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Mezhal F, Ahmad A, Abdulle A, Leinberger-Jabari A, Oulhaj A, AlJunaibi A, Alnaeemi A, Al Dhaheri AS, AlZaabi E, Al-Maskari F, AlAnouti F, Alsafar H, Alkaabi J, Wareth LA, Aljaber M, Kazim M, Alblooshi M, Al-Houqani M, Hag Ali M, Oumeziane N, El-Shahawy O, Al-Rifai RH, Sherman S, Shah SM, Loney T, Almahmeed W, Idaghdour Y, Ahmed LA, Ali R. Metabolic Syndrome in Fasting and Non-Fasting Participants: The UAE Healthy Future Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:13757. [PMID: 36360639 PMCID: PMC9654954 DOI: 10.3390/ijerph192113757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 09/26/2022] [Accepted: 10/13/2022] [Indexed: 06/16/2023]
Abstract
INTRODUCTION Metabolic syndrome (MetS) is a multiplex of risk factors that predispose people to the development of diabetes and cardiovascular disease (CVD), two of the major non-communicable diseases that contribute to mortality in the United Arab Emirates (UAE). MetS guidelines require the testing of fasting samples, but there are evidence-based suggestions that non-fasting samples are also reliable for CVD-related screening measures. In this study, we aimed to estimate MetS and its components in a sample of young Emiratis using HbA1c as another glycemic marker. We also aimed to estimate the associations of some known CVD risk factors with MetS in our population. METHODS The study was based on a cross-sectional analysis of baseline data of 5161 participants from the UAE Healthy Future Study (UAEHFS). MetS was identified using the NCEP ATP III criteria, with the addition of HbA1c as another glycemic indicator. Fasting blood glucose (FBG) and HbA1c were used either individually or combined to identify the glycemic component of MetS, based on the fasting status. Multivariate regression analysis was used to test for associations of selected social and behavioral factors with MetS. RESULTS Our sample included 3196 men and 1965 women below the age of 40 years. Only about 21% of the sample were fasting at the time of recruitment. The age-adjusted prevalence of MetS was estimated as 22.7% in males and 12.5% in females. MetS prevalence was not statistically different after substituting FBG by HbA1c in the fasting groups (p > 0.05). Age, increased body mass index (BMI), and family history of any metabolic abnormality and/or heart disease were consistently strongly associated with MetS. CONCLUSION MetS is highly prevalent in our sample of young Emirati adults. Our data showed that HbA1c may be an acceptable tool to test for the glycemic component of MetS in non-fasting samples. We found that the most relevant risk factors for predicting the prevalence of MetS were age, BMI, and family history.
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Affiliation(s)
- Fatima Mezhal
- Public Health Research Center, New York University Abu Dhabi, Abu Dhabi 129188, United Arab Emirates
| | - Amar Ahmad
- Public Health Research Center, New York University Abu Dhabi, Abu Dhabi 129188, United Arab Emirates
| | - Abdishakur Abdulle
- Public Health Research Center, New York University Abu Dhabi, Abu Dhabi 129188, United Arab Emirates
| | - Andrea Leinberger-Jabari
- Public Health Research Center, New York University Abu Dhabi, Abu Dhabi 129188, United Arab Emirates
| | - Abderrahim Oulhaj
- Department of Epidemiology and Public Health, College of Medicine and Health Sciences, Khalifa University, Abu Dhabi 127788, United Arab Emirates
| | - Abdulla AlJunaibi
- Department of Pediatrics, Zayed Military Hospital, Abu Dhabi 72763, United Arab Emirates
| | - Abdulla Alnaeemi
- Department of Cardiology, Zayed Military Hospital, Abu Dhabi 72763, United Arab Emirates
| | - Ayesha S. Al Dhaheri
- Department of Nutrition and Health, College of Medicine and Health Sciences, UAE University, Al-Ain 15551, United Arab Emirates
| | - Eiman AlZaabi
- Department of Pathology, Sheikh Shakhbout Medical City, Abu Dhabi 11001, United Arab Emirates
| | - Fatma Al-Maskari
- Institute of Public Health, College of Medicine and Health Sciences, UAE University, Al-Ain 15551, United Arab Emirates
- Zayed Center for Health Sciences, UAE University, Al-Ain 15551, United Arab Emirates
| | - Fatme AlAnouti
- College of Natural and Health Sciences, Zayed University, Abu Dhabi 144534, United Arab Emirates
| | - Habiba Alsafar
- Center for Biotechnology, Khalifa University, Abu Dhabi 127788, United Arab Emirates
- Department of Genetics and Molecular Biology, Khalifa University, Abu Dhabi 127788, United Arab Emirates
- Department of Biomedical Engineering, Khalifa University, Abu Dhabi 127788, United Arab Emirates
| | - Juma Alkaabi
- Department of Internal Medicine, College of Medicine and Health Sciences, UAE University, Al-Ain 15551, United Arab Emirates
| | - Laila Abdel Wareth
- Pathology and Laboratory Medicine Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi 112412, United Arab Emirates
| | - Mai Aljaber
- Healthpoint Hospital, Abu Dhabi 112308, United Arab Emirates
| | - Marina Kazim
- Abu Dhabi Blood Bank Services, SEHA, Abu Dhabi 109090, United Arab Emirates
| | - Manal Alblooshi
- Public Health Research Center, New York University Abu Dhabi, Abu Dhabi 129188, United Arab Emirates
| | - Mohammad Al-Houqani
- Department of Medicine, College of Medicine and Health Sciences, UAE University, Al-Ain 15551, United Arab Emirates
| | - Mohammad Hag Ali
- Department of Health Science, Higher Colleges of Technology, Abu Dhabi 25026, United Arab Emirates
| | - Naima Oumeziane
- Abu Dhabi Blood Bank Services, SEHA, Abu Dhabi 109090, United Arab Emirates
| | - Omar El-Shahawy
- Department of Population Health, New York University School of Medicine, New York, NY 10595, USA
| | - Rami H. Al-Rifai
- Institute of Public Health, College of Medicine and Health Sciences, UAE University, Al-Ain 15551, United Arab Emirates
| | - Scott Sherman
- Department of Population Health, New York University School of Medicine, New York, NY 10595, USA
| | - Syed M. Shah
- Institute of Public Health, College of Medicine and Health Sciences, UAE University, Al-Ain 15551, United Arab Emirates
| | - Tom Loney
- College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai 505055, United Arab Emirates
| | - Wael Almahmeed
- Heart and Vascular Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi 112412, United Arab Emirates
| | - Youssef Idaghdour
- Public Health Research Center, New York University Abu Dhabi, Abu Dhabi 129188, United Arab Emirates
| | - Luai A. Ahmed
- Institute of Public Health, College of Medicine and Health Sciences, UAE University, Al-Ain 15551, United Arab Emirates
- Zayed Center for Health Sciences, UAE University, Al-Ain 15551, United Arab Emirates
| | - Raghib Ali
- Public Health Research Center, New York University Abu Dhabi, Abu Dhabi 129188, United Arab Emirates
- MRC Epidemiology Unit, University of Cambridge, Cambridge CB2 0SL, UK
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Comparative Abilities of Fasting Plasma Glucose and Haemoglobin A1c in Predicting Metabolic Syndrome among Apparently Healthy Normoglycemic Ghanaian Adults. Int J Chronic Dis 2019; 2019:2578171. [PMID: 31428625 PMCID: PMC6681621 DOI: 10.1155/2019/2578171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 06/01/2019] [Accepted: 07/16/2019] [Indexed: 01/21/2023] Open
Abstract
There are arguments as to whether haemoglobin A1c (HbA1c) better predicts Metabolic syndrome (MetS) than fasting plasma glucose. The aim of the study was to explore the comparative abilities of HbA1c and Fasting plasma glucose (FPG) in predicting cardiometabolic risk among apparently healthy adults in the Tamale metropolis. This study was a cross-sectional study conducted in the Tamale metropolis from September, 2017, to January, 2018, among one hundred and sixty (160) apparently healthy normoglycemic adults. A self-designed questionnaire was administered to gather sociodemographic data. Anthropometric and haemodynamic data were also taken and blood samples collected for haemoglobin A1c (HbA1c), fasting plasma glucose (FPG), and lipid profile. MetS was classified using the harmonised criteria as indicated in the joint interim statement (JIS). Out of the 160 participants, 42.5% were males and 57.5% were females. FPG associated better with MetS and other cardiovascular risk markers, compared to HbA1c. FPG had the largest area under curve for predicting MetS and its components. This study shows a stronger association between FPG and MetS compared with haemoglobin A1c; it also provides evidence of a superior ability of FPG over HbA1c in predicting MetS and other adverse cardiovascular outcomes in apparently heathy normoglycemic individuals.
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Annani-Akollor ME, Laing EF, Osei H, Mensah E, Owiredu EW, Afranie BO, Anto EO. Prevalence of metabolic syndrome and the comparison of fasting plasma glucose and HbA1c as the glycemic criterion for MetS definition in non-diabetic population in Ghana. Diabetol Metab Syndr 2019; 11:26. [PMID: 30949244 PMCID: PMC6431006 DOI: 10.1186/s13098-019-0423-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 03/16/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Glycated hemoglobin (HbA1c), owing to its ability to reflect glycemia over a relatively longer time span, is still been investigated as an adjunct test for fasting plasma glucose (FPG) to identify subjects at risk of metabolic syndrome (MetS) in some Caucasian populations. However, whether or not HbA1c can serve as an adjunct to FPG in the definition of MetS in the Ghanaian population remains unknown. This study determined the prevalence of MetS and evaluated HbA1c ≥ 5.6% and FPG ≥ 5.6 mmol/l as the glycemic component of MetS among non-diabetic population in Ghana. METHODS This was a case-control study conducted at St Francis Xavier Hospital, Assin Fosu, Central Region, Ghana. A total of 264 non-diabetic Ghanaian adults consisting of 158 newly diagnosed hypertensives and 106 normotensives, were recruited for the study. Fasting plasma insulin and glucose, HbA1c, and lipid profile was performed for each respondent. RESULTS Using the FPG as glycemic criterion, the overall MetS prevalence was 46.6%, 37.1%, and 12.5% according by the IDF, NCEP ATP III, and WHO criteria, respectively. The prevalence of MetS using the HbA1c criterion was 54.2%, 52.7%, and 42.4% by the IDF, NCEP ATP III and WHO criteria, respectively. The HbA1c criterion identified more participants with MetS compared to the FPG criterion with a good agreement between HbA1c and FPG using the IDF and NCEP ATP III criteria (κ = 0.484 to 0.899) respectively. However, the overlap between HbA1c and FPG based diagnosis of MetS was limited for the WHO criterion. CONCLUSION The prevalence of metabolic syndrome is high among non-diabetics in Ghana. Introduction of HbA1c in addition to FPG in the screening of MetS improves identification of more people with MetS who would otherwise have been missed when only FPG-based diagnosis of MetS is used; with a substantial agreement with FPG, except when using the WHO criteria.
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Affiliation(s)
- Max Efui Annani-Akollor
- Department of Molecular Medicine, School of Medical Sciences, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Edwin Ferguson Laing
- Department of Molecular Medicine, School of Medical Sciences, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Henry Osei
- Department of Molecular Medicine, School of Medical Sciences, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Evans Mensah
- St Francis Xavier Hospital, Assin Fosu, Central Region Ghana
| | - Eddie-Williams Owiredu
- Department of Molecular Medicine, School of Medical Sciences, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Bright Oppong Afranie
- Department of Molecular Medicine, School of Medical Sciences, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Enoch Odame Anto
- Department of Molecular Medicine, School of Medical Sciences, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
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Giráldez-García C, Sangrós FJ, Díaz-Redondo A, Franch-Nadal J, Serrano R, Díez J, Buil-Cosiales P, García-Soidán FJ, Artola S, Ezkurra P, Carrillo L, Millaruelo JM, Seguí M, Martínez-Candela J, Muñoz P, Goday A, Regidor E. Cardiometabolic Risk Profiles in Patients With Impaired Fasting Glucose and/or Hemoglobin A1c 5.7% to 6.4%: Evidence for a Gradient According to Diagnostic Criteria: The PREDAPS Study. Medicine (Baltimore) 2015; 94:e1935. [PMID: 26554799 PMCID: PMC4915900 DOI: 10.1097/md.0000000000001935] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
It has been suggested that the early detection of individuals with prediabetes can help prevent cardiovascular diseases. The purpose of the current study was to examine the cardiometabolic risk profile in patients with prediabetes according to fasting plasma glucose (FPG) and/or hemoglobin A1c (HbA1c) criteria.Cross-sectional analysis from the 2022 patients in the Cohort study in Primary Health Care on the Evolution of Patients with Prediabetes (PREDAPS Study) was developed. Four glycemic status groups were defined based on American Diabetes Association criteria. Information about cardiovascular risk factors-body mass index, waist circumference, blood pressure, cholesterol, triglycerides, uric acid, gamma-glutamyltransferase, glomerular filtration-and metabolic syndrome components were analyzed. Mean values of clinical and biochemical characteristics and frequencies of metabolic syndrome were estimated adjusting by age, sex, educational level, and family history of diabetes.A linear trend (P < 0.001) was observed in most of the cardiovascular risk factors and in all components of metabolic syndrome. Normoglycemic individuals had the best values, individuals with both criteria of prediabetes had the worst, and individuals with only one-HbA1c or FPG-criterion had an intermediate position. Metabolic syndrome was present in 15.0% (95% confidence interval: 12.6-17.4), 59.5% (54.0-64.9), 62.0% (56.0-68.0), and 76.2% (72.8-79.6) of individuals classified in normoglycemia, isolated HbA1c, isolated FPG, and both criteria groups, respectively.In conclusion, individuals with prediabetes, especially those with both criteria, have worse cardiometabolic risk profile than normoglycemic individuals. These results suggest the need to use both criteria in the clinical practice to identify those individuals with the highest cardiovascular risk, in order to offer them special attention with intensive lifestyle intervention programs.
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Affiliation(s)
- Carolina Giráldez-García
- From the Department of Preventive Medicine and Public Health (History of Science), Universidad Complutense de Madrid (CG-G, ER), Instituto de Investigación Sanitaria del Hospital Clinico San Carlos (IdISSC), Madrid (CG-G, ER), Torrero-La Paz Health Center, Zaragoza (FJS, JMM), Department of Preventive Medicine and Quality Management, Hospital General Universitario Gregorio Marañón, Madrid (AD-R), Raval-Sud Primary Care Team, Barcelona (JF-N), Martín de Vargas Health Center, Madrid (RS), Tafalla Health Center, Navarra (JD), Azpilagaña Primary Care Team, Navarra (PB-C), Porriño Health Center, Pontevedra (JG-S), Hereza Health Center, Madrid (SA), Zumaia Health Center, Guipúzcua (PE), La Victoria de Acentejo Health Center, Santa Cruz de Tenerife (LC), Es Castell Basic Health Unit, Islas Baleares (MS), Yecla Health Center, Murcia (JM-C), Family and Community Medicine Teaching Unit, Cantabria (PM), Endocrinology and Nutrition Department, Del Mar Hospital, Barcelona (AG); and Consortium for Biomedical Research in Epidemiology and Public Health (CIBER en Epidemiología y Salud Pública-CIBERESP), Madrid, Spain (ER)
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Saravia G, Civeira F, Hurtado-Roca Y, Andres E, Leon M, Pocovi M, Ordovas J, Guallar E, Fernandez-Ortiz A, Casasnovas JA, Laclaustra M. Glycated Hemoglobin, Fasting Insulin and the Metabolic Syndrome in Males. Cross-Sectional Analyses of the Aragon Workers' Health Study Baseline. PLoS One 2015; 10:e0132244. [PMID: 26241903 PMCID: PMC4524641 DOI: 10.1371/journal.pone.0132244] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 06/11/2015] [Indexed: 11/18/2022] Open
Abstract
Background and Aims Glycated hemoglobin (HbA1c) is currently used to diagnose diabetes mellitus, while insulin has been relegated to research. Both, however, may help understanding the metabolic syndrome and profiling patients. We examined the association of HbA1c and fasting insulin with clustering of metabolic syndrome criteria and insulin resistance as two essential characteristics of the metabolic syndrome. Methods We used baseline data from 3200 non-diabetic male participants in the Aragon Workers' Health Study. We conducted analysis to estimate age-adjusted odds ratios (ORs) across tertiles of HbA1c and insulin. Fasting glucose and Homeostatic model assessment - Insulin Resistance were used as reference. Here we report the uppermost-to-lowest tertile ORs (95%CI). Results Mean age (SD) was 48.5 (8.8) years and 23% of participants had metabolic syndrome. The ORs for metabolic syndrome criteria tended to be higher across HbA1c than across glucose, except for high blood pressure. Insulin was associated with the criteria more strongly than HbA1c and similarly to Homeostatic model assessment - Insulin Resistance (HOMA-IR). For metabolic syndrome, the OR of HbA1c was 2.68, of insulin, 11.36, of glucose, 7.03, and of HOMA-IR, 14.40. For the clustering of 2 or more non-glycemic criteria, the OR of HbA1c was 2.10, of insulin, 8.94, of glucose, 1.73, and of HOMA-IR, 7.83. All ORs were statistically significant. The areas under the receiver operating characteristics curves for metabolic syndrome were 0.670 (across HbA1c values) and 0.770 (across insulin values), and, for insulin resistance, 0.647 (HbA1c) and 0.995 (insulin). Among non-metabolic syndrome patients, a small insulin elevation identified risk factor clustering. Conclusions HbA1c and specially insulin levels were associated with metabolic syndrome criteria, their clustering, and insulin resistance. Insulin could provide early information in subjects prone to develop metabolic syndrome.
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Affiliation(s)
- Gabriela Saravia
- Department of Epidemiogy, Atherothrombosis and Imaging, Spanish National Center for Cardiovascular Research (CNIC), Madrid, Spain
| | - Fernando Civeira
- Instituto Aragonés de Ciencias de la Salud (I+CS), Zaragoza, Spain
| | - Yamilee Hurtado-Roca
- Department of Epidemiogy, Atherothrombosis and Imaging, Spanish National Center for Cardiovascular Research (CNIC), Madrid, Spain
- Boca Raton Clinical Research Global Peru, Lima, Peru
| | - Eva Andres
- Instituto de Investigación 12 de Octubre. CIBER-Epidemiología y Salud Pública, Madrid, Spain
| | - Montserrat Leon
- Instituto Aragonés de Ciencias de la Salud (I+CS), Zaragoza, Spain
| | - Miguel Pocovi
- Instituto Aragonés de Ciencias de la Salud (I+CS), Zaragoza, Spain
| | - Jose Ordovas
- Department of Epidemiogy, Atherothrombosis and Imaging, Spanish National Center for Cardiovascular Research (CNIC), Madrid, Spain
| | - Eliseo Guallar
- Departments of Epidemiology and Medicine, and Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Antonio Fernandez-Ortiz
- Department of Epidemiogy, Atherothrombosis and Imaging, Spanish National Center for Cardiovascular Research (CNIC), Madrid, Spain
- Hospital Clínico San Carlos, Universidad Complutense, Madrid, Spain
| | | | - Martin Laclaustra
- Department of Epidemiogy, Atherothrombosis and Imaging, Spanish National Center for Cardiovascular Research (CNIC), Madrid, Spain
- Department of Preventive Medicine and Public Health, School of Medicine, Universidad Autonoma de Madrid, Madrid, Spain
- Department of Epidemiology, St. Louis University, St Louis, Missouri, United States of America
- * E-mail:
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Mure K, Yoshimura N, Hashimoto M, Muraki S, Oka H, Tanaka S, Kawaguchi H, Nakamura K, Akune T, Takeshita T. Urinary 8-iso-prostaglandin F2α as a marker of metabolic risks in the general Japanese population: The ROAD study. Obesity (Silver Spring) 2015; 23:1517-24. [PMID: 26054643 DOI: 10.1002/oby.21130] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 01/29/2015] [Accepted: 04/03/2015] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To determine whether 8-iso-prostaglandin F2α (8-iso-PGF2α) is a reliable biomarker of the accumulation of metabolic risks [e.g., overweight, hypertension, impaired glucose tolerance (IGT), and dyslipidemia]. METHODS This was a cross-sectional study of the baseline characteristics of a Japanese general population cohort study: Research on Osteoarthritis/Osteoporosis Against Disability (ROAD). Of 1,690 participants, 1,527 fulfilled all questionnaires and examinations. Free and conjugated urinary 8-iso-PGF2α levels and metabolic syndrome (MetS) components including blood pressure, HbA1c, total cholesterol, high-density lipoprotein cholesterol (HDL-C), and non-HDL-C were analyzed. The data were analyzed by ANCOVA, multiple regression analysis, and multinomial logistic analysis. RESULTS 8-iso-PGF2α was significantly associated with HbA1c and significantly inversely associated with total cholesterol and non-HDL-C. Notably, IGT with an HbA1c cut-off of 5.5% was significantly associated with 8-iso-PGF2α level in participants aged ≤50 years. Multinomial logistic regression analysis revealed 8-iso-PGF2α level was significantly associated with a greater number of MetS risks present; this association was stronger in younger participants. In participants aged ≥71 years, 8-iso-PGF2α was significantly associated with a greater number of MetS risks with higher IGT cut-offs. CONCLUSIONS Urinary 8-iso-PGF2α can be a reliable marker of IGT and the accumulation of MetS risks, especially in younger people.
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Affiliation(s)
- Kanae Mure
- Department of Public Health, Wakayama Medical University School of Medicine, Wakayama, Japan
| | - Noriko Yoshimura
- Department of Joint Disease Research, 22nd Century Medical and Research Center, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Marowa Hashimoto
- Department of Public Health, Wakayama Medical University School of Medicine, Wakayama, Japan
| | - Shigeyuki Muraki
- Department of Clinical Motor System Medicine, 22nd Century Medical and Research Center, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Oka
- Department of Joint Disease Research, 22nd Century Medical and Research Center, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Sakae Tanaka
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | | | - Kozo Nakamura
- National Rehabilitation Center for Persons with Disabilities, Saitama, Japan
| | - Toru Akune
- National Rehabilitation Center for Persons with Disabilities, Saitama, Japan
| | - Tatsuya Takeshita
- Department of Public Health, Wakayama Medical University School of Medicine, Wakayama, Japan
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