Hemostatic abnormalities associated with obesity and the metabolic syndrome

SARS-CoV-2 induced liver injury: Incidence, risk factors, impact on COVID-19 severity and prognosis in different population groups

Liver is unlikely the key organ driving mortality in coronavirus disease 2019 (COVID-19) however, liver function tests (LFTs) abnormalities are widely observed mostly in moderate and severe cases. According to this review, the overall prevalence of abnormal LFTs in COVID-19 patients ranges from 2.5% to 96.8% worldwide. The geographical variability in the prevalence of underlying diseases is the determinant for the observed discrepancies between East and West. Multifactorial mechanisms are implicated in COVID-19-induced liver injury. Among them, hypercytokinemia with "bystander hepatitis", cytokine storm syndrome with subsequent oxidative stress and endotheliopathy, hypercoagulable state and immuno-thromboinflammation are the most determinant mechanisms leading to tissue injury. Liver hypoxia may also contribute under specific conditions, while direct hepatocyte injury is an emerging mechanism. Except for initially observed severe acute respiratory distress syndrome corona virus-2 (SARS-CoV-2) tropism for cholangiocytes, more recent cumulative data show SARS-CoV-2 virions within hepatocytes and sinusoidal endothelial cells using electron microscopy (EM). The best evidence for hepatocellular invasion by the virus is the identification of replicating SARS-CoV-2 RNA, S protein RNA and viral nucleocapsid protein within hepatocytes using in-situ hybridization and immunostaining with observed intrahepatic presence of SARS-CoV-2 by EM and by in-situ hybridization. New data mostly derived from imaging findings indicate possible long-term sequelae for the liver months after recovery, suggesting a post-COVID-19 persistent live injury.

Impaired coagulation, liver dysfunction and COVID-19: Discovering an intriguing relationship

Coronavirus disease 2019 (COVID-19) is, at present, one of the most relevant global health problems. In the literature hepatic alterations have been described in COVID-19 patients, and they are mainly represented by worsening of underlying chronic liver disease leading to hepatic decompensation and liver failure with higher mortality. Several potential mechanisms used by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to cause liver damage have been hypothesized. COVID-19 primary liver injury is less common than secondary liver injury. Most of the available data demonstrate how liver damage in SARS-CoV-2 infection is likely due to systemic inflammation, and it is less likely mediated by a cytopathic effect directed on liver cells. Moreover, liver alterations could be caused by hypoxic injury and drugs (antibiotics and non-steroidal anti-inflammatory drugs, remdesivir, tocilizumab, tofacitinib and dexamethasone). SARS-CoV-2 infection can induce multiple vascular district atherothrombosis by affecting simultaneously cerebral, coronary and peripheral vascular beds. Data in the literature highlight how the virus triggers an exaggerated immune response, which added to the cytopathic effect of the virus can induce endothelial damage and a prothrombotic dysregulation of hemostasis. This leads to a higher incidence of symptomatic and confirmed venous thrombosis and of pulmonary embolisms, especially in central, lobar or segmental pulmonary arteries, in COVID-19. There are currently fewer data for arterial thrombosis, while myocardial injury was identified in 7%-17% of patients hospitalized with SARS-CoV-2 infection and 22%-31% in the intensive care unit setting. Available data also revealed a higher occurrence of stroke and more serious forms of peripheral arterial disease in COVID-19 patients. Hemostasis dysregulation is observed during the COVID-19 course. Lower platelet count, mildly increased prothrombin time and increased D-dimer are typical laboratory features of patients with severe SARS-CoV-2 infection, described as “COVID-19 associated coagulopathy.” These alterations are correlated to poor outcomes. Moreover, patients with severe SARS-CoV-2 infection are characterized by high levels of von Willebrand factor with subsequent ADAMTS13 deficiency and impaired fibrinolysis. Platelet hyperreactivity, hypercoagulability and hypofibrinolysis during SARS-CoV-2 infection induce a pathological state named as “immuno-thromboinflammation.” Finally, liver dysfunction and coagulopathy are often observed at the same time in patients with COVID-19. The hypothesis that liver dysfunction could be mediated by microvascular thrombosis has been supported by post-mortem findings and extensive vascular portal and sinusoidal thrombosis observation. Other evidence has shown a correlation between coagulation and liver damage in COVID-19, underlined by the transaminase association with coagulopathy, identified through laboratory markers such as prothrombin time, international normalized ratio, fibrinogen, D-dimer, fibrin/fibrinogen degradation products and platelet count. Other possible mechanisms like immunogenesis of COVID-19 damage or massive pericyte activation with consequent vessel wall fibrosis have been suggested.

The Prevalence of Coagulopathy and Associated Factors Among Adult Type II Diabetes Mellitus Patients Attending the University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia

INTRODUCTION

Diabetes mellitus is a heterogeneous disorder of metabolism which results hyperglycemic-related atherothrombotic complications. These complications are the leading cause of death in diabetes mellitus patients. Therefore, this study was aimed to determine the prevalence of coagulopathy and associated factors among adult type II diabetes mellitus patients attending at University of Gondar comprehensive specialized hospital.

METHODS

A facility-based cross-sectional study was conducted among 357 study participants. A questionnaire and a data collection sheet were used to collect the sociodemographic and clinical data, respectively. About 6mL of venous blood samples were collected for coagulation tests and complete blood count. For prolonged coagulation tests, a mixing test was performed. Data were entered into EpiInfo and exported to SPSS for statistical analysis. Then, descriptive statistics were done. A binary and multivariable logistic regression model was used to identify the associated factors. P-value <0.05 was considered as statistically significant.

RESULTS

In this study, 357 study participants were included. Of them, 52.1% (186) and 80.7% (288) were females and urban residences, respectively. The prevalence of coagulopathy was 26.6% (95% CI: 22.1, 31.5%). Out of this, 12.3% and 8.7% showed shortened PT and aPTT, respectively. In addition, the prevalence of prolonged PT and aPTT were 5.6% and 3.9%, respectively. From the prolonged PT and aPTT, the prevalence of factor deficiency was 95% and 92.8%, respectively. Being female (AOR = 2.06; 95% CI: 1.11-3.85%), abnormal BMI (AOR = 1.94; 95% CI: 1.08-3.50), and educational status of high school (AOR = 0.26; 95% CI: 0.10-0.83%) were significantly associated with hypercoagulation.

CONCLUSION

Coagulopathy is an important public health problem among type II diabetes mellitus patients. Being female and having abnormal BMI were associated with hypercoagulation. Therefore, regular monitoring of coagulation parameters is vital to reduce the consequence of coagulopathy.

Coronavirus Disease 2019-Associated Coagulopathy

Patients with the severe form of coronavirus disease 2019 (COVID-19) have been frequently found to suffer from both arterial and venous thrombotic events due to the perpetuation of a hypercoagulable state. This phenomenon, termed COVID-19-associated coagulopathy, is now considered a major component of the pathophysiology of this novel infectious disease, leading to widespread thrombosis. While at first, the vascular insults may be limited to the pulmonary microvasculature, as the disease progresses, systemic involvement occurs, culminating in distant organ thrombosis and multiorgan dysfunction syndrome. In this review article, we discuss recent insights into the pathophysiologic mechanisms of COVID-19-associated coagulopathy and review the clinical, histopathologic, and laboratory evidence, which leads us to conclude that COVID-19 is both a pulmonary and vascular disorder.

Obesity and Outcomes in COVID-19: When an Epidemic and Pandemic Collide

Obesity has reached epidemic proportions in the United States and in much of the westernized world, contributing to considerable morbidity. Several of these obesity-related morbidities are associated with greater risk for death with coronavirus disease 2019 (COVID-19). Severe acute respiratory syndrome coronavirus 2 penetrates human cells through direct binding with angiotensin-converting enzyme 2 receptors on the cell surface. Angiotensin-converting enzyme 2 expression in adipose tissue is higher than that in lung tissue, which means that adipose tissue may be vulnerable to COVID-19 infection. Obese patients also have worse outcomes with COVID-19 infection, including respiratory failure, need for mechanical ventilation, and higher mortality. Clinicians need to be more aggressive when treating obese, especially severely obese, patients with COVID-19 infection.

Diabetes and atherothrombosis: The circadian rhythm and role of melatonin in vascular protection

Obesity-related euglycaemic insulin resistance clusters with cardiometabolic risk factors, contributing to the development of both type 2 diabetes and cardiovascular disease. An increased thrombotic tendency in diabetes stems from platelet hyperactivity, enhanced activity of prothrombotic coagulation factors and impaired fibrinolysis. Furthermore, a low-grade inflammatory response and increased oxidative stress accelerate the atherosclerotic process and, together with an enhanced thrombotic environment, result in premature and more severe cardiovascular disease. The disruption of circadian cycles in man secondary to chronic obesity and loss of circadian cues is implicated in the increased risk of developing diabetes and cardiovascular disease. Levels of melatonin, the endogenous synchronizer of circadian rhythm, are reduced in individuals with vascular disease and those with deranged glucose metabolism. The anti-inflammatory, antihypertensive, antioxidative and antithrombotic activities of melatonin make it a potential therapeutic agent to reduce the risk of vascular occlusive disease in diabetes. The mechanisms behind melatonin-associated reduction in procoagulant response are not fully known. Current evidence suggests that melatonin inhibits platelet aggregation and might affect the coagulation cascade, altering fibrin clot structure and/or resistance to fibrinolysis. Large-scale clinical trials are warranted to investigate the effects of modulating the circadian clock on insulin resistance, glycaemia and cardiovascular outcome.

Hypercoagulability in overweight and obese subjects who are asymptomatic for thrombotic events

The role of circulating microparticles (MP) of different origin and tissue factor (TF)-bearing in overweight and obese patients with and without metabolic syndrome is still a matter of debate. In a case-control study, the presence of hypercoagulability was evaluated in overweight and obese patients by measuring MP, thrombin generation (TG) and FVIIa-AT complexes. Twenty overweight patients (body mass index [BMI] range 25–29.9 kg/m2), 20 with I degree (30–34.9 kg/m2), 20 with II degree (35–39.9 kg/m2) and 20 with III degree obesity (≥ 40 kg/m2) were enrolled and compared to 40 age and gender-matched normal weight individuals. A significant increase in median levels of all MP subtypes was observed in the three degrees of obese patients compared to controls. Overweight patients had higher levels of annexin V-MP (AMP), endothelial-derived, leukocyte-derived and TF-bearing MP than controls. Obese patients had a significantly shorter median lag time (p< 0.05), higher median peak thrombin (p< 0.01) and increased median endogenous thrombin potential [ETP] (p< 0.001) compared to controls. Overweight subjects had significantly increased ETP compared to controls (p< 0.05). Both AMP levels and ETP were found to positively correlate with BMI, waist circumference, and inflammatory parameters. No significant increase in FVIIa-AT complex was seen in cases compared to controls. We conclude that obesity is associated with overproduction of procoagulant MP and increase TG. Interestingly, hypercoagulability is found in overweight patients free of metabolic syndrome and increases with the severity of obesity. Assessment of MP and TG may be helpful in the early characterisation of the prothrombotic state in obese patients.

Mendelian randomization: application to cardiovascular disease

In the absence of an ethical, practical, and economical randomized trial, the epidemiologist is left to explore other methods in efforts to assert causality. An approach based on genotypic variation has the potential to mitigate against some of the problems found within conventional observational studies. Genetic variations associated with risk factors of interest at the population level can be used as proxy measures for these risk factors and to generate estimates of causal effect. The potential and the possible limitations of this approach within the cardiovascular field are presented in this review.

C-reactive protein levels and body mass index: elucidating direction of causation through reciprocal Mendelian randomization

CONTEXT

The assignment of direction and causality within networks of observational associations is problematic outside randomized control trials, and the presence of a causal relationship between body mass index (BMI) and C-reactive protein (CRP) is disputed.

OBJECTIVE

Using reciprocal Mendelian randomization, we aim to assess the direction of causality in relationships between BMI and CRP and to demonstrate this as a promising analytical technique.

PARTICIPANTS AND METHODS

The study was based on a large, cross-sectional European study from Copenhagen, Denmark. Genetic associates of BMI (FTO(rs9939609)) and circulating CRP (CRP(rs3091244)) have been used to reexamine observational associations between them.

RESULTS

Observational analyses showed a strong, positive association between circulating CRP and BMI (change in BMI for a doubling in log CRP of 1.03 kg m(-2) (95% confidence interval (95% CI): 1.00, 1.07), P<0.0001). Analysis using CRP(rs3091244) to re-estimate the causal effect of circulating CRP on BMI yielded null effects (change in BMI for a doubling in log CRP of -0.24 kg m(-2) (95% CI: -0.58, 0.11), P=0.2). In contrast, analysis using FTO(rs9939609) to assess the causal effect of BMI on circulating CRP confirmed observational associations (ratio of geometric means of CRP per s.d. increase in BMI 1.41 (95% CI: 1.10, 1.80), P=0.006).

CONCLUSIONS

Taken together, these data suggest that the observed association between circulating CRP and measured BMI is likely to be driven by BMI, with CRP being a marker of elevated adiposity. More generally, the method of reciprocal randomization has general applicability in determining the direction of causation within inter-correlated networks of metabolic components.

Cardiometabolic risk among African American women: a pilot study

OBJECTIVE

This study aimed to determine the associations of the Homeostatic Model of Assessment-insulin resistance (HOMA-ir), acanthosis nigricans, high-sensitivity C-reactive protein (hs-CRP), and plasminogen activator inhibitor-1 (PAI-1) with 2 of the commonly used definitions of metabolic syndrome (Adult Treatment Panel III [ATP III] and International Diabetes Federation [IDF]) among reproductive-age, healthy, free-living African American women.

METHODS

A pilot study with a cross-sectional design examined 33 African American women aged 20 to 46 years (mean [SD], 31.24 [7.25] years) for the presence of metabolic syndrome determined by ATP III and IDF criteria, insulin resistance (HOMA-ir and/or acanthosis nigricans), degree of inflammation (hs-CRP), and presence of dysfibrinolysis (PAI-1).

RESULTS

HOMA-ir identified insulin resistance in 27 (81.8%) women, whereas the presence of acanthosis nigricans indicated that 16 (48%) of these women manifested insulin resistance. Metabolic syndrome was found in 7 women (21.2%) by ATP III or in 9 (27.3%) women by IDF criteria. Bivariate correlations showed associations between HOMA-ir and waist circumference, body mass index (BMI), acanthosis nigricans, and the ATP III and IDF definitions for metabolic syndrome. Plasminogen activator inhibitor-1 was significantly correlated with waist circumference, BMI, fasting glucose, HOMA-ir, and ATP III. Both HOMA-ir and PAI-1 were significantly and negatively correlated with high-density lipoprotein cholesterol. High-sensitivity CRP was significantly correlated with BMI and 2-hour postglucose.

CONCLUSION

Both dysfibrinolysis (PAI-1 levels) and insulin resistance (HOMA-ir), when individually regressed on the ATP III definition of metabolic syndrome, explained 32% and 29% of the respective variance. The addition of HOMA-ir measurement may significantly improve early recognition of cardiometabolic risk among reproductive-age African American women who have not yet met the criteria for the ATP III or IDF definitions of metabolic syndrome. Likewise, acanthosis nigricans is potentially a clinically significant screening tool when used to determine early recognition of insulin resistance and/or cardiometabolic risk among this population. African American women's risk for cardiovascular disease is likely underestimated based on the sole use of ATP III criteria for diagnosis of metabolic syndrome. Clinicians should consider a broader definition of risk than that contained within ATP III. Inclusion of biomarkers of inflammation and dysfibrinolysis, along with measures of insulin resistance, may add to early detection of cardiometabolic risk and ultimate reduction in cardiovascular health disparities among African American women.

Oxysterol as a marker of atherogenic dyslipidemia in adolescence

CONTEXT

Oxysterols represent potentially important oxidative stress biomarkers in adolescence.

OBJECTIVE

The objective of the study was to examine the relationship between the concentrations of serum enzymatically and nonenzymatically generated oxysterols, measures of obesity, and metabolic components including insulin resistance and levels of blood pressure and serum lipids.

DESIGN

This was a cross-sectional study.

SETTING

All subjects were examined between 2003 and 2005 at a hospital, a part of a follow-up evaluation mother-daughter pairs representing pregnancies affected or unaffected by gestational diabetes that resulted in the deliveries in 1989-1991.

SUBJECTS

Subjects included a subset (n=89) of the total study population of 189 adolescent girls with a mean age of 15.32+/-0.65 yr and body mass index of 22.54+/-3.98 kg/m2.

MAIN OUTCOME MEASURES

Measures included serum levels of the oxysterols 7alpha-hydroxy-cholesterol, 7beta-hydroxycholesterol, and 7-ketocholesterol; and body mass index, homeostasis model assessment insulin resistance index, fasting insulin, fasting glucose, blood pressure, total cholesterol, non-high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triglycerides, and apolipoprotein B (ApoB).

RESULTS

Serum oxysterol concentrations in the adolescent cohort correlated positively with insulin (P<0.05), total cholesterol (P<0.05), non-high-density lipoprotein cholesterol (P<0.05), low-density lipoprotein cholesterol (P<0.05), and ApoB (P<0.01). ApoB and fasting insulin were found to be the major determinants of serum oxysterols after adjustment for body mass index. Being a daughter of gestational diabetes pregnancy alone did not seem to be a predisposing factor to increased oxidative stress in our cohort.

CONCLUSION

Serum oxysterol concentrations increase with obesity, insulin, and ApoB, which are established derangements associated with the metabolic syndrome.

Effects of socioeconomic position on inflammatory and hemostatic markers: a life-course analysis in the 1958 British birth cohort

The cumulative effects of socioeconomic position (SEP) on cardiovascular disease have been described, but the pathways are unclear. In this study, the authors examined the effects of life-course SEP on inflammatory and hemostatic markers: fibrinogen, C-reactive protein, von Willebrand factor antigen, and tissue plasminogen activator antigen. Data from the 1958 British birth cohort, including data on persons who underwent a biomedical follow-up in 2002-2004, were used. Social class was determined at three stages of respondents' lives: childhood (birth), early adulthood (age 23 years), and midlife (age 42 years). A cumulative indicator score of SEP was calculated that ranged from 0 (always in the highest social class) to 9 (always in the lowest social class). In men and women, associations were observed between cumulative indicator score and fibrinogen (p < 0.001), C-reactive protein (p < 0.001), von Willebrand factor antigen (p < or = 0.05), and tissue plasminogen activator antigen (p < 0.001 only in women). The trends in fibrinogen and C-reactive protein remained after adjustment for body mass index, smoking, and physical activity. However, the trends became nonsignificant for von Willebrand factor antigen and tissue plasminogen activator antigen in women. Risk exposure related to SEP accumulates across the life course and contributes to raised levels of fibrinogen and C-reactive protein, while childhood SEP influences hemostatic markers more than does adult SEP.

Metabolic syndrome and endothelial fibrinolytic capacity in obese adults

The metabolic syndrome (MetS) often accompanies obesity and contributes to the increased risk of atherothrombotic events with increased body fatness. Indeed, the risks for coronary artery disease and acute vascular events are greater with obesity combined with MetS compared with obesity alone. Endothelial release of tissue-type plasminogen activator (t-PA) is a key defense mechanism against thrombosis and has been shown to be impaired with obesity. The aim of the present study was to determine whether the presence of MetS exacerbates endothelial fibrinolytic dysfunction in obese adults. Net endothelial release of t-PA was determined in vivo in response to intrabrachial infusions of bradykinin and sodium nitroprusside in 47 sedentary adults: 15 normal weight (age 57 +/- 2 yr; body mass index 22.9 +/- 0.5 kg/m(2)), 14 obese but otherwise healthy (55 +/- 1 yr; 29.4 +/- 0.3 kg/m(2)), and 18 obese with MetS (55 +/- 2 yr; 32.3 +/- 1 kg/m(2)). MetS was established according to National Cholesterol Education Program ATP III criteria. Net release of t-PA antigen to bradykinin was approximately 50% lower (P < 0.01) in the obese (from 2.5 +/- 1.9 to 37.1 +/- 5.3 ng.100 ml tissue(-1).min(-1)) and obese with MetS (from 0.4 +/- 0.8 to 32.5 +/- 3.8 ng.100 ml tissue(-1).min(-1)) compared with normal-weight (from 0.9 +/- 1.0 to 74.3 +/- 8.1 ng.100 ml tissue(-1).min(-1)) subjects. However, there were no significant differences in the capacity of the endothelium to release t-PA in the obese and obese with MetS adults. These results indicate that the presence of the MetS does not worsen the obesity-related endothelial fibrinolytic dysfunction.

Impairment of cardiac insulin signaling and myocardial contractile performance in high-cholesterol/fructose-fed rats

Although insulin resistance is recognized as a potent and prevalent risk factor for coronary heart disease, less is known as to whether insulin resistance causes an altered cardiac phenotype independent of coronary atherosclerosis. In this study, we investigated the relationship between insulin resistance and cardiac contractile dysfunctions by generating a new insulin resistance animal model with rats on high cholesterol-fructose diet. Male Sprague-Dawley rats were given high cholesterol-fructose (HCF) diet for 15 wk; the rats developed insulin resistance syndrome characterized by elevated blood pressure, hyperlipidemia, hyperinsulinemia, impaired glucose tolerance, and insulin resistance. The results show that HCF induced insulin resistance not only in metabolic-response tissues (i.e., liver and muscle) but also in the heart as well. Insulin-stimulated cardiac glucose uptake was significantly reduced after 15 wk of HCF feeding, and cardiac insulin resistance was associated with blunted Akt-mediated insulin signaling along with glucose transporter GLUT4 translocation. Basal fatty acid transporter FATP1 levels were increased in HCF rat hearts. The cardiac performance of the HCF rats exhibited a marked reduction in cardiac output, ejection fraction, stroke volume, and end-diastolic volume. It also showed decreases in left ventricular end-systolic elasticity, whereas the effective arterial elasticity was increased. In addition, the relaxation time constant of left ventricular pressure was prolonged in the HCF group. Overall, these results indicate that insulin resistance reduction of cardiac glucose uptake is associated with defects in insulin signaling. The cardiac metabolic alterations that impair contractile functions may lead to the development of cardiomyopathy.

Differences in the association of PAI-1 activity with the metabolic syndrome between African and Caucasian women

BACKGROUND AND AIMS

The association between PAI-1(act) and markers of the metabolic syndrome is well established in Caucasian populations, but data on African subjects is lacking. The aim of this study was to investigate possible differences between the association of PAI-1(act) and markers of the metabolic syndrome in Caucasian and African women.

METHODS AND RESULTS

Cross-sectional data were collected from 95 African and 114 Caucasian women in the Potchefstroom district of the North West Province, South Africa. Plasma PAI-1(act) was almost twice as high in Caucasians compared to Africans (10.2 versus 5.2 U/mL, p<0.001). Correlations between markers of the metabolic syndrome and PAI-1(act) were remarkably stronger in Caucasians than in Africans. In multivariate regression analyses 56% of the variance of PAI-1(act) could be explained by metabolic syndrome variables in the Caucasian group compared to 12% in the African women. Waist circumference was the strongest independent predictor of PAI-1(act) in both groups.

CONCLUSION

This study showed lower PAI-1(act) in African than in Caucasian women, along with less associations of PAI-1(act) with markers of the metabolic syndrome in the African than in the Caucasian women. The role of PAI-1(act) in the metabolic syndrome may be less prominent in Africans than in Caucasians.

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.