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The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 60:466-470 (2005)
© 2005 The Gerontological Society of America

Effect of Metabolic Syndrome on Heart Attack and Mortality in Mexican-American Elderly Persons: Findings of 7-Year Follow-Up From the Hispanic Established Population for the Epidemiological Study of the Elderly

Max E. Otiniano1, Xianglin L. Du2, Mario R. Maldonado3, Laura Ray1 and Kyriakos Markides1,

1 Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston.
2 Department of Epidemiology, University of Texas-School of Public Health, Houston.
3 Department of Medicine, Division of Endocrinology, Baylor College of Medicine, Houston, Texas.

Address correspondence to Kyriakos S. Markides, PhD, Department of Preventive Medicine and Community Health, University of Texas Medical Branch, 700 Harborside Dr., Rm. 1.128, Galveston, TX 77555-1153. E-mail: kmarkide{at}utmb.edu


   Abstract
Top
 Abstract
Methods
 Results
 Discussion
 References
 
Purpose. We aim to examine the effect of Metabolic syndrome (MetS) on heart attack and overall mortality in Mexican-American elderly persons over 7-year follow-up.

Methods. We studied 3050 Mexican Americans aged 65 or older from the Hispanic Established Population for the Epidemiological Study of the Elderly conducted in five Southwestern states of the United States. Participants were categorized into two groups: those with or without MetS. A total of 333 (11%) respondents at baseline had met the criteria of MetS (at least three of five characteristics—hyperinsulinemia or fasting plasma glucose ≥110 mg/dl, abdominal obesity, and hypertension—as defined by the World Health Organization).

Results. Of 333 participants with MetS, the mean age was 71.1 years and 68% were females (compared with 73.2 years and 56% in those without MetS). Eighty percent of participants with MetS rated their health as fair or poor, compared to 55% of those participants without MetS. Fifty-four percent and 65% of patients with MetS had arthritis and at least one impairment in instrumental activities of daily living (IADL), compared to 39% and 55% of those participants without MetS. MetS was significantly associated with increased incidence of heart attack (odds ratio: 2.75, 95% confidence interval: 1.67–4.54) and was a significant predictor for overall mortality (hazard ratio: 1.46, 95% confidence interval: 1.16–1.84) over a 7-year period after adjusting for other demographic and clinical variables.

Conclusions. Among Mexican-American elderly participants, those with MetS had poorer self-rated health. MetS was significantly associated with increased incidence of heart attack and higher mortality over a 7-year period.

METABOLIC syndrome (MetS) is a concurrence of impaired glucose and insulin metabolism, overweight and abdominal fat accumulation, mild dyslipidemia, and hypertension (1). It is extremely common, particularly in older individuals and in Mexican Americans (2). This syndrome is important because of its association with subsequent development of Type 2 diabetes mellitus (3), and cardiovascular diseases (4–6), and because of its association with increased mortality from cardiovascular disease and all causes (7). Alone, each component of the cluster conveys increased cardiovascular risk, but in combination they become a more powerful threat to health (8). MetS is on the rise world-wide because of the obesity epidemic and sedentary lifestyles (9).

MetS is characterized by insulin resistance and is also known as Insulin Resistance Syndrome (IRS) (1,3,10), and Syndrome X (11). The IRS is a condition characterized by decreased tissue sensitivity to the action of insulin, leading to a compensatory increase in insulin secretion (12). It is characterized by the clinical characteristics of hypertension, abdominal obesity, high triglyceride levels, and low HDL levels (11,13). Family history of Type 2 diabetes is another clinical factor that may also increase the risk for insulin resistance (14,15).

The pathogenesis of this syndrome is still unclear, although environmental factors such as diet and physical activity, coupled with still largely unknown genetic factors, clearly interact to produce it (4,6,11,15). However, resistance to insulin-stimulated glucose uptake seems to modify biochemical responses in a way that predispose to metabolic risk factors (11,13,16).

The prevalence of MetS, as defined by the Adult Treatment Panel (ATP III) in the United States, was estimated to be 22% among U.S. adults (17) and it increases rapidly with advancing age (2,6). By age 70, the incidence of metabolic disorders reaches epidemic proportions (13,15). The overall prevalence of MetS is lower in black men than in white or Mexican-American men, and is higher in Mexican-American women than in white or black women (2,6). Epidemiological studies confirmed that MetS occurs commonly in a wide variety of ethnic groups including Europeans, African Americans, Native Americans, Mexican Americans, Asian Indians and Chinese, Australian Aborigines, Polynesians, and Micronesians (11,18).

Despite a substantial amount of research, definitions of the MetS and the various cutoffs for its components have varied widely (4,11). The recently released Third Report of the National Cholesterol Education Program Expert panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults draws attention to the importance of the MetS and provides a working definition of this syndrome for the first time (19). Furthermore, the World Health Organization (WHO) consultation for the classification of diabetes and its complications (20) and the National Cholesterol Education Program (NCEP) expert panel (19) have recently published the definitions of MetS.

Despite high prevalence of MetS, little is known about other factors associated with it in older populations. A variety of factors, including concomitant illnesses, general health status, and socioeconomic factors, may influence treatment decisions (19). We use cross-sectional data at baseline and 7-year follow-up data to examine the impact of MetS on heart attack incidence and overall mortality, and to determine demographic and clinical characteristics associated with MetS in community-dwelling older Mexican Americans.


   METHODS
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 Abstract
 Methods
Results
 Discussion
 References
 
Study Population Sample
The Hispanic Established Population for the Epidemiological Study of the Elderly is a population-based study of non-institutionalized Mexican Americans aged 65 or older from five Southwestern states (Texas, California, New Mexico, Colorado, and Arizona). Participants were selected by using area probability sampling procedures that involved selection of counties and households within selected census tracts. Census tracts were selected with probabilities proportional to the number of Mexican-American elderly persons. These were the primary sampling units. Three thousand fifty Mexican-American elderly persons (representing an 83% response rate) were interviewed in either Spanish or English, depending on their preference. Of these, 2873 completed face-to-face interviews and 177 (5.8%) were interviewed by proxy. In most cases, the proxy was a close family member. Baseline interviews were obtained in 1993–1994, the first follow-up in 1995–1996, the second follow-up in 1998–1999, and the third follow-up in 2000–2001. Detailed information on the sampling plan and interview process can be found in our previous publications (21,22).

Measures
The MetS is defined as presence of either hyperinsulinemia (upper quartile of the nondiabetic population) or fasting plasma glucose ≥110 mg/dl (20,23,24) and at least two of the following: 1) abdominal obesity (waist circumference of >102 cm for men and >88 cm for women or body mass index ≥ 30), 2) dyslipidemia (serum triglyceride ≥ 150 mg/dl or HDL cholesterol < 35 mg/dl); or 3) hypertension (blood pressure ≥ 140/90 mmHg or treated with medication). In our study, a participant was considered to have MetS if he or she had diabetes, hypertension, and abdominal obesity. Serum lipids, which are the other two criteria of the five characteristics of MetS, were not taken into account in this population. Diabetes was determined by asking participants if they had ever been diagnosed with diabetes by a doctor. Blood pressure level and abdominal measurement were taken and recorded by the interviewer at the time of the interview. A respondent was categorized as obese if he or she had a waist circumference of >102 cm for men and >88 cm for women.

Sociodemographic factors included age, sex, marital status (married or not married), years of education, living arrangements, and health insurance coverage. Living arrangements were determined by asking respondents if they lived alone or with others. Respondents were also asked if they had health insurance coverage (including private, Medicare, or Medicaid benefits). Participants were then classified as having or not having any coverage.

Health-related factors assessed at baseline included smoking status, alcohol consumption, self-rated health (excellent, good, fair, or poor), family history of diabetes, duration of diabetes and hypertension, treatment received for hypertension, previous heart attack, stroke, hip fracture, and arthritis. Smoking status was measured by asking respondents if they were current/former smokers or never smoked. The number of cigarettes smoked per day was also computed. Alcohol consumption was measured based on current frequency and volume of consumption of beer, wine, or liquor during the month prior to the interview. The number of cans/bottles of beer, the number of glasses of wine, and the number of alcoholic drinks consumed in the past month were computed. Respondents who reported a diagnosis of diabetes were also asked if they had a family history of diabetes (categorized as none/unknown and one/both parents). Duration of diabetes and/or hypertension was categorized as <10 years or ≥10 years. Treatment received for hypertension was categorized as none, with medication, or unknown. Other medical conditions were assessed by asking respondents if they had ever been told by a doctor that they had a previous history of heart attack, stroke, hip fracture, or arthritis. The number of hospitalizations and number of doctor's visits in the year prior to the baseline interview were also recorded. Physical function was measured using a modified version of the Katz Activities of Daily Living (ADL) scale (25). The Instrumental Activities of Daily Living (IADL) items were measured from the modified Rosow–Breslau scale of mobility function (26). Procedures used to collect information for participants in the Hispanic Established Population for the Epidemiological Study of the Elderly were provided in previous publications (21,22). Causes of deaths among deceased participants were determined from family members and a mortality search performed using the National Death Index.

Data Analysis
The percentages in Tables 1 and 2 were adjusted for sampling weights and design effects to minimize any clustering bias in our estimates using the SUDAAN program (27). Logistic regression analyses and Cox proportional hazards regression analyses were performed using the SAS program (28). Logistic regression analyses (Table 3) were used to assess the risk (odds ratio) of having a new heart attack over the 7-year follow-up. Cox proportional hazards regression analysis (Table 4) was used to estimate the risk of mortality over the 7-year follow-up for people reporting heart attack with and without presence of other risk factors.


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  		Table 1. Sociodemographic Characteristics of Participants With and Without Metabolic Syndrome (MetS) at Baseline (1993–1994).

 

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  		Table 2. Health-Related Characteristics of Participants With and Without Metabolic Syndrome (MetS) at Baseline (1993–1994).

 

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  		Table 3. Logistic Regression Analysis of Incident Heart Attack Over a 7-Year Period.

 

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  		Table 4. Cox Proportional Hazards Analysis of 7-Year Mortality.

 

   RESULTS
Top
 Abstract
 Methods
 Results
Discussion
 References
 
Table 1 presents the sociodemographic characteristics of participants with and without MetS. Of the 3050 participants at baseline, 333 (11%) reported having at least three characteristics of MetS.

Participants with MetS had a mean age of 71.1 years compared with 73.2 years for participants without MetS (N = 2717) (p <.0001). Sixty-eight percent of participants with MetS were females, compared with 56% of those without MetS (p =.001). More participants with MetS (94%) than without MetS (89%) were covered by health insurance (p =.007). No significant differences were found between the two groups by marital status, level of education, and living arrangements.

Table 2 shows that participants with MetS, in comparison with those without MetS, were more likely to rate their health as fair or poor (80% vs 55%) (p <.0001), to have a family history of diabetes (24% vs 13%) (p =.001), to have diabetes (50% vs 38%) (p =.05) and hypertension (46% vs 32%) (p =.0001) for <10 years, to receive treatment for hypertension (60% vs 51%) (p =.0001), to report having arthritis (54% vs 39%) (p =.002), to have more hospitalizations (28% vs 18%) (p =.01), to have more doctors visits (9.4 vs 5.8 mean) (p <.0001), and to report more IADL disabilities (65% vs 55%) (p =.01).

Table 3 shows that participants with MetS were twice as likely than those without MetS to have a heart attack during the 7-year study period (odds ratio: 2.75, 95% CI: 1.67–4.54), controlling for other risk factors (age, being male, living alone, years of education, smoking status, alcohol consumption, ADL limitation, diabetes, hypertension, and obesity).

Table 4 shows that participants with MetS were significantly more likely than those without MetS to die over the 7-year follow-up period (hazard ratio: 1.46, 95% CI: 1.16–1.84), controlling for other risk factors. Age, being male, being a current smoker, and having an ADL limitation were significantly associated with an increased risk of mortality.


   DISCUSSION
Top
 Abstract
 Methods
 Results
 Discussion
References
 
This study addressed the effect of MetS on incidence of heart attacks and all-cause mortality in Mexican-American elderly persons over the 7-year follow-up. The prevalence of MetS in this population was 11%; this group was significantly associated with increased risk of heart attack and mortality over 7-year follow-up.

MetS is a widespread problem among U.S. adults, and the prevalence rates are highly variable among ethnicities, ages, body mass indexes, and lifestyle factors such as smoking status, physical activity, and dietary caloric intake (6). For example, studies based on the National Health and Nutrition Examination Survey (NHANES) reported by Park and colleagues (6) found that 27.2% of Mexican-American females had MetS, followed by black women and white women. Ford and colleagues (17) found that 31.9% of Mexican-American adults have MetS. In both studies (6,17), the age range was between 20 and 74 years; however, in our study, age range was reported between 65 and 99 years. Although lower educational level was not statistically associated with MetS in our study, it is an important factor for weight reduction and exercise program (6,17). One study reported that U.S. blacks with a lower educational level were more likely to engage in less physical activity during leisure time than were whites (29).

The waist circumference measure is a simple and useful tool for identifying patients who are susceptible to MetS (30). Waist circumference measure was one of the tools used in our study to measure abdominal obesity for the MetS definition. Eighty percent of Mexican-American elderly participants with MetS had poorer self-rated health. Also, greater percentages of participants with MetS were hospitalized (p =.01) and had doctor's visits (p ≤.0001) within the year before the interview compared with the participants without MetS. Current smoking was not found to occur more frequently among the participants with MetS, whereas other studies (6,31) reported an association between smoking and MetS. Family history of diabetes was found to be statistically significantly higher in those participants with MetS (p =.001).

At 7-year follow-up, 13% of participants with MetS had a heart attack, and 37% died. MetS (odds ratio: 2.75, 95% CI: 1.67–4.54) was a predicting factor for heart attack in this population. MetS was also a significant predictor for mortality over the 7-year follow-up, after adjusting for other demographic and clinical variables (hazard ratio: 1.46, 95% CI: 1.16–1.84). Slight and moderate alcohol consumption has been found to be associated with lower cardiovascular risk, possibly through beneficial alterations in HDL cholesterol and blood pressure (32).

The importance of MetS from a clinical and public health perspective may be greatest in its predictive value for cardiovascular disease or diabetes (1) and the serious implications for the U.S. health care cost (17). All five components of MetS can be easily evaluated in the clinical setting (6). Knowledge of the impact of MetS, according to the standard definitions of cardiovascular and overall mortality in the general population, is crucial for developing public health policy and clinical guidelines for its prevention and treatment (1). Therefore, an important aspect of identifying features of MetS in Mexican-American elderly persons is to recognize this risk and to initiate early and appropriate treatment to minimize the risk of cardiovascular diseases.

There were several limitations in this study. First, we mainly used self-reported data from older Mexican Americans with no clinical evaluations. However, the self-reported approach is a commonly used methodology in epidemiological research (33) and has been generally documented to provide reasonable information on demographic and health-related problems including heart attack (33–35). Second, we did not have laboratory-based information on triglyceride and/or HDL cholesterol levels, which are the other two criteria of the five characteristics of MetS. Although the diagnosis of this syndrome can be made if any three of the five characteristics are met (20,23,24), our estimate of MetS without these two characteristics is underascertained. Finally, the study findings from this Mexican-American sample may not be generalizable to other populations because we used only a subgroup of the original sample.

Conclusion
Eleven percent of Mexican-American elderly persons had MetS, which was significantly associated with increased risk of heart attack and mortality over the 7-year follow-up. Prevention, better control of diabetes and high blood pressure, and programs for exercise and weight reduction seem important to improve health and to reduce mortality.


   Acknowledgments
 
This research was supported by grants from the National Institute on Aging (AG 10939) and the UTHB Center for Population Health and Health Disparities (SP50CA105631).


   Footnotes
 
Decision Editor: John E. Morley, MB, BCh

Received October 16, 2003

Accepted December 2, 2003


   References
Top
 Abstract
 Methods
 Results
 Discussion
 References
 

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