Prevalence and determinants of metabolic syndrome among patients with type 1 diabetes mellitus attending the Diabetes Center of King Khalid University Hospital, Riyadh, Saudi Arabia

doi:10.21203/rs.3.rs-2216110/v1

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Prevalence and determinants of metabolic syndrome among patients with type 1 diabetes mellitus attending the Diabetes Center of King Khalid University Hospital, Riyadh, Saudi Arabia

https://doi.org/10.21203/rs.3.rs-2216110/v1

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Background: Metabolic syndrome is an important precursor of microangiopathic and macroangiopathic complications among patients with diabetes mellitus (DM). It is more commonly associated with type 2 DM than with type 1 DM. This study aimed to determine the prevalence and determinants of metabolic syndrome in patients with type 1 DM.

Methods: This cross-sectional study included 250 patients aged over 18 years with type 1 DM with a duration of more than 6 months treated in 2022 at the Diabetes Center of King Khalid University Hospital, Riyadh, Saudi Arabia. Metabolic syndrome was detected using the modified criteria proposed by the National Cholesterol Education Program–Adult Treatment Panel III.

Results: Approximately 30.4% (95% confidence interval [CI] = 25.0%–36.0%) of the patients with type 1 DM had metabolic syndrome. The following factors were significantly and independently associated with metabolic syndrome: abdominal obesity (odds ratio [OR] = 12.25; 95% CI = 5.9–15.27), low high-density lipoprotein cholesterol level (OR = 9.56; 95% CI = 3.98–18.68), high triglyceride level (OR = 5.74; 95% CI = 2.54–10.89), high blood pressure (OR = 4.49; 95% CI = 2.27–8.76), and poor blood glucose control based on the HbA1c level (OR = 4.38; 95% CI = 2.13–8.88). In addition, there was a direct relationship between metabolic syndrome and microangiopathic complications.

Conclusion: Metabolic syndrome is common in patients with type 1 DM and is associated with microangiopathic complications.

Diabetes mellitus

Microangiopathic complications

Metabolic syndrome

Diabetes mellitus (DM) is a growing health problem despite substantial advances in DM research and inpatient care. Morbidity and premature death resulting from the long-term complications of DM cause considerable burden on patients and the health care system (1). DM is one of the most prevalent diseases in both developed and developing countries and is recognized as a particular health threat among adults from third-world communities, particularly those living in rapidly developing countries (2). In 1997, the World Health Organization reported that more than 143 million patients were affected with DM; this number is expected to increase to 300 million by 2025 (3).

Type 1 DM is one of the most common diseases of an autoimmune cause among children (4). Insulin therapy decreases the development of microvascular and macrovascular complications of DM (5) but promotes weight gain and obesity, precipitating cardiovascular diseases (6, 7). Metabolic syndrome (MS) is a group of cardiovascular risk factors such as abdominal obesity, insulin resistance, abnormal lipid profile, and hypertension. It is associated with an increased prevalence of atherosclerosis among children with type 1 DM (8). MS increases the mortality rate of children with type 1 DM fourfold to eightfold compared with that of age-matched children without DM (9).

Studies conducted in Norway, Germany, Poland, and the Netherlands assessed the prevalence of MS among children with type 1 DM (5, 10, 11). They found that 13–28% of these children had MS (5, 10, 11). Since the recognition of MS by Reaven in 1988 (12), several studies have confirmed its association with cardiovascular disease and death (13–16).

MS has been diagnosed in 58.4% of patients with type 2 DM and 50.4% of those with impaired fasting glucose (17). Most studies have evaluated patients with type 2 DM or impaired fasting glucose, while insufficient data are available for patients with type 1 DM. This reflects the importance of this study that aimed to evaluate the prevalence and determinants of MS among patients with type 1 DM attending the Diabetes Center of King Khalid University Hospital in Riyadh.

Study design and setting

This cross-sectional study was conducted at the outpatient clinic of the Diabetes Center, King Khalid University Hospital, Riyadh, Saudi Arabia from September 2020 to September 2022.

Study population

The target population was patients with type 1 DM attending the Diabetes Center of King Khalid University Hospital. In particular, the inclusion criteria were age of ≥ 18 years and diagnosis of type 1 DM, while the exclusion criteria were age of ≤ 18 years, diagnosis of type 2 DM, and refusal to participate. A systematic random sampling technique was used for the study population.

Inclusion Criteria:

Adult patients aged 18 years old or above with type 1 diabetes mellitus
Type 1 DM duration of more than 6 months

Exclusion Criteria:

Adult patients aged less than18 years old
Patients with type 2 diabetes mellitus.
Patients refused to participate.

Sampling approach:

Systematic random sampling techniques was used

Data collection

Data were collected using a self-administered standard questionnaire. This questionnaire was divided into the following parts: part 1: socio-demographic and epidemiological characteristics of the patients; part 2: DM-related items and other comorbidities; and part 3: measurements related to the MS diagnostic criteria.

To ensure the reliability of our study tool, we conducted a pilot study involving 30 patients not included in the study sample to assess the internal consistency reliability. Cronbach coefficient alpha was used to estimate the internal consistency reliability coefficients for the initial and retest tool administrations. We found that the mean Cronbach alpha for both initial and retest tool administrations exceeded 0.80. Moreover, test–retest reliability was assessed: Pearson product-moment correlations were computed between the initial and retest administrations to assess the test–retest reliability over a 2-week interval. The correlation coefficients (r) were > 0.72 (𝑃 < 0.01).

Data analysis

Data were analyzed using the Statistical Package for the Social Sciences version 23 for Windows. Descriptive statistics were calculated in the form of frequencies, counts, percentages, means, and SDs. A t test, ANOVA (for normally distributed parametric variables), and the chi-square test (for categorical variables) were used to evaluate data significance. A P value of < 0.5 was considered an indicator of significance. Logistic regression was used to compute univariate and multivariate odds ratios (ORs) to evaluate the association between MS and other variables.

Table 1

General characteristics of the patients
Characteristics	n	%
Sex
Male	118	47.2
Female	132	52.8
Age (year)	Mean ± SD = 28.9 ± 4.8
Residence
Urban	202	80.8
Rural	48	19.2
Parents’ marital status
Married	96	78.4
Divorced	36	14.4
Widowed	18	7.2
Father’s education
Illiterate	35	14.0
Intermediate	90	36.0
University or higher	125	50.0
Mother’s education
Illiterate	47	18.8
Intermediate	131	52.4
University or higher	72	28.8
Family type
Small	144	57.6
Large	88	35.2
Compound	18	7.2

A total of 250 patients with type 1 DM participated in the survey, and the response rate was 100.0%. Among the participants, 47.2% were men, while 52.8% were women. The mean ± SD age of the participants was 28.9 ± 4.8 years. Approximately 80.8% lived in urban areas, while only 19.2% lived in rural areas. Of the participants’ parents, 78.4% were married; 14.4%, divorced; and 7.2%, widowed. Approximately 14.0% of the participants’ fathers were illiterate, while 50.0% had intermediate education; 52.4% of the participants’ mothers had intermediate education, while 28.8% had university education or higher. Among the participants, 57.6% had small families, while 7.2% had compound families (Table 1).

Table 2

Diabetes mellitus-related characteristics of the patients
Characteristics	n	%
History of diabetogenic drug intake
No	196	78.4
Replacement hormones	30	12.0
Diuretics	18	7.2
Others	6	2.4
History of high carbohydrate intake
No	90	36.0
Yes	160	64.0
Duration of diabetes mellitus (year)	Mean ± SD = 13.7 ± 4.4
Control of blood glucose
Controlled	107	42.8
Uncontrolled	143	57.2
Complications of diabetes mellitus
Absent	178	71.2
Present	72	28.8

Table 2 shows that 78.4% of the respondents had no history of diabetogenic drug intake; 12.0% had a history of hormonal intake; and 7.2% had a history of diuretic drug intake. Approximately 64.0% had a history of excessive carbohydrate intake. The mean duration of DM among the patients was 13.7 ± 4.4 years. Of them, 57.2% had uncontrolled DM, while 28.8% had DM complications.

Table 3

Prevalence of metabolic syndrome among the patients
Metabolic syndrome	n	%	95% CI
Positive	76	30.4	0.25–0.36
Negative	174	69.6	0.64–0.75
Total	250	100.0

The prevalence of MS among the patients was 30.4% (95% confidence interval [CI] = 0.25–036), as shown in Table 3.

Table 4

Distribution of the patients with and without metabolic syndrome according to their demographic and clinical characteristics
Characteristics	With metabolic syndrome (n = 76)	Without metabolic syndrome (n = 174)	P value
Sex Male Female	36 (30.5%) 40 (30.3%)	82 (69.5%) 92 (69.7%)	0.972
Age (year)	30.4 ± 5.6	27.8 ± 4.3	< 0.0001
Diabetes mellitus duration (year)	15.9 ± 4.9	13.2 ± 4.5	< 0.0001
BMI (kg/m²)	26.7 ± 0.6	24.2 ± 0.3	< 0.0001
Waist circumference (cm) Men Women	105.3 ± 1.7 93.9 ± 1.9	99.8 ± 1.2 86.1 ± 1.5	< 0.0001 < 0.0001
HbA1c level	8.9 ± 0.1	7.4 ± 0.1	< 0.0001
Systolic blood pressure (mmHg)	140 ± 1.0	125 ± 1.0	< 0.0001
Diastolic blood pressure (mmHg)	84.0 ± 1.0	78 ± 1.0	< 0.0001
Total cholesterol level (mmol/L)	5.24 ± 0.04	4.81 ± 0.02	< 0.0001
HDL cholesterol level (mmol/L)	1.10 ± 0.01	1.44 ± 0.01	< 0.0001
Triglyceride level (mmol/L)	1.72 ± 0.03	0.98 ± 0.01	< 0.0001

Table 4 shows the distribution of the patients with and without MS according to their demographic and clinical characteristics. The prevalence of MS was 30.5% and 30.3% among the men and women, respectively (P > 0.05). The mean age of the patients with MS (30.4 ± 5.6 years) was higher than that of those without MS (27.8 ± 4.3 years) (P < 0.05). The mean duration of DM was longer among the patients with MS (15.9 ± 4.9 years) than among those without MS (13.2 ± 4.5 years) (P < 0.05).

The mean body mass index among the patients with MS (26.7 ± 0.6 kg/m²) was higher than that among those without MS (24.2 ± 0.3 kg/m²) (P < 0.05). In addition, the mean HbA1c level, systolic blood pressure, diastolic blood pressure, total cholesterol level, high-density lipoprotein (HDL) cholesterol level, and triglyceride level significantly differed between the patients with and without MS.

In accordance with the diagnostic criteria for MS, all patients (with and without MS) had hyperglycemia. Of the patients with MS, 60%, 47%, 40%, and 20% had a low HDL cholesterol level, hypertension, abdominal obesity, and a high triglyceride level, respectively (Fig. 1).

Table 5

Association of chronic complications with MS
Chronic complications	With MS	Without MS	P value
Retinopathy, %	32.7	2.4	< 0.001
Neuropathy, %	25.2	5.3	< 0.001
Nephropathy, % Microalbuminuria Macroalbuminuria	14.9 19.6	1.2 0	< 0.001 < 0.001

MS, metabolic syndrome

Table 5 displays the DM complications. The patients with type 1 DM and MS had a significantly higher prevalence of microangiopathic complications (i.e., retinopathy, neuropathy, and nephropathy) than those without MS. The prevalence of retinopathy, neuropathy, microalbuminuria, and macroalbuminuria was 32.7%, 25.2%, 14.9%, and 19.6%, respectively, in the patients with MS.

Table 6

Multivariate multinomial regression analysis of the determinants (criteria) of metabolic syndrome
Determinants	OR	95% CI	P value
Abdominal obesity	12.25	5.94–15.27	< 0.001
Low HDL cholesterol level	9.56	3.98–18.68	< 0.001
High TG level	5.74	2.54–10.89	< 0.001
High blood pressure	4.49	2.27–8.76	< 0.001
Hyperglycemia	4.38	2.13–8.88	< 0.001
High total cholesterol level	2.18	1.08–4.38	0.038

HDL, high-density lipoprotein; TG, triglyceride; OR, odds ratio; CI, confidence interval

In the multivariate multinomial regression analysis of the determinants of MS (Table 6), the following factors were found as the predictors of MS arranged according to their OR: abdominal obesity (OR = 12.25), low HDL cholesterol level (OR = 9.56), high triglyceride level (OR = 5.74), high blood pressure (OR = 4.49), hyperglycemia (OR = 4.38), and high total cholesterol level (OR = 2.18).

This study investigated the prevalence and determinants of MS among patients with type 1 DM attending the Diabetes Center of King Khalid University Hospital. Herein, we found that the prevalence of MS in the patients with type 1 DM was 30.4% (30.5% in men and 30.3% in women). Previous studies have found a prevalence of MS among Americans with type 1 DM ranging from 8–21%, depending on the MS diagnostic criteria used (18). In Europe, the prevalence of MS was 39% in accordance with the National Cholesterol Education Program–Adult Treatment Panel III criteria (19). Similar data—a prevalence of MS of 40.8%—were obtained in Mediterranean regions using the same criteria (20).

In the present study, the most frequently observed component of MS (independently of hyperglycemia, which was present in all participants) was a low HDL cholesterol level, found in 60% and 20% of the participants with and without MS, respectively. This finding agrees with reports in Spain that patients with type 1 DM and MS had low HDL cholesterol levels (< 35 mg/dL in men and < 45 mg/dL in women) (21). Approximately 47% and 20% of our participants with and without MS had hypertension, respectively, while 40% and 12% had abdominal obesity. These findings disagree with previous reports that out of three patients with type 1 DM and MS, two had abdominal obesity (21, 22). The disagreement could be attributed to the different study designs utilized. Meanwhile, the least frequently observed component in the current study was a high triglyceride level, found in 20% and 6% of the patients with and without MS, respectively.

The proportion of patients with microangiopathic complications was higher among those with MS than among those without. This confirms the findings of other European series, in which the prevalence of MS reached 62% in patients with macroalbuminuria, with an OR of 3.75 (95% CI = 2.89–4.85) for diabetic nephropathy in the presence of MS (19). In the present study, the prevalence of retinopathy, neuropathy, microalbuminuria, and macroalbuminuria was 32.7%, 25.2%, 14.9%, and 19.6%, respectively, among the patients with MS. These data agree with previous reports in Spain that the prevalence of MS was 37.9%, 27.6%, 13.8%, 17.2%, 3.4%, and 6.9% in patients with retinopathy, neuropathy, microalbuminuria, macroalbuminuria, cerebrovascular stroke, and peripheral vascular disorder, respectively (21).

Larger-scale studies with a long-term follow-up have found a relationship between MS and macroangiopathy (23–25); this association was not found herein. This might be attributed to the small sample size, mean age, relatively good metabolic control, and short mean duration of DM in our study.

Our multiple logistic regression analysis showed that the most influential determinant of MS was abdominal obesity, followed by a low HDL cholesterol level, high triglyceride level, high blood pressure, poor blood glucose control (based on the HbA1c level), and high total cholesterol level. Other studies found that metabolic control either had the greatest influence on the development of MS (21) or had no influence at all (26). The difference in these findings may be attributed to the varying study designs or sample sizes used.

The limitations of this study are derived from its cross-sectional design. Thus, the possible variations in the studied variables over time and the findings only refer to associations and do not suggest causality.

MS is common in patients with type 1 DM, particularly in those with a high body mass index, a low HDL cholesterol level, hypertension, and poor metabolic control. This syndrome is associated with microvascular complications of type 1 DM.

Ethics approval and consent to participate

Ethical consideration

The study instruments and protocols were approved from the IRB committee of King Saud University (IRB number: 22/0307/IRB). All methods were carried out in accordance with relevant guidelines and regulations. Informed consent was obtained from all participants included in the study. All collected data kept confidential and used only for the purpose of research.

Consent for publication

Not Applicable

Availability of data and materials

The data is available and will be provided by the corresponding author upon a reasonable request.

Competing interests

The authors declared no conflict of interest.

Funding

This research received no external funding.

Authors’ contribution

All authors conceived and designed the study. All authors contributed to collecting and analyzing the data and writing the manuscript and its revision. All authors approved the final version of the manuscript and agreed to be held accountable for the content therein.

The authors gratefully acknowledge Zainab Ibrahim Ali, Rawah Saleh Jaafar, Lujain Eid Omran, and Shahd Mohamed Elrayah. They are medical interns at King Khalid university hospital-Riyadh, for their role in data collection.

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No competing interests reported.

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Prevalence and determinants of metabolic syndrome among patients with type 1 diabetes mellitus attending the Diabetes Center of King Khalid University Hospital, Riyadh, Saudi Arabia

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Version 1

Abstract

Figures

Introduction

Materials And Methods

Study design and setting

Study population

Inclusion Criteria:

Exclusion Criteria:

Sampling approach:

Data collection

Data analysis

Results

MS, metabolic syndrome

HDL, high-density lipoprotein; TG, triglyceride; OR, odds ratio; CI, confidence interval

Discussion

Limitations

Conclusion

Declarations

References

Additional Declarations

Status:

Version 1