The association of the food items of the MD pattern with the five metabolic syndrome criteria prevalence was considered separately (table 7). Cereals intake and high mono-unsaturated to saturated fatty acids showed a protective effect on triglycerides criterion (p = 0.002) and on glycemia criterion (p = 0.02). No noticeable association was observed for the other metabolic syndrome criteria.
Discussion
The objective of the study was to assess the prevalence of MS in women population of Morocco, a Mediterranean country, in relationship with the adherence to Mediterranean diet. To the best of our knowledge, this study is the first one focusing on the possible relationship between the traditional Mediterranean diet (MD) and metabolic syndrome in the region. To better know the determinants of adherence of the women sample to the MD, the effect of the MD specific components is also discussed in this paper.
In Morocco, a developing country that is also experiencing demographic, health and nutrition transitions, few epidemiological studies have been conducted to characterize the magnitude of the prevalence of MS particularly in women; the importance of identifying women who are at risk of developing MS cannot be underestimated.
It is important to note that comparison of the prevalence of MS between studies is difficult, as different criteria are used and, most importantly, sex and age standardization is indispensable, that makes the comparison is not easy to make between published studies.
Although the prevalence of MS differs according to the criteria used to define it, it seems to affect around 25% of the population in developed countries (Alvarez Leon et al., 2003; Athyros et al., 2005). In this study, we used the National Cholesterol Education Program Adult Treatment Panel description of MS which is considered to be the most applicable tool for clinical and epidemiological practices (Isomaa et al., 2003).
Our findings on the prevalence of MS are quite similar to those previously reported in developed countries, indeed, one in every fifth adults presented MS in this population. This prevalence confirms the results of a cross-sectional survey conducted in 1995 in the same population about the magnitude of the prevalence of MS and association of BMI and WC with risk factors for cardiovascular diseases (Belahsen et al., 2005). This prevalence was also greater than that encountered by another study conducted in another region, the south of Morocco (Rguibi et al., 2004). Compared to the North Africa, MS is less prevalent than that observed in Tunisian women (Allal-Elasmi et al., 2010) or Algerian women (Biad et al., 2010) with significantly higher prevalence in women (37.3% and 27,1%) than in men(23.9% and 14,9%) (Bouguerra et al., 2007). It is also the case of the countries in Middle East where MS is among the major health problems testified by the abundant published literature. In Turkey, for instance, the prevalence of MS was estimated as 33.9% more marked in among women [39.6%] than men 28% (Kozan et al., 2007). In Saudi Arabia a prevalence of 13.6% comparable to that found in the present study was reported in adult females (Motlagh et al., 2009). In Oman, another country of the same region, the MS prevalence was estimated as 21.0%. In the same way, the prevalence of MS using the ATP III definition was reported to be 36.3% in a population of the Northern Jordan with higher rates in women than in men.
In this study, all anthropometric indices (BMI, WHR, Skinfold thickness and WC) provided useful information on metabolic risks. Comparative findings about the mean values of anthropometric variables of groups with and without MS can be explained by the recognized association between weight excess and body fat, and metabolic alterations (Oliveira et al., 2009). The proportion of women with ≥ 1 MS abnormalities (91.2%) suggests that each MS component worsens with obesity among women, and is in accordance with previous studies (Mar Bibiloni et al., 2011; Hillier et al., 2006). Low HDL-cholesterol level was the most commonly observed component of MS (82.4%) followed by Hypertension (36.8%), while high triglyceridemia was the least common (6.6%). The prevalence of MS factors in our population follows in part the pattern in developed countries when we stratified by the presence or absence of metabolic syndrome. There are discrepancies in literature about the prevalence of MS components. In developed countries, low HDL-cholesterol levels, and high triglyceridaemia and hypertension were the most common MS factors, whereas high fasting glycaemia was the least common (Do Carmo et al., 2008). In developing countries, high fasting triglyceridaemia was the most common MS factor, whereas low HDL-cholesterol level was the least common (Ebrahimpour et al., 2006).
Diet may also be one of the most important factors determinants of MS. The average adherence to the MDP was 62.84 % (± 12.7). The present study shows a low variability of the percentage of adherence to Mediterranean diet as reflected by the SD values.
There was no association between the adherence to MD and the risk of metabolic syndrome, indicating that there is no protective effect of MD on the prevalence of MS in our study population. Several epidemiological studies have evaluated the role of the MD on the development or progression of the metabolic syndrome; and the association of the adherence to the MD with a beneficial effect on the MS was largely reported (Rumawas et al., 2009; Paletas et al., 2010), In the opposite, other studies in adults (Panagiotakos et al., 2004; Thanopoulou et al., 2006) found contradictory results or do not present a clear benefit of high adherence to MD in lowering prevalence of metabolic syndrome.
In the same way, this study shows that MS components were not significantly associated with adherence to the MDP, while several recent clinical trials demonstrated that adhering to MD has a beneficial effect on abdominal obesity (Romaguera et al., 2009), lipids levels (Tzima et al., 2007), glucose metabolism (Panagiotakos et al., 2007), and blood pressure levels (Estruch et al., 2006) and all the components of the MS, that are also risk factors for the development of cardiovascular disease, insulin resistance, and diabetes.
The multiple beneficial effects of the MD on the parameters of MS are also closely associated with its individual dietary components; in this context, the MS components risk was also evaluated by the MD pattern food groups. In our study, the food items associated with MD protective effect were higher MUFA /SFA for glycemia and higher cereals and roots for triglycerides.
The primary source of MUFA is olive oil; it’s one of the most representative and central food of traditional MD. In the study subjects; this food represents 17.6 % of the fats and oils food group which explains the ratio MUFA/SFA of 1.02 ± 0.35. In Morocco; olive oil is used abundantly as a culinary fat. A recent review demonstrated its beneficial effects of MD on lowering blood pressure, reducing plasma glucose, and improving the cholesterol/HDL ratio and endothelial function (Lopez-Miranda et al., 2010). It is also to be noted that in our study, even not significant, high intakes of MUFA/SFA, Fruits, Vegetables and Fish were associated with lower risk of blood pressure criterion. Polyphenols and flavonoids present in fruits and vegetables, Intake of fish oil N-3 fatty acids have also been shown to decrease plasma triglycerides and blood pressure (Perez-Vizcaino et al., 2009; Duda et al., 2009).
The protective effect of the MD on triglycerides was mediated by higher cereals and roots food items and their known beneficial effect on lipid metabolism due to their water-soluble fiber content (Brown et al., 1999). In our study population, there’s a large intake of cereals and roots (696.4 g day-1); The effect of fiber on plasma triacylglycerol is mainly from such gel-forming fiber which influences the functional properties of the intestinal mucosa by slowing upper intestinal transit, as a result, the intestinal absorption of dietary lipids may impair (Topping et al., 1988).
The study reports also no protective effect of cereals intake on glycemia. Some studies have reported an association of high cereal intake with a lower prevalence of the glycaemic and even insulin resistance criterion. In this study, subjects with cereal intake >150 g day-1 presented half the risk of hyperinsulinemia than subjects with lower intakes. This effect could be explained in part by those foods fiber content, resulting in a lower rate of gastric emptying and an increased satiation (Delzenne et al., 2005).
The results of our analysis showed an association between some life-style characteristics and the adherence to a global MDP. Many studies have associated socioeconomic characteristics and life-styles with the adherence to several population dietary patterns (Sanchez-Villegas et al., 2002; Whichelow et al., 1996; Martinez et al., 2010) but to our knowledge this is the first time that the factors associated with the adherence to MDP have been analyzed in this population. Our subjects belong to a population stratum with a medium education level (half of the population has a primary school education level); there was a direct association between adherence to the MDP and women education level. The latter was reported to have marked effect on family lifestyles and dietary habits (Do Carmo et al., 2008). Nowadays, mothers are still in charge of the home dieting in the Moroccan population, and the mother education level is one of the best predictors of the family diet quality. The present results are also in agreement with previous studies carried out in Spanish adults (Moreno et al., 2002; Tur et al., 2004) suggesting a direct association between low education level and low fruits and vegetables’ consumption..
On average, higher socioeconomic level, defined by education level, has been associated with the adherence to a healthier dietary pattern (Fraser et al., 2000); however, Family income, another direct indicator of socioeconomic level, was not significantly linked to greater or lower adherence to the MD in the present study; this reinforces again the influence of education level especially in terms of food intake behaviour.
Contrary to other investigations, we have not been able to determine the number of women smokers because they do not want to respond to this issue probably for social and culture considerations. It was reported that smoking is positively associated with unhealthy dietary habits (lloveras et al., 2001) and negatively associated with high adherence to the traditional MDP (Martinez-Gonzalez et al., 1997).
We have also considered that Mediterranean lifestyle includes the regular practice of physical activity. In our study, despite a high rate of physical inactivity (94%), an inverse relation can be observed between physical activity during leisure-time and low adherence to the MD, although this difference is not statistically significant; the beneficial effect attributed to the MD against CHD and other related diseases could not be a result of diet only, but also in part to a more active life-style during leisure time of those who adhere to the traditional Mediterranean diet, this association has also been observed in previous studies (Sanchez-Villegas et al., 2002; Martinez et al., 2010; Mariscal-Arcas et al., 2007). Besides, epidemiological evidence supports a detrimental role of sedentary lifestyles on increasing obesity epidemic in Mediterranean countries (Martınez-Gonzalez et al., 2001).
Having children, marital status represents another social dimension, as dietary habits could be influenced by living arrangement. Women not living with spouse tend to have nutritional deficiency of iron, vitamin D and lower consumption of vegetables and fish. It is possible that they pay less attention to meal preparation. Other possible explanations are the low income, or lower education level in these women. Numerous studies have shown that married persons have lower risk of mortality, and enjoy better physical and mental health than their unmarried counterparts (Hu et al., 1990). Moreover, marital termination by death or divorce has been prospectively linked to decline in health and increased mortality risk, with more pronounced effects among men (Ebrahim et al., 1995; Stroebe et al., 1983).
To sum up, MS is prevalent among the study population, especially among obese women. These findings demonstrate an emerging health problem in Morocco because of the number of overweight and obese women that are likely to develop MS. Some components of the MD showed a protective effect on some MS components; however, no association was found between MS and adherence to MD. High education level, increased physical activity level and availability of family environment were also related to a better adherence to MD pattern.
Study Limitations
The key limitations of this study are the small sample size of this work. Furthermore, adherence to the MD was relatively uniform with low variability among the subjects, since the diets of the subjects are not largely different and remained relatively similar. Another concern is that adherence to the MD was determined only from dietary data collected over a few months (between September and December); it is possible that some subjects changed their diet over the many years required for MS to develop. It’s for this reason that we chose subjects who are not taking medication or recently changed their diet on the recommendation of their physician because of the detection of abnormalities (e.g., hypertension) linked to MS.
Conclusion
The present study demonstrates that despite the uniformity of the adhesion of the population to the MD that is the original Moroccan diet, there is an absence of its effect on the MS. The effect is still present in some components of MD, which shows an increasing abandonment of this diet that it is replaced by the nutrition transition that crosses Morocco. MD is often lost regardless of age and income, especially among people with low education and physical activity, living alone and having no children. These groups should be targeted for intervention strategies to deviate the development of detrimental mechanisms involved in the genesis of the synergistic effects of MS components, and to slow down the effects of nutrition transition that is the major source of alteration of the traditional MD pattern considered as the original diet in Morocco.
Acknowledgements
This study has been carried out with the financial support (Joint grant) of INSERM (Institut National de la Santé et de la Recherche Medicale, France) and CNCPRST (Centre National de Coopération et de Recherche Scientifique, Morocco).
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