The metabolic syndrome as a link between smoking and cardiovascular disease

Associations of smoking status with carotid atherosclerosis: Mediated role of blood indexes and blood pressure

BACKGROUND AND AIMS

We aimed to assess the relationship between smoking status and carotid atherosclerosis (CA) with different manifestations and to explore the underlying mechanisms.

METHODS AND RESULTS

A total of 60,655 middle-aged and elderly participants were recruited. Logistic regression models were used to examine the association of smoking, various blood indexes [i.e., blood pressure, blood lipid, glycated hemoglobin (HbA1c) and homocysteine (Hcy)] with CA in different manifestations including carotid intima-media thickness (cIMT), plaques, and stenosis. Compared with nonsmokers, current smokers were associated with a higher prevalence of CA (OR = 3.48, 95%CI: 3.21-3.77) and its specific manifestations including cIMT (OR = 2.66, 95%CI: 2.42-2.93), plaques (OR = 3.67, 95%CI: 3.35-4.02) and stenosis (OR = 2.04, 95%CI: 1.64-2.54), after adjusting for potential confounders. Former smokers were also associated with an increased prevalence of CA (OR = 1.82, 95%CI: 1.54-2.14), cIMT (OR = 1.39, 95%CI: 1.14-1.69), plaques (OR = 2.04, 95%CI: 1.71-2.44) and stenosis (OR = 1.72, 95%CI: 1.18-2.51), but the associations were consistently weaker than that of the current smokers. The prevalence of CA, cIMT, plaques and stenosis among current smokers was positively associated with pack-years of cigarette smoking, partially mediated by SBP, HbA1c, TG, HDL-C and Hcy with a mediated proportion of 1.12%, 3.28%, 6.33%, 6.01% and 12.7%, respectively. Stratified analysis by sex showed a significantly higher CA among the current male smokers than females.

CONCLUSIONS

Current and former smoking was associated with increased carotid atherosclerosis, predominantly by current male smokers. A positive gradient between pack-years and carotid atherosclerosis among current smokers is partially mediated by SBP, HbA1c, TG, HDL-C and Hcy.

The Association between Lifestyle Choices and Schizophrenia Symptoms

Due to poor eating habits, insufficient physical activity, and nicotine use, schizophrenia patients are at increased risk of lifestyle diseases. Factors contributing to unhealthy behaviors include lower socioeconomic status and level of education as well as social isolation. Schizophrenia manifestations such as amotivation, apathy, and cognitive deficits can further hinder development of proper health habits. The aim of this study was to assess the possible association between lifestyle-related choices and schizophrenia symptoms severity. This observational study enrolled 106 patients with schizophrenia (42 Males/64 Females), 18–69 years (mean: 41.89 ± 9.7 years). Mean duration of schizophrenia was 14.61 ± 9.7 years. Multiple significant correlations were found between patients’ lifestyle and their biochemical laboratory parameters (lipid profile and fasting glucose). Most importantly, a significant link emerged between presented habits and schizophrenia symptom severity. There were also significant gender differences in the intake of sweets and sweet beverages. Quite unexpectedly, a behavioral shift towards more healthy lifestyle choices was observed after completion of questionnaires on lifestyle and health habits. There are clear benefits to systematic provision of educational interventions concerning physical activity and proper eating habits to schizophrenia patients. These simple preventive measures could significantly improve both mental and physical health outcomes in schizophrenia patient populations.

Epidemiology, risk factors across the spectrum of age-related metabolic diseases

BACKGROUND

Population aging is dynamic process of increasing proportion of older adults in the total population, which is an inescapable result of decline in fertility rate and extension in life expectancy. Inevitably, age-related metabolic diseases, for example obesity, type 2 diabetes, metabolic syndrome, dyslipidemia, and nonalcoholic fatty liver disease, are becoming epidemic globally along with the demographic transition.

CONTENT

The review examines the literatures related to: 1) the epidemiology of age related metabolic diseases including obesity, type 2 diabetes, metabolic syndrome, dyslipidemia, and nonalcoholic fatty liver disease; and 2) the risk factors of age related metabolic diseases including genetic factors, diet, smoking, Physical activity, intestinal microbiota and environmental factors.

CONCLUSION

Population aging is becoming epidemic worldwide, resulting in increasing incidence and prevalence of a serious of age-related metabolic diseases. Both genetic and environmental factors contribute to the diseases, thus interventions targeting on these factors may have beneficial effect on the development of age-related metabolic diseases.

Biochemical Data and Metabolic Profiles of Male Exclusive Narghile Smokers (ENSs) Compared With Apparently Healthy Nonsmokers (AHNSs)

Studies evaluating the metabolic profiles of ENSs are scarce and presented controversial conclusions. This study aimed to compare the metabolic profiles of ENSs' and AHNSs' groups. Males aged 25-45 years and free from a known history of metabolic and/or cardiovascular diseases were included. According to the smoking status, two groups of ENSs and AHNSs were identified. Body mass index (BMI, kg/m2), waist circumference (WC, cm), systolic and diastolic blood pressures (SBP, DBP, mmHg), fasting blood data in mmol/L (blood glycemia [FBG], triglycerides [TG], total cholesterol [TC], high- and low- density lipoprotein cholesterol [HDL-C, LDL-C]) and obesity status were evaluated. The metabolic syndrome (MetS) was defined according to the 2006 International Diabetes Federation (IDF) recommendations. Data were expressed as mean ± standard deviation ( SD) or percentages. Compared to the AHNSs' group ( n = 29), the ENSs' one ( n = 29) had (a) higher values of BMI (26.5 ± 2.3 vs. 28.2 ± 3.6), WC (95 ± 7 vs. 100 ± 10), and TG (1.22 ± 0.40 vs. 1.87 ± 0.85); and (b) included a lower percentage of males having low HDL-C (82.7% vs. 62.0%), and higher percentages of males having obesity (6.9% vs. 37.9%) or hypertriglyceridemia (10.7% vs. 51.7%). Both the ENSs' and AHNSs' groups: (a) had similar values of FBG (5.38 ± 0.58 vs. 5.60 ± 0.37), TC (4.87 ± 1.16 vs. 4.36 ± 0.74), HDL-C (0.92 ± 0.30 vs. 0.82 ± 0.21), LDL-C (3.09 ± 0.98 vs. 2.92 ± 0.77), SBP (117 ± 9 vs. 115 ± 8), and DBP (76 ± 6 vs. 73 ± 7); and (b) included similar percentages of males having normal weight (17.2% vs. 31.0%); overweight (44.8% vs. 62.1%); android obesity (79.3% vs. 59.6%), hypertension (10.3% vs. 10.3%), hyperglycemia (37.9% vs. 48.2%), and MetS (51.7% vs. 34.5%). There is a need to monitor narghile use among male metabolic patients since it alters some components of the MetS.

The relationship between hypovitaminosis D and metabolic syndrome: a cross sectional study among employees of a private university in Lebanon

BACKGROUND

The prevalence of low vitamin D status and metabolic syndrome is increasing globally and in Lebanon. The objectives of this study are to assess the prevalence of metabolic syndrome (MetS) and its components (elevated triglycerides, low HDL, abdominal obesity defined by high waist circumference, hypertension, impaired fasting blood glucose) and investigate the association between serum 25-hydroxyvitamin D (25(OH)D) concentrations and MetS and its components among a sample of Lebanese adults.

METHODS

A cross-sectional study was carried out on Notre Dame University employees. A background questionnaire, a short-form of the International Physical Activity Questionnaire and a food frequency questionnaire were administered. Participants were invited to the nutrition laboratory to gather data on anthropometric (height, waist circumference, weight, body composition and body mass index) and biochemical measurements (serum vitamin D, triglycerides, HDL and fasting blood glucose). Vitamin D status was assessed according to the Institute of Medicine cut-offs (inadequate or adequate: 25(OH)D < or ≥ 50 nmol/L).The definition of the Third Report of the National Cholesterol Education Program was used to identify individuals who had MetS. The data were analyzed using the SPSS version 22. P < 0.05 was considered statistically significant.

RESULTS

A total of 344 participants (age range of 20 to 74 years) were included in the study. The prevalence of MetS was 23.5%. Among MetS components, central obesity was the most prevalent condition (50.6%), while the least prevalent was impaired fasting blood glucose (20.3%). The odds of having MetS were found to be 2.5 (95% CI 1.3-4.7) higher among those with inadequate vitamin D status, than among those with adequate vitamin D status while controlling for important confounders (age, marital status, education level, income, medical morbidity, smoking and percent body fat and gender). Among the components of MetS, only hypertriglyceridemia (OR: 2.4, 95%CI: 1.3-4.2) and low HDL (OR: 1.8, 95% CI: 1.0-3.0) were associated with inadequate vitamin D status while controlling for important confounders.

CONCLUSIONS

Early identification and control of risk factors for cardiovascular diseases in the primary care level is needed, particularly among adults who have low vitamin D status, are obese, and have low income level.

Using structural equation model to illustrate the relationship between metabolic risk factors and cardiovascular complications in Taiwan

BACKGROUND

The objective of this study was to perform a population-based screening programme to determine the prevalence of the metabolic syndrome (MetS) and the relationship between metabolic risk factors and prevalent cardiovascular complications in Taiwan.

DESIGN

A screening programme recruited residents aged 40 years and older in Sanchih, Taipei County, Taiwan, and collected demographic data, blood and urine samples. Fasting plasma glucose level, serum total cholesterol, high-density lipoprotein cholesterol, and triglyceride were measured. Atherosclerotic complications, including myocardial infarction, stress-positive angina, ischaemic stroke, and proteinuria were confirmed.

METHODS

A structural equation model (SEM) was constructed to identify the association between metabolic abnormality and atherosclerosis.

RESULTS

A total of 1494 subjects, 776 male and 718 female, were recruited in this study. The crude prevalence of the MetS was 19.3% for men [95% confidence interval (CI) 16.3-22.2%] and 18.7% for women (95% CI 15.6-22.0%). The presence of the MetS posed a substantial risk to microvascular complications in both sexes [odds ratio (OR) 3.29, P<0.001] and to macrovascular complications in men (OR 1.95, P=0.04) and also a trend in women (OR 2.24, P=0.089). There was a positive association between metabolic abnormality and atherosclerosis (B=0.55, P<0.001).

CONCLUSIONS

This study has found the prevalence of the MetS and the association with atherosclerotic complications in Taiwan. The SEM approach has demonstrated a positive correlation between metabolic abnormality and atherosclerosis and can be used to explore new risk factors for cardiovascular diseases.

Metabolic syndrome, glucose tolerance categories and the cardiovascular risk in Spanish population

We examined the prevalence of metabolic syndrome (MetS), glucose tolerance categories and risk factors of cardiovascular-disease (CVD) in the general Spanish population. We studied 3844 randomly sampled subjects (46% males) aged 35-74 years. Glucose tolerance categories were defined according to the 2003 ADA and MetS according to the Harmonized Consensus Criteria with waist circumference (WC) cut-off-points previously reported in Spanish population (≥94.5/≥89.5cm for males/females). The prevalences of normoglycemia (NG), impaired fasting glucose (IFG), impaired glucose tolerance (IGT), IFG and IGT considered together (IFG/IGT), and diabetes mellitus (DM) were 67.6/16.6/5.0/3.3, and 7.5%, respectively. The overall prevalence of MetS was 31.2%. In subjects with NG, IFG, IGT, IFG/IGT, and DM the MetS prevalence's were 16.3/57.1/31.5/66.1, and 74.4% (p<0.001), respectively. MetS was more common in males, older subjects, smokers, and/or individuals with obesity, IFG, IFG/IGT, DM, or insulin resistance (HOMA-IR ≥3.8). MetS was less prevalent in individuals with low alcohol intake and/or high education level. Regarding the risk level of CVD estimated by Framingham and SCORE risk charts, IGT had higher estimated CVD-risk than IFG and IFG/IGT. The presence of MetS increases the risk 4.85 times by Framingham and 2.43 times by SCORE. Prevalence of prediabetes (IFG/IGT) and MetS were 25% and 31.2% respectively. Prevalence of MetS has not changed in the past decade in Spanish females, but has slightly increased in males. We found that subjects with IGT showed a higher risk of CVD than IFG and IFG/IGT according to the Framingham and SCORE. MetS increased the CVD-risk previously estimated by Framingham and SCORE.

Klotho-related Molecules Upregulated by Smoking Habit in Apparently Healthy Men: A Cross-sectional Study

While aging is unavoidable, the aging mechanism is still unclear because of its complexity. Smoking causes premature death and is considered as an environmental aging accelerator. In the present study, we focused on the influence of smoking to the serum concentration of anti-aging protein α-klotho (αKl) and the β-klotho-associated protein fibroblast growth factor (FGF)-21 in men. Subjects consisted of apparently healthy men over 40 years of age who underwent health examination. Physical and biochemical parameters, including the levels of several cytokines and growth factors, were obtained from the subjects. Among middle-aged men (46.1 ± 5.1 years), serum levels of FGF-21, soluble αKl (sαKl), and inflammation-related cytokine interleukin (IL)-6 were significantly higher in smokers than in never-smokers. Serum levels of FGF-21 increased and correlated with alanine transaminase, γ guanosine-5′-triphosphate, and total cholesterol only in smokers, suggesting FGF-21 as a metabolic disorder-related factor in smokers. In aged men (60.3 ± 1.7 years), although the serum levels of sαKl in never-smokers were low, smokers showed highly increased serum levels of sαKl. Serum levels of sαKl was correlated with IL-6 in middle-aged never-smokers, suggesting sαKl regulates IL-6. However, this correlation was disrupted in smokers and aged men.

The Relationship between Smoking Level and Metabolic Syndrome in Male Health Check-up Examinees over 40 Years of Age

BACKGROUND

The objective of this study was to investigate the relationship between smoking and metabolic syndrome in men.

METHODS

This cross-sectional study included 1,852 men over age 40 who underwent health screening from April 2009 to December 2010. We classified them into three smoking levels as non-, intermediate-, and heavy-smoker, considering their smoking status (non, ex, current) and amount (0, 1-29, ≥30 pack year [PYR]). The relationship between smoking level and metabolic syndrome was analyzed by logistic regression analysis, after covariates (age, body mass index, education, house income, alcohol intake, and physical activity) were controlled.

RESULTS

The proportions of non-, intermediate-, and heavy-smokers were 31.8%, 56.2%, and 12.0%, respectively. Odds ratios (ORs) and 95% confidence intervals (95% CIs) for metabolic syndrome were 1.0, 1.58 (1.09-2.23), 1.92 (1.29-2.81) in non-, intermediate-, and heavy-smokers, respectively. For heavy-smokers compared with non-smokers, ORs and 95% CIs of a lower high density lipoprotein cholesterol, higher triglyceride, and higher fasting glucose were 2.47 (1.63-3.74), 1.71 (1.17-2.52), and 1.43 (1.02-2.00), respectively. In current-smokers, we divided into three subgroups according to PYR, and compared with 1-19 PYR, ORs and 95% CIs of 20-29 PYR and ≥30 PYR for metabolic syndrome were 2.07 (1.14-3.74) and 3.06 (1.66-5.62), respectively.

CONCLUSION

This study showed a positive dose-response relationship between smoking level and metabolic syndrome in men.

Association of cigarette smoking and metabolic syndrome in a Puerto Rican adult population

Metabolic syndrome (MetSyn) is related to an increased risk for type 2 diabetes and cardiovascular disease. Smokers are at greater risk than nonsmokers of becoming insulin resistant and to develop cardiovascular disease. This study aimed to explore the association between cigarette smoking, MetSyn and its components among Puerto Rican adults. A representative sample of 856 persons aged 21-79 years from the San Juan Metropolitan area participated in this study. Demographic and lifestyle characteristics, including smoking habits, were gathered from a self-reported questionnaire. MetSyn was defined according to the revised NCEP-ATP III criteria and measured using biochemical measurements and anthropometric indices. Logistic regression models were used to estimate prevalence odds ratios (POR) and its 95 % confidence intervals (CI). MetSyn was significantly (P < 0.001) more prevalent in former smokers (48.4 %) as compared to current (42.7 %) and never smokers (40.0 %). However, after adjusting for possible confounders, current smokers who used more than 20 cigarettes per day were 2.24 (95 % CI = 1.00-4.99) times more likely to have MetSyn as compared to never smokers. Heavy smokers were also more likely to have high triglyceride levels (POR = 2.22, 95 % CI = 1.12-4.38) and low HDL-cholesterol levels (POR = 2.49, 95 % CI = 1.28-4.86) as compared to never smokers. This study supports previous reports of an increased risk of MetSyn among current smokers, particularly those with a heavier consumption. Tobacco control strategies, such as preventing smoking initiation and disseminating evidence-based cessation programs, are necessary to reduce the burden of MetSyn in Puerto Rico.

High serum phosphate and triglyceride levels in smoking women and men with CVD risk and type 2 diabetes

BACKGROUND

Both low and high serum phosphate levels may be associated with morbidity and mortality from cardiovascular disease. As smoking increases risk for type 2 diabetes (as shown by dyslipidemia and hyperglycemia), we wanted to study whether smoking and type 2 diabetes were associated with serum phosphate and triglyceride levels independently from other CVD risk factors.

METHODS

Upon admittance to the Vindeln Health Education Centre (VHE-centre) for a four-week comprehensive lifestyle intervention, the participants (1408 women and 1096 men) completed a questionnaire that included their smoking habits - current smoker or non-smoker. We used multiple linear regression analyses to investigate the association between smoking and other CVD risk factors with S-P and S-TG levels.

RESULTS

In the non-type 2 diabetes populations, the smokers, compared to the non-smokers, had higher S-P and higher serum triglycerides (S-TG). In women, serum-TG in smokers with type 2 diabetes was higher than in smokers with non-type 2 diabetes. Non-type 2 diabetes patients exhibited an inverse relation between S-Glucose (S-Glu) and S-P and a positive association with S-TG. For men only, an association was seen between age (-) and S-Crea (-) and S-P. For women only, an association was seen between BMI (-) and S-Cholesterol (+) (S-Chol) and S-P.

CONCLUSIONS

Compared to non-smokers, smoking women with non-type 2 diabetes and smoking men with type 2 diabetes had a higher level of S-P and S-TG. The association between smoking and S-P and S-TG levels still existed after adjusting for age and CVD risk factors in the multiple linear regression analyses.

TRIAL REGISTRATION

The study has been registered as a sub-study to the Lifestyle Intervention Trial no. ISRCTN79355192.

Smoking associates with visceral fat accumulation especially in women

BACKGROUND

Smoking and metabolic syndrome (MetS) are major public health problems in modern society and are important risk factors of cardiovascular disease (CVD). The association of smoking, MetS, and CVD is widely reported, but reports targeted to women are few. In the present study, we evaluated risk factors, including visceral fat area (VFA), for CVD and development of subclinical atherosclerosis in female smokers especially.

METHODS AND RESULTS

Subjects consisted of 162 apparent healthy female and male smokers, and 315 age-matched never-smokers who underwent a health examination in the Osaka University Health Care Center. For female smokers, lifestyle and carotid intima-media thickness (IMT) were evaluated. Triglycerides were significantly higher and high-density lipoprotein-cholesterol significantly lower in smokers than in never-smokers for both men and women. However, VFA was significantly high only in smoking women when compared with never-smokers. Multivariate analysis revealed that age, body mass index, and smoking were the independent predictors of high VFA in women. In addition, annual IMT increase was significantly higher in smokers than never-smokers in women.

CONCLUSIONS

VFA was notably high in female smokers, but the difference was not observed in men. Smoking habit is an important risk factor of visceral fat accumulation and progression of subclinical atherosclerosis in women.

Water-pipe smoking and metabolic syndrome: a population-based study

Water-pipe (WP) smoking has significantly increased in the last decade worldwide. Compelling evidence suggests that the toxicants in WP smoke are similar to that of cigarette smoke. The WP smoking in a single session could have acute harmful health effects even worse than cigarette smoking. However, there is no evidence as such on long term WP smoking and its impact on chronic health conditions particularly cardiovascular and metabolic conditions. Therefore, we conducted this study to investigate the relationship between WP smoking and metabolic syndrome (MetS). This was a cross-sectional study carried out in Punjab province of Pakistan using the baseline data of a population-based study – Urban Rural Chronic Diseases Study (URCDS). Information was collected by trained nurses regarding the socio-demographic profile, lifestyle factors including WP smoking, current and past illnesses. A blood sample was obtained for measurement of complete blood count, lipid profile and fasting glucose level. MetS was ascertained by using the International Diabetic Federation’s criteria. We carried out multiple logistic regressions to investigate the association between WP smoking and MetS. Final sample included 2,032 individuals – of those 325 (16.0%) were current WP smokers. Age adjusted-prevalence of MetS was significantly higher among current WP smokers (33.1%) compared with non-smokers (14.8%). Water-pipe smokers were three times more likely to have MetS (OR 3.21, 95% CI 2.38–4.33) compared with non-smokers after adjustment for age, sex and social class. WP smokers were significantly more likely to have hypertriglyceridemia (OR 1.63, 95% CI 1.25–2.10), hyperglycaemia (OR 1.82, 95% CI 1.37–2.41), Hypertension (OR 1.95, 95% CI 1.51–2.51) and abdominal obesity (OR 1.93, 95% CI 1.52–2.45). However, there were no significant differences in HDL level between WP smokers and non-smokers. This study suggests that WP smoking has a significant positive (harmful) relationship with MetS and its components.

Tobacco and metabolic syndrome

Tobacco is a leading contributor to morbidity and mortality globally. Metabolic syndrome is a constellation of abdominal obesity, atherogenic dyslipidemia, raised blood pressure, insulin resistance (with and without glucose intolerance), pro-inflammatory state, and pro-thrombotic state. Tobacco use is associated with various core components of metabolic syndrome. It has been found to play a causal role in various pathways leading on to development this condition, the current article discusses various facets of this association.

Dietary, behavioural and socio-economic determinants of the metabolic syndrome among adults in Luxembourg: findings from the ORISCAV-LUX study

OBJECTIVE

The purpose of the present research was to investigate the epidemiological profile of the metabolic syndrome (MetS) and to explore its potential dietary, behavioural and socio-economic determinants among European adults residing in Luxembourg.

DESIGN

Cross-sectional, population-based ORISCAV-LUX survey.

SETTING

European adults aged 18-69 years residing in Luxembourg.

SUBJECTS

A total of 1349 Europid adults, who participated in the ORISCAV-LUX survey, were included in the study. The prevalence of MetS was estimated according to the Revised-Adult Treatment Panel (R-ATPIII) criteria. Multivariate logistic regression was used to identify the dietary, behavioural and socio-economic factors independently associated with MetS.

RESULTS

The overall prevalence of MetS was 24.7 % with significant gender difference (18.5 % for women v. 30.8 % for men, P < 0.0001). Age, male gender, primary level of education, physical inactivity, family history of diabetes and hypertension and inadequate protein intake were identified as significant determinants of MetS, after adjusting for other socio-economic, family medical history and lifestyle factors.

CONCLUSIONS

MetS is a common condition among Europid adults in Luxembourg and increases dramatically with age, in both genders. Several dietary, socio-economic and behavioural factors explain the disparity observed. These findings highlight the importance of a comprehensive approach to MetS encompassing dietary, lifestyle and socio-economic aspects, both in clinical and community settings.

Relationships of cigarette smoking and alcohol consumption to metabolic syndrome in Japanese men

BACKGROUND

Cigarette smoking is an important, aggravating factor in metabolic syndrome (MetS). In addition, some studies have reported that MetS is related to alcohol consumption irrespective of the amount consumed. However, the relationship of the combination of the 2 habits to MetS has not been fully described.

METHODS

In this cross-sectional survey, a questionnaire was used to collect information on cigarette smoking and alcohol consumption from 3904 Japanese men aged 20 years or older. MetS was defined according to Japanese criteria. Logistic regression analysis was used to analyze relationships of cigarette smoking and alcohol consumption with MetS, after adjustment for potential confounding factors.

RESULTS

Among the subjects, 581 (14.9%) had MetS. Daily cigarette and alcohol consumption were significantly associated with the prevalence of MetS (P < 0.0001, P = 0.030 for trend). The multivariate-adjusted odds ratio for the prevalence of MetS was 1.89 (95% confidence interval: 1.34-2.65) for subjects who smoked ≥30 cigarettes/day, as compared with nonsmokers; 1.54 (1.06-2.23) for those who consumed ≥69 grams of ethanol/day, as compared with nondrinkers; and 3.63 (1.91-6.90) for those who smoked ≥30 cigarettes/day and consumed ≥69 grams of ethanol/day, as compared with those who neither smoked nor drank. The interaction of smoking ≥30 cigarettes/day with drinking ≥69 grams/day was 2.03 (1.02-4.01, P = 0.043).

CONCLUSIONS

Cigarette smoking and alcohol drinking had independent relations to the prevalence of MetS. In addition, the prevalence of MetS was higher among Japanese men who smoked and drank heavily.

[Association of current and past smoking with metabolic syndrome in men]

OBJECTIVES

The objective of this study was to determine the relationship between past smoking and the risk factors for metabolic syndrome.

METHODS

From January 2007 to December 2007, a total of 3,916 over thirty years old male health screen examinees were divided into the nonsmoking, smoking, ex-smoking groups. The diagnosis of metabolic syndrome was based on the criteria of the NCEP ATP (Executive Summary of The Third Report of The National Cholesterol Education Program). Metabolic syndrome was defined as the presence of three or more of the following: a blood pressure > or =130/85 mmHg, a fasting glucose level > or = 110 mg/dL, a HDL-C (High Density Lipoprotein Cholesterol) level < 40 mg/dL, a triglyceride level > or = 150 mg/dL and, a waist circumference men > or = 102 cm, but a waist to hip ratio > 0.90 was used as a surrogate for the waist circumference.

RESULTS

After adjustment for age, alcohol consumption and, exercise in the smokers, for the ex-smokers compared with the nonsmokers, the odds ratio (OR) of a lower HDL cholesterol level (< 40 mg/dL) was 1.29 (95% CI=1.03-1.61) in the smokers, the ORs of a higher triglyceride level were 1.35 (95% CI=1.09-1.66) in the ex-smokers and, 2.12 (95% CI=1.75-2.57) in the smokers, and the OR of a waist to hip ratio was 1.25 (95% CI=1.03-1.52) in the ex-smokers. When there were over three components of metabolic syndrome in the ex-smokers and smokers as compared with the nonsmokers, the odds ratio against the risk of metabolic syndrome were 2.39 (95% CI=1.00-6.63) and 2.37 (95% CI=1.02-6.46), respectively.

CONCLUSIONS

The present study suggested that there is an association of smoking with metabolic syndrome in men.

Comparison of insulin resistance, metabolic syndrome and adiponectin in overweight bipolar patients taking sodium valproate and controls

OBJECTIVE

Metabolic abnormalities in patients with bipolar disorder may be secondary to obesity, aspects of the disorder or its treatment. To investigate this further, the purpose the present study was to compare insulin resistance, components of the metabolic syndrome and adiponectin levels in a group of overweight bipolar patients taking sodium valproate and a group of non-psychiatric control subjects.

METHODS

Data were collected from 60 overweight bipolar patients who had experienced clinically significant weight gain thought to be related to sodium valproate treatment and from 60 control subjects without psychiatric illness matched for age, gender, body mass index and ethnicity.

RESULTS

The frequency of the metabolic syndrome was high in both groups (50% and 32%, respectively), although not significantly different between groups (p = 0.06). Similar frequencies of insulin resistance (HOMA-IR), abdominal obesity, hypertriglyceridaemia, hypertension and fasting hyperglycaemia were found in both groups. High-density lipoprotein cholesterol levels were lower in patients (p = 0.006), while adiponectin was unexpectedly higher than in control subjects (9.6+/-5.9 microg mL(-1) vs 7.4+/-4.3 microg mL(-1), p = 0.03). The frequencies of insulin resistance (HOMA-IR), the metabolic syndrome and its individual components were not significantly different in patients taking atypical antipsychotic medication and patients not on these medications.

CONCLUSIONS

Frequencies of insulin resistance and the metabolic syndrome were similar in bipolar patients taking sodium valproate and matched control subjects, but dyslipidaemia was more frequent. Adiponectin levels were higher in patients. Further research is required to clarify the reasons for these findings.

The metabolic syndrome, insulin resistance, and its surrogates in African and white subjects with type 2 diabetes in South Africa

BACKGROUND

Coronary heart disease (CHD) is rare in diabetic Africans in South Africa, unlike diabetic African-Americans, despite moderate levels of conventional risk factors, with absence of the usual male predominance. Because the metabolic syndrome and insulin resistance (IR) are associated with CHD, we have analyzed the prevalence and severity of the metabolic syndrome, and IR, in African and white subjects with type 2 diabetes.

METHODS

A total of 500 African and 254 white diabetic patients were evaluated for features of the metabolic syndrome (International Diabetes Federation [IDF] definition); insulin resistance (homeostasis model assessment-insulin resistance [HOMA-IR]) was calculated in subgroups.

RESULTS

In men, Africans had a lower body mass index (BMI) and smaller waists than white subjects (p < 0.0001); the metabolic syndrome was present in 46.5% and 74.1% of African and white patients respectively (p < 0.0001). In women, frequencies of the metabolic syndrome were similar, but severe metabolic syndrome (4 or 5 criteria) was more frequent in the white group (73.1%) than in the Africans (52.9%) (p = 0.0003). The prevalence of hypertriglyceridemia was lower in African men and women (p < 0.0001) and contributed to their lower prevalence of the metabolic syndrome/severe metabolic syndrome. Compared with the white patients, in African subjects HOMA-IR was 40% lower (p < 0.0001), and correlated with the triglyceride:high-density lipoprotein cholesterol ratio (TG:HDL-C) (r = 0.409, p < 0.0001).

CONCLUSIONS

In diabetic Africans, in comparison with white patients, the lower prevalence of the metabolic syndrome in men and severe metabolic syndrome in women, and lesser insulin resistance, might contribute to their lower risk of CHD; the higher prevalence in women might contribute to the reversal of the male:female ratio. The TG:HDL-C ratio appears to be a valid estimate of insulin resistance in diabetic Africans.

The effects of pre-disease risk factors within metabolic syndrome on all-cause and cardiovascular disease mortality

The metabolic syndrome has been criticized for being "polluted with the inclusion of frank "diseases" with "pre-diseases". We assessed the effect of a single and a combination of "pre-disease" risk factors of metabolic syndrome on the overall and cardiovascular disease (CVD) mortality. These pre-disease risk factors included pre-diabetes, pre-hypertension, overweight and borderline hypertriglycerdemia and were defined as: fasting glucose at 110-125 mg/dL, systolic blood pressure at 120-139 mmHg, body mass index at 25-29.9 kg/m(2) and serum triglyceride at 150-199 mg/dL, respectively. The metabolic syndrome in this paper was based on the version defined by the ATP III. The cohort consisted of 35,259 adults (>==40 years) with a medium follow-up of 15 years. Relative risks (RRs) for all-causes, CVD and "CVD plus diabetes" mortality were calculated with the Cox proportional hazards model. Prevalence of the pre-disease risk factors (40.2%) was nearly four times larger than the metabolic syndrome (10.6%). Individual pre-disease risk factor was associated with significant increases of 13% and 67% (pre-diabetes), 22% and 62% (pre-hypertension), 23% and 32% (overweight) and 17% and 46% (borderline hypertriglyceridemia) on all-cause and "CVD plus diabetes" mortality, respectively. Smoking had comparable risks as "pre-diseases", and, as such, should also be considered as the fifth "pre-disease". Like metabolic syndrome, each "Pre-disease" is a major and significant risk factor for all cause and cardiovascular mortality, but unlike metabolic syndrome, the definition or clinical follow up of "Pre-disease" is simple and straightforward. Recognizing each of the four "pre-disease" as a clinical entity, a hitherto sub-clinical status but involving significantly increased mortality, can alert and justify early intervention through changing lifestyle and modifying biologic risk factors.

Optimizing management of metabolic syndrome to reduce risk: focus on life-style

The prevalence of metabolic syndrome (MS) is increasing all over the world and its incidence is expected to rise in the next years. Although genetic predisposition appears to play an important role in the regulation of metabolic parameters and in particular of body weight, the rapid increase in the prevalence of obesity and MS suggests that ecological factors (social, economic, cultural and physical environment) are promoting those conditions in susceptible individuals. People with MS are at increased risk of type 2 diabetes and cardiovascular disease and therefore they represent a priority target for preventive strategies. Life-style modifications based on healthy diet and increased physical activity are an effective preventing and therapeutic approach. Unfortunately, implementation of life-style modification and maintenance of effects is a difficult task both at personal and social level, thus drug therapy can be taken into account.

Consequences of smoking for body weight, body fat distribution, and insulin resistance

Our aim was to critically evaluate the relations among smoking, body weight, body fat distribution, and insulin resistance as reported in the literature. In the short term, nicotine increases energy expenditure and could reduce appetite, which may explain why smokers tend to have lower body weight than do nonsmokers and why smoking cessation is frequently followed by weight gain. In contrast, heavy smokers tend to have greater body weight than do light smokers or nonsmokers, which likely reflects a clustering of risky behaviors (eg, low degree of physical activity, poor diet, and smoking) that is conducive to weight gain. Other factors, such as weight cycling, could also be involved. In addition, smoking increases insulin resistance and is associated with central fat accumulation. As a result, smoking increases the risk of metabolic syndrome and diabetes, and these factors increase risk of cardiovascular disease. In the context of the worldwide obesity epidemic and a high prevalence of smoking, the greater risk of (central) obesity and insulin resistance among smokers is a matter of major concern.

Detrimental metabolic effects of combining long-term cigarette smoke exposure and high-fat diet in mice

Obesity and cigarette smoking are both important risk factors for insulin resistance, cardiovascular disease, and cancer. Smoking reduces appetite, which makes many people reluctant to quit. Few studies have documented the metabolic impact of combined smoke exposure (se) and high-fat-diet (HFD). Neuropeptide Y (NPY) is a powerful hypothalamic feeding stimulator that promotes obesity. We investigated how chronic se affects caloric intake, adiposity, plasma hormones, inflammatory mediators, and hypothalamic NPY peptide in animals fed a palatable HFD. Balb/c mice (5 wk old, male) were exposed to smoke (2 cigarettes, twice/day, 6 days/wk, for 7 wk) with or without HFD. Sham-exposed mice were handled similarly without se. Plasma leptin, hypothalamic NPY, and adipose triglyceride lipase (ATGL) mRNA were measured. HFD induced a 2.3-fold increase in caloric intake, increased adiposity, and glucose in both sham and se cohorts. Smoke exposure decreased caloric intake by 23%, with reduced body weight in both dietary groups. Fat mass and glucose were reduced only by se in the chow-fed animals. ATGL mRNA was reduced by HFD in se animals. Total hypothalamic NPY was reduced by HFD, but only in sham-exposed animals; se increased arcuate NPY. We conclude that although se ameliorated hyperphagia and reversed the weight gain associated with HFD, it failed to reverse fat accumulation and hyperglycemia. The reduced ATGL mRNA expression induced by combined HFD and se may contribute to fat retention. Our data support a powerful health message that smoking in the presence of an unhealthy Western diet increases metabolic disorders and fat accumulation.

Unfairness and the social gradient of metabolic syndrome in the Whitehall II Study

OBJECTIVES

Little work has investigated the relationship between unfairness and risk factors for heart disease. We examine the role of unfairness in predicting the metabolic syndrome and explaining the social gradient of the metabolic syndrome.

METHODS

The design is a prospective study with an average follow-up of 5.8 years. Participants were 4128 males and 1715 females of 20 civil service departments in London (Whitehall II study). Sociodemographics, unfairness, employment grade, behavioral risk factors, and other psychosocial factors were measured at baseline (Phase 3, 1991-1993). Waist circumference, triglycerides, high-density lipoprotein (HDL) cholesterol, fasting glucose, and hypertension were used to define metabolic syndrome at follow-up (Phase 5, 1997-2000), according to the National Cholesterol Education Program/Adult Treatment Panel III guidelines.

RESULTS

Unfairness is positively associated with waist circumference, hypertension, triglycerides, and fasting glucose and negatively associated with serum HDL cholesterol. High levels of unfairness are also associated with the metabolic syndrome [odds ratio (OR)=1.72, 95% CI=1.31-2.25], after adjustment for age and gender. After additional adjustment for employment grade, behavioral risk factors, and other psychosocial factors, the relationship between high unfairness and metabolic syndrome weakened but remained significant (OR=1.37, 95% CI=1.00-1.93). When adjusting for unfairness, the social gradient of metabolic syndrome was reduced by approximately 10%.

CONCLUSION

Unfairness may be a risk factor for the metabolic syndrome and its components. Future research is needed to study the biological mechanisms linking unfairness and the metabolic syndrome.

Smoking is associated with urinary albumin excretion: an evaluation of premenopausal patients with type 2 diabetes mellitus

Cigarette smoking and an increase in urinary albumin excretion are associated with high mortality in patients with type 2 diabetes mellitus. We tested the hypothesis that the presence of a smoking habit correlates with increased urinary albumin excretion in premenopausal Japanese women with type 2 diabetes mellitus. The study consisted of 20 premenopausal Japanese patients with type 2 diabetes mellitus in the current-smokers group (age, 45 +/- 4 years, mean +/- SD). The control group consisted of 35 age-matched never-smoker patients (age, 45 +/- 5 years). Serum triglyceride levels were higher and high-density lipoprotein cholesterol levels were lower in the current-smokers group than in the never-smokers group (P < .05 and P < .01, respectively). Furthermore, fasting plasma insulin concentrations and the homeostasis model assessment index were higher in the current-smokers group than in the never-smokers group (P < .005 and P < .001, respectively). Urinary albumin excretion also was higher in the current-smokers group than in the never-smokers group (P < .0001). Multivariate logistic analysis revealed that urinary albumin excretion is independently associated with current smoking in Japanese premenopausal with type 2 diabetes mellitus (odds ratio, 1.79; 95% confidence interval, 1.08-3.87; P < .01). The results of this study show that current smoking is associated with an increased level of urinary albumin excretion, suggesting that smoking was a risk factor in the development of increased urinary albumin excretion in these patients.

Lifecourse predictors of normal metabolic parameters in overweight and obese adults

OBJECTIVE

Not all overweight and obese individuals appear to be at equal risk of developing metabolic abnormalities. We sought to examine the effect of factors from different stages of life on risk of metabolic abnormalities at age 50 years in overweight and obese adults.

DESIGN AND SUBJECTS

Longitudinal study of all persons born in Newcastle upon Tyne, UK in May and June 1947 and followed to age 50 years when a clinical examination took place and a detailed questionnaire on health and lifestyle was completed. Participants in this study (n=223) were those defined as being overweight or obese with a body mass index (BMI) greater than or equal to 25 at age 50 years. Subjects were defined as 'metabolically normal' if they had normal lipids, glucose and blood pressure.

RESULTS

Lower BMI was the strongest predictor of remaining metabolically normal in both men and women. After adjusting for BMI, lower levels of cigarette smoking and higher levels of physical activity were independently associated with being metabolically normal in men. No other factors were independently associated with being metabolically normal in women. A stronger inverse relationship between BMI and metabolic status was found in men (Odds ratio (OR) per unit increase in BMI=0.65, 95% confidence intervals (95% CI) 0.52-0.81) than in women (OR=0.90, 95% CI 0.82-0.99). No association was seen for factors operating in fetal, infant and childhood life.

CONCLUSIONS

Adult factors made a greater contribution to remaining metabolically normal than birth or childhood factors in this sample of overweight and obese adults. A lower adult BMI appeared to reduce the risk in men and women and lower cigarette smoking and higher level of physical activity also independently reduced the risk in men. Public health policy to reduce the burden of morbidity associated with obesity should continue to encourage weight loss, physical activity and smoking cessation.

The impact of central obesity as a prerequisite for the diagnosis of metabolic syndrome

OBJECTIVE

To compare the prevalence of metabolic syndrome (MS) defined according to the American Heart Association (AHA)/National Heart Lung and Blood Institute (NHLBI) and the International Diabetes Federation (IDF) and to determine the effect of the presence of central obesity on the phenotype (insulin resistance and other cardiovascular risk factors) associated with MS.

RESEARCH METHODS AND PROCEDURES

We studied 4723 Chinese, Malays, and Asian Indians living in Singapore. Each individual was categorized according to the five criteria for MS as defined by the AHA/NHLBI and the IDF. The population was categorized according to the presence of three or more criteria and then further subcategorized according to the presence or absence of central obesity. Characteristics of each group were compared using ANOVA and the chi2 test.

RESULTS

MS was present in 20.2% (IDF) and 26.9% (AHA/NHLBI) of the population. Of the population, 6.7% exhibited three or more features of MS without central obesity. Use of the IDF definition, which requires central obesity, is associated with greater insulin resistance but similar levels of other cardiovascular disease risk factors than the use of the AHA/NHLBI definition, which does not require central obesity.

DISCUSSION

In this Southeast Asian population, the IDF and the AHA/NHLBI definitions of MS identify different segments of the MS population. The IDF definition may be more appropriate for the identification of those with insulin resistance and increased risk of type 2 diabetes. In contrast, the AHA/NHLBI definition may better identify those at increased risk of cardiovascular disease.

Insulin resistance in diabetic nephropathy--cause or consequence?

Insulin resistance (IR) is associated with multiple risk factors for cardiovascular disease. Many studies have shown that IR is present in chronic renal failure (CRF), and recent evidence suggests that IR can also occur in the early stages of renal disease. Patients with diabetic nephropathy (DN) have an increase in cardiovascular mortality, and since IR may be a contributing factor, this emphasizes the importance of a detailed understanding of the mechanisms linking IR and renal dysfunction at different stages of DN. IR can be detected early on in DN, e.g. at the stage of microalbuminuria (MA) and this could indicate a common genetic trait for IR and DN. As DN progresses further, IR is aggravated and it may, in addition to other factors, possibly accelerate the decline in renal function toward end-stage renal disease (ESRD). Several potentially modifiable mechanisms including circulating hormones, neuroendocrine pathways and chronic inflammation, are said to contribute to the worsening of IR. In ESRD, uremic toxins are of major importance. In this review article, we address the association between different stages of DN and IR and attempt to summarize major findings on potential mechanisms linking DN and IR. We conclude that IR is a consequence, and potentially also a cause of DN. In addition, there are probably genetic and environmental background factors that predispose to both IR and DN.

A cardiologist's guide to waist management

Clinical management of obesity remains a challenge.

Risk indicators of metabolic syndrome in young adults: A preliminary investigation on the influence of tobacco smoke exposure and gender

BACKGROUND

Metabolic syndrome is characterized by hypertension, dyslipidemia, insulin resistance, and obesity. Limited investigations have studied early indicators of metabolic syndrome in healthy young adults before diagnosis of disease.

PURPOSE

The purpose of this investigation is to identify shifts in cardiovascular (CV), metabolic, and immune variables consistent with metabolic syndrome but occurring before development of the disorder, and to determine whether these variables are influenced by gender or cigarette smoking.

METHODS

A pilot study of 41 subjects ages 18 to 39 years, with 20 smokers and 21 nonsmokers, was undertaken. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured to evaluate CV status; cholesterol, body mass index, leptin, percent glycated albumin, and homocysteine were measured to evaluate metabolic status; C-reactive protein, interleukin-1beta, and interleukin-10 were measured to evaluate immunologic status. Risk scores were assigned to each indicator, and total risk score was computed.

RESULTS

Men had higher SBP (P<.001), DBP (P=.046), and body mass index (P=.01), whereas women had higher leptin (P=.002). Total risk scores in men were greater (P=.02). There was no effect of smoking on risk score, related to the increase in two risks for smokers (SBP, P=.04, DBP; P=.027) reciprocated by a decrease in another (percentage of glycated albumin; P=.02).

CONCLUSION

Risk factors contributing to metabolic syndrome are present and highest in young men compared with women, whereas the effects of cigarette smoking on the syndrome are mixed. Early intervention to reduce modifiable risks may prevent full expression of disease.

Medical check-up findings characteristic of smokers: aimed at improving smoking cessation interventions by physicians

OBJECTIVE

The purpose of this study was to elucidate the medical check-up findings associated with smoking habit, which medical professionals, particularly physicians, should use for the promotion of quitting smoking.

METHODS

In 6,215 male and 1,627 female employees who participated in annual medical check-up, we compared the results of each test between smokers and nonsmokers.

RESULTS

Many results were significantly different between smokers and nonsmokers in both males and females. Among them, the hematocrit, leukocyte count, and levels of hemoglobin and triglyceride were significantly higher, the level of high-density lipoprotein cholesterol was significantly lower, and the frequencies of positive urinary occult blood and hearing loss were significantly higher in male smokers than in male nonsmokers. Furthermore, the hematocrit, leukocyte count, positive urinary occult blood, hearing loss, and levels of hemoglobin, triglyceride, and high-density lipoprotein cholesterol showed significant trends for male nonsmoker, and light, moderate, and heavy male smokers, that is, significant associations with larger numbers of cigarettes smoked per day.

CONCLUSION

Not only polycythemia and low high-density lipoprotein cholesterol level but also high leukocyte count, hearing loss, positive urinary occult blood, and high triglyceride level are smoking-related abnormal findings. In the medical check-up, medical professionals should inform smokers of these data and encourage them to quit smoking.

Association between cigarette smoking, metabolic syndrome, and carotid arteriosclerosis in Japanese individuals

Cigarette smoking is associated with increased insulin resistance and other metabolic abnormalities. Here, we investigate the prevalence of metabolic syndrome (MetS) in cigarette smokers and people who never smoked by analyzing cross-sectional data of 5033 subjects aged between 35 and 65 years who underwent general health screening. Both former and current smoking was associated with an increased incidence of metabolic syndrome defined by modified-National Cholesterol Education Program (NCEP) criteria with odds ratios of 1.77 (95% CI 1.42-2.22, P < 0.0001) and 2.38 (95% CI 1.95-2.91, P < 0.0001), respectively. In both former and current smokers, prevalence of metabolic syndrome increased when the duration of cigarette smoking was > or = 10 years. The positive association between metabolic syndrome and smoking was only partially reversed even 5 years after quitting. Multivariate logistic regression analysis showed that metabolic syndrome was an independent risk factor for carotid plaque with an odds ratio of 1.72 (95% CI 1.43-2.08, P < 0.0001). On the other hand, when limited to individuals without metabolic syndrome, former and current smoking was still found to be associated with carotid plaque with odds ratios of 1.49 (95% CI 1.15-1.92, P = 0.0023) and 1.57 (95% CI 1.22-2.03, P = 0.0005), respectively, in men. Collectively, these data suggest that the atherogenic consequences of smoking may, at least in part, be explained by its association with metabolic syndrome.

Protein intake is inversely associated with abdominal obesity in a multi-ethnic population

Abdominal obesity is related to significant morbidity and mortality and differs by ethnicity; however, the relation between diet and abdominal obesity has not been extensively studied. The aim of this study was to evaluate the dietary and lifestyle determinants of abdominal obesity in a multi-ethnic population. We conducted a cross-sectional study among 617 Canadians of Aboriginal, South Asian, Chinese, and European origins, with diet evaluated using validated, culture specific, interviewer-administered FFQs, and abdominal obesity measured as waist-hip ratio (WHR). The mean proportion of energy intake from protein in the diet was 17.4 vs. 15.8% comparing the lowest and highest tertiles of WHR. Energy-adjusted protein substituted for an equivalent amount of carbohydrate was associated with a reduction in WHR (difference in WHR for every g/d increase in protein intake = -0.0005, P = 0.01) after accounting for age, sex, ethnicity, smoking status, BMI, alcohol intake, height, physical activity, and total energy. Fat or total energy were not related to WHR in the same linear regression model. Smoking was positively and physical activity inversely related to WHR in the multivariate model independent of BMI and other potential confounders. Substituting a modest amount of protein for carbohydrate may reduce abdominal obesity in a diverse multi-ethnic population. Smoking was positively related to abdominal obesity after accounting for BMI.

Cigarette smoking and the risk of the metabolic syndrome in middle-aged Japanese male office workers

To examine the association between cigarette smoking and the risk of the metabolic syndrome (MS), 3649 Japanese male office workers aged 35-59 yr who did not have a history of cardiovascular disease were enrolled in this study. 2994 men without the MS at entry were followed up over a 7-yr period. A modified National Cholesterol Education Program definition with body mass index instead of waist circumference was used for the MS. With adjustment for age, family history of diabetes, alcohol intake, and regular physical activity, the odds ratios of the MS were 1.0 (referent), 1.30 (95% confidence interval (CI), 1.00-1.68), 1.07 (95% CI, 0.82-1.39), 1.17 (95% CI, 0.88-1.56), and 1.66 (95% CI, 1.24-2.20) for never smokers, ex-smokers, and those who smoked 1-20 cigarettes/d, 21-30 cigarettes/d, and > or =31 cigarettes/d, respectively (P for trend for current smokers only =0.006). As for the risk of developing the MS, the respective multivariate-adjusted hazard ratios of developing the MS were 1.0 (referent), 1.43 (95% CI, 1.14-1.79), 1.14 (95% CI, 0.91-1.44), 1.45 (95% CI, 1.14-1.84), and 1.59 (95% CI, 1.24-2.05) (P for trend for current smokers only =0.001). Among men without the MS at entry, body weight gain over 7 yr, compared with never smokers, was significantly higher in smokers who quit smoking. It is important for the prevention of the MS not only to quit smoking but also to prevent weight gain after smoking cessation.