Racial and Ethnic Differences in the Presentation of Metabolic Syndrome

Article Outline

• Abstract
• Background
• Methods
• Review of Relevant Research
  • Waist Circumference
  • Insulin Resistance
  • Blood Pressure
  • Cardiovascular Risk
• Summary of Findings
• Application to Practice
• Implications for Future Research
• Conclusion
• References
• Uncited reference
• Copyright

Abstract 

This paper explores the effectiveness of the Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (ATP III) recommendations for diagnosing metabolic syndrome in people from specific racial and ethnic groups. More than 50 million adult Americans have metabolic syndrome. Some racial and ethnic minority groups have much higher percentages of the metabolic syndrome than general population estimates suggest. However, some minority populations in the United States such as Hispanics appear to be underdiagnosed. A literature review was conducted to determine whether the general ATP III guidelines have sufficient screening criteria for detecting metabolic syndrome in various racial and ethnic minority groups. Research articles published in the United States from 2000 to 2005 were reviewed. Studies were included that presented data related to black, Hispanic, and Asian American male and female subjects older than age 18. Waist circumference appears to be the most predictive screening factor among the metabolic syndrome criteria. Patients with normal body mass indexes may still have elevated waist circumferences that meet the ATP III risk criteria for metabolic syndrome. Blacks have high rates of hypertension even without considering metabolic syndrome, and they may have more disease risk than other populations. Hispanics have an increased risk of diabetes associated with metabolic syndrome. Because the criteria may not be sufficient to diagnose metabolic syndrome in Asian Americans as a result of different body types, the diagnosis might be missed in this group. There is a need for more research on how the diagnosis of metabolic syndrome presents in different racial and ethnic minority groups in the United States. Practitioners need evidence-based screening tools that will provide the most accurate information for evaluating persons of racial and ethnic groups who are most at risk of diabetes, cardiovascular disease, and stroke. The determination of the applicability of screening criteria to diverse patient populations is vital to providers who are obligated to provide culturally competent care to their patients. This paper synthesizes selected literature and presents recommendations to assist nurse practitioners in the assessment of metabolic syndrome in specific racial and ethnic minority groups.

Keywords:  African American , Asian American , black , Hispanic , metabolic syndrome , Mexican American , screening

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Current estimates are that more than 50 million Americans older than 18 years have metabolic syndrome.¹, ² This estimate represents approximately 24% of the adult population. However, some racial and ethnic minorities have much higher percentages of the metabolic syndrome than general population estimates suggest.², ³ For example, Hispanics have a prevalence rate of 32%, blacks have a 22% prevalence rate (women have much higher prevalence than men), and rates for Asians often conflict depending on the diagnostic criteria used for their specific ethnic group.², ⁴

Metabolic syndrome is defined as a set of health risk factors that are associated with increased chance of developing heart disease, stroke, diabetes, or a combination. Several factors contribute to the metabolic syndrome, including being overweight, physical inactivity, and genetic factors. Further, the metabolic syndrome has been closely linked to insulin resistance. Although the exact pathophysiology is not well understood, the metabolic syndrome represents a clustering of several metabolic abnormalities that increase the risk of cardiovascular disease.¹ Persons with metabolic syndrome have a 65% greater risk of death from coronary artery disease (CAD).², ³ They also have increased risk of peripheral vascular disease and lipid abnormalities. The syndrome is diagnosed when a person has three or more of the criteria listed in Table 1.

Table 1. ATP III Clinical Criteria for the Metabolic Syndrome

ATP III indicates Adult Treatment Panel III; HDL, high-density lipoprotein. Source: Grundy SM, Becker D, Clark LT, et al. Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) Executive Summary. Bethesda, MD: National Institutes of Health, National Heart, Lung, and Blood Institute; 2001. NIH publication 01-3670.

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Background 

Appropriate screening and diagnosis of metabolic syndrome is important for the prevention of further disease in patients. Screening is an especially important tool for practitioners because one in four of their adult patients will have metabolic syndrome. Hypertension, obesity, and diabetes are all associated with metabolic syndrome, and cost of care for these diseases continues to rise. Hyper-tension, one of the criteria for the metabolic syndrome, is the most frequently occurring diagnosis in primary care.⁵, ⁶ Obesity care now demands greater than 9% of medical expenditures in the United States.⁷ Obese persons with metabolic syndrome have a risk of stroke that is more than three times the risk of persons without the syndrome.² Also, diabetes prevalence is increasing along with obesity rates. Obesity and diabetes are considered important risk factors for cardiovascular disease, and a diagnosis of diabetes often implies the need for at least two antihypertensive medications to achieve blood pressure control.⁵

During the past several years, metabolic syndrome has been studied extensively. Much of the research on metabolic syndrome published between 1988 and 2001 focused more often on white subjects than on minorities, even though minorities have higher prevalence rates.², ³, ⁸, ⁹ Consequently, many researchers shifted their focus to studies on minority populations, yielding a larger amount of data during the past 5 years, reflective of minority screening needs relative to metabolic syndrome. It remains unclear whether current scientific evidence is conclusive or extensive enough to support changes in the screening requirements that might allow for better diagnosis of minorities who have or are at risk of developing metabolic syndrome and its associated adverse health effects. In fact, recommendations of the Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (ATP III) for cholesterol management concluded that, although racial and ethnic groups vary in risk of CAD, there was not sufficient evidence to modify general ATP III recommendations.¹

Nevertheless, there is a practice dilemma caused by the discrepancy between the guidelines and the actual clinical presentation of patients because some minority populations in the United States such as Hispanics appear to be underdiagnosed, possibly by as much as 50% compared with whites.⁹ Other ethnic minority groups (eg, Asian Americans) do not appear to be diagnosed in relation to their actual risk, based on the current criteria for metabolic syndrome established by ATP III guidelines, specifically for waist circumference and body mass index (BMI; in kg/m²). Cases of missed diagnosis may be due to differences in body type, because some minorities appear to have metabolic syndrome at much smaller measurements of waist circumference than whites.⁴

Clearly, practitioners must be aware of possible inadequacies associated with the general guidelines before they are used to screen many American ethnic minority populations. They should develop culturally specific guidelines to screen for metabolic syndrome and to better identify patients at risk of CAD and other diseases associated with metabolic syndrome. Current literature indicates statistically significant findings that different guidelines for BMI criteria, abdominal girth requirements, and screening age are necessary for different subpopulations.⁴, ⁵, ¹⁰, ¹¹ Although ATP III guidelines on cholesterol management and the Joint National Committee VII guidelines on blood pressure management have established algorithms to diagnose and treat metabolic syndrome, a synthesis of the limited research on ethnic differences is needed. Including ethnic considerations in the screening protocols would help practitioners to better diagnose the syndrome in all Americans; however, these current protocols do not account for racial differences found in recent research findings.

The purpose of this article is to review current scientific literature that focused on screening for metabolic syndrome in different populations within the United States to determine whether the general ATP III guidelines have sufficient screening criteria for detecting metabolic syndrome in various racial and ethnic minority groups. Clinical recommendations based on our findings are presented.

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Methods 

A literature search was conducted to determine whether the general ATP III guidelines included sufficient screening criteria for detecting metabolic syndrome in various racial and ethnic minority groups. Research and review articles published in the United States from 2000 to 2005 were selected. Studies were included that presented data related to black, Hispanic, and Asian American male and female subjects aged 18 and older. Many of the studies also included white subjects. Language was limited to English, and keywords included Asian American, Hispanic, Mexican American, African American, black, metabolic syndrome, and screening. Studies were excluded if the research focused on these groups living outside the United States. Studies that included Asian American subjects were limited to those with ancestry from Japan, the Philippines, and the Pacific Islands because of the great amount of diversity in this heterogeneous racial group. Most studies of metabolic syndrome with Asian Americans adults (that matched the other inclusion criteria) included one of these groups. Sixteen articles that incorporated screening for the metabolic syndrome were identified and reviewed. Quality of the studies was determined as articles were evaluated. Studies with representative samples and appropriate methods were included. These studies are summarized in Table 2.

Table 2. Summary of Literature Related to the Presentation of Metabolic Syndrome in Various Racial and Ethnic Groups

CVD indicates cardiovascular disease; HDL, high-density lipoprotein; SBP, systolic blood pressure; DBP, diastolic blood pressure; FPG, fasting plasma glucose; OGTT, oral glucose tolerance test; DM, diabetes mellitus; BMI, body mass index (in kg/m²); WHO, World Health Organization; ATP III, Adult Treatment Panel III; TG, triglycerides; HTN, hypertension; CAD, coronary artery disease; NCEP, National Cholesterol Education Program; CV, cardiovascular; BP, blood pressure; LDL-C, low-density lipoprotein cholesterol; HDL-C, high-density lipoprotein cholesterol; NHANES, National Health and Nutrition Survey; BG, blood glucose.

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Review of Relevant Research 

Waist Circumference 

Waist circumference was one of the most studied components of metabolic syndrome. Some literature published between 2000 and 2005 suggested that waist circumference guidelines may need to be altered for the different ethnicities, but no findings from research conducted in the United States were found to support specific numerical changes to the ATP III criteria for all races.²⁴, ²⁶ Also, because of the diversity found within subjects classified as Asian, no research study focusing on all Asian Americans as a broad group was found in this review, although many focused on Filipino Americans and Japanese Americans.¹², ¹⁹, ²⁰ Many researchers reported that the prevalence of increased waist circumference was different for various minority groups, although the studies often contradicted previous research findings. Ford et al¹⁶ found that Hispanics and blacks had higher waist circumferences than whites. Few studies were conducted on adults in the United States to determine whether visceral fat (which affected waist circumference) was found in varying amounts related to race, but Bacha et al¹³ found that the visceral fat levels varied between black and white adolescents.

The prevalence of metabolic syndrome also varied by race when waist circumference was studied using ATP III criteria. Waist circumference did not differ by ethnicity when white women were compared with Filipino women, but the prevalence of metabolic syndrome was higher in Filipino women with the same waist circumference than their white counterparts (32.6% compared with 13.8%, respectively, N = 377, p < .001).¹² In the CARDIA study with a sample size of 4192, black women had the highest rate of metabolic syndrome (12.2, p < .0001), the highest BMI (25.6 ± 6.2) and the highest weight change over 15 years (16.2 ± 13.8 kg).²² Only 223 of the 4192 participants developed metabolic syndrome without fulfilling the waist circumference criteria.¹⁴ Specifically, if blacks do not have waist circumference greater than the specified ATP III criteria, they are less likely to have metabolic syndrome than whites.¹⁴ When waist circumference was in a normal range, blacks had a 0.87 relative risk of metabolic syndrome as compared with whites with similar history of weight gain over time.¹⁴

Increased waist circumference in all races correlated with increased rates of hypertension, hyperinsulinemia, and hypertriglyceridemia.¹³, ²³ Increased waist circumference in Hispanics correlated with increased rates of diabetes and increased triglycerides (12.0% and 12.1% for Hispanic men and women, respectively, as compared with 10.4% and 7.7% for white men and women, respectively, in a study with a sample size of 6673).²³ Increased waist circumference in blacks correlated with increased prevalence of hypertension. Specifically, 30.4% of black men compared with 18.5% of Hispanic men had blood pressure that met criteria for metabolic syndrome, and 28.0% of black women compared with 15.2% of Hispanic women had hypertension that qualified as criteria for metabolic syndrome.²³

The key findings in the research about waist circumference are consistent with the ATP III recommendations. However, it is possible to have metabolic syndrome at a normal weight and waist circumference.¹⁴ Most importantly, increased waist circumference is found in persons with BMI values within the “normal” ranges for blacks, Asian Americans, and Hispanics, possibly putting them at higher risk of metabolic syndrome than their providers might believe according to current guidelines.¹⁹, ²³, ²⁵ Patt et al²⁵ found that, although 84% of the 396 black women they studied were overweight by BMI, even in the normal weight category women often had waist circumference greater than 35 inches. This was accompanied by increased rates of hypertension in the normal weight category, again indicating increased risk.²⁵ Waist circumference within metabolic syndrome criteria was also found in 9.7% of white men in the BMI category ranging from 25.0 to 26.9, a normal BMI weight.⁹ In 47.7% of the Hispanic women who had a BMI between 25.0 and 26.9 and in 19.6% of Hispanic women who had a BMI between 23.0 and 24.9, their waist circumference was greater than 35 inches, also indicating that waist circumference is a more important criteria than BMI for determining risk of metabolic syndrome.⁹ The evidence indicates that waist circumference is the more appropriate measurement as defined by ATP III,¹ although the literature suggests that many practitioners use BMI.

An important finding is that waist circumference data from different research studies indicate different diseases and risk factors for different ethnic groups. Waist circumference greater than the cutoff scores for ATP III criteria statistically indicates atherogenic risk in whites and it indicates diabetogenic risk in blacks.¹³ Similarly, increased waist circumference in Filipino American women with high blood pressure and lipid levels did not increase cardiovascular disease (CVD) risk as it did in white women.¹² Because black and Hispanic young adults in the United States are more likely to be obese, they are also more likely to develop diabetes at a younger age. Young adults with diabetes in these two groups do not have the other risk factors seen in whites who are usually older when found to have fasting plasma glucose greater than 110 mg/dL.¹⁷

Insulin Resistance 

Insulin resistance, determined by a fasting glucose greater than 110 mg/dL, is another criterion in the ATP III standards that has been studied frequently. Many researchers asked whether the fasting plasma glucose criteria was the most appropriate predictive value to indicate insulin resistance, and whether insulin levels would have been a better screening tool.²⁰, ²⁴, ²⁷ The results were contradictory. Hayashi et al²⁰ found that in Japanese Americans fasting plasma insulin was only related to hypertension when age was accounted for, because younger adults with insulin resistance usually did not have the other factors present such as hypertension or high triglycerides.²⁰ Insulin resistance was not found as a useful predictor of metabolic syndrome in the Insulin Resistance Atherosclerosis study, but 2-hour glucose levels after a glucose tolerance test combined with waist circumference was an additional predictor of metabolic syndrome for all races.²⁴ Only a few studies that determine rates of insulin resistance have been conducted on Hispanics living in the United States, but studies are being done in South American countries with similar metropolitan lifestyles. Their findings suggest a racial difference in insulin resistance.²⁷

Another problem with insulin resistance was related to the difference in prevalence between races. Insulin resistance was found to be more related to race than obesity, and Hispanic Americans had the highest rates when compared with blacks or whites.¹⁵, ¹⁶ Ford et al¹⁶ found that within the sample of 8814 participants of their study, 20% of the Hispanic population had fasting plasma glucose that exceeded the criteria for metabolic syndrome or were already on diabetes medications. This was compared with 15% of the black participants and 12% of the white participants.¹⁶

Blood Pressure 

Blood pressure as a criterion for metabolic syndrome has been extensively studied. Although increased waist circumference correlated with increased blood pressure in all races, there were racial differences in the severity of hypertension.¹³ This finding held true for Japanese Americans in a study by Hayashi et al¹⁹ which found that increased waist circumference was a significant risk factor for hypertension. In another study, Harris et al¹⁸ found that white women had the highest correlation between increased waist circumference and increased blood pressure.¹⁸ Other empirical evidence indicates that black men and women have the highest rates of hypertension, and hypertension was present even at normal BMI for blacks.¹⁶, ²⁵ However, blood pressure was already increased in this population at any BMI, so looking at blood pressure compared with waist circumference was misleading because of the high prevalence of hypertension in blacks.¹⁸ The key finding in several studies was that, even when black women met only two of the criteria for metabolic syndrome (hypertension and waist circumference) and therefore did not screen positive for metabolic syndrome, risk factors in this group needed to be taken more seriously because of the high prevalence of CVD.²², ²⁵

Cardiovascular Risk 

Although the individual screening criteria for metabolic syndrome have been studied, yielding conflicting findings, the research on the actual risk of CVD associated with metabolic syndrome screening has been the most controversial. Many researchers have concluded that positive results of metabolic syndrome screening imply different problems for different ethnic groups. The current lipid levels in the metabolic syndrome criteria may be too high to adequately assess risk for blacks at risk of CVD.¹⁴ Further, if ATP III guidelines were used to detect CVD risk in black women, many clinicians might falsely reassure their black female patients that the risks of developing CVD was lower than is actually found.⁶

There appear to be sex differences for the hazard ratios that compare metabolic syndrome with risk of death from CVD. Results from the San Antonio Heart Study found that ATP III criteria were more predictive of CVD for women than for men.²¹ When women screened positive for the metabolic syndrome, they were 4.65 times more likely to die of CVD than were women without metabolic syndrome. But men who screened positive for metabolic syndrome were only 1.82 times more likely to die of CVD than men without metabolic syndrome.

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Summary of Findings 

Waist circumference appears to be the most predictive screening factor within the metabolic syndrome criteria. Although there is some controversy over which cutoff numbers should be used for different racial and ethnic groups, there is agreement that practitioners should record BMI on each patient and also obtain a waist circumference, particularly for those with a BMI greater than 25.⁶, ²⁵, ²⁸ This strategy would reduce the chance of missing persons with increased waist circumferences whom health care practitioners might think were at less risk because of BMIs within the “normal” category. Only one study reported high waist circumference scores that correlated with lower BMI, but these scores were associated with increased risk of CVD and diabetes. Waist circumference of approximately 83 cm for Hispanic, white, and black women correlated with a BMI of 25 and an increased CVD risk.²⁸ The researchers who conducted that study concluded that there still was not enough evidence to determine cutoff scores for Asian American women. Compared with women, men's waist circumference measurements and BMI did vary by ethnicity. Even when BMI was held constant at 25, black men had an average waist circumference of 86.4 cm (33.75 inches), whereas white men had a waist circumference of 91.3 cm (35.66 inches). Hispanic men were near the average of the two other ethnicities, so researchers proposed a waist circumference cutoff of 90 cm to indicate increased risk.²⁸, ²⁹

None of the other criteria for metabolic syndrome had sufficient data-based clinical evidence to support recommending changes to the ATP III criteria, but multiple studies suggested that more research needs to be conducted to determine whether lipid levels need to be altered for the different ethnicities to indicate increased CVD risk.⁶, ¹², ¹⁴, ²² Because of the controversy about African American lipid levels compared with the standards used in ATP III, research does seem to support considering black patients at higher risk of CVD if increased waist circumference and increased blood pressure are present at levels above ATP III criteria even when the other ATP III criteria is not met.

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Application to Practice 

The purposes of screening tools are to assist in determining the risk of or the presence of a suspected disease. In today's clinical environment, providers have limited time to spend with patients. Rapid, accurate, and acceptable screening tests become even more important in the provision of culturally competent care.³⁰ Therefore, researchers and clinicians must ensure that accepted screening criteria and tests are appropriate for various ethnic groups living within the United States. Further, because of health care management, often new diagnoses are needed to justify treatments at earlier stages of a disease that will prevent further progression of that disease. Nurse practitioners use diagnoses such as metabolic syndrome and insulin resistance to better manage screening and treatment of their patients so that they can receive payment for services. Practitioners need evidence-based research on available screening tools for metabolic syndrome to determine which are most useful in evaluating persons of racial and ethnic groups who are most at risk of diabetes, CVD, and stroke. The determination of the applicability of screening criteria to patient populations is vital to providers who are obligated to provide culturally competent care to their patients. Key considerations for patient assessment for the metabolic syndrome are included in Table 3.

Table 3. Summary of Key Considerations for the Assessment of Metabolic Syndrome in Racial and Ethnic Minorities

CVD indicates cardiovascular disease; BMI, body mass index (in kg/m²); ATP III, Adult Treatment Panel III.

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Implications for Future Research 

Future research should address whether different racial or ethnic groups require different screening criteria and what additional criteria should be included or excluded to aid in the most effective management of the syndrome and its associated disease sequelae. Further research should address whether positive screening results correlate with varying disease risk of different ethnic groups. Studies have shown that CVD risk can be independent of a positive screening for metabolic syndrome, and other researchers have suggested that elevated blood pressure is a risk factor for CVD not related to the other criteria for metabolic syndrome.¹⁹, ¹⁴, ²⁸, ³¹ Because of the controversy about the applicability of current criteria as a comprehensive screening tool for metabolic syndrome, more research is needed to determine the best combination of criteria to detect the syndrome so that risk of associated disease conditions can be decreased.

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Conclusion 

Current ATP III criteria for metabolic syndrome sufficiently screens for increased risk of disease in white Americans, but questions remain about the sensitivity of the criteria to detect metabolic syndrome and associated disease risk such as CVD and diabetes in other racial and ethnic groups. Better criteria are needed so that nurse practitioners and other providers can accurately assess disease risk in their patient populations. Nurse practitioners should be aware of the controversy about criteria for various populations and should implement strategies to adequately assess CVD and diabetes risk across all racial and ethnic groups.

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Uncited reference 

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