Patients & methods: Study concerned 241 obese patients, meanage 53.27±9.66 years, with or without metabolic syndrome. The data included anthropometric measurements, a 24H nutritional recall, food frequency intake, lipoprotein and apolipoproteins profiles and several lipid ratios.
Results: Obese patients with MetS, presented higher body mass index, waist circumference, systolic and diastolic blood pressures values than patients without MetS. 17.02%, 31.92%, 33.19%, 13.62% and 4.26% of the studied population had one, two, three, four and five MetS components, respectively. The most prevalent MetS components were high waist circumference, hypertension and diabetes while low HDL-C was the least one in both groups. The ratio of TC/HDL and atherogenic index of plasma were the best predictors of MetS and their odd ratios were significantly higher in men than in women. We reported also several lipoprotein alterations in both groups. Furthermore, obese patients with MetS diet was more caloric very rich in saturated fatty acids but poorer in polyunsaturated fatty acids and monounsaturated fatty acids, in vitamins B9 and E. Both groups consume meals which macronutrient compositions were similar, typical Moroccan dishes. The consumption of Retinol, Beta-carotene, Vitamin C and trace elements was significantly higher in obese patients with MetS than in those without, whereas consumption of cholesterol and fibers were not significantly different. Conclusion: Our study shows that Moroccan obese patients with a hypercaloric diet and unbalanced fatty acids intakes, present disturbance in lipoprotein profile, with 3 to 5 components of MetS. All these parameters and disturbance may contribute to the development of CVD. The burden of CVD poses a serious public health problem in the region. It is strongly associated with dietary pattern.
Keywords: Nutrition, obese patients, metabolic syndrome, cardiovascular diseases.
In 2008, cardiovascular deaths represented 30 percent of all global deaths, with 80 percent of those deaths taking place in low- and middle-income countries [6].
In Morocco, as in most developing countries, CVD were responsible for 30.4% mortality and it’s a first cause of mortality. Thus, CVD is today the largest single contributor to global mortality and will continue to dominate mortality trends in the future [6, 7].
A major factor of the increasing prevalence of CVD worldwide is the on-going nutrition transition with progressive shifts to a westernized diet high in saturated fats and sugar, and a more sedentary lifestyle urbanization and globalization are fuelling the nutrition transition. These changes result in rapidly increasing levels of obesity, type 2 diabetes, dyslipidemia and hypertension, collectively known as the metabolic syndrome, which increase the risk of developing cardiovascular diseases [8, 9]. Furthermore, in recent decades the increased occurrence of CVD is not only attributed to changed dietary habits but also a reduced physical activity [5].
Even more, there is no standard of care for treating the metabolic syndrome since the prevalence of individual disorders varies by population and there is no common link between all metabolic abnormalities included. For example, the main predictor of metabolic syndrome among French populations is hypertension, whereas among US populations the main predictor is HDL cholesterol [10-12].
In Morocco, a developing country that is also experiencing demographic and health and nutritional transitions, few epidemiological studies have been conducted to characterize the magnitude of the prevalence of metabolic syndrome and risk of cardiovascular disease, as the country is still mostly focused on the problems associated with poor health and under nutrition in large segments of the population.
This study aimed to identify dietary patterns in Moroccan obese with or without metabolic syndrome and its association to cardiovascular diseases.
In these patients, metabolic syndrome was defined as the presence of at least 3 of the 5 components described by the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III):
• Waist circumference >102 cm for men and > 88 cm for women;
• Fasting plasma TG level ≥150 mg/dl;
• HDL-C HDL-cholesterol level < 50 mg/dL, and a fasting plasma glucose level.110 mg/dL and/or 130/ 85 mmHg systolic and diastolic bloods [13].
At the time of enrolment, the patients completed a health and lifestyle questionnaire indicating socio demographic characteristics, medical history, nutrition (24 recall and food frequency) and lifestyle factors, followed by clinical examination. All participants were Moroccan adult volunteers living in Casablanca and its neighboring areas and all provides their written informed consents. Thus, we excluded from this study all patients having some diseases affecting lipoprotein metabolism.
Low-Density Lipoprotein Cholesterol (LDL-C) and Very Low- Density Lipoprotein Cholesterol (VLDL-C) levels were calculated according to the friedwald’s formula. Furthermore, we have evaluated Apolipoprotein A1 (Apo1), Apolipoprotein B (Apo B) concentrations using nephelometry techniques. Apolipoproteine ratios, such as Apolipoprotein B to Apolipoprotein A1 (Apo B/ Apo A1), LDL to Apo B (LDL/ApoB) and HDL to Apo A1 (HDL/ Apo A1), were calculated; AIP was defined bas the logarithm of the TG/HDL ratio.
Serum equivalent CRP concentrations 10.0 mg/L were considered clinically elevated and indicative of current infection.
The differences in general and clinical characteristics (mean value of the parameters in the recall and the lipid levels) between the with and without MetS groups were with assessed by ANOVA tests.
Linear regression analysis was performed to test associations between lipid ratios and predicted risk of developing a CVD, Myocardial Infarction (MI), stroke and coronary heart disease CHD. Differences with a P < 0.05 were considered statistically significant.
All analyses were conducted using R (free software available at http://www.r-project.org/), version 2.12.0 for statistical analysis.
The reduction of high density lipoprotein cholesterol (HDL-C), observed in patients with MetS, leads to higher lipid and apolipoproteins ratios such as TG/ HDL. LDL/ ApoB and HDL/ ApoA1 decreased in presence of MetS while Apo B/A1 remained similar in both groups. We also noticed greater values of non- HDL-C and Atherogenic Index of Plasma (AIP) in obese with MetS as compared to those without MetS.
Table 2 presents the 24H recall results in obese patients with or without metabolic syndrome. We noticed that obese patients with MetS presented high level in Energy, Retinol, Beta-caroten, Vitamin C, and Magnesium, selenium, zinc and cooper intakes
Parameters |
Obese with out MetS |
Obese with MetS |
Sex-ratio |
0.29 |
0.35 |
Age (years-old) |
52.10±9.99 |
54.45±9.33 |
BMI (Kg/m2) |
33.49±3.46 |
34.68±4.41* |
WC |
108.18±7.90 |
111.10±9.45* |
sBP (mmHg) |
122.07±18.91 |
133.13±17.55+ |
dBP (mmHg) |
73.48±9.81 |
79.43±11.78+ |
CRP category stratification |
||
CRP < 3 mg /dL (%) |
36.11 |
34.69 |
CRP : 3-10 mg /dL (%) |
41.67 |
38.78 |
CRP>10 mg /dL (%) |
22.22 |
26.53 |
Lipid parameters |
||
TC (mmol/L) |
4.98±0.83 |
5.24 ±1.10* |
HDL-C (mmol/L) |
1.43±0.27 |
1.23±0.31+ |
LDL-C (mmol/L) |
3.01±0.78 |
3.12±0.95* |
TG (mmol/L) |
1.21±0.53 |
2.01±0.94+ |
VLDL-C (mmol/L) |
0.55±0.24 |
0.92±0.43+ |
Apo AI (mg /dL) |
158.61±36.70 |
168.42±44.10 |
Apo B (mg /dL) |
106.45±24.47 |
127.01±27.28+ |
TC / HDL |
3.60±0.87 |
4.47±1.23+ |
TG/HDL |
0.91±0.53 |
1.80±1.16+ |
LDL/Apo B |
1.14±0.19 |
1.80±1.16+ |
HDL/Apo A1 |
0.33±0.06 |
0.28±0.06+ |
Apo B / AI |
0.70±0.21 |
0.85±0.44 |
Non HDL-C (mg /dL) |
137.34±32.21 |
154.98±41.76+ |
AIP |
-0.10±0.21 |
0.19±0.25+ |
AIP, atherogenic index of plasma; Apo, apolipoproteine; BMI, body mass index; CRP, C-reactive protein; dBP, diastolic blood pressure; HDL-C, high density lipoprotein cholesterol; LDL-C, low density lipoprotein cholesterol; MetS, metabolic syndrome; sBP, systolic blood pressure; TC total cholesterol; TG, triglycerides; VLDL-C very low density lipoproteine cholesterol; WC waist circumference.
*p < 0.05; +: p< 0.0001
Table 3 and 4 presents, respectively, the consumption frequencies of several food groups and consumption frequencies of several food groups according to their nutritional benefits.
Both groups consume meals which macronutrient composition was similar. And the majority of patients had breakfast a lunch, a teatime and diner.
The breakfast consists of a semolina soup, coffee, milk, bread and butter or olive oil. Lunch is mainly represented by Moroccan tagines, rich in beef met, olive oil, potatoes and carrots. Bread is the essential food taken in this meal.
Otherwise, fruits and green salads represent a secondary intake. For teatime, a rich bread meal too with honey or jam, starchy Moroccan pancakes. In diner time, generally late, a meal that is same as lunch meal or based on paws, vegetable soup or semolina but every time accompanied with bread.
Parameters |
Ob with out MS |
Ob with MS |
Energy (Kcal) |
2880.94±1471.33 |
3433.39±1910.44* |
Proteins (%) |
27.70±34.28 |
21.82±11.25 |
Carbohydrates (%) |
49.53±28.92 |
47.08±13.18 |
Lipids (%) |
39.78±65.98 |
31.06±12.01 |
Wich SFA (%) |
43.53±12.56 |
45.65±15.48 |
MUFA (%) |
41.96±8.66 |
41.77±12.19 |
PUFA (%) |
14.52±10.03 |
12.57±10.15* |
Cholesterol (mg) |
319.88±483.59 |
235.17±249.66 |
Fibers (g) |
20.58±11.45 |
16.64±3.57 |
Vitamin B9 (µg) |
252.32±206.50 |
237.10±249.66* |
Vitamin E (mg) |
13.34±36.06 |
4.90±7.50* |
Retinol (µg) |
140.45±177.50 |
194.62±212.27** |
Beta-Caroten (µg) |
136.51±75.02 |
179.93±253.95* |
Vitamin C (mg) |
59.63±64.62 |
127.60 ± 134.02* |
Magnesium (mg) |
193.71±95.01 |
231.89±58.63* |
Selenium (µg) |
45.07±36.26 |
59.84±40.37** |
Zinc (mg) |
6.93±4.92 |
8.59±3.49* |
Cooper (mg) |
0.88±0.47 |
1.55±0.24* |
*: p< 0.05; **: p< 0.01
Mean of food intake classified in several categories |
Ob with out MetS |
Ob with MetS |
Milk and dairy products |
More than twice /day |
More than twice /day |
Meats, fish and eggs |
More than once /day |
More than once /day |
Fruit and vegetables |
More than 4 times /day |
More than 4 times /day |
Fats |
More than twice /day |
More than twice /day |
Cereals and derivates |
More than 3 times /day |
More than 3 times /day |
Sugar and sweet products |
More than 4 times /day |
More than 3 times /day |
Beverages |
More than twice /day |
More than twice /day |
Spices and condiments |
More than 6 times /day |
More than 7 times /day |
Dried fruits and seeds |
At least once / week |
At least once / week |
Fast food |
At least once / week |
At least once / week |
Mean of intake of food rich in |
Ob without MetS |
Ob with MetS |
Energy |
More than 5 times /day |
More than 4 times /day |
Antioxidants |
Many times/ day |
Many times/ day |
cholesterol |
At least one /week |
At last one / week |
SFA |
At least one /day |
At least one /day |
UFA |
More than twice/day |
More than twice/day |
MUFA |
More than twice/day |
More than twice/day |
PUFA |
At least one /week |
At least one /week |
Vitamins |
More than 5 times /day |
More than 4 times /day |
Vitamin E |
More than twice/day |
More than twice/day |
Vitamin C |
More than twice/day |
More than twice/day |
Trace elements |
Many times/ day |
Many times/day |
Magnesium |
More than 5 times /day |
More than 5 times /day |
Zinc |
More than 5 times /day |
More than 6 times /day |
Cooper |
At least one /week |
At least one /week |
Selenium |
More than one/day |
More than twice /day |
Bêta-caroten |
More than 4 times /day |
More than 4 times /day |
Monounsaturated fatty acids, PUFA: polyunsatured fatty acids.
|
Number of MS components ( vs. 1 MetS component) |
||||||
OR(95% CI) |
Presence vs. absence of MetS |
Men vs. women |
2 MetS Components |
3 MetS Components |
4 MetS Components |
5 MetS Components |
|
TC/ HDL |
2.21 (1. 65-2.95)+ |
1.49(1.15-1.94)** |
1.47 (0.91-2.38)+ |
2.04(1.35-3.09) ** |
5.14(2.33-11.31)+ |
6.91(2.10-22.78) ** |
|
LDL/ HDL |
1.92 (1.38-2.67)*** |
1.44(1.03-2.00)* |
1.48 (0.86-2.56) |
1.94(1.20-3.14)** |
2.94 (1.41-6.16)** |
5.04 (1.81-14.05) ** |
|
Non HDL-C |
3.57 (1.72-7.41)+ |
1.51(0.70-3.29) |
1.02(1.00-1.04) |
3.36(1.15-9.83) * |
1.03 (1.00-1.06) |
1.08 (1.00-1.18) |
|
AIP |
2.09 (1.69-2.57)+ |
1.27(0.93-1.74)+ |
1.37(1.09-1.72)* |
1.96(1.56-2.47)+ |
2.83 (1.30-6.16)+ |
2.89 (0.97-8.57) ** |
|
Apo B/ A1 |
1.42 (1.31-1.56) |
0.97(0.63-1.49) |
1.39(1.09-1.72) |
1.51(1.20-1.90) |
2.24 (0.91-5.57) * |
2.40 (0.80-7.23) * |
|
Apo B/HDL |
2.67(1.42-5.04)* |
1.45(0.88-2.37) |
1.90(0.70-5.18) |
2.96(1.15-7.63) * |
2.83(2.63-3.04) ** |
3.00(1.28-6.99) |
|
Predicted risk of |
CHD |
1.23 (1.15-1.31)+ |
1.13(1.08-1.19)+ |
1.27(1.10-1.46)** |
1.41(1.21-1.63)+ |
1.59(1.30-1.96)+ |
1.49(1.15-1.92) ** |
MI |
1.41 (1.25-1.59)+ |
1.24(1.14-1.35)+ |
1.53 (1.12-2.08)** |
1.97(1.42-2.74)+ |
2.51(1.66-3.78)+ |
2.24(1.31-3.84) ** |
|
Stroke |
1.41 (1.21-1.64)+ |
1.13(1.02-1.26)* |
3.49(1.74-7.01)*** |
3.79(1.91-7.52) *** |
4.02(2.64-6.19)+ |
4.48(1.53-13.11) ** |
|
CVD |
1.12 (1.08-1.17)+ |
1.07(1.04-1.10)+ |
1.22(1.10-1.35)*** |
1.28 (1.15-1.43)+ |
1.39(1.20-1.62)+ |
1.33( 1.10-1.61) ** |
|
CVD Death |
1.27 (1.13-1.42)+ |
1.19(1.09-1.29)+ |
1.71(1.06-2.77) |
2.22(1.31-3.76) ** |
2.54(1.37-4.74) * |
1.90 (1.23-2.93) ** |
*: p< 0.05; **: p< 0, 01; ***: p< 0.001; +: p< 0.0001
Our results showed that Moroccan obese patients are also at high risk for CVDs, since hypo-HD Lemia and hypertriglyceridemia are higher in obese with MetS than obese without Mets, which is in agreement with other research, as well as Hong, et al. they found three metabolic syndrome component combinations that led to the highest risk of CHD: increased sBP and TGs associated with lower HDL cholesterol. And according to, Do Carmo, et al. in developed countries, low HDL-cholesterol levels, and high triglyceridaemia and hypertension were the most common MS factors [17, 18].
On one hand, other lipid measures have shown their own predictive value for CVD. As well as, TC, TG, HDL-C, LDL-C, Apo B, Apo AI was all significant predictors of risk: Apo A1 and Apo B were better predictors of MI and CHD than HDL-C and LDL-C levels because of their respective associations with these lipoproteins [19-23].
On the other hand, using TC/HDL and Apo B/A1 ratios, we have noticed a cholesterol imbalance between atherogenic and anti-atherogenic lipoprotein particles in obese with MetS, adults with 5 MetS features and/or hypertriglyceridemia. Consequently, those people have more cholesterol circulating in the plasma compartment, and this cholesterol is likely to be deposited in the arterial wall, provoking atherogenesis and risk of cardiovascular events [19, 20]. Our findings were consistent with others publications where these ratios were found to be related to MetS and its components [19, 20, 24-26].
In our study, lipoproteins and apolipoproteins disturbances found in obese patients with MetS agreed with previous studies [19, 20]. One explanation would be that excess fat disturbs lipoprotein levels: in obese persons, an increased flux of FFA from fat to the liver might stimulate production of TG-rich lipoproteins leading to a pro-inflammatory state owing to altered production of inflammatory and anti-inflammatory mediators and the recruitment of macrophages to adipose tissue [27].
We have shown that most of obese patients with MetS present CRP levels >3 mg/dl, which is in agreement total with many studies [24, 27, 28, 30, 42]. Recently, some studies suggested that CRP predicted future MetS independent of age and its five components, and that it should be added as a MetS component [28, 29, 31]. Effectively, low-grade inflammation and its association with obesity may promote IR in various tissues [32, 33]. Besides, IR leads to an increased flux of Free Fatty Acids (FFA) into various tissues because of enhanced lipolysis and reduced FFA uptake and esterification. Since FFA competes with glucose for cellular uptake and metabolism, it can further reduce insulin sensitivity, instituting a vicious cycle [20].
Diet may also be one of the most important factors determinants of MS. The current scientific evidence suggests that the adoption of healthy lifestyles, balanced diet, increased physical activity, tobacco abstention, and moderate alcohol consumption can prevent and help control chronic diseases [33]. In the INTERHEART study, daily consumption of fruits and vegetables, regular alcohol consumption, regular physical activity, and other risk factors (history of hypertension, diabetes, abdominal obesity, and psychosocial factors) were all significantly related to acute myocardial infarction [34].
The main observed nutritional anomaly in our population was an excessive energy intake, if in association with sedentarily it well sustains obesity. Furthermore, the food mostly consumed by our population is hyperglycemic, rich in high glycemic index food (bread, paws and semolina) this is clearly established in many studies [36, 37].
Several researches focused on the glycemic index for simple food or mixt meals [36,38-41]. Our patient’s meals are rich in Fatty: Saturated Fatty Acid (SFA) and Monounsaturated Fatty Acid (MUFA) represented by Moroccan tagines prepared with olive oil, beef, meat potatoes and carrots). Our study showed that the obese with MetS, are very exposed to a high cardiovascular risk due to an imbalance, in the different types of fatty acids, insufficient vitamins and antioxidants intake and sedentarily life style.
The burden of CVD poses a serious public health problem in the region. It is strongly associated with dietary pattern. For this reason, there is urgency for development of betters approaches to the prevention and management of the cardiovascular diseases. It is not enough to say “just treat the established risk factors.”
More importantly, an effort must be made to strike at the underlying causes of the metabolic syndrome.
Certainly, reversal of the worldwide epidemic of obesity and physical inactivity must be a high priority. But in addition, better means to treat underlying susceptibility to the metabolic syndrome to ovoid CVD also are needed. Both approaches represent a great challenge to research in the cardiovascular and metabolic syndrome fields and their association with nutrition.
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