Predictive value of body mass index to metabolic syndrome risk factors in Syrian adolescents

The mean values (mean ± SD, maximum and minimum) of the MetS components of the 2064 participants and the range of the BMI are illustrated in Table 1. As shown in Table 1, mean serum concentrations of glucose, TG, total Chol, LDL-Chol, TG/HDL-Chol and HDL-Chol were within the normal limits. These values were as follows: BMI (23.14 kg/m²), SBP (123.43 mmHg), DBP (74.40 mmHg), FBS (89.49 mg/100 ml), TG (91.84 mg/100 ml), total Chol (136.36 mg/100 ml), HDL-Chol (57.11 mg/100 ml), LDL-Chol (62.04 mg/100 ml), and TG/HDL-Chol (1.61).

Of the 2064 participants, the following had values within the normal range: 1670 (81%) had SBP (90 to 135 mmHg), 1440 (70%) had DBP (60 to 89 mmHg), 2039 (99%) had FBS (65 to 110 mg/dl), 1981 (96%) had Chol (50 to 200 mg/dl), 1989 (96%) had TG (25 to 200 mg/dl), 2034 (99%) had HDL-Chol (40 to 75 mg/dl), 2064 (100%) had LDL-Chol (less than 155 mg/dl), 1950 (95%) had TG/HDL-Chol (less than 3). These results are shown in Table 2.

Blood pressure and biomedical markers values increased significantly (p < 0.05) with increasing BMI value. Regarding the measurements of BMI, the obese group (BMI >30 kg/m²) had higher values of SBP (127.3 mmHg), DBP (77.7 mmHg), FBS (91.6 mg/100 ml), TG (125.1 mg/100 ml), Chol (153.6 mg/100 ml), LDL-Chol (71.9 mg/100 ml), and TG/HDL-Chol (2.22) compared to participants who were not obese (20 < BMI <25 kg/m²). However, no significant differences were observed for HDL-Chol between the analyzed groups (Table 3).

ROC curve analysis of the BMI was performed for blood pressure (SBP and DBP) and other lipid biomarkers like FBS, TG, Chol, HDL-Chol, LDL-Chol, and TG/HDL-Chol (Table 4). Area under the ROC curve was the highest for LDL-Chol (0.69%). The BMI cut-off point for LDL-Chol for optimal sensitivity and specificity was (24.35 kg/m²) with sensitivity at 60% and specificity at 72%. Comparable ROC curves of other biomarkers were obtained: DBP (AUC 0.59 of optimal cut-off point 23.45 kg/m²), TG (AUC 0.67 of optimal cut-off point 23.25 kg/m²), Chol (AUC 0.67 of optimal cut-off point 23.75 kg/m²), and TG/HDL-Chol (AUC 0.66 of optimal cut-off point 23.45 kg/m²). AUC ranged between 0.44 and 0.81 and was statically significant for DBP, TG, Chol, LDL-Chol, and TG/HDL-Chol (Table 4).

The prevalence of overweight and obesity is increasing rapidly in young populations worldwide, especially in developing countries. Childhood obesity is a major health issue. According to the International Obesity Task Force (IOTF), at least 500 million school children aged 5 to 17 years are overweight or obese. Many studies have reported an association between childhood obesity and the development of a cluster of cardiometabolic disease risk factors [16‐19]. This cluster, which has been termed MetS, is associated with the development of diabetes and CVD in both childhood and adulthood; CVD is the leading cause of morality worldwide. In addition, MetS was associated with arterial stiffness, which was a cardiovascular outcome of MetS [3, 20]. Results reported recently indicated that the percentage of individuals who presented MetS risk factors almost doubled over a 10-year period [21]. Therefore, it is very important to develop an effective screening tool of MetS and its individual components, and analyze their association with overweight and obesity. To the best of our knowledge, this is the first study addressing the association of BMI and the components of MetS among Syrian adolescents aged 18 to 19 years.

In this study, a strong association between obesity as defined by BMI and the risk of higher concentrations of blood pressure, FBS, total Chol, TG, HDL-Chol, and TG/HDL in Syrian adolescents has been demonstrated. These findings demonstrate the risk of obesity at these early ages, with changes in the MetS components. Among the metabolic components, mean SBP (123.4 ± 14.55) was elevated in 19% of the whole group. Also, mean DBP (74.4 ± 10.72) was elevated in 12.7%. Increased FBS, TG, Chol, and TG/HDL were present in 1.2%, 2.8%, 3.6%, and 5.5% of those investigated. Their blood pressure, both systolic and diastolic, was the most prevalent of the metabolic risk factors, followed by total Chol and TG. There was a significant increase in blood pressure in the overweight group as compared to the normal group and a significant increase in blood pressure in the obese adolescent group compared to the overweight group (p <0.0001). Similar trends were observed for FBS, TG, total Chol, LDL-Chol, and TG/HDL-Chol. We also observed that the metabolic abnormalities were more significant and frequent in individuals with higher BMI values, especially in obese adolescents compared to those considered to have normal weight or overweight. Obese adolescents had higher abdominal fat, which is associated with cardiometabolic alterations such as LDL-Chol, increased triglycerides and LDL-Chol, and increased blood pressure, resulting in increased risk for CVD [22].

Several studies have demonstrated that overweight and obesity in childhood are risk factors for coronary disease and MetS in adulthood. In addition, hyperinsulinemia and hypertension are well-known risk factors for coronary heart disease. Our results show that these risk factors are present in a significant number of Syrian adolescents, mainly in those who are obese. Our data showed that overweight and obesity were associated with increased values in the components of MetS. These results are in agreement with the data of other studies investigating a similar association between the components of MetS and obesity [23‐27].

Anthropometric measurements are crucial for MetS diagnosis. In addition, measurements of serum lipid fractions, fasting glucose values, and blood pressure in overweight and obese individuals are also important [28].

In this study, BMI was used to screen for the presence of MetS. Other studies concluded that BMI can predict the presence of multiple metabolic risk factors [29]. However, some studies found that a high body fat percentage was associated with increased cardiovascular risk regardless of BMI whose categorization resulted in an underestimation of the number of participants with cardiovascular risk factors [30, 31].

CVD is the most common cause of death in the world. The identification of individuals at increased CVD risk represents a priority [32]. Among the metabolic components, mean SBP (123.4 ± 14.55) was elevated in 19% of the whole group. Also, mean DBP (74.4 ± 10.72) was elevated in 12.7%. Increased FBS, TG, Chol, and TG/HDL-Chol were present in 1.2%, 2.8%, 3.6%, and 5.5% of those investigated. Data from the present study suggested that populations who have high BMI, high SBP and DBP, and high levels of serum FBS, TG, Chol, LDL-Chol, and TG/HDL-Chol are more likely to experience a cardiovascular effect. In fact, LDL-Chol, which is closely related to CVD and mortality, remains the cornerstone of lipid management [33]. Epidemiological and clinical studies have consistently demonstrated that increased LDL-Chol is a major atherogenic lipoprotein for developing CVD and is currently recommended as the primary target for lipid-lowering therapy for the prevention and treatment of CVD [32, 34]. In some other studies, a significant relationship was found between cardiorespiratory fitness, BMI, and LDL-Chol [35]. Epidemiological investigations revealed that the occurrence of CVD in the obese population was 2.0 to 2.5 times that in people with a normal BMI [36]. The risk of hypertension is up to five times higher among obese people in comparison to normal weight individuals, and cross-sectional population surveys suggest that more than 85% of hypertension arises in individuals with BMI values above 25 kg/m² [24]. Our findings were in line with reports from many previous studies; Chen et al. [25], Mokdad et al. [26], and Wilson et al. [27] demonstrated that an increased risk of obesity-related morbidities was accompanied by an increase in BMI. Among the indicators used to predict the presence of MetS, TG, Chol, LDL-Chol, and TG/HDL-Chol showed a large area under the ROC curve, but LDL-Chol was the index that showed the greatest area under the ROC curve, which was similar to other studies [3, 32]. Based on the sensitivity, specificity, and ROC calculation, we found that BMI had a good accuracy for identifying adolescents with some metabolic risk factors including DBP, TG, Chol, LDL-Chol, and TG/HDL-Chol; these data suggest the best BMI cut-offs ranged between 23.25 and 24.35 kg/m². Our cut-off values of BMI were lower than the current definitions of overweight (BMI >25) recommended by WHO [1, 13]. These figures are in agreement with data from Asian populations [6], but lower than Western populations in USA and Europe [5]. On the other hand, our findings differ from those found in the Iraqi population (in men) [37]; they found that the best BMI cut-offs ranged between 24.9 and 25.4.

However, many studies have shown that CVDs occur more frequently at lower BMI in Asian than European populations, the mechanisms involved are yet to be demonstrated. Ethnic and racial differences in body composition and fat distribution have been studied. Although these studies have shown increasing BMI associated with larger increase in body fat content in Asians, growing evidence points to factors other than body fat content and fat distribution in determining higher prevalence of CVDs in these populations [38]. In a study on young adult Mauritians, the authors pointed out that the use of BMI cut-off values for classifying overweight and obesity should take into account both ethnicity and gender to avoid gross adiposity status misclassification in this population known to be at high risk for CVDs [39].

This study, however, brings an important epidemiological contribution to Syria, revealing important results, especially due to the lack of studies that evaluate the frequency of cardiovascular risk factors among Syrian adolescents and the value of BMI in predicting the components of MetS. Our findings support the notion of a relevant association between obesity at these early ages and the development of alterations in the components of MetS. Therefore, the planning and implementation of primary prevention programs by health care professionals to reduce potential cardiovascular risk factors is a priority. By such programs CVD risk factors can be reduced. Even small reductions in body weight are able to correct abnormalities in the components of MetS, such as hyperglycemia, hyperinsulinemia, and dyslipidemias. Interventions aimed at increasing physical activity and improving diet are cost effective for reducing the risk of diabetes and CVDs associated with obesity.

In conclusion, a strong association between overweight and obesity as determined by BMI and high concentrations of MetS components has been demonstrated in overweight and obese Syrian adolescents. BMI categories of >23.45 kg/m², >23.25 kg/m², >23.75 kg/m², >24.35 kg/m², and >23.45 kg/m² were found to be positively associated with MetS components of DBP, TG, Chol, LDL-Chol, and TG/HDL-Chol, respectively. These findings demonstrate the high risk of obesity at an early age through abnormal changes in MetS components.