Anthropometric Indexes, Dietary Patterns, and Physical Activity for

Assessing Risk of Metabolic Syndrome

Herfandi Dimas Anugrah1, Iche Andriyani Liberty2, Indri Seta Septadina3,
1
Medical Profession Program Study, Faculty of Medicine, Sriwijaya University, Palembang, Indonesia
2
Departement of Public Health and Community Medicine, Medical Faculty, Sriwijaya University,
Palembang, Indonesia
3
Departement of Anatomy, Medical Faculty, Sriwijaya University, Palembang, Indonesia

Corresponding Author : Iche Andriyani Liberty Email : icheandriyaniliberty@fk.unsri.ac.id

ABSTRACT
Depending on the environmental factors and daily lifestyle choices, one in four or five p
ersons has acquired metabolic syndrome. This study to determine metabolic syndrome ri
sk factors in workers and to provide theoretical bases for assessing risk in metabolic syn
drome. A total of 448 subjects from Palembang population were included in this case-co
ntrol observational study. Bivariate and multivariate logistic regression analysis was use
d to explore possible determinants of prediabetes events in the prehypertension populati
on and make a final model, which was tested by backward elimination. The bivariate lo
gistic regression analysis showed that age, employment, VAI, LAP, TyG index, HDI, an
d MET were independently correlated with metabolic syndrome. After being adjusted, it
was identified the most dominant factors were informal sector workers, VAI, LAP, and
TyG Index. VAI was the strongest risk factor for the incidence of metabolic syndrome.
Anthropometric Indexes are very useful for determining the risk factor of metabolic syn
drome.
Key words: Metabolic Syndrome, Anthropometric Indexes, VAI, LAP, Tyg Index, HDI,
MET

INTRODUCTION ive criteria: waist circumference above

The metabolic syndrome is a collection
of metabolic dysregulations that include
s insulin resistance, atherogenic dyslipid
emia, central obesity, and hypertension.1
Depending on the environmental factors
and daily lifestyle choices, one in four o
r five persons has acquired metabolic sy
ndrome. Studies from throughout the w
orld show that the frequency of people a
ged 20 to 25 is 24% in India, 28% in the
USA, 30.1% in Iran, 33.4% in Turkey, a
nd 39.3% in the Saudi Arabia. 2 Based o
n cohort study research in 2019, the pre
valence of metabolic syndrome in Indon
esia is 23.34%.3 The NCEP ATP III defi
nition states that the presence of metabo
lic syndrome is determined by the fulfill
ment of three or more of the following f
40 inches for men and 35 inches for wo
men, blood pressure greater than 130/85
mmHg, fasting TG level greater than 15
0 mg/dl, fasting HDL level less than 40
mg/dl for males and 50 mg/dl for wome
n, and fasting blood sugar greater than 1
00 mg/dl.4
Diabetes and cardiovascular disease risk
are both greatly raised in the presence o
f metabolic syndrome (CVD). Across th
e entire world, CVD is by far the main f
actor in morbidity and mortality.1 Sever
al studies have clearly shown a link bet
ween metabolic syndrome and the emer
gence of type 2 diabetes and cardiovasc
ular disease. Nevertheless, because it ha
s also been linked to other chronic condi
tions, such brain health and some forms
of cancer, metabolic syndrome and visc

1
eral obesity are receiving increasing foc
us.5 VAI, LAP, and Tyg Index are anthr
opometric indexes that can predict the i
ncidence of metabolic syndrome.6
There are many diseases that could occu
r if metabolic syndrome is left untreated.
Some studies analyze the risk factors of
metabolic syndrome. Several studies ha
ve examined anthropometric indexes, b
ut research on anthropometric indexes,
dietary patterns, and physical activity si
multaneously to determine the risk of m
etabolic syndrome has never been carrie
d out. Also, research on an anthropomet
ric index with metabolic syndrome in In
donesia has never existed. This study ai
ms to determine risk factors in metaboli
c syndrome and to provide theoretical b
ases for assessing risk in metabolic synd
rome.
METHODS
Study method and participants
This observational research was conduct
ed using a case-control study approach f
rom July to November 2022. The popul
ation of this research was the population
in Palembang. The research subjects we
re a group of individuals in Palembang
who met the inclusion and exclusion crit
eria. The inclusion criteria are aged ≥18
years. The exclusion criteria are sample
s that were prescribed medication that w
ould affect insulin, glucose, or cholester
ol serum levels. This study consists of t
wo types of variables. The dependent va
riable was metabolic syndrome, and ther
e were some independent variables: sex,
age, employment, TyG Index, VAI, LA
P, HDI, and MET. After explaining the
research procedures and informed conse
nt, 224 people with metabolic syndrome
and 224 people without metabolic syndr
ome were assessed to be participants in
this study.
Measurement method
Participants visited primary health care
2
service and fasted for 8 hours before. Bl
ood pressure is measured by using a me
rcury sphygmomanometer and stethosco
pe. Venous blood samples were collecte
d and were immediately centrifuged. Se
rum glucose, HDL, LDL, and triglyceri
de were assayed with an autoanalyzer. F
asting triglycerides in mg/dL were multi
plied by fasting plasma glucose in mg/d
L and divided by two to obtain the TyG
Index (ln (FT*FPG/2)).7. Physical activi
ty data was based on MET(Metabolic E
quivalent of Task)-min/week obtained fr
om Indonesian adaptation of IPAQ-SF(I
nternational Physical Activity Question
naire Short Form) 8. VAI and LAP was
calculated by using its formula based on
gender, described as in its first model 9,10.
The tool used and the examiner were th
e same for all samples.
Diagnostic Criteria
NCEP ATP III definition, metabolic syn
drome is present if three or more of the
following five criteria are met: waist cir
cumference over 40 inches (men) or 35
inches (women), blood pressure over 13
0/85 mmHg, fasting triglyceride (TG) le
vel over 150 mg/dl, fasting high-density
lipoprotein (HDL) cholesterol level less
than 40 mg/dl (men) or 50 mg/dl (wome
n) and fasting blood sugar over 100 mg/
dl.4
Statistical analysis
Data analysis used STATA 15.0's Statist
ical Package. Every categorical data had
rates and proportions calculated. Binom
ial logistic regression investigated para
meter correlations. The parameters with
p-value <0,25 in binomial logistic regre
ssion were entered in multivariate logist
ic regression analysis. The final model
was tested by backward elimination afte
r multiple logistic regression models ex
plored metabolic syndrome determinant
s.. In the model, the following independ
ent variables were included: sex (men =
0; women; 1), age (≤30 years = 0; 31-40
years = 1; 41-50 years = 2; 51-60 years
= 3; ≥61 years = 4), employment (stude
nt = 0; informal = 1; formal = 2; unempl
oyed = 3), VAI (non-risk = 0; risk = 1),
LAP (non-risk = 0; risk = 1), HDI (low
= 0; moderate = 1; high = 2), and MET
(low = 0; moderate = 1; high = 2) as cat
egorical variables. A p-value of <0,05 w
as considered to indicate statistical signi
ficance.
Ethical considerations
All procedures in this study involved pa
rticipants per the ethical standards of ins
titutional research committees. All sour
ce documents, including questionnaires,
were anonymized to ensure participants'
anonymity. Sriwijaya University Ethics
Committee approved this study on 15th
July 2022 with Protocol Number 073-20
22. This certificate confirms the ethical
clearance application made by: Iche An
driyani Liberty. As a result, the protocol
has been granted Exempt status.
RESULTS
Table 1 shows the respondent's descripti
on and frequency and percentage consis
ting of sex, age, employment, VAI, LA
P, HDI, TyG Index, and MET.
The bivariate analysis results in Table 2
show that among all independent variab
les examined, sex (p=0,773, 95% CI 0.6
3 – 1,40) was not independently correlat
ed with metabolic syndrome. Age (p=0,
0000, 95% CI 2.37 – 12.55), employme
nt (p=0,0000, 95%CI 1.91 – 23.12), VA
I (p=0,0000, 95%CI 9.98 – 26.64), LAP
(p=0,0009, 95%CI 1.26 – 2.78), HDI (p
=0,0172, 95%CI 0.17 – 0.89), TyG Inde
x (p=0,0000, 95%CI 4.30 – 10.69) and
MET (p=0,1893, 95%CI 0.87 – 1.94) w
ere independently correlated with metab
Table 1. Descriptive Table of Potential Risk Factors of Metabolic Syndrome
3
olic syndrome. Furthermore, other facto
rs, such as sex, were not statistically sig
nificant (p-value>0,05) and had no relati
onship to the incidence of metabolic syn
drome.
Furthermore, Table 2 also shows that th
e six factors with p-value <0,25, which
were employment, VAI, LAP, HDI, and
MET, were used in the multivariate logi
stic regression analysis. Multivariate log
istic regression analysis found that the
most dominant factors or most significa
nt with p-value <0,05 were employment
in the informal sector, VAI, LAP, and T
yG Index It shows that VAI was more
meaningful than other factors as a risk f
actor for developing metabolic syndrom
e (p-value 0,000 95% CI 11.36 – 37.00).
DISCUSSION
Bivariate analysis
The present study studied four hundred
and forty-eight adults with and without
metabolic syndrome. From bivariate ana
lysis, the results in this study found that
sex has not statistically significant and h
ad no relationship to the incidence of m
etabolic syndrome with a p-value of 0.7
73. The results of this study differ from
research conducted by Tsaban et al., wh
ich study that metabolic syndrome is mo
re common among women than men, bu
t still, data regarding the sex-specific as
sociation are sparse.11 Supported by rese
arch in the USA using NHANES survey
data, stating that metabolic syndrome is
more common in women.12 A significan
t sex disparity is apparent, with women
having a seemingly higher risk of havin
g metabolic syndrome but men having a
higher risk of cardiovascular disease.13
Women have higher estrogen levels, inc
reasing insulin sensitivity, and decrease
d blood pressure.
Frequency/n Percent (%)

4
Sex
- Male 181 40,40
- Female 267 59,60
Age
- ≤30 years 126 28,12
- 31-40 years 76 16,96
- 41-50 years 100 22,32
- 51-60 years 84 18,75
- ≥61 years 62 13,84
Employment
- Student 70 15,62
- Informal 104 23,21
- Formal 124 27,68
- Unemployed 150 33,48
LAP
- Non-risk 225 50,22
- Risk 223 49,78
VAI
- Non-risk 221 50,67
- Risk 227 49,23
TyG Index
- 8–9 272 60,71
- 9–10 176 30,29
HDI
- High 104 23,21
- Moderate 308 68,75
- Low 36 8,04
MET
- High 0 0,00
- Moderate 145 32,17
- Low 303 67,63

5
 Table 2. Descriptive Table of Potential Risk Factors of Prediabetes
Metabolic Synd Non-Metabolic S
Bivariate analysis Multivariate analysis
rome yndrome
n (%) n (%) p value OR (95%CI) p value OR (95%CI)
Sex
- Male 92 (41.07) 89 (39.73) - - -
0.773
- Female 132 (58.98) 135 (60.27) 0.95 (0.63 – 1,40) - -
Age
- ≤30 years 29 (23.02) 97 (76.98) - - -
- 31-40 years 44 (57.89) 32 (42.11) 4.59 (2.37 – 8.89) 0.091 2.16 (0.88 – 5.28)
- 41-50 years 58 (58.00) 42 (42.00) 0.0000 4.61 (2.49 – 8.55) 0,054 2.41 (0.98 – 5.93)
- 51-60 years 54 (64.29) 30 (35.71) 6.02 (3.07 –11.77) 0.725 1.18 (0.45 – 3.12)
- ≥61 years 39 (62.90) 23 (37.10) 6.10 (2.97–12.55) 0.638 1.29 (0.44 – 3.72)
Employment
- Student 11 (15.71) 59 (84.29) - -
- Informal 67 (64.42) 37 (35.58) 9.71 (4.07 – 23.12) 0.039 3.33 (1.06 – 10.49)
0.0000
- Formal 54 (43.55) 70 (56.45) 4.13 (1.91 – 9.92) 0.440 1.51 (0.52 – 4.31)
- Unemployed 91 (61.07) 58 (38.93) 8.50 (3.82 – 18.94) 0.182 2.20 (0.69 – 7.03)
VAI
- Non-risk 46 (20.54) 181 (80.80) - - - -
- Risk 178 (79.46) 43 (19.20) 0.0000 16.28 (9.98 – 26.64) 0.000 15.34 (8.34 – 28.21)
LAP
- Non-risk 95 (42.41) 130 (58.04) - - - -
- Risk 129 (57.59) 94 (41.96) 0.0009 1.87 (1.26 – 2.78) 0.000 4.60 (2.54 – 8.31)
TyG Index
-8–9 89 (39.73) 183 (81.07) - - -
0.0000
- 9 – 10 135 (60.27) 41 (18.93) 6.77 (4.30 -10.69) 0.001 2.79 (1.51 – 5.13)
HDI
- High 64 (28.57) 40 (17.86) - - -
- Moderate 146 (65.18) 162 (72.32) 0.0172 0.56 (0.35 – 0.89) 0.438 0.77 (0.41 – 1.46)
- Low 14 (6.25) 22 (9.82) 0.39 (0.17 – 0.88) 0.271 0.54 (0.18 – 1.60)
MET
- Moderate 66 (48.53) 70 (51.47) - - -
0,1893
- Light 158 (50.64) 154 (49.36) 1.30 (0.87 – 1.94) 0.110 0.59 (0.31 – 1.12)

Independent variable showing p value <0,25 in univariate analysis were entered in multivariate analysis.
OR (Odds Ratio), 95%CI (95% Confidence Interval), VAI (Visceral Adiposty Index), LAP (Lipid Accumulation Product), TyG Inde
x (Triglyceride Glucose Index), HDI (Healthy Diet Index) and MET (Metabolic Equivalent of Task)

6
After menopause, women experience a
decline in estrogen levels, which can inc
rease metabolic syndrome risk. Women
tend to have more subcutaneous and vis
ceral fat associated with insulin resistan
ce, dyslipidemia, and hypertension.14
Age has a significant relationship with
metabolic syndrome with a p-value of 0,
0000. The results of this study were con
sistent with the results of Bener et al. in
Qatar study in their bivariate analysis wi
th Chi-square showing an association be
tween age and metabolic syndrome (p v
alue<0,001), which shows increasing ag
e after 30 years will increase the risk of
metabolic syndrome.15 Our findings agr
eed with a cross-sectional study in Ethio
pia that increasing age significantly incr
eases the risk of metabolic syndrome (O
R 18.23; 95% CI (6.66, 49.84)).16 Increa
sing abdominal obesity paralleled the ag
e-related increase in metabolic syndrom
e prevalence in both genders.17
Employment has a significant relationsh
ip with metabolic syndrome with a p-va
lue of 0,0000. Similarly, a cross-section
al study from the Netherlands which stu
dies the incidence of metabolic syndrom
e among worker show that compared to
high skilled white-collar employees, lo
w skilled white-collar workers had a co
nsiderably greater risk of metabolic inci
dence (OR: 1.24; 95% CI: 1.12 - 1.37) a
nd low skilled blue-collar workers had a
significantly higher risk (OR: 1.37; 95%
CI: 1.18 - 1.59). It was more common f
or blue-collar employees to engage in h
armful behavior combinations. In this st
udy, VAI shows significant metabolic s
yndrome increases compared with those
with normal range VAI (p-value <0,001
OR: 16.28; 95% CI:9.98 – 26.64). Other
research shows a similar result. All com
ponents of metabolic syndrome increase
d significantly across VAI quintiles. VA
I was independently associated with bot
h cardiovascular (OR 2.45; 95% CI 1.52
7
–3.95; P< 0.001) and cerebrovascular (1
63; 1.06–2.50; P <0.025) events.19 LAP
shows significant metabolic syndrome i
ncreases by 1,87 times compared with t
hose with normal range LAP (p-value <
0,001 OR: 1.87; 95% CI:1.26 – 2.78). R
esearch conducted in several countries,
China, India, and the USA, shows that L
AP and VAI can be used as markers for
young adults, the elderly population, an
d both sex.19–22 LAP exhibits the best pre
dictive efficacy for the marker in detecti
ng metabolic syndrome .20 TyG Index al
so shows significant increases of metab
olic syndrome by 6,77 times compared
with those with normal range TyG (p-v
alue <0,001 OR: 6.77; 95% CI:4.40 – 1
0.69).
Our findings suggest that moderate and
low HDI are statistically protective agai
nst metabolic syndrome (p-value 0,0172
OR: 1.87; 95% CI:0.17 – 0.89). There is
no research on the correlation between
HDI and metabolic syndrome. There is
another study about diet using HEI. Tot
al HEI-2015 scores were significantly lo
wer in metabolic syndrome subjects tha
n in the control group (65.04 ± 9.71 vs.
66.75 ± 8.88).23 Our study contradicts so
me studies that show an unhealthy diet s
ignificantly becomes a risk factor for m
etabolic syndrome. Poor diet and sedent
ary lifestyle are major contributors to th
e etiopathogenesis of metabolic syndro
me. The prevalence of the metabolic sy
ndrome has also been linked to a low co
nsumption of fruits, vegetables, and wh
ole grain cereal items paired with a high
intake of fast food, white bread, red mea
t, sweets, and sweetened drinks.24 Dietar
y and physical activity interventions for
metabolic syndrome reduce central obes
ity without adverse effects.25 Consumin
g an overall healthy diet for weight loss
and ongoing weight maintenance is the
major method for managing metabolic s
yndrome to lower the risk of developing
cardiovascular and cerebrovascular illne
ss.26
In this study, low MET shows an increa
sed risk of metabolic syndrome compar
ed with those who moderate MET (p-va
lue 0,189 OR: 1.30; 95% CI :0.89 – 1.9
4). Low physical activity can also increa
se β-cell insufficiency of β-cell pancreat
ic, oxidative damage, mitochondrial dys
function, and inflammation which trigge
r insulin resistance.28 Having physical ac
tivity levels above >1,200 MET-minute
s/week had a reduced risk of metabolic
syndrome.27 The results of this study co
ntradict cross-sectional research in the
USA using NHANES survey data. A hi
gh physical activity level was 63% less l
ikely to have metabolic syndrome than i
ndividuals with low physical activity le
vels (OR = 0.37, 95% CI: 0.20, 0.68). A
lthough not statistically significant, parti
cipants with a medium level of physical
activity were 44% less likely to have me
tabolic syndrome than individuals with l
ow PA (OR = 0.56, 95% CI: 0.23, 1.34).
A physical activity level above >1,200
MET-minutes/week reduced the risk of
CONCLUSION
Our study concluded that VAI was the
most important risk factor related to
metabolic syndrome. Other important
risk factors are employment (informal
sector workers), LAP above 36.99, and
TyG Index (9-10). Anthropometric
Indexes is very useful for determining
risk factor of metabolic syndrome.
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