according to the world health organization 's recent update , diabetes , hypertension , and obesity are one of the top five continuing risk factors for cardiovascular deaths in the world .
obesity is increasing substantially and is one of the major contributors of disease prevalence due to its pathophysiological link to other cardiovascular risks such as hypertension and diabetes .
it is estimated that , in 2010 , 6.4% of adults would have diabetes mellitus affecting 285 million in the world and it will increase to 7.7% by 2030 , affecting 439 million adults .
of special note is that there will be a 67% increase in the prevalence of diabetes in developing countries from 2010 to 2030 .
metabolic syndrome ( ms ) is a constellation of overweight / obesity , hypertension , and disturbances of lipid and carbohydrate metabolism .
the definition of ms was debated for a long time to produce a standardized clinical criterion .
the world health organisation describes ms as the presence of type 2 diabetes or impaired glucose tolerance with any two of the following characteristics : obesity , high levels of triglycerides , low levels of high - density lipoprotein , and hypertension .
the international diabetes federation ( idf ) takes central obesity as a prerequisite for the diagnosis of ms with the association of any two of the other factors , that is , high blood pressure , abnormal blood glucose , high levels of triglycerides , and low levels of high - density lipoprotein .
also , the idf has derived specific reference values for central obesity for different ethnicities .
the national cholesterol education programme ( ncep ) expert panel on detection , evaluation , and treatment of high blood cholesterol in adults ( adult treatment panel , or atp , iii ) , the national heart , lung and blood institute , and the american heart association   have released a report on the criteria for diagnosing and managing ms .
the panel describes ms as the presence of any three of the following : abdominal obesity , dislipidemia ( high levels of triglycerides , low hdl ) , increased blood pressure , and elevated fasting glucose .
for the purpose of this paper , the atp iii and idf 's definitions are used and compared .
each component of ms is a known risk factor for the development of type 2 diabetes , atherosclerosis , and coronary artery disease ( cad ) .
people with ms are 310 times more likely to develop cardiovascular disease commensurate with a high risk of morbidity and mortality [ 5 , 6 ] .
central obesity , one of the components of ms , predicts the occurrence of diabetes and overall cardiovascular risk .
the ncep atp iii   states that ms is equal to cigarette smoking as a contributing factor for premature cardiovascular disease .
the prevalence of metabolic syndrome is increasing all over the world with different regions having individual clusters of epidemic risk factors [ 6 , 8 ] , and in particular there is evidence of a high prevalence of ms and diabetes in south asians .
substantial increase in the prevalence of type 2 diabetes in asia in recent years has raised serious concerns about cardiovascular consequences for these populations [ 5 , 10 ] . however , in developing countries , many of these subclinical conditions are not diagnosed until the onset of complications such as myocardial infarction or stroke .
it is essential to initiate early detection of these chronic diseases in underdeveloped countries in asia , such as nepal , so that preventative action can minimize the consequences .
this study aims to establish the prevalence of hypertension , diabetes , obesity , and metabolic syndrome in the participants of a major health screening programme in nepal .
this study also aims to establish the relationship between the components of ms and lifestyle of the participants .
nepal is one of the poorest countries of the world at the 136th position of human development index .
the subjects were the participants of the  programme for detection and management of chronic kidney disease , hypertension , diabetes and cardiovascular disease ,  a community - based screening programme in eastern nepal . in this community - based programme
a series of community awareness programmes were conducted in a specific locality with the help of local leaders , medical students , and community volunteers .
various screening centres such as permanent centers ( in health clinics , community centers , etc . ) and temporary screening centers ( in schools , clubs , houses of worship , and private homes ) were used to screen the population .
each center used a group of five to seven people as community volunteers and consisted of a local leader ( priest , administrator , school teachers , and local political leaders ) , a laboratory technician , and nurse .
medical students ( approximately 100 in number ) and nursing students ( around 25 ) assisted the community volunteers .   prior to screening ,
the community volunteers went from door to door to record the number of family members residing permanently and to inform the members of the family , about the need of the project .
all people of 20 years were invited to come to a predefined place in very close vicinity to their house .
pregnant or menstruating women at the time of analysis , people with a fever or acute illness , and those who had recently engaged in heavy exercise were excluded .
the research team also collected general information on the participants ' demographic data , diet , smoking , alcohol consumption , and physical activity . the data recorded included family and medical history for kidney disease , high blood pressure , diabetes , cardiovascular disease and any current medication or treatment .
blood pressure was measured by the auscultatory method with a random zero mercury sphygmomanometer and standard cuff ( 12  34  cm ) .
the blood pressure measurement was taken in the seated position , quietly in a chair with feet on the floor and an arm support at the heart level .  
hypertension was defined according to the guidelines of the seventh report of the joint national committee on prevention , detection , evaluation and treatment of high blood pressure , that is , systolic blood pressure  140  mm  hg or diastolic blood pressure  90  mm  hg and/or concomitant use of antihypertensive medications .
body weight and height were assessed with all subjects standing without shoes and heavy outer garments to the nearest 0.1  kg and 1  cm , respectively .
waist circumference was measured over light clothing at a level midway between the lower rib margin and the iliac crest in centimetres rounded up to nearest 0.5  cm .
abdominal obesity is defined as an abdominal circumference > 102  cm ( 40 in ) in males and > 88  cm ( 35 in ) in females for ncep criteria and > 90  cm in males and > 80  cm in females for idf criteria for south asians .  
plasma glucose concentration was determined by the glucose oxidase - peroxidase method ( vitalab selectra-2 , merck , germany ) .
the diagnosis of diabetes was defined by either casual plasma glucose  200  mgdl associated with symptoms of diabetes and on fasting samples  plasma glucose  126  mgdl .
individuals with self reported , prior physician - diagnosis of diabetes were classified as having previously diagnosed diabetes .  
serum lipids that include total cholesterol , high - density lipoprotein ( hdl ) , low - density lipoprotein ( ldl ) , and triglycerides ( tg ) were also measured ( vitalab selectra-2 , merck , germany ) .
the results from any person having a history of hypertension or found to have hypertension were verified by qualified doctors .
the biochemical tests were completed in semiautomatic analysers ( microlab 300 , vital scientific , the netherelands ) .
epidata refers to a group of applications used in combination for creating documented data structures and analysis of quantitative data . in this study ,
the idf and ncep atp iii 's criteria for metabolic syndrome were used to calculate and compare the frequency of metabolic syndrome .
the relationships between the prevalence of cardiovascular risk factors , demographic details , lifestyle , and physiological test results were analysed using the spearman correlation test .
further , the differences in the categorical variables were examined using chi - squared test .
odds ratios ( ors ) and their 95% confidence interval were calculated using binary logistic regression ( for gender and age ) and multinomial logistic regression ( for life style factors ) .
in total , 14,425 people , aged 20100 ( mean age 41.4  15.1 ) , were included in the study . among them ,
the percentage of education level is illustrated in accordance to the number of years in education ( 15 years 
the participants were divided into four categories according to their work : labourer / farm , office , house , and none / unknown .
participants ' physical activities were defined according to the time spent every day on physical activity as > 60  min , 3060  min , < 30  min / day , and none .
abdominal obesity was observed in 11.5% ( n = 1607/14002 ) of the participants as per ncep criteria ( mean waist circumference : male107.38  6.19  cm , female94.84  5.84  cm ) and in 34.7% ( n = 5006/14418 ) of the participants as per idf criteria . according to the revised bmi , 10.6% ( n = 1534/14423 ) were underweight ( bmi < 18.5 ) , 28.2% ( n = 4065/14423 ) were overweight ( bmi = 2224.9 ) , and 32.5% ( n = 4689/14423 ) were obese ( bmi > 25 ) .  
diabetic prevalence was 6.3% ( 889/14008 ) of which 4.8% ( n = 673/14008 ) were under treatment .
a figure of 12.3% ( n = 1718/14009 ) had a family history of diabetes .
hypertension was observed in 33.9% ( n = 4894/14422 ) of the participants ( mean systolic 138.72  18.03  mm  hg and mean diastolic 93.09  8.45  mm  hg ) .
only 12.9% ( 1812/14009 ) were previously diagnosed , and 8.5% were receiving treatment for hypertension .
a history of coronary artery disease was present in 1.6% ( n = 218/14007 ) , and 1% ( n = 142 ) were under treatment for ischemic heart disease or stroke . 

table 2 shows the goodness of fit for the prevalence of obesity , hypertension , and diabetes .
prevalence of hypertension showed no difference from these data , and obesity showed only a small difference .
the percentages of the participants who had abnormal lipid profile that includes total serum cholesterol , serum ldl cholesterol , serum hdl cholesterol , serum triglycerides are listed in table 3 . there were 2191 sets of data eligible to meet the criteria for metabolic syndrome .
ms was observed in 22.5% ( n = 494/2191 ) of the participants according to the idf criteria and 20.7% ( 454/2191 ) according to the ncep criteria .
the percentages of individual ms risk factors among the total participants and the participants with ms are illustrated in figures 1 and 2 .
generally , among the total participants and the specific participants with ms , the presence of abnormal lipids was higher than the other factors defining ms . however , the presence of abdominal obesity was higher among ms participants using idf criteria ( figure 2 ) .  

the females had a higher prevalence of ms than males . according to the ncep criteria , the age groups 4160 and 6180 had a higher prevalence of ms than the lower age group .
according to idf criteria , the age groups 4160 and 2040 had a higher prevalence of ms .
the participants who worked at home had a high incidence of ms according to both the criteria used .
the sedentary group had a higher incidence of ms than the participants who were physically active .
the univariate correlations between cardiac risk factors are shown in table 5 , and the chi - squared independence of them in the metabolic syndrome prevalence is listed in table 6 .  
the prevalence of ms ( ncep scores ) had a significant positive relationship with education levels and physical activity .
there were significant positive correlations between physical activity and the three individual ms components : high glucose ( r = 0.03 , p < .01 ) , high bp ( r = 0.04 , p < .01 ) , and low hdl ( r = 0.23 , p < .01 ) .
there was no correlation between physical activity and the other two ms components : high triglyceride ( r = 0.003 , p > .05 ) and abdominal obesity ( r = 0.003 , p >
the ncep scores had a positive correlation between the family history of diabetes ( r = 0.83 , p < .01 ) and hypertension ( r = 0.115 , p < .01 ) .
although a number of these correlations show high levels of significance , the common variance is extremely low , suggesting that the sample size is having a major impact on the significance . as a result of this
table 7 lists the chi - squared independence , odds ratios , and confidence intervals in the association between age , gender , and specific lifestyle factors in metabolic syndrome prevalence .
gender , age , education level , and physical activity show a positive association with the prevalence of metabolic syndrome .
it is important to observe the prevalence of diabetes , hypertension , and obesity individually and also the combination of risk factors as metabolic syndrome to predict the risk of cardiovascular disease .
any association between lifestyle factors and these risk factors would provide the opportunity to encourage a change in lifestyle to promote lower levels of subsequent cvd .  
the large number of poorly educated people and the large number of school dropouts could be linked to the disease prevalence .
the prevalence of hypertension and metabolic syndrome in poorly educated people was large when compared with the educated participants .
though the results are not generalized , the relationship between education levels and the prevalence of hypertension agrees with earlier studies [ 19 , 20 ] .
these found that education levels significantly influence the knowledge of hypertension and the awareness of cardiovascular risk .
this suggests that there is a need to improve the awareness of health and use education to prevent or reduce the risk of ms and cardiovascular risks in these groups .
the office workers had a lower prevalence of ms ( ncep scores ) than the other groups .
a considerable number of office workers ( 64% ) undertook regular physical activity of more than 30  min / day .
the home workers education levels and physical activities were comparatively lower than the other work groups .
these findings clearly show that education and physical activity have an influence on the prevalence of ms .
most of the females were home workers ( 75.5% ) , and their education was comparatively lower than the males .
the amount of physical activity involved in home workers is unknown , but the results suggest it is less than that undertaken by other workers .
asian populations continue to modernize , and levels of physical activity are declining as ( i ) home and work place jobs become more automated and sedentary and ( ii ) transportation is more readily available .
the prevalence of ms among the participants who had no physical activity was surprisingly no different than others .
this may be due to a higher than average number of missing values in these data ( 2191/14425 complete data to meet the criteria for ms ) or to other unknown socioeconomic factors .
controversially , there was a high prevalence of ms among people who regularly ate fruit and vegetables .
.   found that a higher intake of macronutrients such as fruits and vegetables is associated with general obesity .
however , it is not clear how the vegetables and fruits were eaten , for example , overcooked , processed , and so forth .
the exact quantity of the dietary intake was not recorded as it was not the primary area of focus of the study . in these populations ,
these tend to report a low intake of mono - unsaturated fats ( mufas ) , n-3 polyunsaturated fats ( pufa ) , and transfatty acids ( mostly related to widespread use of vanaspati , a hydrogenated oil ) .
the healthy traditional plant - based diets are being replaced by cheaper calorie dense high - fat foods .
these changes are resulting in a rapid increase in the prevalence of obesity throughout asia and the subsequent development of ms .
ness and powles also found in their review   that many studies were reporting the null or negative effects of fruit and vegetable intake on the prevalence of cardiovascular diseases .
however , the correlations found in those studies were generally low , as seen in our study .
further , they suggest that a food - based analysis would complement the nutrient - based analysis to clarify these issues . in nepal ,
the regular diet in addition to fruits and vegetables , that is , such as rice , which is high in carbohydrates , and the methods of cooking may be dietary causes of metabolic syndrome .  
the age groups 4060 had a large prevalence of ms in this study . also , it is important to note that this middle - aged group had a high incidence of overweight or general obesity and abdominal obesity .
the other age groups had a lower prevalence of ms than the 4060 years old , yet it was still relatively high .
inadequate maternal nutrition in pregnancy , low birth weight , and childhood obesity may be important factors for the development of metabolic syndrome and diabetes . specifically in children and young individuals , a high intake of n-6 pufa is correlated with hyperinsulinaemia . in adults ,
unger described metabolic syndrome as  a failure of the system of intracellular lipid homeostasis which prevents lipotoxicity in organs of overnourished individuals  . in this study
in addition to low levels of hdl , the hdl particles are small , dense , and dysfunctional in south asians .
hypertriglyceridaemia is a direct reflection of an insulin resistance condition , and it is interrelated to the low hdl concentrations in developing endothelial dysfunction .   in nepal ,
a high number of the participants had abdominal obesity and were overweight / obese , according to their bmi .
the bmi is a simple useful measure for overall abnormal weight , yet not a standard measure for obesity .
bmi can not differentiate between whether the condition was due to unusual muscular development or the accumulation or distribution of fat in the body [ 26 , 27 ] . despite
the low prevalence of general body obesity compared to western countries , metabolic syndrome is growing into a significant public health problem in asia .
this may be mainly due to the large number of people with central obesity , a feature which was also observed in this study
. the higher prevalence of ms in females is also more likely to be due to a higher incidence of abdominal obesity .
abdominal obesity is an important factor because metabolic syndrome and increased abdominal fat are related to a reduction of adiponectin , an adopicyte - derived hormone with antiatherogenic and anti - inflammatory properties .
the abdominal adipose tissue results in release of free fatty acids directly in the portal veins and altered lipid levels in the blood .
further abdominal adiposity increases insulin secretion , and it would be exaggerated by decreased hepatic clearance leading to hyperinsulinemia .
thus abdominal obesity is an important indicator of cardiovascular disease due to its link to dyslipidemia , hyperinsulinemia , hypertension , and impaired fibrinolytic capacity .
state that if the ncep 's criteria were applied to the asian population , it might underestimate the prevalence of metabolic syndrome and the risk of cardiovascular disease .
idf 's specific reference values for abdominal obesity make a substantial difference to the prevalence of ms between the two criteria . the idf 's cut - off points for south asians ' waist circumference
are lower than the ncep 's general cut - off points ( 90  cm versus 102  cm in men and 80  cm versus 88  cm in women ) .
another study on chinese population also found a large increase in the prevalence of metabolic syndrome using idf criteria compared with ncep criteria .
however , in our study both definitions demonstrated a higher prevalence of metabolic syndrome ( 20.722.5% ) in nepal when compared with the studies done in other southeast asian countries such as thailand ( 1218% using ncep definition ) and india ( 18.3% using idf definition ) .
these findings suggest the need for specific attention to control the disease prevalence in nepal .
although data were prospectively collected , they may not be generalizable outside of eastern nepal .
the results did not show substantiate relationship between smoking histories , diet , family history of cardiovascular , and metabolic syndrome .
abdominal obesity , with the revised reference values , is an important risk due to its physiological relationship to the other ms risk factors .
the ms prevalence may be due to lack of awareness and unhealthy lifestyles , so health education and more preventive measures should decrease the prevalence of ms and cardiac risks in nepal .
 
 background . this study was carried out to establish the prevalence of cardiovascular risks such as hypertension , obesity , and diabetes in eastern nepal . 
 this study also establishes the prevalence of metabolic syndrome ( ms ) and its relationships to these cardiovascular risk factors and lifestyle . methods . 
 14,425 subjects aged 20100 ( mean 41.4  15.1 ) were screened with a physical examination and blood tests . 
 both the international diabetic federation ( idf ) and national cholesterol education programme 's ( ncep ) definitions for ms were used and compared . 
 results . 
 34% of the participants had hypertension , and 6.3% were diabetic . 
 28% were overweight , and 32% were obese . 
 22.5% of the participants had metabolic syndrome based on idf criteria and 20.7% according to the ncep definition . 
 prevalence was higher in the less educated , people working at home , and females . 
 there was no significant correlation between the participants ' lifestyle factors and the prevalence of ms . 
 conclusion 
 . the high incidence of dyslipidemia and abdominal obesity could be the major contributors to ms in nepal . 
 education also appears to be related to the prevalence of ms . 
 this study confirms the need to initiate appropriate treatment options for a condition which is highly prevalent in eastern nepal . 
1. Introduction
2. Methods
3. Results
4. Discussion
5. Conclusion