Althea Medical Journal. 2016;3(3)
477
Metabolic Syndrome Components and Nutritional Status among
Hypertensive Outpatiens at Dr. Hasan Sadikin General Hospital
Bandung
Lira Mirandus,1 Hikmat Permana,2 Siti Nur Fatimah3
1Faculty of Medicine Universitas Padjadjaran, 2Department of Internal Medicine Faculty of
Medicine Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital Bandung, 3Department of
Medical Nutrition Faculty of Medicine, Universitas Padjadjaran
Abstract
Background: Metabolic syndrome and overnutritional status (overweight and obesity) are examples
of determinants that can give rise to hypertension, so the three diseases are correlated with each other.
This study aimed to reveal metabolic syndrome components and nutritional status among hypertensive
outpatients.
Methods: This study involved 44 hypertensive outpatients who visited the Nephrology and Hypertension
Clinic of Dr. Hasan Sadikin Hospital, Bandung in September to October 2013. Anthropometric and blood
pressure measurements, anamnesis, and medical record data collection were carried out to describe the
patient’s metabolic syndrome components by using International Diabetes Federation criteria on South
Asian people and nutritional status by WHO classification in Asian people.
Results: Among respondents, 25 (57%) had abdominal obesity, 14 (32%) had hypertrygliceridemias, 14
(32%) had low HDL cholestrol, 19 (43%) were taking lipid-lowering medications, 20 (45 %) had high
level of fasting blood glucose, 21 (48%) had been diagnosed as mellitus type 2, 15 (34%) had high blood
pressure, 40 (91%) were taking antihypertensive medications, 19 (43%) had metabolic syndrome, and 31
(70%) were overweight or obese.
Conclusions: Less than a half of the respondents meet the metabolic syndrome criteria and over two third
of them are at overnutrition state (overweight or obesity). [AMJ.2016;3(3):477–81]
Keywords: Hypertension, metabolic syndrome, nutritional status
Correspondence: Lira Mirandus, Faculty of Medicine, Universitas Padjadjaran, Jalan Raya Bandung-Sumedang Km.21,
Jatinangor, Sumedang, Indonesia, Phone: +628568517229 Email: liramirandus@gmail.com
Introduction
In recent years, the prevalence of
noncommunicable diseases (NCDs) in world
population has grown rapidly. The NCDs and
all of its negative impacts were responsible
for almost two third of the world’s 57 million
death in 2008, yet more than a half ofthose
occurred in low and middle income countries,
including Indonesia.1
Hypertension, metabolic syndrome,
overnutritional status (overweight and
obesity) are NCDs.2 Hypertension is a
condition where arterial blood pressure rises
abnormally.5 Metabolic syndrome is a cluster
of some metabolic abnormalities that consists
of diabetes melitus or increased fasting
plasma glucose, abdominal obesity, high LDL
cholesterol, low HDL cholesterol and high
blood pressure.6 According to theInternational
Diabetes Federation (IDF), for a person to be
defined with metabolic syndrome they must
have central obesity plus any criteria of four
following factors: raised tryglicerides (≥150
mg/dl), reduced HDL cholesterol (<40 mg/
dl in males and <50 mg/dl in females), raised
blood pressures (systolic BP ≥130 mmHg or
diastolic BP ≥85 mmHg or with treatment
of previously diagnosed hypertension), and
high fasting plasma glucose (≥100 mg/dl or
previously diagnosed diabetes mellitus).6
Nutritional status is a stratification reflecting
whether physiologic needs of nutritions are
being met. It can be assessed by some ways,
one of them is body mass index (BMI) that
furtherly divided into four cathegories, which
two of them, overweight and obesity, reflects
overnutritional status.7 Metabolic syndrome
can give rise to hypertension, as the presence
Althea Medical Journal. 2016;3(3)
478 AMJ September 2016
of insulin resistance activate renin angiotensin
aldosteron system and symphatetic nervous
system.5 Through insulin resistance and
proliferation of glomerular capillary
endothelium, overnutritional status can also
cause hypertension.5 Those facts make the
relationship of the three diseases very clear, yet
there is no study that describes how metabolic
syndrome components and overnutrition exist
in hypertensive people, at least in West Java,
Indonesia’s most populous province. The aim
of this study was to describe the metabolic
syndrome components and nutritional status
among hypertensive patients.
Methods
This cross-sectional study was carried out at
theNephrology and Hypertension Clinic, Dr.
Hasan Sadikin General Hospital Bandung,
in September–October 2013. It involved
previously-diagnosed hypertensive outpatients
who visited the clinic, regardless whether they
were new or follow up patients. The aim and
the way this study would be conducted had
been approved by Dr. Hasan Sadikin General
Hospital’s Ethical Committee. This study
used non probability consecutive sampling
as its data collection method. The amount of
minimal samples was determined by using
the minimal sample formula on cathegorical
descriptive variables with deviation standard
alpha of 1.96 of 95% confidence interval, 10%
precision (d), and presumed proportion of 0.5
that was calculated as 43 samples.
Hypertensive outpatients were evaluated
to define whether they fulfilled IDF metabolic
syndrome criteria on South Asian people, and
then the measurement of body height and
weight were performed to define nutritional
status based on their BMI for Asian people.8
The IDF defines metabolic syndrome as
the presence of abdominal obesity (waist
circumference ≥ 90 cm for South Asian men
and ≥80 cm for South Asian women), plus at
least two of these following factors: raised
tryglicerides (≥150 mg/dl), reduced HDL
cholesterol (<40 mg/dl in males and <50 mg/
dl in females), raised blood pressures (systolic
BP ≥130 mmHg or diastolic BP ≥85 mmHg
or with treatment of previously diagnosed
hypertension), and high fasting plasma glucose
(≥100 mg/dl or previously diagnosed diabetes
mellitus).6 The nutritional status was classiffied
into four categories according to World Health
Organization (WHO) classification of body
mass index in Asian people thus underweight
for BMI <18.5 kg/m2, normal for BMI 18.5–
22.9 kg/m2, overweight for BMI 23–24.9 kg/
m2, and obese for BMI ≥25 kg/m2.8
The patients were included in this study
if they brought laboratory results paper of
HDL cholesterol, tryglicerides, and fasting
plasma glucose for follow up purpose, or
intended to perform such tests by instruction
of the clinic’s doctor in charge. Exclusion
criteria of this study were the patients who
refused to get involved, the patients with non-
complete laboratory medical records, and the
patients with vertebral abnormalities so the
measurement of body height could not be
performed. It was decided that laboratory data
had been performed over two months before
patient’s admission to the clinic, were also
excluded.
Furthermore, blood pressure, waist
circumference, body weight and height
measurements were carried out directly to the
patients. Anamnesis was performed to collect
the patient’s name, age, previous history of
type 2 diabetes melitus, medications, and
medical record numbers. For the patients who
brought the laboratory test results paper, the
data of HDL cholesterol, triglycerides, and
fasting plasma glucose could also be performed
at the clinic; for the patients who did not have
them, those data were taken at the Hospital’s
Clinical Pathology Department several weeks
following the primary data collection. The
previous history of type 2 diabetes melitus
and medications were rechecked by data from
the Outpatient Medical Record Department.
However, 3 diabetes melitus history data were
not successfully rechecked by medical record
data because those were not available.
Results
There were 69 hypertensive outpatients
visiting the clinic included in this study,
however only 44 of them who were free from
the exclusive criteria andwhose data would
be analized. The number of both male and
female subjects were 22 respectively, or with
male:female ratio of 1:1 (Table 1). The 60–
66 age group was the largest group in total
subjects and both sexes. Male patients were
relatively older than female patients, which
was reflected by their means and median of
age.
Moreover, abdominal obesity was present
in the majority of subjects. There were
almost a third of the whole subjects who
had hypertriglyceridemias and low HDL
Althea Medical Journal. 2016;3(3)
479Lira Mirandus, Hikmat Permana, Siti Nur Fatimah: Metabolic Syndrome Components and Nutritional Status
among Hypertensive Outpatiens at Dr. Hasan Sadikin General Hospital Bandung
cholesterol level. High fasting plasma glucose
level existed in slightly less than a half of
the whole subjects, as well as the amount of
subjects who were previously diagnosed as
type 2 diabetes mellitus. There were around a
third of the whole subjetcs classified as having
uncontrolled high blood pressure. Nine out
of ten hypertensive subjects were receiving
antihypertensive medications, compared
to only four of ten who were receiving lipid-
lowering medications. The prevalence of
metabolic syndrome according to IDF criteria
was 43% of the total subjects, with the majority
of female subjects categorized as metabolic
syndrome compared to less than a third of
male subjects.
Seventy per cent of the subject was
classified as overnutrition (overweight and
obese) according to the WHO BMI Criteria for
Asian people.8 Overnutritional status was also
present in majority of both male and female
subjects, both 86% and 54% respectively
(Table 3).
Discussion
More than half of thehypertensive patients
included in this study were aged above 60
Table 2 IDF Metabolic Syndrome Components among Hypertensive Outpatients
Features Total (n=44)
Male
(n=22)
Female
(n=22)
Waist Circumference ≥90 cm for male and
≥80cm for female
25 (57%) 8 (36%) 17 (77%)
Triglycerides ≥150 mg/dl 14 (32%) 9 (41%) 5 (23%)
HDL Cholesterol <40 mg/dl for male and
<50 mg/dl for female
14 (32%) 6 (27%) 8 (36%)
With Lipid-Lowering Medications 19 (43%) 10 (53%) 9 (47%)
Fasting plasma glucose >100 mg/dl 20 (45%) 14 (64%) 6 (27%)
With Previous Diagnosis of Type 2 Diabetes
Mellitus
21 (48%) 14 (64%) 7 (32%)
Blood Pressure ≥130/85 mmHg 15 (34%) 9 (41%) 6 (27%)
With Antihypertensive medications 40 (91%) 18 (82%) 22 (100%)
Fulfill IDF Criteria on Metabolic Syndrome 19 (43%) 7 (32%) 12 (55%)
Note : IDF=International Diabetes Federation, HDL=High Density Lipoprotein
Table 1 General Characteristics of Subjects
Features Total (n=44) Male (n=22) Female (n=22)
Age (years old)
39–45 1 (2%) 1 (5%) 0 (0%)
46–52 4 (9%) 2 (9%) 2 (9%)
53–59 11 (25%) 4 (18%) 7 (32%)
60–66 19 (43%) 11 (50%) 8 (36%)
67–73 6 (14%) 2 (9%) 4 (18%)
74–80 2 (5%) 1 (5%) 1 (5%)
81–87 1 (2%) 1 (5%) 0 (0%)
Patient’s Status
New 1 (2%) 1 (5%) 0 (0%)
Follow up 43 (98%) 21 (95%) 22 (100%)
Althea Medical Journal. 2016;3(3)
480 AMJ September 2016
Table 3 Nutritional Status among Hypertensive Outpatients
BMI Classification Results in Total (n=44)
Results in Male
(n=22)
Results in Female
(n=22)
Underweight 1 (2%) 0 (0%) 1 (5%)
Normal 12 (27%) 3 (14%) 9 (41%)
Overweight 16 (36%) 10 (45%) 6 (27%)
Obese 15 (34%) 9 (41%) 6 (27%)
Note : BMI=Body Mass Index
years, both in male and female sex groups.
That characteristic was considered relatively
to be same with two previous studies
conducted in Taiwan.9,10 The predominance
of follow-up patients group over new patients
might be due to the function of the hospital as
a referral destination from the primary health
care which made thefirst diagnosis and initial
management before referring.
This study revealed that abdominal obesity
was present in the majority of hypertensive
outpatients. In spite of its different amount
of prevalence (62.2%), a study published
by Hsu et al.9 in 2005 has also shown that
phenomenon. Both prevalences revealed in
this study and in the study of Hsu et al.9 were
higher than thegeneral population according
to Indonesia’s National Basic Health Research
2007 which reported only 18.8%.11
There were almost similar prevalence of
hypertrygliceridemia according to this study
and the different studies established by Su
et al.10 and Hsu et al.9 as they reported that
high plasma triglyceride level is present in
34.74% and 40.50% of hypertensive patients.
Nonetheless, Su et al.10 and Hsu et al.9 both
have shown that low HDL cholesterol exist
in 69.7% and 78.2% of the same subjects,
which was quite different with this study.
Those variations could possibly be caused by
differences in the amount of subjets who were
receiving lipid-lowering drug administrations,
and how data were collected. Su et al.10 and
Hsu et al.9 carried out simultaneous blood
sample collection to their subjects and used
standardized laboratory examination method
instead of taking secondary data from the
subjects’ medical record with varying time. In
this study, 43% of the subjects were receiving
lipid-lowering medications. That results
could possibly be influenced by a limitation
such as 3 unrechecked medication history of
anamnesis data because of the medical record
incompleteness.
Furthermore, Su et al.10 reported that high
fasting plasma glucose (above 100 mg/dl) is
present in almost two third of hypertensive
patients, which wasquite varied from less
than a half according to this study. However,
that study only involved hypertensive
outpatients from the Cardiology and
Neurology Department without those from
theEndocrinology Department, as opposed to
this study which included patients from the
two departments, which could influence the
results, since the Endocrinology Department
had significant numbers of diabetic patients
with uncontrolled fasting plasma glucose.
Moreover, Hsu et al.9 stated that 30.11%
of hypertensive outpatients were previously
diagnosed as having type 2 diabetes mellitus,
lower than what this study showed. Having
explained before, that the study have not
involved patients in the Departement of
Endocrinology, hence it could lower the
number of hypertensive subjects.
There were about one third of hypertensive
outpatients who remained having high blood
pressure, although the fact was 91% of them
were receiving antihypertensive medications.
The effectivity of such medication in reducing
blood pressure depends on thepatient’s
obedience, the patient’s condition, and
medication completeness, while the subjects’
blood pressure were measured.
According to this study, there was 43%
of hypertensive outpatients who fulfilled
the IDF criteria on metabolic syndrome.
A previous study revealed that metabolic
syndrome (using IDF criteria) is present in
54.67% of hypertensive outpatients, which
was slightly different with this study.10 Both
two studies established higher prevalences
than a study that used the same criteria and
was conducted by Zainuddin et al.13 in the
Malaysian general population which was
33.33%. A research established by Kelishadi
et al.14 from Isfahan, Iran, concluded that the
prevalence of metabolic syndrome is rather
higher in hypertensive than in normotensive
population. It strongly reflects that metabolic
syndrome tends to be more prevalent in
Althea Medical Journal. 2016;3(3)
481Lira Mirandus, Hikmat Permana, Siti Nur Fatimah: Metabolic Syndrome Components and Nutritional Status
among Hypertensive Outpatiens at Dr. Hasan Sadikin General Hospital Bandung
hypertensive population than in the general
one. Rahajeng and Tuminah3 reported that
there are about 11.2% and 14.7% classified
as overweight or obese among hypertensive
population, which is much lower than this
study revealed. Their study involved over a
hundred thousand rural and urban subjects
taken from 33 provinces across Indonesia
which were very different from this study’s
mostly urban and local subjects. The same
study also revealed that overnutrition is more
prevalent in hypertensive than in general
population.
As a conclusion, the metabolic syndrome
components according to IDF among
hypertensive outpatients are more than a
half have abdominal obesity, almost a third
have hypertriglyceridemia and low plasma
HDL cholesterol level, almost a half have
high fasting blood glucose level, almost two
third have uncontrolled high blood pressure.
Whereas, patients with antihypertensive
medications are much higher than who are not
with 9:1 ratio, and lipid-lowering medicated
patients and patients with previous history of
type 2 diabetes mellitus are less than a half.
The prevalence of metabolic syndrome among
hypertensive outpatients is 43%. There are
more than 70% of hypertensive outpatients
classified as overweight or obese.
References
1. Alwan A, Armstrong T, Bettcher D, Branca
F, Chissholm D, Ezzati M, et al. Global Status
Report of Non Communicable Diseases
2010. In: WHO, editor. Geneva: World
Health Organization; 2011.
2. Soewondo P, Purnamasari D, Oemardi
M, Waspadji S, Soegondo S. Prevalence
of metabolic syndrome using NCEP/
ATP III criteria in Jakarta, Indonesia :
the Jakarta primary non-communicable
disease risk factors surveillance 2006.
Acta Med Indones-Indones J Intern Med.
2010;42(4):199–203.
3. Rahajeng E, Tuminah S. Prevalensi
hipertensi dan determinannya di Indonesia.
Maj Kedokt Indon. 2009;59(12):580–587.
4. Pusat Komunikasi Publik Kementerian
Kesehatan Republik Indonesia. Penyakit
Tidak Menular (PTM) Penyebab Kematian
Terbanyak di Indonesia. Jakarta:
Kementerian Kesehatan RI; 2011; [cited
2 December 2012] Available from:
http://www.depkes.go.id/index.php/
berita/press-release/1637-penyakit-
tidak-menular-ptm-penyebab-kematian-
terbanyak-di-indonesia.html.
5. Kotchen TA. Hypertensive Vascular
Disease. In: Longo DL, Kasper DL, Jameson
JL, Fauci AS, Hauser SL, Loscalzo J, editors.
Harrison’s Principle of Internal Medicine.
18th ed. New York: McGraw-Hill; 2012. p.
2042–59.
6. Alberti SG, Zimmet P, Shaw J, Grundy SM.
The IDF consensus worldwide definition of
the metabolic syndrome. In: International
Diabetes Federation, editor. Brussels:
International Diabetes Federation; 2006.
p. 1–23.
7. Hammond K. Assessment: dietary and
clinical data In: Mahan LK, Escott-Stump S,
editors. Krause’s Food & Nutrition Therapy.
12th ed. St.Louis: Saunders Elsevier; 2008.
p. 383–410.
8. WHO Expert Consultation. Appropriate
body mass index for Asian populations and
its implications for policy and intervention
strategies. The Lancet. 2004;363:157–163.
9. Hsu CN, Chen YC, Wang TD. Prevalence and
Characteristics of the Metabolic Syndrome
in Chinese Hypertensive Patients : A
Hospital-Based Observation. Acta Cardiol
Sin. 2005;21:89–97.
10. Su CH, Fang CY, Chen JS, Po HL, Chou
LP, Chiang CY, et al. Prevalence of
Metabolic Syndrome and Its Relationship
with Cardiovascular Disease among
Hypertensive Patients 55–80 Years of Age.
Acta Cardiol Sin. 2011;27:229–237.
11. Departemen Kesehatan Republik
Indonesia. Prevalensi obesitas sentral pada
orang dewasa diatas 15 tahun menurut
provinsi. In: Riset Kesehatan Dasar 2007,
editor. Jakarta: Departemen Kesehatan
Republik Indonesia; 2007.
12. Departemen Kesehatan Republik
Indonesia. Prevalensi asma, penyakit
jantung, diabetes, dan tumor menurut
provinsi. In: Riset Kesehatan Dasar 2007,
editor. Jakarta: Departemen Kesehatan
Republik Indonesia; 2007.
13. Zainuddin LRM, Isa N, Muda WMW,
Mohamed HJ. The Prevalence of
metabolic syndrome according to various
definitions and hypertriglyceridemic-
waist in Malaysian adults. Int J Prev Med.
2011;2(4):229–37.
14. Lioudaki E, Vrentzos GE, Mavrogeni H,
Zeniodi M-H, Ganatokis ES, Mikhalidis DP,
et al. Prevalence of metabolic syndrome
according to different definitions in
a hypertensive population. Angology.
2011;63(1):39–47.