually leading to hypertension and left ventricular hypertrophy and increasing the likelihood of MetS [61]. Furthermore, another potential mechanism explaining the association between MetS and low vitamin D status is through insulin resistance. Insulin resistance is postulated to be the common underlying pathogenic link between the various components of MetS. Decreased levels of vitamin D may cause insulin resistance [17]. Vitamin D reduces insulin resistance in the surrounding tissues and thus reduces the excessive insulin release in response to increased blood sugar due to insulin resistance. As a result, it increases the insulin sensitivity. Therefore, vitamin D deficiency is a risk factor for MetS and insulin resistance. Vitamin D does not only increase the production capacity of |3-cells, it also accelerates the pro-insulin conversion [18]. On the other hand, some studies discussed reverse causality, suggesting that obesity, a component of MetS, could lead to low vitamin D status [19]. For instance, larger storage capacity for vitamin D in obese individuals leads to lower circulating 25(OH)D concentrations [20].
The results of this study should be interpreted with the following limitations in mind. First, subjects were drawn from a single private university in Lebanon and, therefore, the inferences drawn from the results are not generalizable to the Lebanese population. More diverse samples collected by a nation-wide survey should be considered in future research. Second, 25(OH)D concentrations were measured by ELISA, which is not the gold standard technique for vitamin D assessment, but, it is the most commonly used technique in research since it's relatively simple and inexpensive [62]. Third, as a cross-sectional study, we cannot infer causality from our findings. A longitudinal study design is needed to investigate any causal relationships among the factors included in this study. Fourth, dietary analyses revealed that the Middle Eastern food composition tables did not include the vitamin D content of all foods; accordingly the vitamin D content of these foods had to be derived from the Canadian Nutrient file.
Despite these methodological concerns, to our knowledge, this was the first study to assess the association between MetS and vitamin D status in middle-aged Lebanese adults at risk of developing chronic diseases.

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