CLINICAL & BASIC RESEARCH Sultan Qaboos University Med J, November 2014, Vol. 14, Iss. 4, pp. e460−467, Epub. 14TH Oct 14 Submitted 8TH Jan 14 Revision Req. 17TH Feb 14 Revision Recd. 20TH Mar 14 Accepted 17TH Apr 14 Departments of 1Research & Studies and 4Information & Statistics, Directorate General of Planning and 3Non-Communicable Diseases Surveillance & Control, Directorate General of Health Affairs, Ministry of Health; 2Office of the World Health Organization, Muscat, Oman *Corresponding Author e-mail: rmmabry@gmail.com املتالزمة األيضية ومكوناهتا حتليل ثانوي للمسح الصحي العاملي يف عمان حممود عطيه عبد العاطي، روث مابري، جمدي مر�سي، جواد اللواتي، اآ�سيا الريامية، مدحت ال�سيد abstract: Objectives: The study aimed to describe the prevalence of metabolic syndrome (MS) and its components among Omani adults. Methods: The 2008 Oman World Health Survey dataset was used to determine the national prevalence of MS. Logistic regression using all key sociodemographic, clinical and behavioural variables was used to identify the associations of independent variables with MS. Results: The age-adjusted prevalence of MS was 23.6%. MS was significantly associated with age, marital and work status and wealth level. MS was more common for people aged 50 years and older compared to the youngest cohort (OR 3.6, CI: 2.4–5.3; P <0.001) and in people who were married or employed (OR 1.6, CI: 1.3–2.1; P <0.001 and OR 1.3, CI: 1.1–1.8; P = 0.043, respectively) compared to their unmarried and unemployed counterparts. MS was also more common in people in the second lowest wealth quintile (OR 1.6, CI: 1.2–2.2; P = 0.05) compared to the lowest quintile and in those who sat for more than six hours per day (OR 1.3, CI: 1.1-1.7; P = 0.035). Conclusion: One in four adults had MS in Oman. This may fuel the epidemic of non-communicable diseases (NCDs) in Oman, particularly given the increasingly elderly population. Urgent action is required to ensure quality patient care at all levels of the healthcare system. Further research on behavioural risk factors is needed. Developing and implementing a multisectoral strategy to prevent NCDs should be at the top of the current health agenda for Oman. Keywords: Metabolic Syndrome X; Chronic Diseases; Epidemiology; Public Health; Oman. امللخ�ص: الهدف: هدفت الدرا�سة اإىل و�سف معدل انت�سار املتالزمة الأي�سية ومكوناتها بني العمانيني البالغني. الطريقة: مت ا�ستخدام قاعدة بيانات امل�سح ال�سحي العاملي بال�سلطنة لعام 2008 لتحديد املعدل الوطني لنت�سار املتالزمة الأي�سية، ومت ا�ستخدام معادلة النحدار للمتغريات امل�ستقلة العالقة على للتعرف وال�سلوكيات وال�رسيرية ال�سكانية الجتماعية- للعوامل الأ�سا�سية املتغريات لكل اللوج�ستي امل�ستقلة مع املتالزمة الأي�سية. النتائج: وجد اأن معدل انت�سار املتالزمة الأي�سية املعدل ح�سب ال�سن يبلغ %23.6. ووجد اأي�سا ارتباط ذو دللة اإح�سائية مع العمر واحلالة الزواجية والعمل والرثوة. وكانت املتالزمة اأكرث انت�سارا بني الأفراد البالغني من العمر 50 عاما فاأكرث باملقارنة مع الفئة العمرية الأ�سغر )الحتمال املرجح: 3.6 وحدود الثقة P>0.001 ،2.4-5.3(. ووجد اأي�سا اأن املتالزمة الأي�سية اأكرث �سيوعا بني املتزوجني والعاملني ) الحتمال املرجح: 1.6 حدود الثقة P>0.001 ،1.3–2.1 والحتمال املرجح1.3 وحدود الثقة P = 0.043 ،1.1-1.8 على التوايل( مقارنة بغري املتزوجني والعاطلني عن العمل. كما وجد اأن املتالزمة اأكرث انت�سارا بني امل�ستوى الثاين الأقل من ترتيب اأخما�س الرثوة )الحتمال املرجح:1.6 وحدود الثقة P = 0.05 ،1.2-2.2) مقارنة بالفئة الأدنى. واأظهر اأي�سا الأفراد الذين يجل�سون لأكرث من 6 �ساعات يوميا عالقة ذات دللة معنوية مع املتالزمة الأي�سية )الحتمال املرجح: 1.3 وحدود الثقة P = 0.035 ،1.1-1.7(. اخلال�صة: وجد اأنه من بني كل اأربعة بالغني يف عمان يوجد �سخ�س واحد م�ساب باملتالزمة الأي�سية. وهذا مما يزيد من وبائية الأمرا�س غري املعدية، خا�سة مع زيادة عدد امل�سنني. ويتطلب الأمر عمال عاجال ل�سمان توفري رعاية ذات جودة عالية للمر�سى على كل م�ستويات النظام ال�سحي، واجراء بحوث اأخرى على عوامل ال�سلوكيات الخاطئة ويجب تبني ا�سرتاتيجية متعددة القطاعات للوقاية من الأمرا�س غري املعدية وتنفيذها لتكون يف مقدمة الأجندة ال�سحية يف عمان. مفتاح الكلمات: املتالزمة الي�سية x؛ األمرا�س املزمنة؛ الوبائيات؛ ال�سحة العامة؛ عمان. Metabolic Syndrome and Its Components Secondary analysis of the World Health Survey, Oman Mahmoud Abd El-Aty,1 *Ruth Mabry,2 Magdi Morsi,1 Jawad Al-Lawati,3 Asya Al-Riyami,1 Medhat El-Sayed4 Advances in Knowledge - This is the first descriptive study at the national level in Oman of metabolic syndrome (MS), a precursor of cardiovascular disease and type 2 diabetes. - One in four Omani adults was found to have MS. Furthermore, older adults, people who were married and those who were employed were observed to be some of the key high-risk groups for MS. - From the results of this study, it was found that a large portion of Omani adults did not achieve the recommended amount of daily physical activity and did not consume the recommended amount of fruits and vegetables. Application to Patient Care - The results of this study, which observed a high proportion of Omani adults with MS and its components, highlight the need for appropriate measures to ensure that the healthcare system can provide quality care, including prevention, screening for early diagnosis and management. Mahmoud Abd El-Aty, Ruth Mabry, Magdi Morsi, Jawad Al-Lawati, Asya Al-Riyami and Medhat El-Sayed Clinical and Basic Research | e461 Metabolic syndrome (MS) includes a cluster of cardiovascular and diabetes risk factors.1,2 People with this syndrome are at higher risk of developing diabetes and cardiovascular disease as well as premature mortality.1 MS also increases the risk of other diseases, including cancer, kidney disease and mental illness.3–5 Thus, MS is widely used as a marker for evaluating outcomes of population-based strategies aimed at preventing non- communicable diseases.6 The first internationally recognised working definition for MS was proposed at a World Health Organization (WHO) consultation in 1988 and numerous attempts have been made since then to develop a standard definition. Most identified a person with MS as one who had at least three of the following: central obesity, high fasting blood glucose levels, elevated blood pressure (BP), high cholesterol and high triglycerides, with the main difference between definitions being the cut-off points for each of these clinical indicators.7 Non-communicable diseases account for 83% of all deaths in Oman.8 Despite the increasing rates of overweight/obesity, hypertension and type 2 diabetes, limited information is known about MS in Oman.9–11 A community-based study conducted in 2001 in Nizwa, Oman, reported an age-adjusted prevalence of 19.5% in men and 23.0% in women aged 20 years and older.12,13 A more recent survey in Sur, Oman, found the age-adjusted prevalence of MS to be 24.2% in men and 29.8% in women aged 20 years and above.14 Despite the differences in age groups and definitions for MS, these studies demonstrate a clear gender difference, with a higher prevalence of MS in women, which is a trend that has been identified in other countries of the region as well.15 This study aimed to provide for the first time a descriptive epidemiology of MS and its components at the national level in Oman. Methods The World Health Survey was developed by the WHO more than 10 years ago to obtain comprehensive information on the health of a population using a standard methodology.16 The Oman World Health Survey (OWHS) was a population-based household survey conducted in 2008 to obtain a wide range of reliable and comparable information on the population’s health and healthcare system in Oman. The prevalence of non-communicable diseases and associated risk factors were captured by the survey. The OWHS used the WHO STEPwise approach.17 A multi-stage stratified cluster sampling design was used to select respondents aged 18 years and above. Data were collected at the household level and included the following variables: gender, age, marital status (never married, currently married, separated/ divorced or widowed), education level (illiterate, primary/preparatory, secondary or post-secondary), work status (currently working, previously worked or never worked) and wealth (in quintiles, with quintile 1 being the lowest and quintile 5 being the wealthiest). Respondents were asked to identify if they had ever been diagnosed with hypertension or diabetes and if so, whether they were taking medication or other treatments. Respondents were also asked about their health risk behaviours (tobacco use, physical inactivity, sitting time and fruit and vegetable intake). An individual who was a current user of any tobacco product was defined as a current smoker. Physical activity was assessed according to intensity, duration and frequency in three domains (work, transport and leisure); the total metabolic equivalent of task (MET) in minutes per day was calculated according to the WHO guidelines to estimate the total minutes of moderate physical activity per week for each individual. A person was determined as doing sufficient physical activity if they had performed the equivalent of at least 150 minutes of moderate physical activity per week. One survey item assessed the number of hours the participant sat per day. Fruit and vegetable intake was assessed by totalling the numbers of each item consumed on a typical day. In addition, the anthropometrics (height, weight and waist circumference) of the respondents were assessed and three BP measurements were taken. Blood samples were collected after 8–14 hours of fasting to determine fasting blood glucose levels, total cholesterol levels, high-density lipoprotein (HDL) and low-density lipoprotein (LDL) cholesterol and triglyceride levels. The samples were labelled and transferred immediately in cold boxes filled with ice to a laboratory in a regional hospital. Samples for measuring blood glucose levels were collected in 2 mL sodium fluoride oxalate anticoagulant containers and samples for measuring cholesterol were collected in 2 mL lithium heparin anticoagulant containers. After plasma separation by centrifuge, the blood glucose and lipid levels were estimated using a Hitachi 911 automated clinical chemistry analyser (Roche Diagnostics, Basel, Switzerland) by the enzymatic colourimetric method.18 Out of the 5,465 individuals who were invited, a total of 4,717 individuals successfully completed the interviews with a response rate of 86.3%. Biomarkers were successfully analysed from 3,686 individuals (78.3%).9 Details of the study methodology have been published elsewhere.9 Metabolic Syndrome and Its Components Secondary analysis of the World Health Survey, Oman e462 | SQU Medical Journal, November 2014, Volume 14, Issue 4 Among the participants, MS was identified using the National Cholesterol Education Program’s Revised Adult Treatment Panel III (ATPIII) definition.7 This identified individuals as having MS if they were taking medication for or had at least three of the following: central obesity with a waist circumference of ≥102 cm for men or ≥88 cm for women; raised triglycerides of ≥1.7 mmol/L; reduced HDL cholesterol of <1.03 mmol/L for men or <1.3 mmol/L for women; raised systolic BP of ≥130 mm Hg or diastolic BP of ≥85 mm, and raised fasting plasma glucose of ≥5.6 mmol/L.7 In addition to central obesity, obesity was also assessed using body mass index (BMI) calculated in kg/m2. The prevalence of MS was examined according to sociodemographic and behavioural risk factors for Omani participants with complete information for all adults aged 20 years and above. Data were entered on microcomputers using the Census and Survey Processing (CSPro) System (United States Census Bureau, Washington, D.C., USA). Survey data were cleaned using CSPro as well as Stata, Version 13 (StataCorp LP, College Station, Texas, USA). The Statistical Package for the Social Sciences (SPSS), Version 18 (IBM Corp., Chicago, Illinois, USA) was used for statistical analysis. Logistic regression using all key sociodemographic, clinical and behavioural variables determined the associations of independent variables with MS. Models were age- adjusted to the population of Oman using national 2008 population statistics. Results were reported as percentages, means with standard deviations (SD) and odds ratios (OR) with 95% confidence intervals (CI). This secondary analysis of the OWHS for chronic non-communicable diseases and associated risk factors was approved by the Research and Ethical Review and Approval Committee of the Ministry of Health (MOH). Results A total of 3,137 Omani participants had complete information for all of the variables and were included in this study (85%). The sample was relatively young (39.4 ± 15.8 years) and 46.5% were men. Nearly two- thirds (63.4%) of the participants were married [Table 1]. Approximately half of the men (49.5%) had received at least a secondary school education compared to only 34.7% of the women, and a larger proportion of men (60.3%) were employed compared to women (10.7%). The mean BMI and systolic BP measurements of the sample were higher than normal at 26.1 ± 6.5 kg/ m2 and 131.8 ± 21.9 mm Hg, respectively. Elevated means were observed among men for BMI, systolic BP, Table 1: Distribution of selected sociodemographic, metabolic and lifestyle characteristics by gender of the Omani population sample using the 2008 Oman World Health Survey data (N = 3,137)* Men n = 1,459 Women n = 1,678 Total Sociodemographic characteristics Age group in years 20–29 36.5 32.1 34.2 30–39 23.7 27.0 25.5 40–49 14.8 13.6 14.1 50–59 10.0 14.5 12.4 ≥60 15.1 12.8 13.8 Mean ± SD 39.4 ± 16.6 39.5 ± 15.1 39.4 ± 15.8 Marital status Married 63.6 63.2 63.4 Education level No formal education 29.0 48.1 39.2 Primary or preparatory 21.5 17.2 19.2 Secondary 32.8 24.3 28.3 Post- secondary 16.7 10.4 13.3 Work status Employed 60.3 10.7 33.8 Wealth status† Q1 16.5 17.7 17.1 Q2 23.1 25.0 24.1 Q3 22.1 22.6 22.4 Q4 18.6 20.4 19.6 Q5 19.7 14.2 16.8 Metabolic components BMI in kg/m2 25.9 ± 6.3 26.3 ± 6.6 26.1 ± 6.5 WC in cm 90.5 ± 15.8 89.6 ± 17.8 90.0 ± 16.9 SBP in mm Hg 138.4 ± 21.4 126.0 ± 20.8 131.8 ± 21.9 DBP in mm Hg 84.9 ± 14.3 77.0 ± 13.4 80.7 ± 14.4 FBG in mmol/L 5.7 ± 2.2 5.4 ± 1.9 5.5 ± 2.1 Triglycerides in mmol/L 1.40 ± 1.1 1.17 ± 0.8 1.30 ± 0.9 HDL cholesterol in mmol/L 1.18 ± 0.3 1.36 ± 0.4 1.26 ± 0.4 Lifestyle characteristics Current smoker 15.1 0.3 7.2 <150 minutes of moderate physical activity/week 32.0 40.5 36.6 >6 hours sitting per day 21.5 25.6 23.7 Median sitting time in hours/ day 3.0 4.0 3.0 <5 servings of fruit/ vegetables per day 84.6 80.9 82.6 Servings of fruit/vegetables per day 3.0 ± 2.3 3.2 ± 2.7 3.1 ± 2.5 Q = quintile; SD = standard deviation; BMI = body mass index; WC = waist circumference; SBP = systolic blood pressure; DBP = diastolic blood pressure; FBG = fasting blood glucose; HDL = high-density lipoprotein.*Data is expressed as unweighted percentages or mean ± SD. †Wealth status was divided into quintiles, with Q1 being the lowest and Q5 being the wealthiest. Mahmoud Abd El-Aty, Ruth Mabry, Magdi Morsi, Jawad Al-Lawati, Asya Al-Riyami and Medhat El-Sayed Clinical and Basic Research | e463 blood glucose and triglycerides levels in comparison to women, where these variables were within normal ranges. However, women’s obesity measurements were outside these normal ranges. The mean waist circumferences of women (89.6 ± 17.8 cm) were above the normal range and similar to those of men (90.5 ± 15.8 cm). A high percentage of the sample ate less than the recommended five servings of fruit and vegetables per day (82.6%) and did less than 150 minutes of moderate physical activity per week (36.6%). Tobacco use was relatively common among men (15.1%) but rare among women (0.3%). Overall, the age-adjusted prevalence of MS was 23.6%; it was slightly higher in women (24.4%) than men (22.8%), but this difference was not statistically significant [Table 2]. The age-adjusted prevalence of MS was particularly high in adults aged 40–49 years (33.4%), those aged 50 years and above (39.5%) and those with no formal education (33.7%). The prevalence of the various components of MS varied according to gender [Figure 1]. The components with the highest prevalence for women were central obesity and low HDL cholesterol (73.7% and 59.8%, respectively). For men, the components with the highest prevalence were high BP, high triglycerides and impaired fasting glucose levels (60.1%, 56.4% and 53.0%, respectively). The gender difference in prevalence rates were highly significant for all components (P <0.001). Table 2 presents the results of the logistic regress- ion analysis using all key sociodemographic, clinical and behavioural variables. MS was significantly associated with age, wealth and marital and work status. MS was more common for people aged 50 years Table 2: Adjusted prevalence and odds ratio of demographic and behavioural risk factors for metabolic syndrome* in the Omani population using the 2008 Oman World Health Survey data (N = 3,137) Metabolic syndrome OR (95% CI) P value n Age- adjusted prevalence % Sociodemographic characteristics Gender Women 1,678 24.4 1 - Men 1,459 22.8 0.9 (0.7–1.2) 0.539 Age group in years 20–29 30–39 40–49 >50 1,072 799 444 823 13.5 25.3 33.4 39.5 1 1.5 (1.2–2.1) 2.2 (1.5–3.1) 3.6 (2.4–5.3) - 0.004 <0.001 <0.001 Marital status Other Married 1,148 1,989 16.5 27.9 1 1.6 (1.3–2.1) - <0.001 Education level Illiterate Primary/ preparatory Secondary Post- secondary 1,229 603 886 419 33.7 24.3 16.4 18.1 1 0.98 (0.7–1.4) 0.84 (0.6–1.2) 0.76 (0.5–1.2) - 0.945 0.314 0.199 Work status Not employed Employed 2,077 1,059 23.2 24.4 1 1.3 (1.1–1.8) - 0.043 Wealth status† Q1 Q2 Q3 Q4 Q5 537 756 703 615 526 23.4 29.9 18.6 21.6 23.6 1 1.6 (1.2–2.2) 0.8 (0.6–1.2) 1.0 (0.7–1.4) 1.2 (0.8–1.7) - 0.005 0.308 0.859 0.439 Behavioural risk factors Smoking Not a current smoker Current smoker 2,910 226 23.4 26.1 1 0.9 (0.6–1.3) - 0.500 Moderate physical activity per week ≥150 minutes <150 minutes 1,990 1147 23.4 24.0 1 0.9 (0.7–1.1) - 0.143 Sitting time per day ≤6 hours >6 hours 2,395 742 22.8 26.5 1 1.3 (1.1-1.7) - 0.035 Servings of fruits and vegetables per day ≥5 <5 829 2,308 23.5 24.1 1 1.0 (0.7–1.3) - 0.870 Total 3,173 23.6 - - OR = odds ratio; CI = confidence interval; Q = quintile. *Metabolic syndrome was identified according to the National Cholesterol Education Program’s Revised Adult Treatment Panel III definition. †Wealth status was divided into quintiles, with Q1 being the lowest and Q5 being the wealthiest. Metabolic Syndrome and Its Components Secondary analysis of the World Health Survey, Oman e464 | SQU Medical Journal, November 2014, Volume 14, Issue 4 and over compared to the youngest cohort (OR 3.6, CI: 2.4–5.3; P <0.001). It was more common in people who were married or employed (OR 1.6, CI: 1.3–2.1; P <0.001 and OR 1.3, CI: 1.1–1.8; P = 0.043, respectively) compared to their unmarried and unemployed counterparts. MS was also more common in people in the second lowest wealth quintile (OR 1.6, CI: 1.2– 2.2; P = 0.005) compared to the lowest quintile. Of the behavioural risk factors examined (smoking, physical activity, sitting time and dietary intake), only sitting time showed a significant association with MS. The syndrome was more common in people who sat more than six hours per day in comparison to those who sat less (OR 1.3, CI: 1.1–1.7; P = 0.035). Discussion The results of this study showed a high national prevalence of MS (23.6%). This prevalence differed from other prevalences recorded in Oman—it was slightly higher than that seen in Nizwa in 2001 (21.0%) but lower than that seen in Sur (27.3%).12,14 These differences could be due to the definition of MS that was used in these studies. The prevalence found was also slightly lower than in Qatar (26.5%), but much lower than prevalences recorded among other countries of the Gulf Cooperation Council (GCC) region, like Saudi Arabia (39.3%) and the United Arab Emirates (UAE) (39.6%).15 Like Oman, other countries of the GCC region reported a higher prevalence of MS among women, with gender differences ranging between 4.8% in Saudi Arabia using the ATPIII definition to 13% in the UAE using the International Diabetes Federation definition.15 The prevalence rates in Oman were lower than in the USA, where the rates were 35.1% and 32.6% for men and women, respectively.19 However, the rates for men and women were higher than those found in Australia (15.7% and 14.4%, respectively)20 and European countries such as Italy (15% and 18%, respectively)21 and France (16% and 11%, respectively).22 The lower prevalence seen in Oman compared to neighbouring countries is likely due to the lower rates of obesity and possibly also a reflection of the relatively lower gross domestic product (GDP) per capita.23 It is concerning that despite having a young population compared to developed countries, one in four Omani adults in the 2008 OWHS were found to have MS. The prevalence of non-communicable diseases and their risk factors, such as obesity and high BP, are on the increase.9–11 Evidence indicates that the Omani population is genetically susceptible to some components of MS such as obesity, high cholesterol levels and elevated BP.24 In addition, evidence indicates that malnutrition in utero, a likely scenario for the current generation of adults, is linked to MS in adults.25 Given the population’s increased vulnerability to MS, extensive efforts should be made by the government of Oman to implement multisectoral, cost-effective, population-wide interventions such as the actions outlined in the United Nations’ Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases.8,26 Interestingly, of the behavioural risk factors examined (smoking, physical inactivity, sitting time Figure 1: The age-adjusted prevalence of various components of metabolic syndrome among men and women using the 2008 Oman World Health Survey. Metabolic syndrome was defined according to the National Cholesterol Education Program’s Revised Adult Treatment Panel III criteria. The error bars denote 95% confidence intervals. HDL = high-density lipoproteins. ***Significance was P <.001. Mahmoud Abd El-Aty, Ruth Mabry, Magdi Morsi, Jawad Al-Lawati, Asya Al-Riyami and Medhat El-Sayed Clinical and Basic Research | e465 and dietary intake), only sitting time was found to be associated with MS in this study. Evidence clearly demonstrates that these behaviours can prevent MS and its components.8,14,27,28 Thus, it is concerning that a large portion of Omani adults do not meet the recommended amount of physical activity, sit for long periods of time and do not consume the recommended amount of fruit and vegetables.8,29 Successful interventions within the GCC region, including the Nizwa Healthy Lifestyle Project, demonstrate how community-based activities can bring about behavioural changes.30,31 A more strategic approach to promoting physical activity and healthy eating involves changes in policies which are largely outside the health sector, such as agriculture, commerce, education, media, sports, transportation and urban planning.32 The high proportion of adults suffering from MS and its components is likely to increase in the near future given the increase in life expectancy and the high susceptibility of the population. Despite the existence of well-defined clinical management guidelines and a national screening programme for non-communicable diseases,33–35 several studies have raised concerns regarding the quality of care for people with diabetes.31,36,37 Improving the delivery of care, patient education and training for health workers at the primary care level have been identified as key areas for improvement.36,37 The significant associations of MS with older age and lower education are similar to the findings of other studies in Oman and other GCC countries.12,15,38,39 The positive association with age is also commonly found in other parts of the world.40 However, the association with education and income varies internationally.40 Given the significant associations with age and education in Oman, the growth of the elderly population and a high proportion of older adults with MS, extensive efforts are required to ensure that prevention and disease management messages can be clearly understood and followed by all, including those with limited literacy skills.41 Improving the quality of care by emphasising a patient-centred approach is a key way to address this particular issue.36,37 The main strength of this study is that it was a population-based study with a large sample. By obtaining information and collecting clinical measurements and blood at the household level, participants were not obligated to visit a health centre. On the other hand, the long questionnaire, which required an average of 2.25 hours to complete, may have wearied respondents and potentially lead to inaccuracy, particularly among self-reported items such as the questions regarding health risk behaviours. In addition, as a cross-sectional study, the associations identified do not necessarily denote causality. Four main recommendations can be made based on the findings of this study. First, greater efforts should be made by the MOH to advocate for an all-government approach to promoting healthy behaviours as part of a national strategy to prevent non-communicable diseases and their precursor, MS. Given the vast amount of evidence demonstrating that physical activity and healthy dietary behaviours can prevent MS and its components, further research is recommended to better understand these behaviours and to test interventions. Additionally, a patient- centred approach that ensures the provision of quality primary healthcare interventions to prevent, screen for and manage MS and its components is required in order to prevent complications and reduce hospitalisation and mortality. Prevention and disease management messages need to be developed so that they can be easily understood and followed, particularly by older adults who may have limited literacy skills. Conclusion In conclusion, one in four Omani adults was found to have MS, which is a proximal precursor to cardiovascular disease and diabetes. This prevalence rate is higher than in many developed countries despite the much younger population in Oman. An enormous amount of effort by various sectors is needed to reduce the prevalence of MS and its components in order to build on the health gains of the past and to meet the country’s United Nations commitments to addressing non-communicable diseases. acknowledgements The authors would like to thank the MOH for providing the raw data as well as the WHO Regional Office for the Eastern Mediterranean Region for technical support and the relevant GCC authorities for their coordination with the original OWHS. The views expressed in this paper are those of the authors and do not necessarily reflect those of the WHO. References 1. Alberti KG, Zimmet P, Shaw J. Metabolic syndrome: A new world-wide definition. A consensus statement from the International Diabetes Federation. Diabet Med 2006; 23:469– 80. doi: 10.1111/j.1464-5491.2006.01858.x. 2. Zimmet P, Alberti G, Shaw J. A new IDF worldwide definition of the metabolic syndrome: The rationale and the results. Diabetes Voice 2005; 50:31–3. Metabolic Syndrome and Its Components Secondary analysis of the World Health Survey, Oman e466 | SQU Medical Journal, November 2014, Volume 14, Issue 4 3. Borena W, Edlinger M, Bjørge T, Häggström C, Lindkvist B, Nagel G, et al. A prospective study on metabolic risk factors and gallbladder cancer in the metabolic syndrome and cancer (Me-Can) collaborative study. PLoS One 2014; 9:e89368. doi: 10.1371/journal.pone.0089368. 4. Pan A, Keum N, Okereke OI, Sun Q, Kivimaki M, Rubin RR, et al. Bidirectional association between depression and metabolic syndrome: A systematic review and meta-analysis of epidemiological studies. Diabetes Care 2012; 35:1171–80. doi: 10.2337/dc11-2055. 5. Thomas G, Sehgal AR, Kashyap SR, Srinivas TR, Kirwan JP, Navaneethan SD. Metabolic syndrome and kidney disease: A systematic review and meta-analysis. Clin J Am Soc Nephrol 2011; 6:2364–73. doi: 10.2215/CJN.02180311. 6. Simmons RK, Alberti KG, Gale EA, Colagiuri S, Tuomilehto J, Qiao Q, et al. The metabolic syndrome: Useful concept or clinical tool? Report of a WHO Expert Consultation. Diabetologia 2010; 53:600–5. doi: 10.1007/s00125-009-1620-4. 7. Kassi E, Pervanidou P, Kaltsas G, Chrousos G. Metabolic syndrome: Definitions and controversies. BMC Med 2011; 9:48. doi: 10.1186/1741-7015-9-48. 8. World Health Organization. Global status report on noncommunicable disease: 2010. From: www.whqlibdoc. who.int/publications/2011/9789240686458_eng.pdf?ua=1 Accessed: May 2014. 9. Al Riyami A, Elaty MA, Morsi M, Al Kharusi H, Al Shukaily W, Jaju S. Oman World Health Survey: Part 1 - Methodology, sociodemographic profile and epidemiology of non- communicable diseases in Oman. Oman Med J 2012; 27:425– 43. 10. Al-Lawati JA, Al Riyami AM, Mohammed AJ, Jousilahti P. Increasing prevalence of diabetes mellitus in Oman. Diabet Med 2002; 19:954–7. doi: 10.1046/j.1464-5491.2002.00818.x. 11. Al Riyami AA, Afifi MM. Hypertension in Oman: Distribution and correlates. J Egypt Public Health Assoc 2002; 77:383–407. 12. Al-Lawati JA, Mohammed AJ, Al-Hinai HQ, Jousilahti P. Prevalence of the metabolic syndrome among Omani adults. Diabetes Care 2003; 26:1781–5. doi: 10.2337/diacare.26.6.1781. 13. Al-Lawati JA, Jousilahti P. Prevalence of metabolic syndrome in Oman using the International Diabetes Federation’s criteria. Saudi Med J 2006; 27:1925–6. 14. Mabry RM, Winkler EA, Reeves MM, Eakin EG, Owen N. Associations of physical activity and sitting time with the metabolic syndrome among Omani adults. Obesity (Silver Spring) 2012; 20:2290–5. doi: 10.1038/oby.2012.26. 15. Mabry RM, Reeves MM, Eakin EG, Owen N. Gender differences in prevalence of the metabolic syndrome in Gulf Cooperation Council countries: A systematic review. Diabet Med 2010; 27:593–7. doi: 10.1111/j.1464-5491.2010.02998.x. 16. World Health Organization. WHO World Health Survey. From: www.who.int/healthinfo/survey/en/ Accessed: May 2014. 17. World Health Organization. Chronic diseases and health promotion: STEPwise approach to chronic disease risk factor surveillance (STEPS). From: www.who.int/chp/steps/ riskfactor/en/ Accessed: May 2014. 18. Oman Ministry of Health. World Health Survey - Oman. From: www.moh.gov.om/en/reports/WHSSurvey2008(1).pdf and www.moh.gov.om/en/reports/WHSSurvey2008(2).pdf Accessed: May 2014. 19. Ervin RB. Prevalence of metabolic syndrome among adults 20 years of age and over, by sex, age, race and ethnicity, and body mass index: United States, 2003–2006. Natl Health Stat Report 2009; 5:1–7. 20. Adams RJ, Appleton S, Wilson DH, Taylor AW, Dal Grande E, Chittleborough C, et al. Population comparison of two clinical approaches to the metabolic syndrome: Implications of the new International Diabetes Federation consensus definition. Diabetes Care 2005; 28:2777–9. doi: 10.2337/ diacare.28.11.2777. 21. Miccoli R, Bianchi C, Odoguardi L, Penno G, Caricato F, Giovannitti MG, et al. Prevalence of the metabolic syndrome among Italian adults according to ATP III definition. Nutr Metab Cardiovasc Dis 2005; 15:250–4. doi: 10.1016/j. numecd.2004.09.002. 22. Balkau B, Vernay M, Mhamdi L, Novak M, Arondel D, Vol S, et al. The incidence and persistence of the NCEP (National Cholesterol Education Program) metabolic syndrome: The French D.E.S.I.R. study. Diabetes Metab 2003 29:526–32. doi: 10.1016/S1262-3636(07)70067-8. 23. Ng SW, Zaghloul S, Ali HI, Harrison G, Popkin BM. The prevalence and trends of overweight, obesity and nutrition- related non-communicable diseases in the Arabian Gulf states. Obes Rev 2011; 12:1–13. doi: 10.1111/j.1467-789X. 2010.00750.x. 24. Bayoumi RA, Al-Yahyaee SA, Albarwani SA, Rizvi SG, Al- Hadabi S, Al-Ubaidi FF, et al. Heritability of determinants of the metabolic syndrome among healthy Arabs of the Oman Family Study. Obesity (Silver Spring) 2007; 15:551–6. doi: 10.1038/ oby.2007.555. 25. Wang J, Wu Z, Li D, Li N, Dindot SV, Satterfield MC, et al. Nutrition, epigenetics, and metabolic syndrome. Antioxid Redox Signal 2012; 17:282–301. doi: 10.1089/ars.2011.4381. 26. United Nations General Assembly. Political Declaration of the High-Level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases. From: www.who. int/nmh/events/un_ncd_summit2011/political_declaration_ en.pdf?ua=1 Accessed: May 2014. 27. Edwardson CL, Gorely T, Davies MJ, Gray LJ, Khunti K, Wilmot EG, et al. Association of sedentary behaviour with metabolic syndrome: A meta-analysis. PLoS One 2012; 7:e34916. doi: 10.1371/journal.pone.0034916. 28. Healy GN, Matthews CE, Dunstan D, Winkler EA, Owen N. Sedentary time and cardio-metabolic biomarkers in US adults: NHANES 2003–06. Eur Heart J 2011; 32:590–7. doi: 10.1093/ eurheartj/ehq451. 29. Alasfoor D, Rajab H, Al-Rassasi B. Food Based Dietary Guidelines: Technical background and description. From: www.fao.org/ag/humannutrition/19542-0561250979706400b7 cc8ca7366cc07c0.pdf Accessed: May 2014. 30. Midhet FM, Sharaf FK. Impact of health education on lifestyles in central Saudi Arabia. Saudi Med J 2011; 32:71–6. 31. Al-Sinani M, Min Y, Ghebremeskel K, Qazaq HS. Effectiveness of and adherence to dietary and lifestyle counselling: Effect on metabolic control in type 2 diabetic Omani patients. Sultan Qaboos Univ Med J 2011; 10:341–9. 32. Gortmaker SL, Swinburn BA, Levy D, Carter R, Mabry PL, Finegood DT, et al. Changing the future of obesity: Science, policy, and action. Lancet 2011; 378:838–47. doi: 10.1016/ S0140-6736(11)60815-5. 33. Oman Ministry of Health. A manual for the management of hypertension in primary health care. From: www.moh.gov.om/ en/stat/2010/index_eng.htm Accessed: May 2014. 34. Oman Ministry of Health. Diabetes mellitus: Management Guidelines for Primary Health Care. From: www.moh.gov. om/en/reports/DiabetesAfterCorrection1.pdf Accessed: May 2014. 35. Oman Ministry of Health. Operational and Management Guidelines for the National Non-communicable Diseases Screening Program. From: www.moh.gov.om/en/reports/ Guidelines_Manual_for_the_national_N C D_scre ening_ program.pdf Accessed: May 2014. 36. Elliott JA, Abdulhadi NN, Al-Maniri AA, Al-Shafaee MA, Wahlström R. Diabetes self-management and education of people living with diabetes: A survey in primary health care in Muscat Oman. PLoS One 2013; 8:e57400. doi: 10.1371/journal. pone.0057400. Mahmoud Abd El-Aty, Ruth Mabry, Magdi Morsi, Jawad Al-Lawati, Asya Al-Riyami and Medhat El-Sayed Clinical and Basic Research | e467 37. Al-Shookri A, Khor GL, Chan YM, Loke SC, Al-Maskari M. Effectiveness of medical nutrition treatment delivered by dietitians on glycaemic outcomes and lipid profiles of Arab, Omani patients with type 2 diabetes. Diabet Med 2012; 29:236– 44. doi: 10.1111/j.1464-5491.2011.03405.x. 38. Al Rashdan I, Al Nesef Y. Prevalence of overweight, obesity, and metabolic syndrome among adult Kuwaitis: Results from community-based national survey. Angiology 2010; 61:42–8. doi: 10.1177/0003319709333226. 39. Bener A, Zirie M, Musallam M, Khader YS, Al-Hamaq AO. Prevalence of metabolic syndrome according to Adult Treatment Panel III and International Diabetes Federation criteria: A population-based study. Metab Syndr Relat Disord 2009; 7:221–9. doi: 10.1089/met.2008.0077. 40. Cameron AJ, Shaw JE, Zimmet PZ. The metabolic syndrome: Prevalence in worldwide populations. Endocrinol Metab Clin North Am 2004; 33:351–75. doi: 10.1016/j.ecl.2004.03.005. 41. Al-Lawati JA, Mabry R, Mohammed AJ. Addressing the threat of chronic diseases in Oman. Prev Chronic Dis 2008; 5:A99.