Abstract
Objective
To determine the prevalence of obesity and metabolic syndrome (MS) in the population older than 45 years in rural Western Honduras and contribute to the limited literature on MS in Central America.
Methods
Descriptive cross-sectional study conducted in the District of Copan. The study includes 382 men and women aged 45 to 75 years. With proper consent, anthropometric parameters, blood pressure, blood sugar, and lipid profile were evaluated. MS was diagnosed by using the National Cholesterol Education Program Criteria - Adult Panel Treatment III (NCEP-ATP III). Data were stored in REDCap (Research Electronic Data Capture) and analyzed with STATA14.
Results
Data were collected on 382 patients; of these, 38% were male and 62% female. The prevalence of obesity was 24.1% for both sexes. The prevalence of MS was 64.9%. Prevalence in males and females was 54% and 71%, respectively. Notable parameters were elevated triglycerides (71%), low High-density lipoprotein cholesterol (HDL-C) (63.4%), and abdominal obesity (56.8%). In men, the distribution of MS was more homogeneous, with a mean result of 80% amongst all ages.
Conclusions
The overall prevalence of obesity and MS is severely underestimated in rural Honduras. The most remarkable parameter for MS was high triglycerides (71%). Sixty-nine percent of the population has above-normal Body Mass Index (BMI). Public health efforts to control comorbidities and tackle risk factors in this population should take utmost priority.
Keywords: Metabolic Syndrome, Diabetes, Hypertension, Obesity, Public Health
Introduction
Cardiovascular diseases (CVDs) are the leading cause of global mortality and a significant contributor to a reduced quality of life.1,2 Approximately 80% of global CVD deaths occur in low-and middle-income countries (LMICs). These countries have a limited health care infrastructure, leading to an increase in CVD risk factors.3,4 Latinos/Hispanics are the largest minority in the United States since 2000 and are expected to grow by more than 273% by 2050.5 The Latino community faces many obstacles that can impact their health outcomes, starting with the barriers they face with the immigration process, access to the health care system, language barriers, and others.6–8 Understanding the root cause of and all risk factors that predispose to CVD can help providers identify better strategies to improve health outcomes within the Latino community.
Obesity has been identified as a major risk factor for CVD.9 The World Obesity Atlas estimates that by 2030, 1 of 5 women and 1 of 7 men will be living with obesity. Obesity is defined as an abnormal distribution of body fat with Body Mass Index (BMI) ≥30 kg/m2.10 In 2018, Hispanic women were 1.8 times more likely to be obese than American women.11 Abdominal (visceral) obesity is linked to metabolic syndrome (MS).12 Conversely, MS is the association between cardiac and metabolic risk factors predisposing to CVD and type 2 diabetes mellitus.13 It is estimated that one-fourth of the world population has MS.14 CARMELA, a Latin American population–based study that examined MS prevalence, reported that 22% of females and 20% of males between the ages of 25 and 64 years have MS.8,15 A cross-sectional population-based study in Central America showed that the prevalence of MS was 39.4% in females and 21.3% in males.16 Obesity and MS are the major cardiovascular risk factors for the Latino community, and currently, the United States and Latin American statistics have shown an increasing trend. The predicted impact of MS and obesity on CVD should not be underestimated. These negative effects include but are not limited to expedited progression of atherosclerosis, increased rates of ventricular remodeling, and increased risk of other associated diseases such as stroke, myocardial infarction, and heart failure.17 A longitudinal study reported that patients with MS have a 4-fold risk of diabetes when compared with the non-MS group.18 In terms of cardiovascular events, MS presence was associated with a 50% increase in the risk of developing coronary artery disease and stroke in men.18 In an 11-year follow-up study, it was observed that the risk increased nearly to 100% in women.18
Central Americans are the fastest-growing group among Hispanics in the United States and have not been studied properly. Honduras is a country located in Central America where CVD burden among regions of the Americas accounted for 241.1 CVD deaths per 100,000 after age standardization.19 Several studies have been conducted in Honduras to identify risk factors, but only a few have focused on MS independently. A study in a small, rural town in Central Honduras reported a prevalence of 65.8% in those older than 18 years.20 The literature on the Northern region of the Central America Four (CA-4) is scarce; this area represents the core of LMICs of Latin America. The CA-4 consists of Guatemala, Honduras, El Salvador, and Nicaragua, which share a common history, language, and socioeconomic development. We hypothesized that they also share common CVD risk factors. The CA-4 is a region of importance for the United States and Western Europe, as the immigrants from these countries represent a potentially significant burden to their health systems. This study aimed to calculate the prevalence of obesity and MS in adults in rural Western Honduras and contribute to the limited literature on CA-4 for MS.
Methods
A single-center cross-sectional study evaluating the prevalence of MS in the District of Copan was performed. An estimate of the total adult population by the INE (National Statistics Institute, in English) of the Copan district in 2018 was 68,016. The age group of 45-75 years represented the whole of the study with a population of 57,299. We hypothesized a difference between the proportion of men and women with an effect size of 0.1. To achieve a statistical power of 80%, the sample was calculated for a 95% CI, with a maximum error of 0.05, for a total sample size of 382. Patients were randomly recruited within the area. It should be noted that all patients selected met the study’s inclusion criteria.
Selection Criteria
Subjects who met the inclusion criteria were between 45 and 75 years of age, of both sexes, and living in the Copan district to attend the clinical appointment. We confirmed that they had not taken their antidiabetic medication within at least 8 hours of fasting. Exclusion criteria included a personal history of CVD, including myocardial infarction, cerebrovascular accident, or heart failure (New York Heart Association Class III, or IV); history of atrial fibrillation, cardiac catheterization, or ongoing cancer treatment; and pregnancy or significant medical or psychiatric conditions that could interfere with the patient’s ability to consent to participation in the study.
Variables
Demographic variables, past medical history, past family history, medication history, cardiovascular risk factors, blood pressure, anthropometric measures (waist circumference, height, weight, and BMI), and blood sampling data (fasting glucose, total cholesterol, high-density lipoprotein cholesterol [HDL-C], and low-density lipoprotein-cholesterol [LDL-C]) were acquired from every participant with prior informed consent.
Calculations of prevalence for each risk factor and MS diagnosis were established to fulfill the minimum criteria stated by the Harmonized Adult Panel Treatment III (International Diabetes Federation; American Heart Association/National Heart, Lung, and Blood Institute; Adult Panel Treatment III [ATP III]) guidelines.20,21 Abdominal obesity was defined as waist circumference ≥102 cm (men) or ≥88 cm (women); high triglycerides level was defined as ≥150 mg/dL or in treatment with specific lipid-lowering drugs; low HDL-C was defined as <40 mg/dL (men) or <50 mg/dL (women) or in a treatment with effect on HDL-C; high blood pressure was defined as systolic blood pressure ≥130 mm Hg and/or diastolic blood pressure ≥85 mm Hg; and impaired glucose regulation was defined as fasting blood sugar ≥100 mg/dL or in treatment with a blood sugar–lowering agent.22–24
Since MS increases the risk of developing type 2 diabetes, we considered evaluating it in our study.10 Therefore, we divided patients into nondiabetic and diabetic groups; participants without fasting plasma glucose values ≥7.0 mmol/L (126 mg/dL) and/or self-reported diabetes were considered in the nondiabetic group. Participants with fasting plasma glucose >6.11 mmol/L (110 mg/dL) or a previous diagnosis of diabetes mellitus represented the diabetic group.
Health care professionals performed data collection in the electronic data capture cloud-based REDCap (Research Electronic Data Capture). Data depuration and analysis were done in STATA 17 StataCorp 2021. Patient informed consent was obtained before all study procedures, and measurements followed all protocols by trained health professionals with REDCap.
Approval was granted by the local Western Honduras Hospital Institutional Review Board (Ethics Committee ID number IORG0009835 and approval number 3340HN201). All procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000. Informed consent was obtained from all participants included in the study.
Patients’ priorities, experiences, and preferences did not influence the study design. Patients were surveyed, and blood sampling data/anthropometric measures were taken with prior informed consent. They were involved in the recruitment and process of the study. The results were not disseminated to study participants. Patient advisers were not engaged in the contributorship statement/acknowledgments.
Results
Data were acquired for 382 subjects aged 45 to 75 years from the Copan district in Honduras; 38.0% (n=145) were men, and 62.0% (n=237) were women. The mean age was 57±7.9 years (mean ± SD). According to the ATP III harmonized criteria, 248 participants had MS or 64.9% (95% CI, 60.0%-59.6%). We found a higher prevalence in females than males: 71.7% vs 53.8%, respectively (95% CI, 65.5%-77.2%; 95% CI, 45.3%-62.1%). MS was more prevalent in the 55-64 age group in 37.5% (95% CI, 31.7%-43.7%) of all participants, and it was equally bimodal in the 45-54 and 55-64 age groups at 39.5% (95% CI, 32.2%-47.3%) in the participants with MS excluding diabetic individuals and subjects with plasma glucose ≥7.0 mmol/L (126 mg/dL). No statistically significant differences were observed between age groups (Table 1).
Table 1.
MS prevalence in participants with and without diabetes and according to NCEP ATP III by age
| Nondiabeticsa, % (95% CI) | Diabeticsb, % (95% CI) | |
|---|---|---|
| Overall | 42.4 (37.5-47.4) | 64.9 (60.0-69.6) |
| 45-54 y | 39.8 (32.4-47.5) | 55.3 (7.5-62.8) |
| 55-64 y | 47.8 (39.4-56.3) | 69.4 (61.0-76.) |
| >65 y | 39.1 (29.3-49.8) | 75.9 (65.7-83.8) |
N=382. Values are in % (95% CI). All participants, with or without diabetes mellitus, were grouped by the presence of specific characteristics, and the prevalence of MS within each group is reported here
MS, metabolic syndrome; NCEP ATP III, National Cholesterol Education Program Criteria - Adult Panel Treatment III
Participants without fasting plasma glucose ≥7.0 mmol/L (126 mg/dL) and/or self-reported diabetes
Participants with fasting plasma glucose >6.11 mmol/L (110 mg/dL) or previous diagnosis of diabetes mellitus
The most prevalent contributing criteria to MS were high triglyceride levels at 73.8% for males (95% CI, 65.9%-80.4%) and 69.6% (95% CI, 63.4%-75.2%) for females. The least prevalent contributing criterion for males was abdominal obesity at 35.2% (95% CI, 27.8%-43.4%), and in females, it was high blood pressure at 47.3% (95% CI, 40.9%-53.7%). Other criteria are listed in Table 2 among nondiabetic patients.
Table 2.
NCEP ATP III risk factor components prevalence in participants by sex with and without diabetes mellitus
| Nondiabetica |
Diabeticb |
|||
|---|---|---|---|---|
| Male, % (95% CI) | Female, % (95% CI) | Male, % (95% CI) | Female, % (95% CI) | |
| Abdominal obesityc | 26.2 (19.7-34.0) | 47.3 (40.9-53.7) | 35.2 (27.8-43.3) | 70.0 (63.9-75.6) |
| High triglyceridesd | 55.9 (47.6-63.8) | 46.8 (40.5-53.2) | 73.8 (66.0-80.3) | 69.5 (63.4-75.2) |
| Low HDL-Ce | 36.6 (29.1-44.7) | 48.1 (41.8-54.5) | 52.4 (44.2-60.5) | 70.0 (63.9-75.6) |
| High blood pressuref | 44.1 (36.2-52.3) | 29.9 (24.4-36.1) | 53.1 (44.9-61.1) | 47.3 (41.0-53.7) |
| Impaired glucose regulationg | 35.2 (27.8-43.3) | 24.5 (19.4-30.4) | 56.6 (48.3-64.4) | 49.8 (43.4-56.2) |
| Metabolic syndromeh | 35.9 (28.4-44.0) | 46.4 (40.1-52.8) | 53.8 (45.6-61.8) | 71.7 (65.6-77.1) |
N=382. Values are in % (95% CI)
NCEP ATP III, National Cholesterol Education Program Criteria - Adult Panel Treatment III; HDL-C, high-density lipoprotein cholesterol
Participants without fasting plasma glucose ≥7.0 mmol/L (126 mg/dL) and/or self-reported diabetes
Participants with fasting plasma glucose >7.0 mmol/L (126 mg/dL) or previous diagnosis of diabetes mellitus
Abdominal obesity defined as waist circumference ≥102 cm in men and ≥88 cm in women
High triglycerides at 150 mg/dL or in treatment with specific lipid-lowering drugs
Low HDL-C defined as <40 mg/dL in men and <50 mg/dL in women or a treatment with effect on HDL-C
High blood pressure defined as systolic blood pressure ≥130 mm Hg and/or diastolic blood pressure ≥85 mm Hg
Impaired glucose regulation defined as fasting blood sugar ≥100 mg/dL or in treatment with blood sugar–lowering agent
Diagnosed by the presence of 3 or more of the above risk factors
MS prevalence in males showed a significant decrease with increasing age, with a peak prevalence in subjects 45-54 years of age: 64.9% (95% CI, 60.0%-69.6%) for both sexes, 51.5% in males and 40% in females (Table 3). Males older than 65 years had a higher prevalence of MS than females of the same age category (42.4% vs 12.9%).
Table 3.
NCEP ATP III risk factor components prevalence of MS according to age and sex
| Age group | Abdominal obesitya, % (95% CI) | High triglyceridesb,% (95% CI) | Low HDL-Cc, % (95% CI) | High blood pressured, % (95% CI) | Impaired glucose regulatione, % (95% CI) | Meets criteria for MSf, % (95% CI) |
|---|---|---|---|---|---|---|
| Male | ||||||
| 45–54 | 31.8 (21.6–44.1) | 74.1 (61.5–83.7) | 22.6 (13.4–34.7) | 51.7 (39.1–64.0) | 48.2 (35.9–60.8) | 51.5 (39.4–63.4) |
| 55–64 | 41.3 (27.9–56.1) | 79.2 (66.3–88.1) | 22.6 (13.3–35.6) | 71.7 (58.3–82.1) | 56.6 (43.2–69.0) | 41.3 (27.9–56.1) |
| >65 | 33.3 (19.2–51.2) | 62.5 (45.2–77.1) | 21.8 (10.7–39.0) | 65.6 (48.2–79.6) | 68.7 (51.3–82.1) | 42.4 (26.7–59.9) |
| Female | ||||||
| 45–54 | 61.1 (50.8–70.4) | 70.3 (59.6–79.2) | 18.5 (11.4–28.4) | 37.0 (27.3–47.9) | 44.4 (34.1–55.2) | 40.0 (30.6–50.2) |
| 55–64 | 76.1 (66.0–83.9) | 63.7 (54.0–72.4) | 26.4 (18.8–35.8) | 60.7 (51.0–69.7) | 50 (40.4–59.5) | 25.0 (17.0–35.2) |
| >65 | 75.9 (62.6–85.6) | 79.6 (66.9–88.3) | 38.8 (27.0–52.2) | 88.8 (77.4–95.1) | 59.2 (45.9–71.3) | 12.9 (6.2–25.0) |
N=382. Values are in % (95% CI). All participants, with or without diabetes mellitus, were grouped by the presence of specific components, and the prevalence of MS within each group is reported here
NCEP ATP III, National Cholesterol Education Program Criteria - Adult Panel Treatment III; HDL-C, high-density lipoprotein cholesterol; MS, metabolic syndrome
Abdominal obesity is defined as waist circumference ≥102 cm in men and ≥88 cm in women
High triglycerides at 150 mg/dL or in treatment with specific lipid-lowering drugs
Low HDL-C defined as <40 mg/dL in men and <50 mg/dL in women or a treatment with effect on HDL-C
High blood pressure defined as systolic blood pressure ≥130 mm Hg and/or diastolic blood pressure ≥85 mm Hg
Impaired glucose regulation defined as fasting blood sugar ≥100 mg/dL or in treatment with blood sugar–lowering agent
Diagnosed by the presence of 3 or more of the above risk factors
Approximately 14.4% of males and 12.7% of females had 0 to 1 MS criteria, according to NCEP. The overall prevalence of the number of components in any possible combination is shown in Table 4.
Table 4.
Number of each possible combination of NCEP ATP III MS criteria by sex
| Number of components | Male, % (95% CI) | Female, % (95% CI) |
|---|---|---|
| 0 | 2.7 (1.0–7.1) | 3.8 (2.0–7.2) |
| 1 | 11.7 (7.4–18.1) | 8.9 (5.8–13.2) |
| 2 | 31.7 (24.6–39.8) | 15.6 (11.5–20.8) |
| 3 | 25.5 (19.0–33.3) | 33.8 (28.0–40.0) |
| 4 | 22.1 (16.0–29.6) | 24.5 (19.4–30.4) |
| 5 | 6.2 (3.2–11.5) | 13.5 (9.6–18.5) |
N=382. Values are in % (95% CI). For all participants, with or without diabetes mellitus, several possible combinations of NCEP ATP III risk factors criteria are grouped by sex. Number of components can be any possible combination of each of the 5 criteria
NCEP ATP III, National Cholesterol Education Program Criteria - Adult Panel Treatment III; MS, metabolic syndrome
Discussion
This study reports an overall higher prevalence of MS in Western Honduras by NCEP ATP III criteria than previously reported in the country or in Central America (65% and 42% when excluding known diabetic persons and subjects with fasting glucose in the diabetic range). A higher prevalence of MS in women has been reported in Latin American population studies, contrasting with developed countries.7,8,12 As expected, the incidence of MS was higher among women than men in our study.
LMICs are predicted to carry most of the burden of chronic disease by 2030.11 Understanding this population, its comorbidities, and risk factors through the evaluation of MS is paramount for establishing a baseline and for future resource allocation.
The CARMELA study was conducted a decade ago in other Latin American cities.7 The CARMELA study reported a pooled prevalence of MS ranging from 14% in Quito, Ecuador, to 27% in Mexico City, which was lower than the prevalence in our study population (64.9%). Another study conducted in 5 different countries of Central America showed a prevalence of MS of 30.3%.16 The predominance of individual components of MS was also assessed in these studies, with a significant difference between the main contributing NCEP ATP III criteria. An evident discrepancy in the prevalence of these comorbidities is the presence of low HDL-C and high triglycerides, which are the least prevalent in the CARMELA study7 but the most prevailing in our region and in the study conducted in 5 different countries in Central America.16
The differences between studies may be due to different sample sizes and age ranges. Similarly, it is interesting that the proportion of obesity in males and females is inverted in our population when compared to the frequencies reported in CARMELA (our study: 70% and 35% vs CARMELA: 49% and 64% for females and males, respectively).7 The proportion of obesity was similar in our study compared to the study conducted in 5 different countries in Central America, showing a higher prevalence in women than in men.16 However, obesity must not be underestimated, as 80% of the global increase in obesity during the last 30 years has been in rural areas.13
Regarding Latin America’s prevalence of MS, a meta-analysis by Márquez-Sandoval and colleagues pooled a combined weighted prevalence of MS of 25% (range, 18.8%-43.3%).24 Moreover, studies conducted in Puerto Rico reported a prevalence for MS of 43.3% and 31%.25,26 Single studies in South America reported a similar prevalence; for Chile, Venezuela, and Peru, 35.5%, 35.3%, and 18%, respectively.27–29 Other studies in Mexico reported a pooled prevalence of approximately 27%.30
MS studies in the Central American region are scarce. In the past 5 years, the most extensive study yielded a pooled prevalence of 30.3%, lower than this study (42%).8 The possible explanations for the higher prevalence reported in this study include the accelerated development in the area, the effects of westernization, and the difference in lifestyle and customs in this area compared to others in Honduras.
A previous study was conducted in a rural population in Honduras; it reported a prevalence of 66% with a significantly higher proportion of women as described in other Latino population studies, and very similar to our findings.12 However, most MS studies in Latino populations have shown a higher prevalence in females than males.7,8 Our study supports these data. Public health efforts to control comorbidities and tackle cardiovascular risk factors should take utmost priority in this population. Its high prevalence raises concern and follows the sustained increasing trend of these factors in the Americas.31
Limited data are available from Central American countries. Understanding local epidemiology and the accurate assessment of potentially modifiable risk factors will guide the decision-making process in education and public health policies.32
Overall, there is a dramatically high prevalence of cardiometabolic risk factors among subjects in Western Honduras, raising epidemiologic concerns. Previous studies in the same area reported obesity in up to 24% of the population and significantly high cardiovascular risk scores.22,33
Limitations
One of the limitations of our study is its generalizability to the Honduran population. This was a cross-sectional study with a sample size encompassing a particular country area despite being statistically significant for this population. Therefore, more extensive, nationwide studies would be necessary to better understand the prevalence of MS and CVD in Honduras. Efforts are being made to follow up on these patients and determine mortality and cardiovascular outcomes over time. However, limitations to performing prospective cohort studies in resource-limited settings are well known. This research provides us with a cornerstone for future developments in cardiovascular research in Central America with a view to the relationship between the CA-4, North America, and Europe owing to the surge of immigration from this region and its consequent burden on their health care systems.
Conclusions
These results provide insights into MS and its burden in Honduras. A more extensive and more representative cohort study with successful follow-up to determine the correlation between the prevalence of MS and cardiovascular outcomes is deemed necessary. This data provide valuable information for developing targeted interventions in public health policy to alleviate the growing epidemic of CVD.
Further epidemiologic data are warranted to fill the data gap on the prevalence of MS in the CA-4 countries, its economic burden, and its impact on mortality and cardiovascular outcomes.
Acknowledgments
The authors would like to acknowledge Mrs Mirian Ramirez-Rojas, Ruth Lilly Medical Library, Indiana University School of Medicine, for her support and literature review of this manuscript.
Footnotes
Conflict of Interest: No conflicts of interest reported by authors.
Author Contributions: Design and concept of study: Rodriguez-Murillo, K Torres, Montalvan-Sanchez, Norwood; Acquisition of data: Montalvan-Sanchez, Rodriguez-Murillo, Jerez-Moreno, Reyes-Guerra, Montalvan-Sanchez; Data analysis and interpretation: Carrasco-Stoval, Beas, Izquierdo-Veraza, T Torres; Manuscript draft: Montalvan-Sanchez, Izquierdo-Veraza, Beas, T Torres, Norwood; Statistical expertise: Norwood, Carrasco-Stoval; Acquisition of funding: K Torres; Administrative support: Carrera, Soriano Turcios, Giron, T Torres, Montalvan-Sanchez, Beran; Supervision: Carrera, K Torres, Soriano Turcios, Giron, Beran. All authors provided a critical review of the manuscript and approved the final manuscript.
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