ORIGINAL ARTICLE Prevlence of Metolic Syndrome in Lrge Integrted Helth Cre System in North Crolin Rohn Mhleshwrkr, Yhenneko J. Tylor, Melnie D. Spencer, Svet Mohnn ckground Metolic syndrome (MetS) is cluster of conditions including dominl oesity, dyslipidemi, hypertension, nd hyperglycemi tht re ssocited with significntly incresed risk of developing dietes nd crdiovsculr diseses. No informtion currently exists regrding the prevlence of MetS in North Crolin. This study determined the prevlence of MetS mong dults receiving cre in lrge integrted helth cre system in North Crolin. methods This study used dt from the Crolins HelthCre System s electronic medicl record system nd included dults receiving cre during 2014. The ssocition etween ptient demogrphic chrcteristics nd MetS ws determined using multivrile logistic regression. results The prevlence of MetS ws pproximtely 22.5%. Individuls ged 18 29 yers were less likely to hve MetS compred with those ged 80 yers nd older (odds rtio [OR], 0.61; 95% confidence intervl [CI], 0.56 0.67). Groups tht were more likely to hve MetS included women (OR, 1.07; 95% CI, 1.05 1.10), Hispnics (OR, 1.14; 95% CI, 1.05 1.23), individuls with Medicre (OR, 1.38; 95% CI, 1.33 1.42), nd those with Medicid (OR, 1.68; 95% CI, 1.58 1.78) compred with men, whites, nd those with commercil insurnce, respectively. limittions We excluded individuls with missing dt for ny of the conditions tht define MetS, which my underestimte the ctul prevlence of this condition. conclusions The considerle prevlence of MetS in our North Crolin smple suggests tht interventions re needed to chieve the stte s popultion helth gols. Metolic syndrome (MetS) is defined y group of relted nd co-occurring metolic disorders including dominl oesity, dyslipidemi, hypertension, nd hyperglycemi ll of which increse the risk of developing dietes, crdiovsculr disese, nd stroke [1]. The common risk fctors for MetS re physicl inctivity, older ge, minority rce, fmily history of dietes, history of gesttionl dietes, history of nonlcoholic ftty liver disese, nd polycystic ovry syndrome [2]. Compred to people without MetS, those with MetS re twice s likely to develop crdiovsculr disese, 5 times more likely to develop dietes, 2 4 times more likely to hve stroke, nd 3 4 times more likely to develop myocrdil infrction [1, 2]. The economic urden of MetS is lso significnt, with incrementl nnul medicl costs eing 60% higher for individuls with MetS thn for those without this condition [3]. The prevlence of MetS in the United Sttes hs een well studied [4-11]. The mjority of these nlyses used dt from the Ntionl Helth nd Nutrition Exmintion Survey (NHANES) [4, 6, 7, 9-11]. In the most recent reserch, which used the 2009 2010 NHANES dt, Beltrán-Sánchez nd collegues reported the ntionl prevlence of MetS to e 22.9%. In tht study, the investigtors lso exmined chnges in the prevlence of MetS over the yers, nd they found tht it hd decresed slightly, from pproximtely 25.5% in 1999 2000 to 22.9% in 2009 2010 [11]. While these studies provide useful informtion, mjor shortcoming of the NHANES dt is tht the survey design does not llow for regionl estimtes. With diet nd exercise ptterns vrying cross regions of the United Sttes [12], it is likely tht MetS prevlence lso vries cross regions. Very few studies hve determined the regionl prevlence of MetS in the United Sttes. Meigs nd collegues studied the prevlence of MetS mong prticipnts in the Frminghm offspring study (FOS) nd the Sn Antonio Hert Study (SAHS) nd found ge- nd sex-djusted prevlences of 24% mong FOS prticipnts, 21% 23% mong white sujects in SAHS, nd 30% 31% mong Mexicn- Americn sujects in SAHS [5]. In n nlysis of ptients in 12 outptient helth cre prctices in Msschusetts during 2003 2004, Hivert nd collegues found the prevlence of MetS to e 23% [8]. A thorough literture review reveled no such studies conducted in North Crolin. Electroniclly pulished My 6, 2016. Address correspondence to Dr. Rohn Mhleshwrkr, 720 Est Morehed St, Ste 202, Chrlotte, NC 28202 (Rohn.Mhleshwrkr @crolinshelthcre.org). N C Med J. 2016;77(3):168-174. 2016 y the North Crolin Institute of Medicine nd The Duke Endowment. All rights reserved. 0029-2559/2016/77302 168
The ojective of the current study ws to determine the recent prevlence of MetS in lrge, verticlly integrted helth cre system in North Crolin. In ddition, demogrphic vritions in the prevlence of MetS were ssessed. Methods Dt Source This cross-sectionl study used 2014 dt from the Crolins HelthCre System s electronic medicl record (EMR) system. Crolins HelthCre System is the 2nd lrgest integrted nonprofit helth cre system in the United Sttes, with more thn 900 cre loctions including hospitls, physicin prctices, destintion centers, surgicl nd rehilittion centers, home helth gencies, nursing homes, nd hospice nd pllitive cre centers in North Crolin, South Crolin, nd Georgi. The Crolins HelthCre System EMR system contins dt from more thn 10 million ptient visits nnully. Dt fields within the Crolins HelthCre System EMR system include selfreported ptient demogrphic chrcteristics, including ge, rce/ethnicity, sex, mritl sttus, nd helth insurnce sttus; helth cre encounter dt, including dmission nd dischrge dtes nd times, dignosis nd procedure codes, nd results of clinicl tests; nd inptient nd outptient mediction order dt, including ctive ingredient, numer of dys of supply, dosge, rnd nme, nd generic nme. The study protocol ws pproved y the institutionl review ord of Crolins HelthCre System. Study Popultion The study smple included dult ptients (18 yers nd older) who hd vlid records for ll 5 MetS mesurements (ody mss index [BMI], triglyceride levels, cholesterol levels, lood pressure, nd lood glucose level) during 2014 nd t lest one helth cre visit (inptient or outptient) prior to documenttion of their lortory vlues in 2014. The smple ws limited to ptients receiving cre t Crolins HelthCre System s fcilities in North Crolin. Extreme outliers (individuls with l vlues elow the 0.25th percentile or ove the 99.75th percentile) were excluded from the study ecuse of the high possiility of inccurte l vlues in these individuls. Mesures MetS ws defined sed on the dignostic criteri developed y Hivert nd collegues (see Tle 1). While helth cre orgniztions such s the Ntionl Cholesterol Eduction Progrm Adult Tretment Pnel III nd the Americn Hert Assocition hve relesed dignostic criteri to define MetS (dominl oesity, elevted lood pressure, elevted fsting glucose, elevted fsting triglycerides, nd low high-density lipoprotein cholesterol) [9], informtion for ll of these criteri ws not ville for mny ptients in the Crolins HelthCre System EMR system. Therefore, we used surrogte dignostic criteri developed y Hivert nd collegues to define MetS. These criteri hve een found to hve sensitivity of 73%, specificity of 91%, nd c-sttistic of 0.818 [8]. Using this definition, individuls were considered to hve MetS if they stisfied t lest 3 of the 5 criteri listed in Tle 1 during the study yer. If multiple mesures were ville for ny of the criteri, the most recent mesure ws used. The prevlence of MetS ws defined s the rtio etween the numer of individuls with MetS nd the totl numer of individuls included in the study. In ddition to reporting the overll prevlence of MetS, we lso reported the prevlence of individul criteri for MetS. Finlly, we reported gestndrdized MetS proportions, using the 2000 US Census popultion s the stndrd, in order to enle comprison of our results with those of previous studies. The independent vriles in the study were ge, sex, rce/ethnicity, nd insurnce sttus. Age ws clssified into 7 ctegories: 18 29 yers, 30 39 yers, 40 49 yers, 50 59 yers, 60 69 yers, 70 79 yers, nd 80 yers nd older. Rce/ethnicity consisted of 4 ctegories: white, Africn Americn, Hispnic, nd other (consisting of tle 1. Criteri Used to Define Metolic Syndrome Metolic syndrome criteri Forml NCEP-ATPIII chrcteristic Surrogte chrcteristic Centrl oesity Wist circumference >102 cm (40 inches) in men Body mss index 29.1 kg/m 2 in men or 27.2 kg/m 2 in or > 88 cm (35 inches) in women women; if height dt re missing, then weight 94.4 kg (201 ls) in men or 73.6 kg (162 ls) in women Elevted lood pressure Averge of lst 2 redings 130 mmhg nd/or Any of the following: 1 lood pressure 130 mmhg nd/or 85 mmhg (systolic nd distolic, respectively); 85 mmhg (systolic nd distolic, respectively); on or dignosis of hypertension on prolem list nd ntihypertensive mediction ut no dignosis on prolem ntihypertensive gent on mediction list list; or hypertension listed mong illing codes Elevted glucose levels Fsting plsm glucose > 5.6 mmol/l (100 mg/dl) Any plsm glucose 7.8 mmol/l (140 mg/dl) Elevted triglyceride levels Fsting plsm level 1.7 mmol/l (150 mg/dl) Any plsm level 2.3 mmol/l (200 mg/dl) Low high-density lipoprotein Plsm level < 1.0 mmol/l (40 mg/dl) in men Plsm totl cholesterol > 5.2 mmol/l (200 mg/dl) cholesterol level or < 1.3 mmol/l (50 mg/dl) in women Individuls who stisfy 3 or more of the listed criteri were considered to hve metolic syndrome. Note. NCEP-ATPIII, Ntionl Cholesterol Eduction Progrm Adult Tretment Pnel III. Source: Hivert MF, et l [8]. 169
Americn Indins, Alskn ntives, Asins, Hwiins, Pcific Islnders, nd those with multiple or unknown rces). Insurnce sttus consisted of 4 ctegories: commercil, Medicre, Medicid, nd other (including ptients receiving chrity cre, self-py ptients, or those whose insurnce sttus ws unknown). Insurnce ws ctegorized sed on the ptient s primry pyer for the most recent helth cre visit prior to reporting of the lortory vlues used to define MetS. Sttisticl Anlysis The ivrite ssocitions etween MetS prevlence rtes nd the independent vriles were determined using chi-squre test, nd multivrile ssocitions were determined using logistic regression model. Frequencies nd percentges re reported for the ivrite nlyses, nd odds rtios (ORs) re reported for the logistic regression model. All nlyses were conducted using SAS version 9.4. Results The study smple consisted of 217,056 individuls, with n verge ge of 56.2 yers (± 15.5 yers). The mjority of the smple ws femle (56.2%), white (72.9%), nd insured y commercil insurnce policy (60.6%; see Tle 2). A totl of 48,786 individuls (22.5%) were clssified s hving MetS (see Figure 1). MetS prevlence ws highest mong those 50 59 yers of ge, femles, Hispnics, nd those with Medicid insurnce (P <.001; see Figures 1 nd 2). Individul MetS criteri occurred t prevlences of 54.1% for high BMI, 60.9% for elevted lood pressure, 11.0% for elevted glucose levels, 15.3% for elevted triglyceride levels, nd 29.9% for elevted cholesterol levels. Prevlences of individul criteri vried y ge, sex, rce, nd type of insurnce (see Tle 3). The ge-stndrdized MetS prevlence ws 18.8%. It ws highest mong mles, Hispnics, nd those with Medicre (see Figure 2). The ge-stndrdized prevlence estimtes for the individul MetS criteri were 51.4% for high BMI, 49.5% for elevted lood pressure, 8.4% for elevted glucose levels, 13.7% for elevted triglyceride levels, nd 28.7% for elevted cholesterol levels. Tle 4 presents the results of the multivrile logistic regression nlysis conducted to determine how demogrphic chrcteristics impct MetS. Compred to individuls ged 80 yers nd older, the estimted odds of hving MetS were 39% lower in individuls ged 18 29 yers (OR, 0.61; 95% CI, 0.56 0.67; P <.001). Femles hd 7% higher estimted odds of hving MetS compred to mles (OR, 1.07; 95% CI, 1.05 1.10; P <.001), nd Hispnics hd 14% higher odds of hving MetS compred to whites (OR, 1.14; 95% CI, 1.05 1.23; P <.001). Individuls with Medicre (OR, 1.38; 95% CI, 1.33 1.42; P <.001) or Medicid (OR, 1.68; 95% CI, 1.58 1.78; P <.001) hd 38% nd 68% higher estimted odds, respectively, of hving MetS compred to those with commercil insurnce. Discussion tle 2. Study Smple Chrcteristics (N = 217,056) Chrcteristic n % Age (in yers) Sex 18 29 12,331 5.7 30 39 22,243 10.2 40 49 39,344 18.1 50 59 50,651 23.3 60 69 50,074 23.1 70 79 30,104 13.9 80 12,309 5.7 Femle 121,895 56.2 Mle 95,161 43.8 Rce/ethnicity Africn Americn 36,533 16.8 Hispnic 3,439 1.6 Other 18,917 8.7 White 158,167 72.9 Insurnce sttus Medicre 76,127 35.1 Medicid 5,846 2.7 Other 3,590 1.7 Commercil 131,493 60.6 The rce/ethnicity ctegory other includes Americn Indins, Alskn ntives, Asins, Hwiins or Pcific Islnders, nd those with multiple or unknown rces. The insurnce ctegory other includes those receiving chrity cre, self-py ptients, nd those whose insurnce sttus is unknown. The current study determined the prevlence of MetS in lrge helth cre system in North Crolin nd ssessed the ssocition etween demogrphic chrcteristics nd MetS. This study is one of very few to hve investigted the prevlence of MetS for specific region in the United Sttes. Also, to the est of our knowledge, this is the first study determining the prevlence of MetS in North Crolin. The crude prevlence of MetS ws 22.5%. This finding is similr to the crude prevlence of 23% reported y Hivert nd collegues in their study of ptients receiving cre t 12 outptient helth cre prctices in Msschusetts during 2003 2004 [8]. However, we found n ge-stndrdized prevlence of MetS of 18.8%, which ws lower thn the most recent ntionl estimte of 22.9% sed on the 2009 2010 NHANES dt [11]. The likely reson for the lower ge-stndrdized MetS prevlence in our study is the use of surrogte criteri for MetS, which hve sensitivity of 73% compred to the forml criteri for this condition. In terms of individul criteri, the mjor fctors contriuting to MetS were elevted BMI (crude proportion of 54.1% nd ge-stndrdized proportion of 51.4%) nd elevted lood pressure (crude proportion of 60.9% nd ge-stndrdized proportion of 49.5%). This finding is similr to tht found y Hivert nd collegues in their study of ptients in 170
figure 1. Crude Prevlence of Metolic Syndrome in Lrge Helth Cre System in North Crolin, y Ptient Age, 2014 Msschusetts. However, in study exmining the ntionl prevlence of MetS, Beltrán-Sánchez nd collegues found tht incresed wist circumference nd elevted cholesterol levels were the criteri with the highest prevlence. Interesting findings emerged from the logistic regression nlysis conducted to exmine the ssocition etween demogrphic fctors nd MetS. Ptients ged 30 39 yers nd those ged 70 79 yers were more likely to hve MetS, nd those ged 18 29 yers were less likely to hve MetS, compred to ptients ged 80 yers nd older. MetS prevlence incresed with ge until the 6th decde nd then decresed in the 7th nd 8th decdes of life. Incresing MetS prevlence with ge hs een reported in previous reserch [4, 8, 13]. The lower MetS prevlence mong those in the 7th nd 8th decdes of life might e due to survivl is of individuls with etter helth in these ge groups. Women were 7% more likely to hve MetS compred to men. The min criteri contriuting to higher prevlence of MetS mong women were elevted BMI (58.2% in women versus 49.0% in men) nd elevted cholesterol levels (34.8% in women versus 23.6% in men). Fctors such s weight gin fter pregnncy, gesttionl dietes mellitus, preeclmpsi, polycystic ovry syndrome, use of hormonl contrceptives, nd menopuse increse the odds of femles hving MetS [14]. In terms of rce nd ethnicity, Hispnic individuls were 14% more likely to hve MetS compred with non-hispnic whites. This finding is consistent with previous reserch [4] figure 2. Crude nd Age-Stndrdized Prevlence of Metolic Syndrome in Lrge Helth Cre System in North Crolin, y Sex, Rce, nd Insurnce Sttus, 2014 The ivrite ssocitions etween crude metolic syndrome prevlence nd sex, rce, nd insurnce sttus re sttisticlly significnt (P <.001). Age-stndrdized prevlence estimtes re sed on the 2000 US Census popultion. 171
tle 3. Prevlence of Individul Metolic Syndrome Criteri in Lrge Helth Cre System in North Crolin, 2014 Elevted Elevted Elevted Elevted Elevted lood glucose triglyceride cholesterol Chrcteristic BMI, % P-vlue pressure, % P-vlue level, % P-vlue level, % P-vlue level, % P-vlue All ptients 54.1 60.9 11.0 15.3 29.9 Age (in yers) <.001 <.001 <.001 <.001 <.001 18 29 39.8 25.0 3.3 7.9 20.4 30 39 52.2 36.5 5.1 13.1 29.8 40 49 59.1 50.3 8.4 16.6 34.9 50 59 59.4 62.0 11.4 17.1 36.4 60 69 57.6 72.3 14.1 16.4 28.9 70 79 49.3 78.9 15.1 14.8 22.3 80 32.0 80.5 14.2 12.0 19.0 Sex <.001 <.001 <.001 <.001 <.001 Femle 58.2 56.9 9.4 13.0 34.8 Mle 49.0 66.1 13.0 18.2 23.6 Rce/ethnicity <.001 <.001 <.001 <.001 <.001 Africn Americn 67.6 68.7 12.9 7.7 27.1 Hispnic 55.1 50.1 12.3 20.7 32.9 Other 44.0 48.5 7.9 13.8 33.5 White 52.2 60.8 10.9 17.1 30.0 Insurnce sttus <.001 <.001 <.001 <.001 <.001 Medicre 51.9 76.8 15.8 16.5 23.8 Medicid 66.2 61.8 16.5 21.3 26.7 Other 58.9 62.0 13.7 17.9 28.6 Commercil 54.8 51.6 7.9 14.2 33.6 The rce/ethnicity ctegory other includes Americn Indins, Alskn ntives, Asins, Hwiins or Pcific Islnders, nd those with multiple or unknown rces. The insurnce ctegory other includes those receiving chrity cre, self-py ptients, nd those whose insurnce sttus is unknown. Note. BMI, ody mss index. nd could e ssocited with the high prevlence of insulin resistnce, the high prevlence of dietes mellitus, nd the propensity for elevted triglyceride levels in the Hispnic popultion [13]. In our study, ptients with Medicid nd Medicre were more likely to hve MetS compred with those who hd commercil insurnce. Previous work hs shown tht hving less ccess to helth cre nd limited fmily nd community resources is ssocited with poorer helth outcomes nd more chronic helth conditions in the Medicid popultion [15, 16]; this trend ws lso seen in our study. Medicre eneficiries include individuls ove 65 yers of ge, individuls with disilities, those with end-stge renl disese, nd ptients with myotrophic lterl sclerosis. It is not surprising to see higher prevlence of MetS in these individuls, s they hve een found to hve worse helth sttus compred to those with privte helth insurnce [17]. To the est of our knowledge, this is the first study determining the ssocition etween insurnce sttus nd MetS. The findings of this study hve importnt implictions for helth cre providers nd policy mkers in North Crolin. Finding tht 22.5% of ptients in the lrgest helth cre system in North Crolin hve MetS suggests tht the urden of this condition in North Crolin could e significnt. North Crolin is currently mong the qurtile of US sttes with the highest prevlence proportions of dietes nd crdiovsculr disese [18]. The Helthy North Crolin 2020 ojectives include reducing dietes prevlence nd crdiovsculr mortlity rtes [19]. Reducing the urden of MetS will e importnt for chieving these gols. Prior studies hve found tht MetS cn e effectively mnged with lifestyle interventions such s counseling out diet modifictions nd physicl exercise y fmily physicins, nurses, nd dieticins, which trget ll the MetS components together s well s phrmcologicl tretments trgeting individul MetS components [20-22]. The ssocitions oserved in this study etween demogrphic chrcteristics nd MetS nd its components could help policy mkers in North Crolin to select trgets for such interventions. The MetS prevlence estimtes oserved in this study could lso e used s seline for judging the effectiveness of future interventions. Issuing cler guidelines concerning the screening of ptients for MetS would lso further efforts to ddress the high prevlence of this condition. Jpn hs led the wy in the development of such guidelines y recommending since 2008 tht nnul MetS screening e performed for individuls ged 40 74 yers [23]. Currently, there re no specific guidelines regrding screening for MetS in clinicl prctice in the United Sttes, nd vritions in the recommended 172
tle 4. Estimted Odds of Metolic Syndrome Among Adults in Lrge Helth Cre System in North Crolin, 2014 Chrcteristic Odds rtio 95% CI P-vlue Age (in yers) Sex 18 29 0.61 0.56 0.67 <.001 30 39 1.42 1.32 1.52 <.001 40 49 2.20 2.07 2.34 <.001 50 59 2.60 2.45 2.76 <.001 60 69 2.22 2.10 2.34 <.001 70 79 1.60 1.51 1.69 <.001 80 Femle 1.07 1.05 1.10 <.001 Mle Rce/ethnicity Africn Americn 1.01 0.99 1.04.358 Hispnic 1.14 1.05 1.23.002 Other 0.77 0.74 0.81 <.001 White Insurnce sttus Medicre 1.38 1.33 1.42 <.001 Medicid 1.68 1.58 1.78 <.001 Other 1.28 1.19 1.39 <.001 Commercil The rce/ethnicity ctegory other includes Americn Indins, Alskn ntives, Asins, Hwiins or Pcific Islnders, nd those with multiple or unknown rces. The insurnce ctegory other includes those receiving chrity cre, self-py ptients, nd those whose insurnce sttus is unknown. Note. CI, confidence intervl. ges nd time intervls etween tests for individul components of MetS (lood pressure, lood glucose, nd lipids) could result in missed opportunities to identify ptients with this condition. This reserch hs few limittions. Collection of study dt from n EMR system could hve ffected these results due to potentil mistkes in dt entry. Crolins HelthCre System s fcilities re minly in Western North Crolin; therefore, the MetS prevlence proportions oserved in this study my not e generlized to the entire stte. We excluded cses without dt for ll 5 MetS prmeters, which reduced the size of the se popultion nd could hve ised our results. The direction nd mgnitude of such is is difficult to predict. For exmple, some helthier nd/or younger ptients without MetS my not regulrly visit helth cre providers nd/or hve routine lood work performed. Such ptients would hve een excluded from our study, thus incresing the MetS prevlence estimtes. On the other hnd, some ptients with MetS might hve hd only few lortory vlues mesured during the study yer. These ptients lso would hve een excluded from our nlysis, decresing the MetS prevlence proportions. The use of surrogte criteri to exmine the presence of MetS could hve underestimted the ctul MetS prevlence. Finlly, we determined the insurnce sttus of the study cohort sed on the primry pyer listed on the most recent illing record prior to collection of lortory mesurements. Using this process, we could not tke into ccount chnges in insurnce sttus or the presence of multiple insurnce policies. The findings of the study should e interpreted in light of these limittions. Conclusion Progress towrds reducing the impct of dietes nd crdiovsculr disese in North Crolin requires ttention to risk fctors such s MetS. We found the prevlence of MetS to e 22.5% in n dult popultion receiving cre in lrge integrted helth cre system. For individul MetS criteri, the prevlence ws highest for elevted lood pressure (60.9%), followed y elevted BMI (54.1%). Groups of ptients with the highest estimted odds of hving MetS included individuls ged 50 59 yers, women, Hispnics, nd those with Medicid. These results provide some of the most current region-specific dt to inform clinicl prctice nd helth cre policy. Future policy should ddress oth strtegies to etter screen for MetS risk fctors nd interventions imed t reducing the prevlence of MetS. Rohn Mhleshwrkr, PhD helth services resercher, Dickson Advnced Anlytics, Crolins HelthCre System, Chrlotte, North Crolin. Yhenneko J. Tylor, PhD director, outcomes reserch nd evlution, Dickson Advnced Anlytics, Crolins HelthCre System, Chrlotte, North Crolin. Melnie D. Spencer, PhD, MBA ssistnt vice president, pplied outcomes reserch, Dickson Advnced Anlytics, Crolins HelthCre System, Chrlotte, North Crolin. Svet Mohnn, MD physicin, Crolins Medicl Center, Crolins HelthCre System, Chrlotte, North Crolin. Acknowledgments The uthors would like to thnk Ms. Holly Petruso for her ssistnce in dt mngement. Potentil conflicts of interest. All uthors hve no relevnt conflicts of interest. s 1. Kur J. A comprehensive review on metolic syndrome. Crdiol Res Prct. 2014;2014:943162. 2. Ntionl Hert, Lung, nd Blood Institute. Wht is metolic syndrome? US Deprtment of Helth & Humn Services wesite. http:// www.nhli.nih.gov/helth/helth-topics/topics/ms. Accessed Decemer 8, 2014. 3. Boudreu DM, Mlone DC, Reel MA, et l. Helth cre utiliztion nd costs y metolic syndrome risk fctors. Met Syndr Relt Disord. 2009;7(4):305-314. 4. Ford ES, Giles WH, Dietz WH. Prevlence of the metolic syndrome mong US dults: findings from the third Ntionl Helth nd Nutrition Exmintion Survey. JAMA. 2002;287(3):356-359. 5. Meigs JB, Wilson PW, Nthn DM, D Agostino RB Sr, Willims K, Hffner SM. 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