Comparison of metabolic risk factors, lipid indices, healthy eating index and physical activity among premenopausal, menopausal, and Postmenopausal women

doi:10.21203/rs.3.rs-2850571/v1

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Comparison of metabolic risk factors, lipid indices, healthy eating index and physical activity among premenopausal, menopausal, and Postmenopausal women

https://doi.org/10.21203/rs.3.rs-2850571/v1

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published 27 Mar, 2024

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Introduction:

The prevalence of cardiovascular diseases increases with age in women, especially at menopause. Metabolic syndrome is one of the important factors that cause heart disease. Therefore, the importance screening of people at risk of this syndrome, especially with cheap tests, led to the introduction of new cardio metabolic indicators such as AIP, TyG and WWI. Also, due to the importance of healthy eating and physical activity in preventing metabolic syndrome, more emphasis should be placed on their use.

Methods

In this cross-sectional study, the number of 4732 women participating in the Hoveyzeh cohort study, after considering the entry and exit criteria, were placed into three groups: pre-menopausal (n = 736), menopausal (n = 396) and post-menopausal (n = 917).

Results

The prevalence of metabolic syndrome was 43.3%, 55.6%, and 62.8% in pre menopause, menopause, and post menopause, respectively. The prevalence of hypertension (50.2%), dyslipidemia (61.2%), diabetes (37.7%) and abdominal obesity according to the Iranian definition (75.9%) was higher after menopause than before menopause. Cardiovascular disease had the highest prevalence after menopause (23%). The WWI index had the highest OR among the indices with a value of 2.94 and 1.93 in menopause and after menopause, respectively. (P < 0.001). In the HEI-2015 survey, the consumption of total fruit, vegetables, seafood and protein in premenopausal women was more than after menopause, and the consumption of foods containing sugar in menopause was more than in premenopausal women. The amount of physical activity had the highest and lowest values in pre menopause and post-menopause, respectively. (P < 0.001)

Conclusion

Menopause leads to an increase in the prevalence of metabolic syndrome. The indices of AIP, TyG index, WWI and physical activity increase in women after menopause compared to before menopause. TyG-INDEX ،WWI ،HEI-2015 healthy eating index in this study did not show significant differences between groups after multi-regression analysis.

Healthy Eating Index

Atherogenic Index plasma

Metabolic Syndrome

Menopause

Metabolic syndrome is defined according to the ATPIII criteria as the presence of three of the following five cases: abdominal obesity, i.e. waist circumference greater than or equal to 88 cm in women or ≥ 102 cm in men, TG ≥ 150, or use of triglyceride-lowering drugs and HDL < 50 in women, and HDL < 40 in men, blood pressure greater than or equal to 130/85 or drug treatment to control blood pressure, FPG ≥ 100 or drug treatment to treat high blood sugar is defined. [1] Metabolic syndrome increases the risk of cardiovascular diseases and cancer, which are two causes. It is important for mortality among women [2], and according to various studies, the prevalence of this syndrome increases with age and menopause.[3]

Menopause is defined as the cessation of menstruation for twelve consecutive months, and history is the most reliable method for determining menopause status in women. [4] Before menopause, cardiovascular events are rare in the absence of other cardiac risk factors, but after menopause, these events are more common than in men, the mechanism of which is not yet known correctly, due to the increase in the prevalence of metabolic syndrome in menopause, it can be a part of this increase in events. [5] In a number of studies comparing pre-menopausal and post-menopausal groups, there is no difference in the risk of coronary artery disease, and in a number of studies, a decrease in HDL and an increase in systolic blood pressure and cholesterol and triglyceride levels have increased risk after menopause. [6]

Almost 75% of women over 60 are overweight, and fat mass increases or worsens with the onset of menopause.[7] and this sharp increase in fat mass in menopause can be a risk factor for cardiovascular disease.[7] Some of the structural changes of the body in menopause cannot be changed, but behavior and lifestyle, especially diet and activity, are among the causes that can be corrected in this period of risk factors and can reduce the risk factors of this period such as weight gain and osteoporosis.[8] Studies have shown that considering the food pattern of people in metabolic syndrome is preferable to considering a specific food composition because people's diet consists of different food combinations and nutrients. [9–11]

The healthy eating index is a new food index and it has been shown in studies that adherence to the healthy eating index reduces the incidence of metabolic syndrome and cardiovascular disease, diabetes and cancer [12]

In order to evaluate, screen and predict cardiovascular disease, insulin resistance and check visceral obesity in people in recent years, research has been conducted on new cardiometabolic and lipid indicators, including AIP, LCI and LAP, which reflect the balance between atherogenic and anti atherogenic factors. Recently, AIP has been used as a powerful marker to predict the risk of cardiovascular disease [13–15]. In a study in Iran, the value of AIP had a strong positive relationship with waist circumference and body mass index and an inverse relationship with physical activity. [16]

Another index is the cardiometabolic index, which is an index of visceral fat distribution and is a risk factor for cardiovascular disease, diabetes, blood pressure, and left ventricular hypertrophy, and this index includes the measurement of waist circumference to height and the ratio of triglycerides to HDL. [17]

The TyG index and its related indices are also a new cheap marker with high sensitivity and specificity for insulin resistance and can confirm the metabolic syndrome, and in the studies of this index, it is associated with atherosclerosis and cardiovascular diseases. [18, 19]

Other indicators related to TyG are TyG-WC and TyG-BMI, which are used to determine the level of insulin resistance. In this study, these indicators have been used. [20, 21]

In Iran, the prevalence of metabolic syndrome in postmenopausal women was reported to be 69%, and the prevalence was high and increasing during the transition from premenopause to postmenopause [22] but due to the racial and genetic differences of different regions, which affects the prevalence of metabolic syndrome and Each of its components can be effective separately, as well as the cultural differences in the nutrition and physical activity patterns of the people of this region and the lack of similar studies in this field in the study group (menopause and post-menopause women) in the southwest of the country and This study is carried out using a large sample size from the Hoveyzeh cohort. In this study, in addition to comparing the prevalence of metabolic syndrome and its components in the three groups of pre-menopause, post-menopause, and post-menopause, nutrition indicators, lipid indicators, and the amount of physical activity between the three groups are examined and the results are compared.

Study Design

In this study, the data first phase of the Hoveyzeh cohort study were used, The aim is to compare the prevalence of metabolic syndrome and its components, lipid indices, physical activity and healthy eating index in premenopausal, menopausal and postmenopausal women.

Study setting and participants

4732 women were studied in terms of demographic characteristics, prevalence of metabolic syndrome and its components. In this cross-sectional study. The number of 2049 women aged 40 to 70 years studied in the Hoveyzeh cohort population who met the inclusion criteria were divided into three groups based on the Persian cohort questionnaire. The first group includes 917 post-menopausal women (at least 3 years have passed since menopause), the second group includes 396 menopausal women (1 year to less than 3 years have passed since menopause), the third group includes 736 pre-menopausal women aged 49 - They are 40 years old and have a menstrual cycle. In these groups, the prevalence of metabolic syndrome and its components were calculated based on the ATPIII criteria separately in the following groups: post-menopause, menopause, pre-menopause. And then the results were compared between 3 groups. In order to evaluate the accuracy of the information and information about the menopause status, the history of menstruation and the time of cessation of menstruation and its irregularity were determined with a questionnaire, and the results were matched according to the age group., history of hysterectomy, HRT, psychiatric diseases, eating disorders and menopause at the age of less than 40 years of pregnancy, unwillingness to cooperate, breastfeeding and those who do not remember their menopause age. The protocol of this study was accepted by the ethics committee based on the Helsinki guidelines. The code of ethics of this study was IR.AJUMS.HGOLESTAN.REC.1400.100.

Demographic information and other information related to the level of literacy, height (measured by wall scale 206 Seka), weight (measured by hand scale Seka 755 in standing position), waist circumference (measured according to NIH definition), fasting blood sugar level Blood lipids were separated by components including TG, HDL, total cholesterol after 12 hours of fasting with the protocol defined in the Persian cohort, systolic and diastolic blood pressure was measured after 15 minutes of rest, BMI was calculated and the results were compared between the three groups. In order to evaluate physical activity and compare information in three groups separately based on the physical activity questionnaire based on MET, the level of physical activity was measured in each of the pre-menopausal, menopausal and post-menopausal groups.

Food intake and food groups using the Food Frequency Questionnaire (FFQ), and based on the "Intake Index" Scored "healthy". This index will be calculated based on 10 components, each component representing a different aspect of a healthy diet. Part 1 to 5 will be the degree to which a person's food plan follows the recommendations of the food guide pyramid regarding 5 food groups, Intakes equal to or equivalent to the recommended amount in terms of servings per day will get a score of 10, and finally the score of "healthy eating index" was calculated out of 100. [10] Nutritional data was done with Nutritionist4 software. Calculation of lipid indices:[23, 24]

LAP: The Lipid Accumulation Product:

[WC–65] × [TG] in men

[WC–58] × [TG] in women

AIP; Atherogenic index of plasma: Log (TG/ HDL-C)

LCI: The lipoprotein combine index: TC∗TG∗LDL/HDL-C

Cardiometabolic index (CMI): TG/HDL x (waist to height ratio)

TyG index: In [(FBS × TG)/2]

TyG-BMI: TyG index × BMI

TyG -WC: TyG INDEX × wc

Weight adjusted waist index (WWI): WC/\(\sqrt{weight}\)

Data analysis

The test ANOVA was used for the quantitative variables and the test Chi-square was used for the qualitative variables. LSD Post hoc test was used to compare variables between three groups. Also, multiple regression analysis was used for more detailed investigation and correction of intervening factors.

A total of 4732 women participated in this study, after considering the inclusion and exclusion criteria, 736 women were in the pre-menopausal (group 1), 396 post-menopausal (group 2) and 917 post-menopausal (group 3) based on Flowchart (Fig. 1).

The average age of all women participating in this study was 53.97 (SD: 7.36) years and the average age of these women in the first to third groups was 46.7 (SD: 1.36), 53.3 (SD: 4.35) and 60 (SD: 5.64) years, respectively. Table 1 shows the average age and its standard deviation.

Table 1

Baseline characteristics between menopause groups in a cross sectional study of Hoveyzeh Cohort Study
Variables	Total (N = 2049)	Pre-menopause (N = 736)	Menopause (N = 396)	Post-menopause (N = 917)	P-value^a
Age (years)	53.97 ± 7.36	46.71 ± 1.36 ^{a, b}	53.31 ± 4.35 ^c	60.06 ± 5.64	< 0.001
Marital state n (%)
Single	65 (3.2)	41 (5.6)	12 (3.0)	12 (1.3)	< 0.001
Married	1579 (77.1)	635 (86.3)	330 (83.3)	614 (67.0)
Widow	353 (17.2)	39 (5.3)	45 (11.4)	269 (29.3)
Divorced	52 (2.5)	21 (2.9)	9 (2.3)	22 (2.4)
Education (years)	1.39 ± 2.70	2.28 ± 3.17 ^{a, b}	1.42 ± 2.81 ^c	0.66 ± 1.91	< 0.001
Weight (kg)	74.16 ± 15.06	76.61 ± 15.46 ^b	75.94 ± 15.07 ^c	71.43 ± 14.29	< 0.001
Height (cm)	158.37 ± 5.70	159.19 ± 5.44 ^b	158.93 ± 5.67 ^c	157.47 ± 5.83	< 0.001
Waist circumference (cm)	102.40 ± 12.23	101.22 ± 12.19 ^{a, b}	104.17 ± 12.26 ^c	102.58 ± 12.17	< 0.001
Hip circumference (cm)	105.54 ± 10.52	107.34 ± 10.50 ^b	106.60 ± 10.58 ^c	103.63 ± 10.24	< 0.001
Wrist circumference (cm)	17.15 ± 1.35	17.29 ± 1.41 ^b	17.19 ± 1.26 ^c	17.01 ± 1.33	< 0.001
Physical activity (MET)	35.84 ± 4.18	37.26 ± 3.92 ^{a, b}	36.00 ± 3.91 ^c	34.63 ± 4.12	< 0.001
Use Contraceptive Drug, n (%)	1215 (59.3)	538 (73.1)	255 (64.4)	422 (46.0)	< 0.001
Hypertension, n (%)	788 (38.5)	183 (24.9)	145 (36.6)	460 (50.2)	< 0.001
Diabetes, n (%)	617 (30.1)	150 (20.4)	121 (30.6)	346 (37.7)	< 0.001
Metabolic syndrome, n (%)	1115 (54.4)	319 (43.3)	220 (55.6)	576 (62.8)	< 0.001
Dyslipidemia, n (%)	1213 (59.2)	417 (56.7)	235 (59.3)	561 (61.2)	< 0.001
TG ≥ 150 mg/dl	858 (41.9)	272 (37.0)	174 (43.9)	412 (44.9)	0.003
HDL ≤ 50 mg/dl	799 (39.0)	289 (39.3)	152 (38.4)	358 (39.0)	0.958
Prediabetes, n (%)	470 (23.0)	173 (23.5)	98 (24.7)	199 (21.7)	0.677
Central obesity, n (%)	1977 (96.5)	704 (95.6)	387 (97.7)	886 (96.6)	0.187
Regional central obesity, n (%)	1538 (75.1)	531 (72.1)	311 (78.5)	696 (75.9)	0.044
Data are means ± SD for quantitative variables and frequency (percent) for qualitative variables
^a ANOVA for quantitative variables, chi-square for qualitative variables.

The average height, weight, hip circumference and wrist circumference in pre-menopausal and menopausal women were higher than post-menopausal women and this difference was significant. The average waist circumference in menopausal and post-menopausal women was more than that of pre-menopausal women and also in menopausal women was more than that of post-menopausal women and there was a significant difference (P < 0.001). The average amount of physical activity in pre-menopausal women was higher than in menopausal and post-menopausal women, and also in menopausal women than in post-menopausal women, which had a significant difference (P < 0.001). The prevalence of hypertension, diabetes, dyslipidemia (TG ≥ 150 or HDL < 50 or both) and metabolic syndrome were the most prevalent in postmenopausal women and the lowest in premenopausal women, except for HDL < 50, statistically this difference It was meaningful. The prevalence of dyslipidemia with the highest average in the post-menopausal group showed a significant difference between the three groups (P < 0.001).The prevalence of hypertriglyceridemia showed the highest prevalence in the post-menopausal group and it increased significantly from pre-menopause to post-menopause (P = 0.003). The prevalence of abdominal obesity with the definition of ATPIII was the most prevalent in the menopause group, 97.7%, but there was no significant difference between the three groups (P = 0.18) (Table 1).

The prevalence of abdominal obesity according to the definition of Iranian guidelines was the highest in the menopausal group, 78.5%, and the lowest in the premenopausal group, which was statistically significant (P = 0.044). Prevalence of metabolic syndrome in per menopause, menopause and postmenopause nodes was 43.3%, 55.6%, 62.8% respectively. The prevalence of cardiovascular disease was the highest prevalence of 23% in the post-menopausal group and the lowest prevalence of 16% in the pre-menopausal group (P = 0.001) (Table 1).

Table 2 shows the anthropometric and laboratory indices between the three groups. The average fasting blood sugar, triglyceride level, cholesterol, LDL, waist to height ratio, AIP index were significantly higher in the menopause and post-menopause groups than in the pre-menopause group. The average BMI in premenopausal women was higher than in menopause, and in postmenopausal women it was higher than in postmenopausal women, which was a significant difference. The mean systolic blood pressure, weight adjusted waist index and waist to hip ratio were higher after menopause than before menopause and after menopause was higher than before menopause and this difference was significant. The average diastolic blood pressure in menopause was significantly higher than pre-menopause. Cardio metabolic index was not significant in this study. TyG index in menopausal and post-menopausal women was significantly higher than pre-menopausal women. P value < 0.001. LAP and LCI were not significant between groups.

Table 2

Biochemical and anthropometric measures between menopause groups in a cross sectional study of Hoveyzeh Cohort Study
Variables	Total (N = 2049)	Pre-menopause (N = 736)	Menopause (N = 396)	Post-menopause (N = 917)	P-value^a
Fasting blood sugar (mg/dl)	119.53 ± 54.27	109.01 ± 42.52 ^{a, b}	123.36 ± 57.19	126.31 ± 59.83	< 0.001
Triglycerides (mg/dl)	155.81 ± 97.44	148.01 ± 82.25 ^{a, b}	160.27 ± 84.66	160.12 ± 112.39	0.025
Cholesterol (mg/dl)	197.13 ± 43.17	188.99 ± 39.91 ^{a, b}	200.80 ± 41.53	202.07 ± 45.41	< 0.001
High-density lipoprotein (mg/dl)	53.69 ± 12.10	53.42 ± 12.37	53.68 ± 11.18	53.91 ± 12.26	0.720
Low-density lipoprotein (mg/dl)	112.49 ± 35.81	106.16 ± 32.82 ^{a, b}	115.05 ± 34.78	116.45 ± 37.83	< 0.001
Systolic blood pressure	113.59 ± 19.81	109.21 ± 18.26 ^{a, b}	112.16 ± 19.12 ^c	117.72 ± 20.47	< 0.001
Diastolic blood pressure	70.85 ± 11.28	70.10 ± 10.67 ^b	70.80 ± 11.22	71.48 ± 11.74	0.047
Heart rate	79.64 ± 9.53	79.47 ± 8.85	79.74 ± 9.80	79.74 ± 9.93	0.824
Waist-To-Hip Ratio	0.97 ± 0.07	0.94 ± 0.06 ^{a, b}	0.98 ± 0.06 ^c	0.99 ± 0.06	< 0.001
Waist-To-Height Ratio	0.65 ± 0.08	0.64 ± 0.07 ^{a, b}	0.66 ± 0.08	0.65 ± 0.06 ^f	< 0.001
Body mass index	29.53 ± 5.59	30.18 ± 5.68 ^b	30.05 ± 5.80 ^c	28.78 ± 5.35	< 0.001
Weight adjusted waist Index	11.95 ± 0.66	11.61 ± 0.60 ^{a, b}	12.00 ± 0.61 ^c	12.19 ± 0.61	< 0.001
Cardiometabolic index	2.07 ± 1.50	1.97 ± 1.53	2.14 ± 151	2.11 ± 1.46	0.099
Atherogenic index of plasma	0.06 ± 0.25	0.04 ± 0.26 ^{a, b}	0.08 ± 0.25	0.07 ± 0.25	0.016
TyG Index	8.95 ± 0.65	8.82 ± 0.63 ^{a, b}	9.02 ± 0.64	9.03 ± 0.65	< 0.001
TyG-BMI	264.84 ± 55.28	267.06 ± 56.40 ^b	271.16 ± 55.85 ^c	260.35 ± 53.81	0.002
TyG-WC	918.47 ± 137.82	136.99 ± 5.05 ^{a, b}	134.87 ± 6.78	137.24 ± 3.04	< 0.001
Lipid accumulation product	74.98 ± 50.74	75.83 ± 49.40	75.84 ± 52.57	73.92 ± 51.04	0.70
The lipoprotein combine index	20.08 ± 19.03	20.66 ± 18.77	20.48 ± 19.75	19.43 ± 18.93	0.385
Data are means ± SD for quantitative variables and frequency (percent) for qualitative variables
^a ANOVA for quantitative variables, chi-square for qualitative variables.
^a Significant difference between pre-menopause compared to menopause.
^b Significant difference between pre-menopause compared to post-menopause.
^c Significant difference between menopause compared to post-menopause.

In the comparison between the three groups based on the HEI-2015 score and its components, the results were as follows. The mean score of total fruit consumption in the pre-menopausal group was higher compared to menopause and post-menopause and there was a significant difference. (P = 0.007). The average score of vegetable consumption in pre-menopausal and menopausal groups was higher than post-menopausal, which was statistically significant (P = 0.036). (The average score of consumption of seafood and vegetable proteins in pre-menopausal and menopausal groups was higher than post-menopausal, which was a significant difference (P < 0.001). The average score of added sugar in menopause and post-menopause groups was higher than pre-menopause and the difference was significant (P = 0.002) (Table 3).

Table 3

A Comparison between menopause groups based on scores of HEI-2015 and its components
Variables	Total (N = 7464)	Pre-menopause (N = 736)	Menopause (N = 396)	Post-menopause (N = 917)	P-Value^*
Adequacy components
Total fruits (5)	4.43 ± 1.05	4.52 ± 0.96 ^a,b	4.33 ± 1.14	4.40 ± 1.08	0.007
Whole fruits (5)	4.86 ± 1.60	4.89 ± 1.50	4.83 ± 1.66	4.84 ± 1.64	0.161
Total vegetables (5)	4.82 ± 1.51	4.85 ± 1.44 ^b	4.86 ± 1.44 ^c	4.79 ± 1.58	0.036
Greens and beans (5)	4.75 ± 0.74	4.77 ± 0.67	4.76 ± 0.75	4.73 ± 0.79	0.453
Whole grains (10)	0.55 ± 1.68	0.54 ± 1.60	0.62 ± 1.84	0.53 ± 1.67	0.671
Dairy (10)	3.87 ± 2.42	3.74 ± 2.36	3.87 ± 2.41	3.98 ± 2.46	0.126
Total protein foods (5)	2.97 ± 1.13	2.97 ± 1.09	3.00 ± 1.13	2.95 ± 1.16	0.785
Seafood and plant proteins (5)	3.08 ± 1.38	3.20 ± 1.32 ^b	3.17 ± 1.37 ^c	2.94 ± 1.42	< 0.001
Fatty acids (10)	3.55 ± 3.51	3.72 ± 3.53	3.43 ± 3.34	3.47 ± 3.55	0.244
Moderation components					-
Refined grains (10)	0.37 ± 1.73	0.37 ± 1.73	0.44 ± 1.89	0.34 ± 1.66	0.641
Sodium (10)	1.44 ± 2.18	1.56 ± 2.34	1.23 ± 1.98	1.43 ± 2.12	0.052
Added sugars (10)	3.74 ± 2.64	3.47 ± 2.50 ^{a, b}	3.99 ± 2.67	3.85 ± 2.72	0.002
Saturated fats (10)	9.23 ± 1.81	9.18 ± 1.87	9.35 ± 1.65	9.21 ± 1.82	0.322
Total score3	47.66 ± 6.37	47.79 ± 6.27	47.85 ± 6.18	47.47 ± 6.53	0.464
Data are means ± SD for quantitative variables
^* ANOVA for quantitative variables
^a Significant difference between pre-menopause compared to menopause.
^b Significant difference between pre-menopause compared to post-menopause.
^c Significant difference between menopause compared to post-menopause.

In multivariable regression logistic analysis, which was conducted to investigate anthropometric and cardiometabolic indices, two models were investigated, with the premenopausal group as a control and comparison. It was done between two groups of menopause and after menopause, and the results were as follows: The average waist to hip ratio in both menopausal and premenopausal OR groups had a significant increase. Average waist to height ratio, although there was a significant risk increase in the one OR model in two groups, but after adjusting the variables, there was a significant increase in the menopause group, but it was not significant in the post-menopausal group. The average cardio metabolic index, AIP, LCI, BMI, LAP and healthy eating index did not have a significant increase in OR between the menopausal and postmenopausal groups after adjusting the findings. WWI index in models 1 and 2 had a significant increase in risk in both groups and had the highest OR rate among metabolic indices of 1.93 and 2.26 in the menopause and post-menopause groups, respectively (Table 4).

Table 4

Multivariable logistic regression analysis on cardiometabolic and anthropometric indices between between menopause groups
Variables	Pre-menopause	Menopause			Post-menopause
Variables		OR	(95%CI)	P-V	OR	(95%CI)	P-V
Waist-To-Hip Ratio Model 1 Model 2	Reference	1.08 1.06	(1.06–1.11) (1.03–1.10)	< 0.001 < 0.001	1.12 1.06	(1.10–1.14) (1.03–1.10)	< 0.001 < 0.001
Waist-To-Height Ratio Model 1 Model 2	Reference	1.03 1.04	(1.02–1.05) (1.01–1.07)	< 0.001 0.010	1.03 1.03	(1.01–1.04) (0.99–1.06)	< 0.001 0.098
Body mass index Model 1 Model 2	Reference	1.00 1.01	(0.97–1.02) (0.96–1.06)	0.706 0.670	0.95 0.97	(0.94–0.97) (0.92–1.02)	< 0.001 0.260
Weight-adjusted Waist Index Model 1 Model 2	Reference	2.94 1.93	(2.37–3.65) (1.40–2.66)	< 0.001 < 0.0001	4.91 2.26	(4.06–5.94) (1.57–3.26)	< 0.001 < 0.001
Cardiometabolic index Model 1 Model 2	Reference	1.08 1.10	(0.99–1.17) (0.97–1.26)	0.07 0.140	1.07 1.07	(1.00-1.14) (0.92–1.25)	0.06 0.345
Atherogenic index of plasma Model 1 Model 2	Reference	1.77 1.88	(1.09–2.88) (0.89–3.98)	0.021 0.099	1.66 1.57	(1.12–2.44) (0.66–3.70)	0.011 0.306
TyG Index Model 1 Model 2	Reference	1.63 1.37	(1.34–1.98) (1.02–1.85)	< 0.001 0.040	1.68 1.24	(1.43–1.97) (0.88–1.74)	< 0.001 0.217
TyG-BMI Model 1 Model 2	Reference	1.00 1.00	(1.00-1.01) (1.00-1.01)	0.236 0.227	1.00 1.00	(1.00–1.00) (1.00-1.01)	0.014 0.616
TyG-WC Model 1 Model 2	Reference	1.00 1.00	(1.00–1.00) (1.00–1.00)	< 0.001 0.002	1.00 1.00	(1.00–1.00) (1.00–1.00)	< 0.001 0.142
Lipid accumulation product Model 1 Model 2	Reference	1.00 1.00	(1.00–1.00) (0.99-1.00)	0.996 0.440	1.00 1.00	(1.00–1.00) (0.99-1.00)	0.447 0.224
The lipoprotein combine index Model 1 Model 2	Reference	1.00 1.00	(0.99–1.01) (0.99-1.00)	0.885 0.815	1.00 1.00	(0.99-1.00) (0.99-1.00)	0.191 0.634
Health eating index-2015 Model 1 Model 2	Reference	1.00 1.00	(0.98–1.02) (0.97–1.03)	0.871 0.911	0.99 0.99	(0.98–1.02) (0.96–1.02)	0.302 0.533
Model 1: unadjusted
Model 2: Adjusted for age, wrist circumference, physical activity, education years

In this cross-sectional study, the prevalence of diabetes, hypertriglyceridemia, systolic blood pressure, abdominal obesity according to Iranian guidelines, and cardiovascular disease were more common in menopause and post-menopause than pre-menopause. The prevalence of metabolic syndrome was the highest after menopause. In the Tehran Lipid study, the incidence of metabolic syndrome increased during the post-menopause period and its components from pre-menopause to menopause and from menopause to post-menopause. [22]. The average HDL in menopause did not show any significant change. Of course, it may be due to the influence of various factors except estrogen level, smoking, physical activity and diet on HDL levels in the study group.[25] Before menopause, the accumulation of fat in the lower body is widely distributed due to the secretion of estrogen. During menopause, changes in hormone secretion are the cause of visceral fat accumulation in the abdomen and abdominal obesity and insulin resistance. [26, 27] has an increased risk in menopause among metabolic indicators. In our study, it was shown that although the components of metabolic syndrome in menopause are higher than after menopause and even HDL is unchanged, the prevalence of metabolic syndrome increases clearly after menopause. Lipid profile changes occur with estrogen reduction in menopause. [28]

Matti stated that due to the progressive changes due to menopause in the metabolic health of middle-aged women, although physical activity can change the lipid profile in middle-aged women, it does not change or increase many metabolic indicators during menopause. It becomes systolic blood pressure [29].These results show that perhaps the importance of physical activity at a younger age in order to prevent the development of metabolic syndrome, blood pressure and eventually heart disease may be more effective than physical activity at the age after menopause, which of course is probably the ability. The person is reduced to perform effective physical activity. In China, a study by examining anthropometric factors found that in women without overweight and obesity, WHR is an important factor in predicting and diagnosing metabolic syndrome [30]. In our study, based on HEI-2015, menopausal women consumed more sugar-containing foods than premenopausal women, and total fruit, vegetable, fish, and protein consumption were higher in premenopausal women than in postmenopausal women. According to the above results, restricting drinks and foods containing sugar and increasing the consumption of fish and plant protein and vegetables and reducing the consumption of fruit juice in the diet of menopausal and postmenopausal women can create a healthy diet according to the results of this study. In menopausal and postmenopausal women, the relationship between the HEI-2015 total score and the components of metabolic syndrome was conducted and a weak positive relationship with HDL level and a weak negative relationship with waist circumference was seen according to the total score. Among the components of metabolic syndrome, HEI had the highest correlation with waist circumference. In women with metabolic syndrome, the lowest score was in the consumption of dairy products, whole grains, seafood and protein substances, fatty acids and saturated fat, and the highest amount was attributed to the consumption of total fruit, total sodium and vegetables .In order to reduce metabolic syndrome, insulin resistance, metabolic syndrome reduction and lifestyle changes including diet, physical activity, weight control, blood pressure and lipids are recommended. TyG is an index of insulin resistance, which decreases in menopause due to estrogen hormone secretion. TyG Index and other indices related to it are nowadays considered as cheap and easy index of insulin resistance. Irene Lambrinoudaki and her colleagues showed in a study of Athens Hospital, TyG index is associated with arterial wall stiffness and atherosclerosis in thin postmenopausal women, while in obese or overweight women, metabolic syndrome is a valuable marker for subclinical prediction. It is atherosclerosis, and perhaps this index can be used as an index of atherosclerosis in women with normal weight. [31] In studies, this index shows the risk of diabetes in young people more than in old people, and also as an index in non-obese and non-overweight people. It is more useful for the risk of diabetes. [32]

In our study, this index was significantly lower in the pre-menopausal group compared to the menopausal and post-menopausal groups, and it can indicate an increase in insulin resistance in the menopausal group compared to the pre-menopausal group. In the study by Jinsook Lim and his colleagues in Korea, TyG was preferable to other tests to check insulin resistance, and it can be used as a substitute method to evaluate insulin resistance in clinical conditions. [20] In this study, the AIP index was significantly higher in the menopausal and post-menopausal groups than in the pre-menopausal group. In the study of Qianyun et al AIP was introduced as a powerful and independent index to predict the risk of heart disease in Chinese postmenopausal women, which can be superior to conventional lipid indices. [33] In our study, unlike other Iranian studies, new cardio metabolic and lipid indices were used and their results were analyzed. Due to the quick, convenient and cheap use of these indicators, using them to calculate heart risk and insulin resistance, unlike the previous complex methods, it is possible to identify high-risk people and with simple measures such as weight loss, exercise and Diet and blood pressure, lipid and blood sugar control prevented cardiovascular disease

Considering that in this study, the highest OR in increasing the risk of cardio metabolic indicators in menopausal and post-menopausal women was related to the WWI index. It is suggested that this index can be a better indicator of metabolic syndrome in menopausal women than other traditional lipid indices, and also according to a 10-year follow-up study, this index can indicate the ten-year mortality of deaths from all causes.[19] In a study, it was seen that post-menopausal women should be advised to follow a healthy diet due to the use of a diet containing a lot of saturated fat, which is effective on their metabolic indicators

and body composition.[34] In the comparison of cardiometabolic indices, the average indices of WHR, WHtR, WWI, AIP and TgY were higher in the group of menopausal women than in premenopausal women. LCI, LAP, CMI indices did not differ significantly between groups

Your limitations and suggestions Among the strengths of this study, in contrast to other studies, the amount of physical activity and healthy eating index and new cardiometabolic indices were investigated and compared simultaneously in the above three groups. The strengths of this study include the large number of sample groups and their comparison. Also, this study was conducted in the southwest of the country, where the majority of the population is Arab and whose lifestyle includes physical activity and diet is different from Persians, which can be done with simple and cheap measures and available in all regions, it reduced the risk of cardiovascular disease and risk factors, among other strengths of this study is the use of standard IPAQ questionnaires to check physical activity and FFQ questionnaire to check people's diet. Also, in this study, new cardio metabolic indicators and their comparison with traditional cardiovascular indicators have been done, and at the same time, these indicators, metabolic syndrome and its components, the amount of physical activity and diet have been investigated simultaneously in one study. Concurrency is seen.

One of the limitations of our study was the age range of 40–70 years, and by increasing the age range to below 40 years and above 70 years, perhaps the role of risk factors can be shown better. Also, this study was conducted cross-sectionally, and because these studies do not show the role of cause and effect well, and the role of other confounding factors may be effective in the results, therefore, case-control or cohort studies should be conducted. Tyg index was used in this study. It is suggested that HOmA-IR or other standard indices of insulin resistance should be used simultaneously in future studies so that the results can be compared.

In this study, the prevalence of metabolic syndrome and its components, including blood pressure, diabetes, triglycerides > 150, abdominal obesity according to Iranian guidelines, and the prevalence of cardiovascular disease increased in menopause compared to premenopause, but HDL did not decrease significantly with menopause. Compared to pre-menopausal women, cardio metabolic indices W/H ratio, TyG index, WWI have a higher mean after adjustment of other risk factors, but their BMI is lower. Among the measured metabolic indices associated with menopause, the WWI index. In menopausal women compared to pre-menopause with OR, 2.94, it has the highest risk in menopause among metabolic indicators.

Acknowledgments

The reported results were a part of the fellowship thesis of Maryam Sharifzadeh1 (D-0007). This study was supported by the Vice Chancellor for Research Affairs of Ahvaz Jundishapur University of Medical Sciences.

Author Contributions

Conceptualization, L.M., an M.SH.; data curation, Z.F. and F.Z.; formal analysis, M.SH. and M.A.; funding acquisition, L.M.; investigation, S.J.H. and M.SH.; project administration, L.M. and F.Z.; resources, A.Z. and S.P.P.; software, M.A.; supervision, L.M.; validation, S.J.H. and Z.F.; visualization, S.J.H. and Z.F.; writing—review & editing, L.M., M.SH and M.A. All authors have read and agreed to the published version of the manuscript.

Funding

The Iranian Ministry of Health and Medical Education has contributed to the funding used in the PERSIAN Cohort through Grant number 700/534 and the Vice-Chancellor for Research at Ahvaz Jundishapur University of Medical Sciences grant number D-0007.

Data Availability Statement

Data used in this study can be obtained from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran (Date: 2021, October 12 /No: IR.AGUMS.HGOLESTAN.REC.1400.100). Informed consent was obtained from all individual participants included in the study before taking part.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no conflict of interest.

Author details

¹Diabetes research center, Health research institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.

²Department of Nutrition, Shoushtar Faculty of Medical Sciences, Shoushtar, Iran

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No competing interests reported.

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Comparison of metabolic risk factors, lipid indices, healthy eating index and physical activity among premenopausal, menopausal, and Postmenopausal women

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INTRODUCTION

METHODS

Study Design

Study setting and participants

[WC–65] × [TG] in men

[WC–58] × [TG] in women

Data analysis

RESULTS

DISCUSSION

CONCLUSION

Declarations

References

Additional Declarations

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