ORIGINAL ARTICLE
Prevalence of Metabolic Syndrome Using NCEP/ATP III
Criteria in Jakarta, Indonesia: The Jakarta Primary
Non-communicable Disease Risk Factors Surveillance 2006
Pradana Soewondo, Dyah Purnamasari, Maryantoro Oemardi, Sarwono Waspadji,
Sidartawan Soegondo
Department of Internal Medicine, Faculty of Medicine, University of Indonesia - Dr. Cipto Mangunkusumo Hospital.
Jl. Diponegoro no. 71, Jakarta Pusat 10430, Indonesia.
Correspondence mail to: [email protected]
ABSTRACT
Aim: to obtain the prevalence of MetS in Jakarta, as a
capital city of Indonesia.
Methods: data were obtained from surveillance of
primary non-communicable disease in five regions in
Jakarta, Indonesia, conducted in 2006. Targeting for 1,800
samples, we performed a purposive and simple random
sampling of subjects within the age range of 25 – 64 years
old in selected sampling areas, and stratified random
sampling by adjusting to age and sex within those selected
sampling areas. We use The WHO Step Wise in collecting
data. We also collected blood sample for total cholesterol,
LDL cholesterol, HDL cholesterol and triglyceride level.
The ATP III modified Asian criteria require the presence of
3 or more of the following: 1. Abdominal obesity (waist
circumference > 90 cm in men and > 80 cm in women; 2. A
high triglyceride level (> 150 mg/dL); 3. A low HDLcholesterol level < 40 mg/dL for men and <50 mg/dL for
women); 4. High blood pressure (systolic > 130 mmHg or
diastolic >80 mmHg; and 5. A high fasting plasma glucose
concentration (>110 mg/dL).
Results: among 1,591 subjects, there are 641 men
(40.3%) and 950 women (59.7%). The crude prevalence of
MetS using the ATP III modified Asian criteria is 28.4%
with prevalences in men and women are 25.4 and 30.4%
respectively. The prevalences of MetS in NGT, prediabetes,
and diabetes group are 16.4, 35.1, and 73.4% respectively.
The prevalences of MetS and central obesity in prediabetes
group and diabetes group are higher significantly than
those in normal glucose tolerance group (p<0.01). The
most common component of MetS in men is hypertension
(84.7%), followed by hypertriglyceridemia (83.4%),
central obesity (75.5%), hyperglycemia (50.9%) and low
HDL-cholesterol (43.6%). While in women, the most
common component is central obesity (84.1%), followed
by hypertension (84.1%), hypertriglyceridemia (66.1%),
low HDL-cholesterol (57.8%), and hyperglycemia (50.2%).
Conclusion: the prevalence of MetS in this study is
28.4%. The most component found in men is hypertension
while in women is central obesity.
Key words: metabolic syndrome, ATP III modified Asian
criteria, prevalence.
INTRODUCTION
Based on the Household Health Survey in 2001,
cardiovascular disease (CVD) is the leading cause of
mortality in Indonesia. The survey also reported that
CVD mortality due to non-communicable disease
(NCD) has increased twice as much within the last 10
years which attributed to the increase of obesity,
dyslipidemia, hypertension and diabetes mellitus.1 As a
developing country, Indonesia has transformed its
economy from agricultural-based to industrial-based.
One of the prominent characteristics of industrial-based
economy is the widespread use of technology as
opposed to human factor often used in agriculturalbased economy. This transition has inevitably changed
the society life style whereby people tend to do less
physical activities and eat fast-served food (often called
junk food). This phenomena transformed the cause of
mortal diseases from infection-type diseases to
metabolic-type diseases, mostly caused by physical
inactivity and obesity.2
To identify persons at greater risk of cardiovascular
disease due to metabolic abnormalities, the World
Health Organization (WHO), the European Group for
Study of Insulin Resistance (EGIR), International
Diabetes Foundation (IDF) and National Cholesterol
Education Program Adult Treatment Panel III (NCEP
ATP III) created a diagnostic criteria called metabolic
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Pradana Soewondo
syndrome (MetS). Metabolic syndrome is a cluster of
metabolic abnormalities closely related to the risk of
coronary heart disease (CHD), stroke and cardiovascular mortality. Each component of metabolic syndrome
has been known as the major cardiovascular risk
factor. Once they occur simultaneously, the adverse
outcome should be more likely.3 In some cases, those
metabolic disorders were found unpredictable when
those people got routine general medical check up.
Soebardi found that among newly diagnosed diabetes
mellitus, the prevalence of dyslipidemia was higher than
those without glucose intolerance.4
Based on some recent studies, ATP III criteria are
more simple and reliable in daily practice than those of
WHO, EGIR and IDF. In 1994, National Health and
Nutrition Examination Survey (NHANES) in the US
reported that the prevalence of MetS using NCEP/
ATP III criteria in men and women were 22.8% and
22.6%, respectively.5 Among other Asia regions, the
prevalence of MetS is also highly enough. In 1996, the
prevalence of MetS in Malaysia among subjects whose
age > 20 years old was 49.4% (the 2nd Malaysian
National Health and Morbidity Survey).6 A National
survey of MetS in the Thai population in the year 2000
reported the prevalence of MetS according to NCEP/
ATP III criteria was 21,9%.7 In Indonesia, NCD study
in Depok (2001) reported that the prevalence of MetS
using ATP III modified Asian Criteria was 25.3%.
Depok is one of the suburbs in West Java which is
relatively near to Jakarta. Like other suburb regions
surrounding Jakarta, the development of industrial area
in Depok increases rapidly. Since Depok Study reported
high prevalence of MetS, we assumed that the
prevalence of MetS in Jakarta may be higher than or
similar to that of Depok.8 The purpose of this study is
to obtain the prevalence of MetS in Jakarta, as a
capital city of Indonesia.
Acta Med Indones-Indones J Intern Med
(weight, height and waist circumference) and blood
pressure. The third step is performing laboratory
examination such as an oral glucose tolerance test
(OGTT) and lipid profile. Height (to the nearest
millimeters) is recorded in all subjects without wearing
shoes. Weight (in kilograms) is measured in light
clothing using a microtoise. Body Mass Index (BMI)
is calculated using weight divided by the square of the
height (kilograms per meter squares).9
Waist circumference is measured in the middle
between the last arcus costae and spina iliaca anterior
superior (SIAS). There are three readings of blood
pressure taken from each respondent who had rest
adequately before being measured using standard
mercury sphygmomanometer in sitting position. The
mean value of the three readings is then calculated.
All subjects, except those with diagnosed diabetes, are
then given an OGTT. OGTT is collected after subjects
did overnight (about 12 hours) fasting and two hour
after taking 75 gram of glucose in 200 ml water.10 We
also collected blood sample for total cholesterol, LDL
cholesterol, HDL cholesterol, and triglyceride level.
Initially, this study recruited 1,800 subjects from five
regions in Jakarta. Among 1,800 subjects, 155 subjects
withdrew from the study and 54 subjects did not
perform blood sample collection, so there were 1,591
subjects elligible for the study.
Definition
The ATP III modified Asian criteria require the
presence of 3 or more of the following: 1. Abdominal
obesity (waist circumference >90 cm in men and >80
cm in women; 2. A high triglyceride level (>150 mg/dL);
3. A low HDL-cholesterol level <40 mg/dL for men and
<50 mg/dL for women); 4. High blood pressure (systolic >130 mmHg or diastolic >80 mmHg; and 5. A high
fasting plasma glucose concentration (>110 mg/dL).3
Statistical Analysis
METHODS
The Jakarta NCD-S is a cooperation study by
Research and Health Development, Ministry of Health
and Department of Medicine, Faculty of Medicine,
University of Indonesia. Area sampling is determined
by purposive random sampling and simple random
sampling. In those sampling areas, subjects are selected
by stratified random sampling based on age and sex.
We use The WHO Step Wise in collecting data
which consist of three steps. The first step is
collecting demographic factor by interviewing subjects
of the study. The second step is conducting physical
examination such as anthropometric measurement
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Data were analyzed using SPSS v13 software. We
calculated estimates of mean or percentage of risk
factors level in the overall population. Comparison of
risk factors between population subgroup were
performed using chi square test for categorical
variables.
RESULTS
Among 1,591 subjects, there are 641 men (40.3%)
and 950 women (59.7%). The crude prevalence of
MetS using the ATP III modified Asian criteria is 28.4%
with prevalences in men and women are 25.4 and
30.4%, respectively.
Vol 42 • Number 4 • October 2010
Prevalence of Metabolic Syndrome Using NCEP/ATP III Criteria in Jakarta
In men, the prevalence of MetS increases more
than twice in the age group of thirties compared to the
age group of twenties. The prevalence in the age group
of fifties is relatively flat until the the age group of
sixties. While the prevalence of MetS in the age group
of sixties to the above increases less than one half.
While in women, the prevalence of MetS increases
three fold in the age group of thirties compared to that
of the twenties. While in the age group of fourties the
prevalence increases twice as many as the previous
age group. In the age group of fourties to the above
the prevalence is relatively flat (less than one half fold).
The prevalences of central obesity increase with age
and have similar pattern to the increase prevalences
of MetS. (Figure 1A and 1B)
The prevalences of MetS in NGT, prediabetes and
diabetes group are 16.4, 35.1, and 73.4%, respectively.
The prevalences of MetS and central obesity in
prediabetes group and diabetes group are higher
significantly than those in normal glucose tolerance
group (p<0.01).
The most common component of MetS in men is
hypertension (84.7%), followed by hypertriglyceridemia
(83.4%), central obesity (75.5%), hyperglycemia
(50.9%) and low HDL-cholesterol (43.6%). While in
women, the most common component is central
obesity (84.1%), followed by hypertension (84.1%),
hypertriglyceridemia (66.1%), low HDL-cholesterol
(57.8%) and hyperglycemia (50.2%). Besides central
obesity, the profile of dyslipidemia among men and
women is different. The proportion of low HDL
cholesterol is higher among women than that among
men, while the proportion of high triglyceride is higher
among men than that among women. These
differences are statistically significant (p<0.05).
Table 1. The proportion of components of MetS in women
and men with MetS
MetS components
(A)
Hypertension
Hyperglycemia
Central obesity
Low HDL-C
High Triglyceride
Men (%)
Women (%)
p
84.7
50.9
75.5
43.6
83.4
84.1
50.2
91.3
57.8
66.1
0.871
0.879
0.000
0.004
0.000
DISCUSSION
(B)
(C)
Figure 1. Prevalence of MetS and central obesity in men (A),
women (B), and subgroup according to glucose tolerance
classifications (C)
The prevalence of MetS in Asian region increases
as modernization is underway. Indonesia is one of the
Southeast Asia developing countries which has rapid
economic and social growth.2 It causes two opposite
effects, better economical condition and the increase
of non-communicable disease such as obesity,
hypertension, coronary artery disease, and diabetes
mellitus. Other Asia regions such as Malaysia,
Thailand, Philippines and Singapore also reported the
high prevalence of MetS (>20%).6,7
Several studies in terms of the prevalence of MetS
in some regions in Indonesia (Depok, Surabaya, Bali,
Bandung, Semarang, North Sumatera, and Maskassar)
have been performed. Almost all of the studies reported
the prevalence of MetS using Asian modification ATP
III criteria. They reported the prevalence of MetS was
in the range of 16.6% (Semarang, 2005) to 34.0%
(Surabaya, 2005). Budhiarta (2004) in Bali reported
the difference between the prevalence of MetS in
urban and in rural area whereby the prevalence of MetS
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Pradana Soewondo
in urban is higher than that in rural, as many as 24.8%
and 7.8%, respectvely. Jakarta as the capital city of
Indonesia consist of various cultural and socioeconomical backgraound. The crude prevalence of
MetS in this study is 28.4% with similar prevalences
between men and women. Theoretically, the prevalence of MetS among men is higher than that among
women especially in the age below 50. But, in recent
years, the prevalences of MetS among women are
increasing parallel with that in obesity. The prevalence
of MetS in this study is similar to that in Depok
(suburban area near to Jakarta in 2002 where the
prevalence of MetS was 25.3%.8,11-15
In men, the prevalence rises with age and reaches
the peak at the age group of sixties. The increase of
prevalence is relatively flat within age group. The
prevalence of central obesity also rises, follows the
prevalence of MetS. It shows the influence of central
obesity in the pathogenesis of cardiovascular diseases.
Several studies have shown the relationship between
abdominal obesity and unfavorable cardiovascular risks
and markers of inflammation. By this finding, it is
reasonable to use waist circumference as a simple tool
in routine screening besides body mass index. Among
MetS components, hypertension is the most common
components of MetS found in men. It is difficult to
explain this finding because this study didn’t recall the
family history of hypertension. Study in Semarang
Central Java (Suhartono et al, 2005) also reported that
hypertension was the most common component of
MetS found in their study. This study recruited
subjects who visited the clinic and more than half of
those subjects were older than 50 years old.14,16,17
In women, the prevalence also rises with age but
the trend is sharper and reaches the peak level at the
age group of fifties. The sharp increase of prevalences
happens before the age group of fifties but remains
flat thereafter. The proportion of low HDL cholesterol
among women is also higher than that in men. This
figure is different from that of men and it may show
that in women, hormonal changes during pregnancy
and menopause could play an important role in
metabolic changes. Another explanation is about the
different proportion between age groups. The
proportion of women in the range of 30 - <40 and
40 - <50 years old were higher than that in the other
age group. Many of these women work as housewives
and spent all of their time in their home. It is better to
evaluate the physical activity among this group.
Unfortunately, this study did not recall the daily activity
in detail. This study also did not recall the history of
pregnancy and menopause as we know that pregnancy
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Acta Med Indones-Indones J Intern Med
and menopause could be important factors that
influence the increase of waist circumference in
women. In menopause, there is loss of estrogen and
causes an increase in central fat (android fat
deposition) which has higher risk of diabetes and
cardiovascular disease. In these ranges of age, the
prevalence of central obesity in women is higher than
those in other age group. It may influence the pattern
of the rising prevalence and the crude prevalence of
central obesity and MetS in this study.18 In women,
central obesity is the most common components found
in almost all age groups as well.
The prevalences of MetS increase along with the
disturbance of glucose tolerance level as reported by
Alexander from NHANES III Study.19 It shows that
insulin resistance persists and will be heavier as
glucose intolerance and diabetes develop. Since MetS
can predict the risks of cardiovascular events, it can
be assumed that subjects with glucose intolerance and
DM will have higer risk for developing CVD event
compared with normal glucose tolerance one.16
CONCLUSION
The prevalence of MetS in five areas in Jakarta is
28.4% and there are no significant differences of
prevalences between men and women. The prevalence
of MetS increases along with age, central obesity and
the level of glucose intolerance. The most component
found in men is hypertension while in women is central
obesity.
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