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 Table of Contents  
Year : 2021  |  Volume : 9  |  Issue : 2  |  Page : 252-259

Hematological parameters as a risk for developing metabolic syndrome in the adult population of Kashmir (India)

1 Departments of Clinical Biochemistry, University of Kashmir India, Ganderbal, India
2 Department of Biotechnology, Central University of Kashmir (CUK), Ganderbal, India
3 Department of Pyschology, University of Kashmir India, Ganderbal, India

Date of Submission14-Mar-2021
Date of Decision10-May-2021
Date of Acceptance13-May-2021
Date of Web Publication29-Dec-2021

Correspondence Address:
Dr. Fouzia Rashid
Department of Clinical Biochemistry, University of Kashmir, Srinagar, Jammu and Kashmir
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/amhs.amhs_62_21

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Background and Aim: Various studies have reported an association of hematological parameters such as red blood cell (RBC), hemoglobin (Hb), hematocrit (HCT), white blood cell (WBC), and platelets with metabolic syndrome (MS) in many parts of the world. However, the association of these parameters with MS in terms of gender has not been elucidated particularly in the ethnic population of northern India. Thus, the study aimed at exploring the association of these hematological parameters with MS stratified by gender in the Kashmiri region of India. Materials and Methods: A total of 400 people were enrolled in this study consisting of 204 men and 196 women. MS was diagnosed by the International Diabetes Federation criteria. For statistical analysis, SPSS software and Pearson Partial coefficient analysis were used. Results: The prevalence of MS was (50.6% vs. 20.6%) in women and men. WBC and platelets were significantly increased in men with MS (P ≤ 0.05). RBC, Hb, HCT, and platelets were significantly increased in women with MS (P ≤ 0.05). Furthermore, in men, WBC and platelet count increased with the increasing number of MS components. Whereas, in women RBC, Hb, HCT, and platelet count increased with the increasing number of MS components (0, 1, 2, and ≥3). Conclusion: MS was more widespread in women than men than women. The association of hematological parameters differed between the genders. WBC and platelets were found to be the risk factors in men and RBC, Hb, HCT, and platelets were found to be the risk factors in women for MS. These hematological parameters could be used for assessing the risk of MS on the basis of gender.

Keywords: Hematological parameters, insulin resistance, Kashmir, metabolic syndrome

How to cite this article:
Wazir S, Zargar MA, Muzamil M, Rashid F. Hematological parameters as a risk for developing metabolic syndrome in the adult population of Kashmir (India). Arch Med Health Sci 2021;9:252-9

How to cite this URL:
Wazir S, Zargar MA, Muzamil M, Rashid F. Hematological parameters as a risk for developing metabolic syndrome in the adult population of Kashmir (India). Arch Med Health Sci [serial online] 2021 [cited 2022 Aug 19];9:252-9. Available from: https://www.amhsjournal.org/text.asp?2021/9/2/252/334025

  Introduction Top

Metabolic syndrome (MS) is a constellation of various risk factors that can lead to various chronic diseases like cardiovascular diseases[1],[2] type 2 diabetes mellitus.[3] The conditions that may cluster together in MS are many viz; impaired regulation of glucose, obesity, hypertension, dyslipidemia (elevated triglycerides and lower high-density lipoprotein [HDL] cholesterol), pro-thrombotic and pro-inflammatory state and leaving these untreated can turn into a biological disaster. All these conditions increase the risk of death[4],[5] thus identification of biomarker for this syndrome is of great importance. MS has become a global public health concern due to its increasing prevalence not only in India but also worldwideworld. It is estimated that MS affects nearly 20%–30% of adults in various countries.[6],[7],[8] Due to the increased prevalence and chronic consequences of this syndrome, early identification of individuals at high risk of MS may prove important for the prevention of associated chronic diseases. The exact mechanism of MS pathogenesis is not clear but it is generally linked with insulin resistance and chronic low-grade systemic inflammation.[9],[10] Several substitute or surrogate molecules have been studied as markers for MS like uric acid, adiponectin, interleukin (IL) β.[11],[12] In addition, there have been many reports that elucidate the connection of various hematological parameters with insulin resistance and chronic low-grade inflammation, hence MS.[13],[14],[15],[16],[17] These hematological parameters include red blood cell (RBC), white blood cell (WBC), hemoglobin (HGB), hematocrit (HCT), platelets.[18],[19],[20] Hemogram or complete blood count is a fairly inexpensive procedure which is frequently estimated in the clinical field and can be of great importance in providing important information regarding the risk of MS in any person. The association of hematological parameters with that of MS remains controversial due to the inconsistency in the reports depending upon the ethnicity of various populations and the differences between the genders. The gender discrepancies in terms of the hematological parameters in MS have been revealed in various studies. For example, some studies showed increased WBC to be associated with MS in males but not in females,[21] whereas in others it was associated with MS in both genders.[22] Similarly, some reports suggested higher RBC levels to be linked with MS in both males and females, while in other studies no such association was found. HCT, hemoglobin (Hb) and Platelet count also showed inconsistent results. In one study, higher platelet counts were associated with the increased risk of MS in females but not in males.[23],[24] The exact cause of this difference with respect is yet not clear. To the best of our knowledge, there has been no such study conducted for evaluating the relationship between hematological parameters and MS for men and women in the adult population in Kashmir. Therefore, the aim of this study was to explore the incidence of MS and to estimate the prospective association of various hematological parameters with MS in the Kashmiri adult population.

  Materials and Methods Top

Study design and setting

This observational study was carried out at the Department of Clinical Biochemistry, University of Kashmir, J and K, India. The study was done in accordance to Helsinki Declaration and was approved by the Institutional Board of Research Studies under registration No. 47771-W-2006. The study was conducted from August 2014 to March 2019.

Study population

A total of 400 participants, which included 196 Kashmiri women and 204 Kashmiri men who attended various medical screening camps held in various parts of the valley were enrolled in this study. The proper written informed consent were obtained from all the participants prior to the study.

Anthropometric analysis

The baseline data and anthropometry were collected through a proper structured questionnaire. All the anthropometric parameters were measured three times and then the mean values were considered. Weight has been measured in kilograms. The measurement of the waist circumference (WC) at the point was halfway between the iliac crest in a horizontal plane and lower ribs border which has been undertaken with the help of a measuring tape in minimal light clothing. BP was measured at a rest for at least 5 min in sitting position through mercury manometer, the diastolic and systolic blood pressures have been calculated.

Biochemical analysis

Fasting blood samples were collected from all the subjects in the morning after overnight fasting and were analyzed for various biochemical parameters like the serum levels of triglycerides, fasting glucose, and concentrations of HDL-cholesterol. These parameters were estimated using an ERBA semi-automatic analyzer with the commercially available enzymatic reagents (ERBA diagnostics Manheim Gmbh). Furthermore, various hematological parameters such as RBC, WBC, Hb, HCT, and platelets were analyzed using fully automated analyzer (Sysmex kx-21) again with the help of standard commercially available reagents.

Criterion used for determining metabolic syndrome

MS was diagnosed according to International Diabetes Federation (IDF) criterion, according to which any women having WC ≥80 cm along with any two below-mentioned risk factors is considered positive for MS:

  1. Triglycerides levels >150 mg/dl (or receiving treatment for dyslipidemia)
  2. HDL levels lower than 50 mg/dl (or receiving treatment for dyslipidemia)
  3. Increased blood pressure which includes diastolic blood pressure >85 mmHg and systolic blood pressure >130 mmHg (or treatment for the same)
  4. Elevated fasting blood glucose levels (>100 mg/dl) or early diagnosed for diabetes 2 mellitus

Statistical analysis

For anthropometry, biochemical and hematological parameters, readings were taken as triplicates, and results or the outcome of this study were calculated in terms of mean ± standard deviation (SD) and percentages. In order to investigate and analyze the data, the statistical analysis was conducted with the help of IBM SPSS Statistics for Windows, Version 22.0.NY: IBM Corp. All statistical analysis was performed for males and females separately. The independent t-tests were carried out and at a P < 0.05 were considered statistically significant. We also examined the correlation between above-mentioned hematological parameters and various components of MS by Pearson partial coefficient analysis.

  Results Top

Prevalence of metabolic syndrome

In total, there were 400 participants enrolled in the study, of whom 204 were men and 196 were women. Based on the IDF criterion, 42 (20.6%) men and 103 (52.6%) women were diagnosed with Met S.

Baseline features of the study population

Comparison of baseline features of both men and women are shown in [Table 1]. The men with MS showed significant differences in all of the biochemical and anthropometric parameters compared to the men without MS. Men with MS had significantly higher anthropometric parameters like weight, WC, body mass index, systolic blood pressure, and diastolic blood pressure compared to men without MS. Metabolic parameters were also significantly higher in men with Met S in comparison to men without MS like triglycerides, fasting blood glucose, and HDL (P ≤ 0.05). For women a similar trend was observed with anthropometric and metabolic parameters significantly differing in women with MS and those without MS, such as weight, WC, body mass index, systolic blood pressure, diastolic blood pressure, triglycerides, fasting blood glucose, and HDL levels (P ≤ 0.05).
Table 1: Baseline data of Kashmiri adult men and women

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Comparison of hematological features of both men and women are shown in [Table 2]. The men with MS showed a significant differences in WBC (6.52 ± 1.93 vs. 5.75 ± 1.74; P ≤ 0.05) and platelet (229.3 ± 55.8 vs. 165.1 ± 50.25; P ≤ 0.05) counts compared to the men without MS. Among women, a significant difference was observed in almost all the hematological parameters between women with MS compared to the women without MS like RBC (5.10 ± 0.66 vs. 4.72 ± 0.59; P ≤ 0.05), HB (12.72 ± 1.73 vs. 11.79 ± 1.85; P ≤ 0.05), HCT (41.53 ± 4.97 vs. 40.01 ± 4.97; P ≤ 0.05), and platelet counts (231.2 ± 48.5 vs. 175.0 ± 53.85; P ≤ 0.05).
Table 2: Hematological features of the study population

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We estimated the association of the various hematological parameters with different components of MS in men and women as shown in [Table 3]. We observed a statistically positive association of WBC levels with triglyceride (P < 0.05) among men. Furthermore, platelet counts were positively associated with WC, triglycerides, fasting blood glucose, and diastolic blood pressure levels (P < 0.01, P < 0.01, and P < 0.05, respectively). A statistically significant inverse association was noted between Hb levels and HDL concentration (P < 0.05). WBC and platelet counts were inversely and significantly associated with HDL levels (P < 0.05 and P < 0.01). RBC and HCT counts were not associated with any of the Met S components among men.
Table 3: Pearson partial coefficient between hematological parameters to the individual components of metabolic syndrome for both men and women

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In women, however, a positive association was observed between Hb levels with triglyceride levels (P < 0.05). Platelet counts were positively associated with WC and triglycerides and fasting blood glucose levels (P < 0.05, P < 0.01, and P < 0.01, respectively). Furthermore, RBC count was positively associated with triglyceride and diastolic blood pressure levels (P < 0.05). An inverse but statistically significant association was found between Hb and HDL levels (P < 0.05). RBC, platelet and HCT counts were inversely but statistically significantly associated with HDL levels (P < 0.05, P < 0.01, and P < 0.01, respectively). WBC counts were not associated with any of the Met S components among women [Table 3].

All the participants (men and women separately) were divided into 4 groups depending upon the presence of components of MS. These included 0 (no component of MS), 1 (1 component of MS), 2 (2 components of MS), and ≥ 3 (3 or more components of MS). For each hematological parameter, mean ± SD values were calculated pertaining to each subgroup. Then the significance was assessed in terms of the P value (<0.005). In the case of men, the WBC (P = 0.049) and platelet (P = 0.001) count showed an increased trend in their mean concentrations with the increasing number of the components of MS. Other parameters like Hb, RBC, and HCT did not significantly change with respect to the number of components of MS. Whereas, among women, all the hematological parameters like Hb (P = 0.006), RBC (P = 0.002), platelet (P = 0.001) and HCT (P = 0.04) except WBC (P = 0.49) were strongly associated with increasing numbers of MS components as shown in [Table 4].
Table 4: Hematological parameters in relation to the number of components of metabolic syndrome (men and women)

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  Discussion Top

To the best of our knowledge, this study is the first to evaluate the association of various hematological parameters with the risk of developing MS or its components in Kashmir. According to the findings of our study, it is revealed that the prevalence of MS is high in females as compared to males. Furthermore, we found gender differences in the ability to predict MS risk. In case of men, WBC and Platelet counts were significantly associated with increased risk for MS. In case of women, Hb, RBC, platelet, and hematocrit counts were found significantly associated with MS risk.

MS is a combination of various metabolic abnormalities associated with insulin resistance and chronic inflammatory state. RBCs are the type of cells that are responsible for carrying oxygen in our blood. According to our study, RBC was found to be increased in women with MS. Also, RBC was inversely associated with HDL and showed positive association with triglycerides and fasting blood glucose levels in women. Previous researches have reported an increase in RBC counts with the increasing components of MS.[19],[25] Similar trend was found in our study, particularly among women. The mechanism for the increase in RBC counts in MS cases is unclear. However, both insulin-linked and insulin non-linked mechanisms have been proposed as the probable causes for this process. It is believed that insulin binds to the cell surface receptors of the erythropoietic cells stimulating their proliferation and differentiation.[26] The high levels of RBC could lead to an increased release of oxygen from the organs[27] accompanying reduction in microvascular circulation[28],[29] and hence, high RBC count could apparently be a reason for ischemic heart disease. HCT is the percentage of RBC in blood. In our study, hematocrit count was elevated in women with MS. In addition, hematocrit level was found to be increased with the number of MS components and was found significantly but inversely associated with the levels of HDL in women. Increased levels of RBCs and hematocrit can cause increase in the blood viscosity and affects the blood flow at microvessels and large arteries. This could lead to reduced circulation of oxygen, insulin, and glucose to the important tissues. Thus, the gathering of all these hematological parameters can speed up the progression to type 2 diabetes.[30]

Hb has been shown to be connected with MS in various cross-sectional and cohort studies.[17],[19],[20],[31] In our studies, Hb levels were significantly raised in females with MS than those without MS. Furthermore, the levels in women increased with the increasing number of MS components in them. In both men and women, Hb levels were negatively associated with HDL levels, whereas, its positive association was found with triglyceride levels and fasting blood glucose in women. Hb is an important carrier and buffer of nitric oxide and affects the levels of nitric oxide which is crucial in maintaining the endothelial function of blood vessels.[32] Nitric oxide also regulates the affinity between oxygen and Hb which can cause a vascular endothelial dysfunction[33] which has been associated with MS.[34],[35] A sCD40L is involved in the formation of thrombus and process of inflammation, which is a risk factor for atherosclerosis and MS.[36] The levels of this glycoprotein are regulated by Hb itself.

WBCs are involved in low-grade systemic inflammation which has a key role in the pathogenesis of MS and coronary heart diseases.[37] Hence, the evaluation of the WBC count can provide an idea with regard to the development of MS. WBC has been seen significantly raised in people with MS in comparison with those without MS.[38] Similar reports were shown by various other studies.[39],[40] In our study also, WBC levels were significantly raised in men with MS but not in women. WBC count was significantly but inversely associated with HDL and positively associated with triglycerides level in men. WBC levels also increase with the increased number of MS components in men. The results of this study are in line with the one carried out by Kim and colleagues.[21] The mechanism for the increase in WBC counts in MS patients is not quite clear but the propositions suggest the role of insulin resistance. Insulin resistance causes an increase in the levels of proinflammatory cytokines like IL-6, tumor necrosis factor-alpha, which could lead to elevated counts of WBC.[41],[42] Furthermore, it is ambiguous why WBC counts are associated with MS only in men in our study. It is assumed that the vascular protective effects of estrogen[43] might be contributing to this difference. This female sex hormone is strongly believed to protect women from atherosclerosis both by increasing nitric oxide production or vasodilation and by lowering the inflammatory cell adhesion.[44] These effects of estrogen in women could explain the gender bias in our study, where WBC is increased only in men with MS.

Platelets are involved in blood clotting. Decreased platelet count predisposes to bleeding and elevated platelet count increases the risk of thrombosis or clot formation.[45],[46] Platelets have a role in inflammation and atherogenesis.[47],[48] Jesri et al. have demonstrated that the MS people had higher platelet counts than those without MS.[49] Our study shows a significant association of platelet count with the MS in both genders. Platelet count was found to be significantly and inversely associated with HDL levels in both genders. In addition, a positive association was found with WC, triglycerides, fasting blood glucose among men. Platelets count was significantly increased with the increasing number of MS components in both genders.

Regardless of the reports showing the associations of various hematological parameters and risk of MS, the clear-cut mechanism for these associations remains to be explained. Increased number of MS components has been associated with insulin resistance. RBC, hematocrit, and Hb levels are significantly related to insulin resistance,[15],[50] thus it can be assumed that their increased levels in our study could be indicative of insulin resistance. Furthermore, various researchers have given different mechanisms but these need to be evaluated further in future studies. It has been noted that the presence of various risk factors such as hyperglycemia, dyslipidemia, and elevated blood pressure can activate vascular dysfunction and thus result in a systemic inflammatory response. This inflammatory state can cause activation of endothelial cells, platelets, and WBC which lead to the clot formation.[51] MS has been strongly associated with chronic inflammation[10] and is thought to play a crucial link between various hematological parameters and MS reflected by the derangement in these parameters.

The average elevation of the Kashmir valley is 1850 m (6070 feet). The physiological and hematological changes have been observed in people living at high altitudes in comparison with those living in low altitudes. The alteration in hematological parameters like RBC, WBC, HCT, HGB has been associated with the MS and other conditions like cardiovascular disease and coronary heart disease in various diseases.[52],[53],[54],[55] The RBC, HCT, HGB counts have been found raised in people living in high altitudes as compared with those living in low altitudes.[56] There have been evidence that blood parameters change after a stay in high altitude environment (1800–2300 m) where the amount of oxygen in the air is smaller as compared to the sea levels. The HBG, HCT, and RBC levels are increased in high altitudes even during shorter stays.[57]

Hence, we can assume that the high altitude of the valley may certainly lead to change in hematological parameters due to lower oxygen concentration in the air when compared to sea-dwelling people. Similarly, Kashmir being a region of high altitude might affect the levels of hematological parameters of the overall population. However, we have observed a slightly more increase in the counts of various hematological parameters among the people with Met S than their normal counterparts. Another factor that could be taken into consideration is the diet. For example, food items rich in omega-3-fatty acid which have been reported to be beneficial for avoiding the development of MS. As far as our Kashmir valley is concerned, there are no data available on the mean intake of omega-3-fatty acid in our population but usually people here take fish 2–3 times a month which is a great source of omega-3-fatty acid. Furthermore, the spinach intake is quite high here. In addition, the trend of incorporating walnuts, chia seeds, canola oils in the diet of Kashmiri people has been increased at a high rate since the past few years, all of which are rich in omega-3-fatty acid. Hence, the amount of omega-3-fatty acids intake would be mild. An increased intake of omega-3-fatty acids have been observed to reduce the prevalence of MS,[58] which is usually attributed to the presence of linolenic acid, docosahexaenoic acid and eicosapentaenoic acid.[59] According to research omega-3-fatty acids intake has showed a reduction in blood pressure levels and WC. An important observation is a decrease in hepatic lipogenesis and reduced secretion of hepatic Very low-density lipoprotein. Omega-3-fatty acids has anti-thrombotic, anti-inflammatory effects.[60] The effect of omega-3-fatty acids on the albino Wistar rats has shown an increase in the levels of various hematological parameters such as HGB, WBC, HCT.[61] Among, humans there have been reports showing nonsignificant association between omega-3-fatty acids levels and the hematological parameters in them.

  Conclusion Top

In our study, the prevalence of MS was high in women than the men. The association between various hematological parameters and MS differed between the gender: WBC and platelet were identified as risk factors for MS in men and RBC, Hb, hematocrit, and platelet as risk factors in women. This has an important clinical relevance for the health professionals and medicos to detect the risk of MS at the early stage on a gender-dependent basis. Furthermore, early detection can be helpful for the effective treatment of MS.

Financial support and sponsorship

We acknowledge the research grants provided by DST INSPIRE (DST/INSPIRE fellowship/2013/948).

Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4]


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