Non-dipping blood pressure in the metabolic syndrome among Arabs of the Oman family study

Elevated oxidative stress biomarkers in adults with segmented sleep patterns

STUDY OBJECTIVES

We investigated the association between different sleep patterns and inflammatory and oxidative stress biomarkers in adults.

METHODS

A total of 321 consented adults who fulfilled the inclusion criteria were recruited in this cross-sectional study. The inclusion criteria were mainly based on apparently healthy adults aged 18-59 years. To identify sleep patterns, participants were requested to wear the actigraph for 1 week for 24 hours a day. Fasting blood was collected from each participant at day 8. The blood serum was analyzed for inflammatory and oxidative stress biomarkers. Sleep patterns were defined as monophasic (1 episode of night sleep) biphasic (2 episodes of sleep; night and aternoon siesta), and polyphasic sleep pattern (3 or more sleep episodes).

RESULTS

There was no correlation between night sleep duration, total sleep in 24 hours, and napping among inflammatory and oxidative stress biomarkers: high-sensitivity C-reactive protein, malondialdehyde, total glutathione, and basal oxidizability status. Actigraphy reports showed 3 sleep patterns in this cohort, monophasic (24.3%), biphasic-napping (45.2%) and polyphasic (30.5%). Individuals with segmented sleep patterns were significantly associated with oxidative stress biomarkers. A polyphasic sleep pattern was significantly associated with higher basal oxidizability status (P = .023), whereas a biphasic sleep pattern showed higher malondialdehyde (P = .036) as compared to a monophasic sleep pattern. Total glutathione was significantly higher in monophasic sleepers (P = .046). There was no difference in serum high-sensitivity C-reactive protein among all sleep patterns.

CONCLUSIONS

Segmented sleep in polyphasic and biphasic sleep patterns is associated with higher serum malondialdehyde and basal oxidizability status in particular. Further studies are recommended on the cardiometabolic impact of oxidative stress biomarkers in individuals with segmented sleep.

CITATION

Al Lawati I, Zadjali F, Al-Abri MA. Elevated oxidative stress biomarkers in adults with segmented sleep patterns. J Clin Sleep Med. 2024;20(6):959-966.

High Levels of Thromboxane (TX) Are Associated with the Sex-Dependent Non-Dipping Phenomenon in Ischemic Stroke Patients

BACKGROUND

Inflammation and high blood pressure (nondipping profile) during the rest/sleep period have been associated with an effect on the incidence of cardiovascular disorders and a more severe course in the ischemic cerebrovascular event. There are no available data on the relationship between dipping status and the pro-inflammatory metabolites of arachidonic acid (AA); therefore, we undertook a study to investigate the influence of thromboxane on the incidence of nondipping among patients after stroke.

METHODS

Sixty-two patients with ischemic stroke (including 34 women and 28 men) were tested for the involvement of thromboxane in the nondipping phenomenon. Subjects were analyzed for the presence of the physiological phenomenon of dipping (DIP group) versus its absence-nondipping (NDIP group). Thromboxane (TX) measurements were performed using liquid chromatography, and blood pressure was measured 24 h a day in all subjects.

RESULTS

The analysis of the thromboxane level in the plasma of patients after ischemic stroke showed significant differences in terms of sex (p = 0.0004). Among women in both groups, the concentration of TX was high, while similar levels were observed in the group of men from the NDIP group. However, when comparing men in the DIP and NDIP groups, a lower TX level was noticeable in the DIP group.

CONCLUSIONS

A higher level of TX may be associated with a disturbance of the physiological phenomenon of DIP in men and women. However, in our opinion, TX is not the main determinant of the DIP phenomenon and, at the same time, other pro-inflammatory factors may also be involved in the occurrence of this singularity.

Mucolipidosis Type IV in Omani Families with a Novel MCOLN1 Mutation: Search for Evidence of Founder Effect

Mucolipidosis Type IV (MLIV) is caused by a deficiency of the mucolipin cation channel encoded by Mucolipin TRP Cation Channel 1 gene (MCOLN1). It is a slowly progressive neurodevelopmental and neurodegenerative disorder causing severe psychomotor developmental delay and progressive visual impairment, which is often misdiagnosed as cerebral palsy. We describe six patients with MLIV from two Omani families with a novel c.237+5G>A mutation in the MCOLN1 gene predicted to affect mRNA splicing. Mutation screening with a high-resolution melting (HRM) assay in a large population sample did not detect this mutation in control subjects. This report highlights the importance of considering MLIV in the differential diagnosis of patients in a pediatric age group with cerebral palsy-like presentation. Although the same rare mutation was seen in two apparently unrelated families, this was not seen in the sample screened from the general population. The HRM assay provides a cost-effective assay for population screening for the c.237+5G>A mutation.

Digital sleep measures and white matter health in the Framingham Heart Study

AIM

Impaired sleep quality and sleep oxygenation are common sleep pathologies. This study assessed the impact of these abnormalities on white matter (WM) integrity in an epidemiological cohort.

METHODS

The target population was the Framingham Heart Study Generation-2/Omni-1 Cohorts. Magnetic resonance imaging (diffusion tensor imaging) was used to assess WM integrity. Wearable digital devices were used to assess sleep quality: the (M1-SleepImage™ system) and the Nonin WristOx for nocturnal oxygenation. The M1 device collects trunk actigraphy and the electrocardiogram (ECG); sleep stability indices were computed using cardiopulmonary coupling using the ECG. Two nights of recording were averaged.

RESULTS

Stable sleep was positively associated with WM health. Actigraphic periods of wake during the sleep period were associated with increased mean diffusivity. One marker of sleep fragmentation which covaries with respiratory chemoreflex activation was associated with reduced fractional anisotropy and increased mean diffusivity. Both oxygen desaturation index and oxygen saturation time under 90% were associated with pathological directions of diffusion tensor imaging signals. Gender differences were noted across most variables, with female sex showing the larger and significant impact.

CONCLUSIONS

Sleep quality assessed by a novel digital analysis and sleep hypoxia was associated with WM injury, especially in women.

Wavelet analysis for early identification of HRV changes in offspring with genetic predisposition to hypertension in Oman

BACKGROUND

Offspring with a genetic predisposition to hypertension may have higher blood pressure (BP) at rest compared with those without a genetic predisposition to hypertension. They are also expected to have a higher sympathetic component in the heart rate variability (HRV) which could be computed with signal processing algorithms.

OBJECTIVE

The purpose of this study is to design a wavelet-based system to estimate the heart rate variability that can be used to detect early cardiovascular changes in offspring with a genetic predisposition to hypertension. Early detection will help in the treatment of those young people. In this work, the relation between the hypertension and the changes in HRV is investigated.

METHODS

The frequency domain and time domain analysis of heart rate variability (HRV) are studied to understand their relationship to the autonomic nervous system in offspring with and without a genetic predisposition to hypertension in Oman at resting state. The wavelet-based soft-decision algorithm is used as the spectral analysis tool to obtain different features from the HRV signal and to select the best performing features for detection of hypertension. The main task is to classify between three categories of subjects: 36 subjects with both normotensive parents (ONT), 22 subjects with single hypertensive parent (OHT1), and 11 subjects with both hypertensive parents (OHT2).

RESULTS

The summation of the power of bands B4 and B5 of the 32 bands HRV wavelet-based spectrum, which is equivalent to the frequency range (0.046875 Hz-0.078125 Hz), is used as a classification factor among OHT2, OHT1, and ONT groups. The efficiency of classification between ONT and OHT2 is 85.10%, and between OHT1 and OHT2 is 81.81%. The result of classifying between (ONT and OHT1 as one group) and OHT2 is 85.50%.

CONCLUSIONS

The work proves that the wavelet-based spectral analysis technique is a successful tool for classifying the three groups of subjects (ONT, OHT1, and OHT2) with different susceptibility for development of hypertension.

The Circadian Syndrome: is the Metabolic Syndrome and much more!

The Metabolic Syndrome is a cluster of cardio-metabolic risk factors and comorbidities conveying high risk of both cardiovascular disease and type 2 diabetes. It is responsible for huge socio-economic costs with its resulting morbidity and mortality in most countries. The underlying aetiology of this clustering has been the subject of much debate. More recently, significant interest has focussed on the involvement of the circadian system, a major regulator of almost every aspect of human health and metabolism. The Circadian Syndrome has now been implicated in several chronic diseases including type 2 diabetes and cardiovascular disease. There is now increasing evidence connecting disturbances in circadian rhythm with not only the key components of the Metabolic Syndrome but also its main comorbidities including sleep disturbances, depression, steatohepatitis and cognitive dysfunction. Based on this, we now propose that circadian disruption may be an important underlying aetiological factor for the Metabolic Syndrome and we suggest that it be renamed the 'Circadian Syndrome'. With the increased recognition of the 'Circadian Syndrome', circadian medicine, through the timing of exercise, light exposure, food consumption, dispensing of medications and sleep, is likely to play a much greater role in the maintenance of both individual and population health in the future.

Biomarkers of nondipper hypertension in prehypertensive and hypertensive patients

Aim: The aim of this study was to evaluate the relation of gamma glutamyl transferase (GGT), neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) with nondipper hypertension. Methods: This study included a total of 409 patients. Patients were grouped into hypertension, prehypertension and normotensive groups, according to their clinical blood pressure. All patients were also followed by ambulatory blood pressure. Results: Mean PLR and NLR were higher in the nondippers compared with dippers among both prehypertensive and hypertensive patients. In addition, PLR (OR: 1.011; 95% CI: 1004-1017; p = 0.001), NLR (OR: 2.296, 95% CI: 1634-3225; p < 0.001), and GGT (OR: 1.067; 95% CI: 1042-1092; p < 0.001) were found to be associated with nondipper pattern among whole study population. Conclusion: The PLR, NLR and GGT values are easily accessible and fairly useful, independently associated with nondipper hypertension for both hypertensive and prehypertensive patients.

A Perception on Genome-Wide Genetic Analysis of Metabolic Traits in Arab Populations

Despite dedicated nation-wide efforts to raise awareness against the harmful effects of fast-food consumption and sedentary lifestyle, the Arab population continues to struggle with an increased risk for metabolic disorders. Unlike the European population, the Arab population lacks well-established genetic risk determinants for metabolic disorders, and the transferability of established risk loci to this population has not been satisfactorily demonstrated. The most recent findings have identified over 240 genetic risk loci (with ~400 independent association signals) for type 2 diabetes, but thus far only 25 risk loci (ADAMTS9, ALX4, BCL11A, CDKAL1, CDKN2A/B, COL8A1, DUSP9, FTO, GCK, GNPDA2, HMG20A, HNF1A, HNF1B, HNF4A, IGF2BP2, JAZF1, KCNJ11, KCNQ1, MC4R, PPARγ, SLC30A8, TCF7L2, TFAP2B, TP53INP1, and WFS1) have been replicated in Arab populations. To our knowledge, large-scale population- or family-based association studies are non-existent in this region. Recently, we conducted genome-wide association studies on Arab individuals from Kuwait to delineate the genetic determinants for quantitative traits associated with anthropometry, lipid profile, insulin resistance, and blood pressure levels. Although these studies led to the identification of novel recessive variants, they failed to reproduce the established loci. However, they provided insights into the genetic architecture of the population, the applicability of genetic models based on recessive mode of inheritance, the presence of genetic signatures of inbreeding due to the practice of consanguinity, and the pleiotropic effects of rare disorders on complex metabolic disorders. This perspective presents analysis strategies and study designs for identifying genetic risk variants associated with diabetes and related traits in Arab populations.

Sleep Disturbances as a Risk Factor for Stroke

Sleep, a vital process of human being, is carefully orchestrated by the brain and consists of cyclic transitions between rapid eye movement (REM) and non-REM (NREM) sleep. Autonomic tranquility during NREM sleep is characterized by vagal dominance and stable breathing, providing an opportunity for the cardiovascular-neural axis to restore homeostasis, in response to use, distress or fatigue inflicted during wakefulness. Abrupt irregular swings in sympathovagal balance during REM sleep act as phasic loads on the resting cardiovascular system. Any causes of sleep curtailment or fragmentation such as sleep restriction, sleep apnea, insomnia, periodic limb movements during sleep, and shift work, not only impair cardiovascular restoration but also impose a stress on the cardiovascular system. Sleep disturbances have been reported to play a role in the development of stroke and other cardiovascular disorders. This review aims to provide updated information on the role of abnormal sleep in the development of stroke, to discuss the implications of recent research findings, and to help both stroke clinicians and researchers understand the importance of identification and management of sleep pathology for stroke prevention and care.

The impact of non-dipper circadian rhythm of blood pressure on left ventricular hypertrophy in patients with non-dialysis chronic kidney disease

Objective The aim of this study was to investigate the correlation between non-dipper circadian rhythm of blood pressure (BP) and left ventricular hypertrophy (LVH) in patients with chronic kidney disease (CKD). Methods and results All 257 patients with stage 1 to 5 CKD were enrolled in the study and classified into a CKD1-3 group and a CKD4-5 group according to renal function. The parameters and circadian rhythm of BP were measured by a GE Marquette Tonoport V Eng dynamic sphygmomanometer, and cardiac structure was examined by echocardiography. The incidence of abnormal circadian BP rhythm (non-dipper rhythm) was quite high (75.4% in all enrolled patients and 71.3% in the patients with normal BP levels) in CKD patients and increased with the deterioration of renal function. Changes of cardiac structure such as LVH in patients with non-dipper BP were more distinct than in patients with dipper BP. The development of left ventricular mass index (LVMI) correlated positively with the incidence of non-dipper BP rhythm. Multiple regression analysis showed that 24-h systolic BP (β = 0.417, P < 0.01), triglycerides (TG) (β = -0.132, P = 0.007), Hb (β = -0.394, P = 0.016) and gender (β = 0.158, P = 0.039) were independent risk factors of LVMI. Conclusions The incidence of non-dipper circadian rhythm of blood pressure was quite high in CKD patients and increased with the deterioration of renal function. Non-dipper circadian rhythm of BP is closely related with LVMI.

Assessment of primary healthcare professionals' management of hypertensive patients with riser pattern

BACKGROUND

Ambulatory blood pressure monitoring (ABPM) was implemented in our primary care setting four years ago. Since then, 450 ABPMs have been performed and 69 riser subjects identified. The riser pattern is an independent risk factor for both incidence of cardiovascular events and their associated mortality.

OBJECTIVE

The purpose of this study was to assess the amount of control of essential hypertension (EH) among riser patients and to evaluate how our health professionals manage therapeutic changes in riser individuals.

MATERIALS AND METHODOLOGY

This retrospective study involved 34,289 inhabitants served in a centre in the Barcelona metropolitan area. EH individuals (450) were recruited and ABPM was performed following guidelines of the MAPAPRES (www.cardiorisc.com/MP/index_MP.asp).

RESULTS

Good control of blood pressure was observed in 46% of dipper and non-dipper subjects but only 35% of riser subjects had blood pressures within good control ranges. The measured cardiovascular risk was either high or very high in 35% of riser individuals. Changes in medication were introduced in riser patients with both good and poor blood pressure control. A second follow-up ABPM was done in only 27% of the riser individuals. In these subjects, therapeutic changes successfully modified ABPM patterns in 87% of cases.

CONCLUSIONS

Therapeutic changes in riser patients were introduced when these subjects were poorly controlled and these changes were highly effective. Additional ABPM to confirm the effectiveness of therapeutic changes was only performed in some individuals. Thus, for management of riser patients, more specific training of health professionals is needed.

Relationship between nocturnal blood pressure and 24-h urinary sodium excretion in a rural population in Korea

BACKGROUND

The relationship between sodium intake and blood pressure (BP) is affected by many factors such as absolute level of sodium intake, salt sensitivity, and the accuracy or the timing of the BP measurement. There is no epidemiologic study using both ambulatory BP monitoring (ABPM) and 24-h urine sample in a middle-aged general population.

METHODS

In the rural area, Yeojoo County, Gyunggi Province in South Korea, 218 subjects with age between 30 and 59 years old were measured with ABPM and 24-h urine sample. ABPM device was TM2430, and the 24-h urine sample was collected using the aliquot cup. Metabolic syndrome (MetS) score was calculated by the sum of the number of abnormal criteria other than BP.

RESULTS

For both ABPM and 24-h urine sample, 148 subject data was acceptable for the analysis by the creatinine equation and/or the completeness of collection. Age was 47.4 ± 8.3 years (range 30 to 59 years), and female was 85 (57.4%). In multiple linear regression analysis, sodium intake was not an independent factor for casual BPs and daytime BPs whereas sodium intake was an independent factor for nighttime systolic BP (β = 1.625, p = 0.0026) and nighttime diastolic BP (β = 1.066, p = 0.0017). When compared to the lowest quartiles of sodium intake, daytime diastolic BP and nighttime BPs were in the higher three quartile groups.

CONCLUSIONS

Sodium intake was associated not with casual BPs and daytime BPs but with increased nighttime BPs in the middle-aged general population in Korea.

Associations between nocturnal blood pressure dipping and the metabolic syndrome in high- vs. low-acculturated Mexican American women

BACKGROUND

Less nocturnal blood pressure (BP) dipping has been associated with greater odds for the metabolic syndrome (MetS), a constellation of risk factors associated with cardiovascular disease (CVD). Little work has examined this association in Hispanics, who have elevated rates of MetS, or investigated differences in this relationship by level of acculturation. The purpose of this study was to examine the association between BP dipping and MetS in Hispanic women and to determine if this association is moderated by acculturation status.

METHODS

Two hundred eighty-six Mexican American women underwent assessment of MetS components (BP, waist circumference, fasting glucose, high-density lipoprotein cholesterol, and triglycerides) and completed a 36-hour ambulatory BP monitoring protocol, during which systolic BP (SBP) and diastolic BP readings were obtained. Nocturnal BP dipping was calculated as the percentage difference between average daytime and nighttime BP. Acculturation was defined by the language (Spanish, English) in which participants preferred to complete study instruments.

RESULTS

Although no significant main effects for BP dipping or acculturation emerged for MetS, the SBP dipping by acculturation interaction was significantly related to MetS (P < 0.01). Simple slope analyses revealed that less SBP dipping related to greater odds of MetS in high-acculturated women, but SBP dipping and MetS were unrelated in low-acculturated women.

CONCLUSIONS

The strength of the association between BP dipping and CVD risk (as measured by MetS) appears to vary by acculturation in Hispanic women. Future studies should explore mechanisms behind the BP dipping and CVD risk association and relevant modifying factors.

Association between metabolic syndrome and parameters of 24-hour blood pressure ambulatory monitoring

OBJECTIVE: To investigate associations between metabolic syndrome (MS) and 24-hour blood pressure parameters as a measure of cardiovascular risk (CVR). SUBJECTS AND METHODS: 136 hypertensive subjects, of both sexes, aged between 29 and 83 years were studied. CVR was defined as having at least three of the following conditions: 1) systolic/diastolic blood pressure (BP) ≥ 140/90 mmHg, absence/atennuation of nighttime fall in BP during sleep, pulse pressure (PP) ≥ 53 mmHg; 2) 24-h PP > 53 mmHg, 3) nighttime PP > 53 mmHg, 4) daytime PP > 53 mmHg and 5) nighttime fall in BP during sleep. RESULTS: The 24-h PP, daytime PP and nighttime PP were elevated in 54% of the population. Hypertriglyceridemia (52%), low HDL (72.8%), abdominal obesity (60.3%), MS (58.1%), dyslipidemia (88.8%), overweight (74.3%) and obesity (33.8%) were also elevated. Age-adjusted MS was associated with higher CVR (OR = 4.5 and 3.6), 24-h PP (OR = 2.3 and 4.7), and daytime PP (OR = 2.2 and 4.6). CONCLUSIONS: MS was highly prevalent and correlated with altered 24-hour blood pressure parameters.

Ambulatory blood pressure monitoring in diabetes and obesity-a review

Diabetes mellitus and obesity are both related to the risk of cardiovascular disease and sudden death. In hypertensive guidelines, diabetes and obesity, especially abdominal obesity, are regarded as high-risk factors. Ambulatory blood pressure monitoring (ABPM) is an established method for the management of hypertension. However, ABPM is not a standard tool for the management of hypertension in diabetes and obesity. In this paper, recent data on the use of ABPM in diabetes and obesity will be discussed. In patients with diabetes, the ambulatory BP level has been shown to be better than clinic BP in predicting cardiovascular events. A riser pattern has been associated with increased risk of cardiovascular disease. White-coat hypertension and masked hypertension in diabetics constitute a moderate risk. A nondipping pattern is very common in obese hypertensive patients. In this paper, we will summarize the findings on the use of ABPM in patients with diabetes and obesity.

Ambulatory blood pressure monitoring in type 2 diabetes and metabolic syndrome: a review

We reviewed the literature on ambulatory blood pressure (BP) monitoring in type 2 diabetes mellitus (T2DM) (focusing on organ damage progression, prognosis, white coat hypertension, and masked hypertension) and metabolic syndrome (MetS). In the text we reported 21 articles about T2DM and 11 about MetS, part of which were included in meta-analyses. In T2DM, individual studies and meta-analyses indicate that 24-h pulse pressure and reduced night-time BP fall or reverse dipping predict organ damage progression, total cardiovascular events and all-cause mortality. Moreover, white coat hypertension seems to be less frequent in T2DM and its impact on cardiovascular complications remains controversial. In contrast, masked hypertension is more frequent in T2DM and seems to be associated with increased organ damage. Some studies reported higher ambulatory BP in patients with MetS, but these patients were older and had higher clinical BP than those without MetS. With regard to the circadian BP profile, contrasting data have been reported, although pooled data suggest a higher risk of nondipping in patients with MetS.

Non-dipping pattern in ambulatory blood pressure monitoring is associated with metabolic abnormalities in a random sample of middle-aged subjects

A reduction in the blood pressure decline at night (<10% from daytime systolic blood pressure (SBP)) during 24-h ambulatory blood pressure monitoring (ABPM) ('non-dipping pattern') is associated with cardiovascular morbidity. Our aim was to evaluate whether ABPM characteristics are associated with metabolic abnormalities in subjects without known hypertension or type 2 diabetes mellitus (T2DM). This is a cross-sectional population-based study on middle-aged subjects (n=462). Two distinct definitions of metabolic syndrome (MetS) were used: National Cholesterol Education Program-Third Adult Treatment Panel (NCEP-ATPIII) and International Diabetes Federation (IDF) criteria. Results suggested that subjects characterized by non-dipping in 24 h ABPM were more obese (P=0.014). After adjustment for body mass index, age and sex, non-dippers had higher very-low-density lipoprotein (VLDL)-cholesterol (P=0.003), total (P=0.029)-and VLDL-triglycerides (P=0.026) and oral glucose tolerance test 2 h blood glucose (P=0.027) compared with dippers. Non-dipping status was more common among subjects with MetS (P< or =0.01), impaired glucose tolerance (IGT) (P<0.05) and in those with the combination of IGT-T2DM (P< or =0.01) than among those without these abnormalities. ABPM non-dipping status was an independent predictor of IGT in multivariate models (P<0.05). With respect to MetS components, high triglycerides (P< or =0.005) and low high density lipoprotein-cholesterol (P<0.05) were associated with a non-dipping pattern. The percentage decline in blood pressure from day to night decreased with the number of metabolic abnormalities (P=0.012). In conclusion, ABPM non-dipping status is an independent predictor of glucose intolerance. It is also associated with several other metabolic abnormalities. Whether non-dipping pattern is causally related to these metabolic aberrations remains to be explored in a future prospective follow-up of this cohort.

Prevalence and heritability of clusters for diagnostic components of metabolic syndrome: the Oman family study

BACKGROUND

Prevalence and heritability of metabolic syndrome (MetS) vary between populations according to the currently used criteria. We examined combinations for joint probabilities and heritabilities of MetS criteria from the National Cholesterol Education Program Adult Treatment Panel III (NCEP), World Health Organization (WHO), and International Diabetes Federation (IDF) in a sample of Omani families.

METHODS

We included 1277 subjects from 5 pedigrees. The likelihood ratio of diagnostic cluster dependence over clustering by chance was LDep = P(dependent)/P(independent). Heritabilities were adjusted by sex and age.

RESULTS

The highest LDep were central obesity (CO) + high glucose level (HGl) + triglycerides (IDF, 3.08; NCEP, 4.38; WHO, 3.17; P < 0.001). Triglycerides combined with any other component were the most common cluster. The lowest LDep for IDF were high blood pressure (HBP) + CO + low HDL-C (1.21, P < 0.025); for NCEP were HBP + HGl + low HDL-C (1.21, P < 0.07). These components were gathered almost by chance alone. In contrast, the lowest LDep for WHO were HGl + CO + low HDL-C (2.01, P < 0.001). The WHO criteria yielded the highest heritability for a MetS diagnosis (h(2) = 0.9), followed by NCEP (0.48) and IDF (0.38). The rationale of the MetS diagnostics is based on insulin resistance. This base would be lost if we continue lowering cut-off points for diagnosis for increasing the sensitivity. The WHO showed the highest values for LDep for all components because they used the highest cut-off points.