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Body adiposity in a sample of prediabetic and diabetic adult Egyptian patients

Sarry El-Din, Azza M.; Zaki, Moushira E.; Kandeel, Wafaa A.; Mohamed, Sanaa K.

doi: 10.1097/01.MJX.0000429692.39856.9d

Objective Fat percentage and its distribution exert a strong influence on the development of glucose intolerance and type 2 diabetes. The aim of this study was to evaluate the impact of body adiposity on the presence of prediabetes and type 2 diabetes in a sample of Egyptian adults.

Methods This is a cross-sectional study on 866 Egyptian adults aged between 20 and 75 years. The study evaluated the presence of prediabetes or type 2 diabetes and compared BMI, percentage of body fat (BF%), visceral fat, waist circumference, and the waist-to-hip ratio between normoglycemic patients and individuals with prediabetes or type 2 diabetes.

Results BF% was significantly higher in prediabetic and diabetic individuals than in normoglycemic individuals. Both prediabetic and diabetic lean and obese men showed higher visceral fat levels than their corresponding normoglycemic counterparts.

However, among women, a significant increase was observed only in prediabetic obese individuals. There is coexistence of diabetes and hypertension in obese and old patients.

Conclusion Type 2 diabetes is more frequent in older obese Egyptians and is associated with elevated systolic and diastolic blood pressure. Although total BF% is an important risk factor for type 2 diabetes, visceral fat is considered the most strongly related factor to the disease especially in men.

Department of Biological Anthropology, Medical Research Division, National Research Centre, Cairo, Egypt

Correspondence to Azza M. Sarry El Din, PhD, Department of Biological Anthropology, National Research Centre, El-Bohouth Street, Dokki, PO Box 2311, 12622 Cairo, Egypt Tel: +20 10 06077370; fax: +20 02 33371564; e-mail:

Received March 12, 2013

Accepted April 15, 2013

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Diabetes mellitus, long considered a disease of minor significance to world health, is now considered one of the main threats to human health in this century. The global epidemic of type 2 diabetes is largely due to population growth, aging, urbanization, and the scourge of obesity and physical inactivity. The total number of people worldwide with type 2 diabetes was expected to increase from 171 million in 2000 to 366 million in 2030 1.

Obesity is defined medically as an increase adipose tissue to a magnitude that produces adverse health consequences; it is associated with increased morbidity and mortality 1. It is a major risk factor for developing type 2 diabetes, as shown by the relationship between increases in BMI and the risk of developing type 2 diabetes 2–4, and is considered a strong predictor for type 2 diabetes in both sexes, as well as in all ethnic groups 5,6.

Obesity is commonly used to imply excess fat, but it is ordinarily classified according to excess weight. This semantic inconsistency may help us to explain why the BMI performs only modestly as a predictor of medical risk. However, BMI has been traditionally used as a surrogate measure of adiposity and is the most frequently used diagnostic tool in the current classification system for obesity 7. It is well known that body fat distribution exerts a strong influence on the development of glucose intolerance and type 2 diabetes 8,9. Anthropometric measures such as the waist circumference or the waist-to-hip ratio (WHR) are considered better estimators of the risk for obesity-associated type 2 diabetes compared with BMI 10. Epidemiological studies analyzing the impact of the percentage of body fat (BF%) on the levels of metabolic risk factors are scarce 1. It has been suggested that BF% is a better indicator of other comorbidities associated with obesity, such risk for coronary heart disease, compared with waist circumference 11. Further, BF% has been associated with all-cause and cardiovascular mortality 12,13 with high fat mass being more strongly associated with mortality risk than BMI 14.

Intra-abdominal fat accumulation can occur in both men and women, and BMI does not provide a reliable indication of the extent of intra-abdominal adiposity 15. Although there is solid evidence that body fat distribution (and therefore intra-abdominal obesity) has a very significant genetic basis, an increasing tendency toward sedentary habits and excessive intake of high-energy foods are efficient promoters of abdominal obesity. Abdominal obesity and type 2 diabetes often coexist 11,12, and patients with type 2 diabetes are well known to be at an elevated risk for first or repeat cardiovascular events, compared with their nondiabetic counterparts 16.

Therefore, it may be crucial to evaluate the clinical usefulness of measuring BF% in estimating the obesity-associated risk for type 2 diabetes.

The aim of this study was to analyze the impact of body adiposity on the presence of prediabetes and type 2 diabetes in a sample of Egyptian adults. This was achieved by evaluating the relationship between the criteria used for the diagnosis of obesity and the presence of prediabetes or type 2 diabetes and comparing BMI, BF%, visceral fat, waist circumference, and the WHR between normoglycemic individuals and individuals with prediabetes or type 2 diabetes.

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Participants and methods

This is a cross-sectional analysis of 866 adult Egyptian individuals of both sexes (484 women and 382 men) aged between 20 and 75 years. In 2010, a team from NRC initiated a community-based cross-sectional survey for establishing comprehensive anthropometric measurements for the dimensions of the Egyptian human body to be used for obtaining the standards needed for the Egyptian clothing industry. The study sample in this survey included 8250 adult individuals of both sexes, aged 20 years or older. Individuals who participated in this study were part of the study sample of the previous project mentioned. The participants represented different geographic localities and different social classes. The sample was selected from the cities of Greater Cairo, Alexandria, and El Mehala, representing lower Egypt and El Fayoum, Bany Souif, and El Menia, representing upper Egypt. The survey included individuals working in government organizations, those working in factories, and those attending social clubs. The study was performed to evaluate the presence of prediabetes or type 2 diabetes in relation to the criteria used for the diagnosis of obesity. The study design was approved from an ethical and scientific standpoint by the ethical committee board of the National Research Centre of Egypt (No. 09/038). Informed written consent was obtained from all participants. All participants completed a questionnaire that includes personal, socioeconomic, demographic, and medical data.

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Anthropometric and body composition measurements

Anthropometric measurements including height, weight, waist circumference, and hip circumference were taken by practitioners. Height was measured in the standing position using fixed stadiometers (Seca, Japan). Body weight was measured in light clothing to the nearest 0.1 kg. Waist circumference was measured at the midpoint between the lower rib margin and the iliac crest, with the participant standing at the end of normal expiration. Hip circumference was measured at the level of the greater trochanters with the individual wearing minimum clothing. Nonstretchable tape was used for measurement of both circumferences. The WHR was calculated. The mean of three consecutive measurements of each anthropometric measure was evaluated using standardized equipment and following the recommendations of the International Biological Program 17. Body composition was measured using the Tanita BC-418 MA Segmental Body Composition Analyzer (Tanita, Japan). It prints out a complete body composition profile including weight, BF%, body fat mass and BMI, and visceral fat rating, in which the rate from 1 to 12 indicates a healthy level of visceral fat and that from 13 to 59 indicates an excess level of visceral fat. Participants were classified according to BF% into lean, overweight, and obese groups. The most frequently used cutoff points for BF% defining overweight were 20.1–24.9% for men and 30.1–34.9% for women and defining obesity were 25% or more for men and 35% or more for women 18–20. Further, participants were classified according to BMI as lean, overweight, or obese.

Systolic and diastolic blood pressures were measured in the sitting position using a standard mercury sphygmomanometer with appropriate cuff sizes after a 5-min rest period. Systolic blood pressure was measured at the first appearance of a pulse sound (Korotkoff phase 1) and diastolic blood pressure at the disappearance of the pulse sound (Korotkoff phase 5). Two blood pressure readings were averaged, and the average was used for analyses 21.

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Determination of serum glucose levels

Serum glucose levels were measured by the glucose oxidase peroxidase method using an enzymatic colorimetric kit (Biodiagnostic kit, Egypt) according to the Trinder method 22.

Data were analyzed using SPSS for Windows (version 16; SPSS Inc., Chicago, Illinois, USA). The Kolmogorov–Smirnov test was used to check for normality in the continuous variables. Quantitative variables are presented as mean±SD. The analysis of variance test was used to compare groups. All post-hoc comparisons were made using t-tests with Bonferroni adjustment. Significance was assumed for P-values less than 0.05.

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Urban and rural groups were analyzed together because they had similar body adiposity patterns. Table 1 shows the distribution of individuals with normoglycemia, prediabetes, and type 2 diabetes according to BF%. The χ 2-test shows that, in the obese and overweight groups, prediabetic and diabetic patients had significantly higher frequencies of BF% compared with normoglycemic individuals.

Table 1

Table 1

Participants were classified according to their BMI into lean, overweight, and obese groups and their clinical characteristics were compared (Tables 2 and 3).

Table 2

Table 2

Table 3

Table 3

Fasting blood sugar levels showed a significant increase in the prediabetic and diabetic individuals of the three groups (lean, overweight, and obese). The mean ages are significantly higher in type 2 diabetic individuals than in normoglycemic individuals across all the three groups for both men and women (Tables 2 and 3).

Among men, BMI, BF%, and fat mass were significantly higher in the diabetic individuals than in the normoglycemic ones only in the obese group, whereas no significant differences were observed in the lean or overweight groups when we compared prediabetic and diabetics patients with normoglycemic individuals (Table 2). Visceral fat showed significantly higher levels in all prediabetic and diabetic individuals of the three groups (lean, overweight, and obese) compared with normoglycemic individuals. As regards waist circumference, it shows significant higher values in individuals with type 2 diabetes in both the overweight and obese groups, whereas the WHR showed a highly significant difference only in diabetic individuals of the obese group (Table 2).

Among women, no significant differences were observed in BF% or fat mass among the three groups. Visceral fat levels were increased in the prediabetic and diabetic individuals of the three groups but a significant difference was recorded only in the prediabetic individuals of the obese group. Moreover, waist circumference showed a significant increase in the diabetic individuals of the lean group (P<0.004); in addition, there is a tendency for an increase in the waist circumference in the prediabetic and diabetic individuals of the obese group; however, this does not reach a significant level (P=0.760). In contrast, WHR showed a significant increase among prediabetic and diabetic individuals of the lean and obese groups (Table 3).

Systolic and diastolic blood pressures were recorded. Among men, there are significant increases in both systolic and diastolic blood pressure in prediabetic and diabetic individuals of both lean and obese groups (Table 2), whereas among women, a significant increase in the systolic and diastolic blood pressure was found only among prediabetic and diabetic individuals of the obese group (Table 3).

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Type 2 diabetes is an emerging epidemic of titanic proportions worldwide and in Arabic-speaking countries 1. Obesity is a major risk factor for the development of prediabetes and type 2 diabetes; it is defined by the presence of excessive of body fat, the amount of which is correlated with the development of comorbidity 23. Both total BF% and fat distribution have to be measured when estimating the risk for prediabetes and type 2 diabetes, even in individuals with a BMI less than 25 kg/m2, in particular, those over 40 years of age, especially men 24.

This study showed a highly significant increase in BF% in prediabetic and diabetic individuals compared with normoglycemic individuals. The worldwide epidemic of obesity and its association with chronic disease have also contributed to the need to study body composition 25,26 and the distribution of the components of body composition 27. The definition of obesity on the basis of body size has been challenged in different populations because of the different relationships with BF% and BMI levels 28. Therefore, a definition of obesity on the basis of body composition can help clarify this issue 27.

Of the various methods of assessing human body composition, bioelectrical impedance analysis, which was used in this study, has emerged as a promising technique because of its simplicity, low cost, high reproducibility, and patient acceptability. Studies have shown that no significant difference could be detected in the BF% estimated using BIA and that estimated using other methods such as DXA or under water weighing and dilution techniques 27–31.

Fields et al. 32 reported that individuals of both sexes with BMI greater than 35 kg/m2 were ∼20 times more likely to develop type 2 diabetes compared with controls. On the basis of the results of the present study, participants were divided according to BMI and sex into lean, overweight, and obese groups. BMI, total BF%, and fat mass were significantly higher in diabetic men than in normoglycemic men in the obese group. A similar result was found in a sample of white individuals aged between 18 and 80 years living in Navarra, situated in the north of Spain 24. Studies comparing BMI, waist circumference, and WHR in relation to the incidence and prevalence of type 2 diabetes were reviewed 33. All studies included in this review showed that either BMI, waist circumference, or WHR was associated with type 2 diabetes independently. Similarly, other studies concluded that BMI and waist circumference were equally good predictors for type 2 diabetes 34,35.

As regards visceral fat, it showed significantly higher levels in all prediabetic and diabetic men of the lean, overweight, and obese groups, whereas it showed significant difference only among prediabetic women of the obese group. Sandeep et al. 36 indicated that in nondiabetic Asian Indians, the visceral, but not subcutaneous, component of abdominal fat is associated with insulin resistance, cardiovascular risk factors, and metabolic syndrome. Veilleux et al. 37 reported that visceral adipose tissue accumulation is an important predictor of metabolic alterations. Bray et al. 38 reported on the measurement of subcutaneous and visceral fat as a predictor for the development of diabetes in a subgroup of the Diabetes Prevention Program that underwent computed tomography scans at baseline. They found that, among men, higher visceral fat levels, waist circumference, BMI, and WHR significantly predicted the onset of diabetes. None of these measures was significantly better than any other. In contrast, subcutaneous fat did not predict diabetes 39.

Among women, BMI, waist circumference, WHR, and visceral fat are generally not strong predictors of diabetes. These outcomes may bebecause of the fact that women have more subcutaneous fat than men and because of the possibility that the higher levels of subcutaneous fat may have diluted the effect of visceral fat because subcutaneous fat did not predict diabetes 38.

It is possible that in lean individuals classified according to BMI, BF% is a better marker of increased obesity-associated risk than body fat distribution, especially among men 24. Further, it has been reported that an equivalent increase in body fat had lesser impact on insulin sensitivity in women than in men 40. This goes in agreement with our results which revealed that obese females had more pronounced significant differences in clinical characteristics in normoglycemic compared to prediabetic and diabetic groups.

Although general obesity is an important risk factor for many diseases, several human studies have demonstrated that regional fat distribution rather than overall fat volume is important to understand the link between obesity and metabolic disorders 41,42. Although more than 80% of the total body fat is distributed in the subcutaneous compartment and only 10–20% is distributed within visceral adipose tissue in adults 43, visceral fat is thought to play an important role in the expression of metabolic complications of obesity because of its unique position with respect to portal circulation 44 and its secretory function for various bioactive substances 45,46. The mechanism linking visceral fat with the metabolic syndrome was suggested by Trayhurn and Wood 47. They considered visceral adipose tissue to be an active endocrine organ capable of secreting many cytokines, often referred to as adipokines, that can promote inflammation and interfere with insulin action. Further, studies 48,49 have shown that subcutaneous fat and visceral fat are biologically distinct, with visceral fat demonstrating far greater proinflammatory characteristics than subcutaneous fat.

In the men of this study, significantly higher levels visceral fat were seen in all prediabetics and diabetic individuals compared with normoglycemic individuals, whereas a significant difference was observed only in the prediabetic women of the obese group. The percentage of the obese prediabetic and diabetic men having visceral fat values over the normal level was 59.1 and 81.4%, respectively, whereas the percentage of obese prediabetic and diabetic women with high visceral fat levels was 27.2 and 25.8%, respectively. This may be due to sex differences in fat distribution, as men have greater visceral fat mass than women and women have more subcutaneous fat 50.

The incidence of hypertension in patients with type 2 diabetes is ∼two-fold higher than that in age-matched individuals without the disease 51. Arafa and El Din 52 found that the prevalence of hypertension among Egyptian diabetic individuals was 75% for men and 66.9% for women. Recently, Sarry El Din et al. 53 reported that the percentages of hypertensive men among normal and diabetic adult Egyptian patients were 9.8 and 29%, respectively, whereas those of hypertensive women were 9.5 and 32.5%. The prevalence of hypertension is particularly high among obese individuals and it increases with age. This study reported coexistence of diabetes and hypertension in obese and/or elderly patients. This coincides with the results of other studies 51,54.

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Type 2 diabetes is more frequent among older obese Egyptians and is associated with increased systolic and diastolic blood pressure. The present study emphasized that BF% plays an important role in the development of type 2 diabetes, and visceral fat has a key role in the development of diabetes, especially among men.



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The authors thank the Science and Technology Development Fund (STDF) for funding the project entitled ‘Standardization of adult Egyptian dimensions for implementation in development of clothing industries’ (1256), the data from which was used to establish this work.

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Conflicts of interest

There are no conflicts of interest.

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