The Relationship Between Physical Activity Levels and Metabolic Syndrome in Kuwaiti Adults

Background: Little is known about the relationship between physical activity (PA) and metabolic syndrome in the Kuwaiti population. This is the first study to examine the relationship between PA and metabolic syndrome in a nationally representative sample of adult Kuwaitis. Methods: Data from the STEPS survey of noncommunicable disease (NCD) risk factors in Kuwait were used for this secondary cross-sectional study with a total of 1616 adults (726 males; and 890 females) aged 18-69 randomly sampled from the target population using the database of the Public Authority of Civil Information (PACI). Results: The Body Mass Index (BMI) of females was higher than males (31.5±7.7 vs. 29.4±5.1). Males had higher metabolic equivalent than females (2202±3394.8 vs. 1180±2379.5). The total prevalence of metabolic syndrome in Kuwaiti males and females was 28.4%. The relationship between total metabolic equivalent and the Metabolic syndrome was negatively correlated (r=-0.196), also annual household income was negatively correlated with Metabolic syndrome; the higher level of income the lower presence of metabolic syndrome. Finally, Metabolic Syndrome Score can be predicted by gender, age, BMI and Total Metabolic Equivalent (MET) as a predictors which explain approximately 32.6% of the variance in Metabolic Syndrome Score. Conclusions: The prevalence of metabolic syndrome in Kuwait is alarmingly high. Sedentary lifestyles and high caloric intake are few of the responsible factors. Therefore, the Ministry of Health and Policy makers should adapt strategies to promote higher levels of physical activity such as using sidewalks and bicycling facilities and promoting public health messages to decrease caloric intake.


Introduction
Metabolic syndrome (MetS) is a clustering of multiple risk factors containing high fasting glucose level, systemic hypertension, high triglycerides levels, low high-density lipoprotein cholesterol (HDL-c) level, and high waist circumference (Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults, 2001). The National Cholesterol Education Program's Adult Treatment Panel III report (ATP III) defines metabolic syndrome as the presence of three or more of the following risk factors: central obesity (waist circumference over 102 centimeters (men) or 88 centimeters (women), systemic hypertension (blood pressure ≥130/≥85 mm Hg), high fasting glucose (> 5.6 mmol/L), hypertriglyceridemia (fasting triglyceride level over 1.7 mmol/L), and low fasting high density lipoprotein (HDL) cholesterol level (<1.04 mmol/L in men and <1.29 mmol/L in women) (Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults, 2001).
Metabolic syndrome is associated with a 2-fold increased risk of cardiovascular disease and cardiovascular disease mortality, and a 50% increase in all-cause mortality ("Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) Final Report," 2002). MetS is profoundly prevalent in adults around the globe but Asian populations in particular are more predisposed to MetS (Mottillo et al., 2010). In fact, the prevalence of Mets in the Gulf Cooperative Council is higher than in most developed countries by 10-15%, and it was higher in women than in men (Yusuf et al., 2001). Prior research has found the prevalence of metabolic syndrome in adult Kuwaiti population to be 36.2% with no difference between genders (Mabry et al., 2010).
Studies have shown a negative relationship between physical activity and the occurrence of coronary heart disease, obesity, and the risk of type 2 diabetes mellitus (Al Rashdan & Al Nesef, 2009). Although many studies have shown that physical activity is protective against Mets, not all data were consistent. For instance, physical activity was negatively associated with hypertension in Brazilian men (Reiner et al., 2013), but had no effect on Malaysian adults (Perez et al., 2013). Moreover, Portuguese and Costa Rican adults differ on their response to physical activity, while the former had a lower Mets with higher physical activity, the latter did not show any association (Teh et al., 2015;Santos et al., 2007).
Little is known about the relationship between physical activity (PA) and metabolic syndrome in the Kuwaiti population. Thus, the purpose of present study is to investigate the association between different levels of PA and the prevalence of metabolic syndrome in Kuwaiti adults. This is the first study to examine this relationship in a nationally representative sample of adult Kuwaitis.

Study Design and Population
Data from the STEPS survey of non communicable disease (NCD) risk factors in Kuwait were used for this secondary cross-sectional study. The survey was conducted from March 2014 to September 2014 and included 4319 adults aged 18-69. The survey used a simple random sampling procedure to select subjects from the target population using the database of the Public Authority of Civil Information (PACI).

Study Sample
Survey sample size calculations were based on the number of overweight and obesity needed to assume a 95% confidence interval (CI) (Z = 1.96). The researcher used a 5% acceptable margin of error, coefficient of 1, and similar number of both sexes in each group. Therefore, with our estimate of 3842 participants, we should account for contingencies such as non-response and recording errors. For this reason, we increase the sample size by 12.5% (4391). The researchers have selected 1,616 participants out of 4391 (726 male and 890 female individuals) because only this number had completed the interview, blood sampling, and physical measurements.

Data Collection Tool and Ethical Consideration
The survey's ethical approval was obtained from the Kuwait ministry of health ethics committee. All participants signed their approval to participate on a written informed consent that informed them about the goal, objective, relative risks and benefits of participating in the survey. The survey was composed of an interview, blood sampling, and physical measurements which were conducted in the five health regions of Kuwait. One primary health care clinic was selected per health region to conduct the survey.

Questionnaire and Assessments of Physical Activity
A trained team interviewed the participants using validated questionnaires (WHO STEPS Instrument for Chronic Disease Risk Factors Surveillance, Version II). The questionnaire consisted of 15 items, all the items intended to gather information on duration, frequency, and intensity of the physical activity at work, travel to and from places, and recreational activities. PA was classified into moderate and vigorous intensity PA according to Metabolic Equivalent (MET) values to the compendium of PA (Hastert et al., 2015). Moderate-intensity PA causes small increases in breathing or heart rate and includes activities such as brisk walking, cycling, swimming, and volleyball. Moderate-intensity PAs were given a mean MET value of four. Vigorous-intensity PA or sports included any activity that caused large increase in breathing or heart rate like running and football. Vigorous-intensity PA were given a mean MET value of 8 (Hastert et al., 2015). The physical activity prevalence was categorised into low, moderate and high based on standard scoring criteria (Ainsworth et al., 2011).
Low: Participants who do not meet either 'moderate' nor 'high' criteria.
Moderate: Participants who have met one of the following three conditions: three or more days of high-intensity activity such as running and contact sports of at least 20 minutes per day, more than five or five days of moderate-intensity sports such as swimming or walking of at least 30 minutes per day, or more than 5 days or 5 days of any combination of walking, swimming, moderate-intensity or high-intensity sports accomplishing a minimum of at least 600 MET-min/week.
High: Participants who have met either of two conditions: high-intensity sports accomplishing a minimum of at least 3000 MET-minutes/week or high-intensity sports accumulating at least 1500 MET-minutes/week and at least three days, or every day of any combination of walking, swimming, moderate-intensity.

Body Weight and Composition
Body weight and height were measured with the electronic Growth Management Scale. Waist circumference was measured using MioTape, a non-stretch tape with millimetre precision. Waist circumference was measured at minimal respiration midway between the lower margin of the last palpable rib and the top of the iliac crest. Resting blood pressure was measured three times on the right arm in a seated position with mercury type sphygmomanometers and stethoscopes with a universal cuff after subjects had been seated for 15 minutes. There was a three minutes rest between the three measurements and a mean result of the three measurements was used for analysis.

Blood Samples Collection and Biochemical Markers Analyses
Fasting glucose and lipid profile samples were collected by qualified phlebotomists after a 12-hour fast (no food or drink, except water) in Sodium fluoride and serum/plasma separator vacutainer tubes. All samples were transported to the Biochemistry Laboratory of Kuwait Cancer Control Centre and analysed within 6 hours of collection using an Autoanalyzer Architect after passing an acceptable external and internal quality control. Glucose was measured by hexokinase enzymatic methods. The lipid profile is a direct measure of total cholesterol, triglycerides, and high-density lipoproteins cholesterol. Low-density lipoprotein cholesterol was calculated using Friedwald equation.

Statistical Analysis
The survey data were collected using PDAs. The data were downloaded into a database and then converted into Microsoft Excel® format. Independent t-tests were used to detect significant differences between the mean values for all variables of male and female individuals using SPSS Version 26.0 (SPSS Inc.). Statistical significance was set at p < 0.05 for all analyses. Data are presented as mean ± standard deviation (SD) unless otherwise stated. Pearson correlation was used to determine the association between total MET and the Metabolic Syndrome risk factors, Pearson's Chi-squared test (χ2) were used to find the association between the presence of metabolic syndrome and socio-demographic variables; Pearson's Chi-squared test (χ2) is a statistical test applied to sets of categorical data to test the independence of two variables, expressed in a contingency table (Plackett, 1983). Multiple linear regression is a useful technique to model the strength and direction of relationship between one or more independent variables and a dependent variable (Katz, 2011;Tabachnick & Fidell, 2007). This technique has been used to establish if Metabolic Syndrome Score can be predicted using any of the key demographic variables. The authors used multiple regression model including selected Independent variables using a stepwise method and a .05 criterion of statistical significance. In regard the assumptions of multiple regression involving linearity of the relationship between dependent and independent variables, the authors tested the independence of errors; homoscedasticity; and normality of errors between dependent and independent variables to meet all the models.

Results
Independent sample T-test were used for comparison between males and females' participants which reveals significant differences in age, weight, height, and Body Mass Index (BMI) (p<0.05) ( Table 1). Males had significantly higher MET than females (2202±3394.8 vs 1180±2379.5 min/week). Although males have greater weight (87.3±15.8) and height (172.2±7.1) than females who has lower weight (78.4±18.5) and lower height (158.0±6.5), the BMIs of females were higher (31.5±7.7 vs 29.4±5.1 kg/m 2 ) (p<0.05) ( Table 1). The number of school years was not significantly different between groups (p>0.05). Males and females had a significantly different levels of systolic and diastolic blood pressure, HDL, and waist circumference (p<0.05) ( Table 2). Males had higher results in all those risk factors except for HDL level (1.10±0.26 mmol/L in males and 1.34±0.32 in females). Triglycerides and glucose levels were not different between male and female participants. The prevalence of metabolic syndrome in Kuwaiti males is 32.6% and in females is 24.9%. The total prevalence of the metabolic syndrome in both genders is 28.4%. The relationship between Total MET and the Metabolic syndrome, waist circumference, triglycerides, and fasting glucose was negatively correlated (MetS -0.196, WC -0.120, TG -0.089, FG -0.128) (p<0.01). However, systolic blood pressure, diastolic blood pressure, and HDL cholesterol did not show significant relationships (Table 3). In males, the prevalence of high physical activity was the highest (42.3%) and the moderate category was the lowest (17.7%) ( Table 4). In females, the highest prevalence of physical activity was the low category (57.1%) and the lowest was the moderate category (21%) ( Table 4). Chi-square results shows that there is significant relation between the presence of Metabolic Syndrome and both of gender and income (p <0.05). The prevalence of metabolic syndrome in males is higher than females. About annual household income, the higher level of income the lower percent of metabolic syndrome; since 20% participants with annual household income (more than 2000) had metabolic syndrome vs 80% had not, while 56.3% of the participants with annual household income (760-999) had metabolic syndrome vs 43.8% had not.  Vol. 15, No. 7;2023 Otherwise, there is no significant relation between metabolic syndrome and smoking (p>0.05) ( Table 5).  (Table 6).

Discussion
The present study investigated the relationship between MET level and metabolic syndrome in 1616 Kuwaiti participants aged 18-69 years. The study's results showed a significant negative correlation between MET level and metabolic syndrome, waist circumference, triglyceride level, and fasting glucose level but no correlation with systolic and diastolic blood pressure or HDL cholesterol. The inverse association between physical activity and MetS confirms several previous studies (Craig et al., 2003;Huang et al., 2017;Xiao et al., 2016).
The prevalence of MetS in Kuwait from the national nutrition survey (N= 1830) was 37.7% in females and 34.2% in males by NCEP criteria (Petersen et al., 2014) which is similar to the prevalence of MetS found in other study (36.2% and 36.1% in men and women, respectively) (Al Rashdan & Al Nesef, 2009). Comparing MetS prevalence in Kuwait to 12 other nations, Kuwaiti men came the second highest after USA Native American men, and Kuwaiti women came 5 th highest after Iran, Mexico, Turkey and USA (Al Zenki et al., 2012). However, the present study showed higher prevalence of MetS in males (32.2%) than females (24.8%) and the total for both genders is 28.3%. Bauman et al., (2009) conducted a comparative international study of population physical activity prevalence across 20 countries. In the present study we categorized the prevalence of physical activity using the same criteria as Bauman et al. (2009) and compared Kuwait with the same 20 countries (Cameron et al., 2004). The highest prevalence of low activity for men was in Saudi Arabia (42.8%). Based on the present study the prevalence of low physical activity is 40% and would come in 4 th after Saudi Arabia, Taiwan and Japan. In the previously mentioned study Belgium had the highest prevalence of low activity for women (48.7%), but in our study Kuwaiti women were higher (57.1%). The lowest countries for moderate activity for men was New Zealand and for women was the USA (18% and 25% respectively). However, in both Kuwaiti men and women the prevalence of moderate activity was the lowest (17.7% and 21% respectively) of all countries. The lowest countries for high activity in men was Saudi Arabia (20.2%) and in women was Brazil (13%) while Kuwaiti men and women had a prevalence of high physical activity of 42.3% and 21.9% respectively.
There are several environmental variables which are associated with spending more time being physically active . Several of those variables are lacking in Kuwait including low number of streets having sidewalks and lack of bicycle facilities in most areas. Also, in Kuwait the access to low-cost recreational facilities is limited. Kuwaiti women scored the highest in the low activity category and the lowest in the moderate category among 20 countries (Cameron et al., 2004). This could be attributed to the fact that Kuwaiti culture discourage women from playing in public places which lead to lower activity.

Conclusions
The prevalence of metabolic syndrome in Kuwait is alarmingly high. Sedentary lifestyles and high caloric intake are few of the responsible factors. In fact, Kuwaiti women scored the lowest physical activity level across 20 countries and both genders scored the lowest on prevalence of moderate activity. Policy makers should adapt strategies to promote higher levels of physical activity such as using sidewalks and bicycling facilities and promoting public health messages to decrease caloric intake .

Limitations
Our study relied on self-reporting physical activity level instead of an objective tool, such as an accelerometer. However, the high number of participants in this study may overcome this limitation.

Funding
This research received no external funding

Institutional Review Board Statement
The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Ethics Committee of the ministry of health of Kuwait.

Informed Consent Statement
Informed consent was obtained from all subjects involved in the study

Data Availability Statement
Restrictions apply to the availability of these data. Data was obtained from [Kuwait ministry of health] and are not available for the public.