Prevalence of the Metabolic Syndrome in Latin America and
its association with sub-clinical carotid atherosclerosis: the
CARMELA cross sectional study

Jorge Escobedo*1,2, Herman Schargrodsky3, Beatriz Champagne4,
Honorio Silva5, Carlos P Boissonnet6, Raul Vinueza7, Marta Torres8,
Rafael Hernandez9 and Elinor Wilson10

Address: 1Medical Research Unit on Clinical Epidemiology, Mexican Social Security Institute, Mexico City, Mexico, 2Gabriel Mancera 222m Col.
Del Valle, 03100 Mexico City, Mexico, 3Department of Cardiology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina, 4InterAmerican
Heart Foundation, Dallas, Texas, USA, 5InterAmerican Foundation for Clinical Research, New York, New York, USA, 6Coronary Care Unit, Centro
de Educación Médica e Investigaciones Clínicas "Norberto Quirno," Buenos Aires, Argentina, 7Clinical Protocol Manager Canada/Latin America/
Africa/Middle East Region Worldwide Development Operations, Pfizer Inc., New York, New York, USA, 8Programa Buenos Aires de Control de
Calidad Externo-CEMIC, Buenos Aires, Argentina, 9Clinical Pharmacology Unit and Hypertension Clinic, School of Medicine, Universidad
Centroccidental "Lisandro Alvarado," Decanato de Medicina, Barquisimeto, Venezuela and 10Department of Community and Preventive Health,
School of Medicine & Dentistry, University of Rochester, Rochester, New York, USA
Email: Jorge Escobedo* - jorgeep@unam.mx; Herman Schargrodsky - bubyscha@fibertel.com.ar;
Beatriz Champagne - beatriz.champagne@interamericanheart.org; Honorio Silva - honorio.silva@globecpd.org;
Carlos P Boissonnet - pboisson@intramed.net.ar; Raul Vinueza - Raul.Vinueza@pfizer.com; Marta Torres - progba@cemic.edu.ar;
Rafael Hernandez - rahernandez001@msn.com; Elinor Wilson - elinor_wilson@ahrc-pac.gc.ca
* Corresponding author

Abstract
Background: Metabolic syndrome increases cardiovascular risk. Limited information on its
prevalence in Latin America is available. The Cardiovascular Risk Factor Multiple Evaluation in Latin America (CARMELA) study included assessment of metabolic syndrome in 7 urban Latin American populations.
Methods: CARMELA was a cross-sectional, population-based, observational study conducted in Barquisimeto, Venezuela; Bogota, Colombia; Buenos Aires, Argentina; Lima, Peru; Mexico City, Mexico; Quito, Ecuador; and Santiago, Chile. The prevalence of metabolic syndrome, defined according to the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III), and associated carotid atherosclerosis were investigated in 11,502 participants aged 25 to 64 years.
Results: Across CARMELA cities, metabolic syndrome was most prevalent in Mexico City (27%) and Barquisimeto (26%), followed by Santiago (21%), Bogota (20%), Lima (18%), Buenos Aires (17%), and Quito (14%). In nondiabetic participants, prevalence was slightly lower but followed a comparable ranking. Overall, 59%, 59%, and 73% of women with high triglycerides, hypertension, or glucose abnormalities, respectively, and 64%, 48% and 71% of men with abdominal obesity, hypertension, or glucose abnormalities, respectively, had the full metabolic syndrome. Prevalence of metabolic syndrome increased with age, markedly so in women. Mean common carotid artery intima-media thickness (CCAIMT) and prevalence of carotid plaque increased steeply with increasing numbers of metabolic syndrome components; mean CCAIMT was higher and plaque more prevalent in participants with metabolic syndrome than without.
Conclusion: The prevalence of metabolic syndrome and its components by NCEP ATP III criteria was substantial across cities, ranging from 14% to 27%. CARMELA findings, including evidence of the association of metabolic syndrome and carotid atherosclerosis, should inform appropriate clinical and public health interventions.

Background
The concept of the metabolic syndrome has developed in stages over the past 80 years; it is now recognized that the combination of abdominal obesity, glucose metabolism abnormalities, hypertension, and dyslipidemia, accompanied by prothrombotic and proinflammatory states, leads to type 2 diabetes and vascular diseases, including coronary heart disease and stroke [1,2]. Metabolic syndrome predicts total, cardiovascular, and coronary heart disease mortality; in fact, the presence of even 1 or 2 components of the metabolic syndrome increases overall mortality compared with the absence of any component of the metabolic syndrome [3-6]. A 65% excess risk has been estimated for cardiovascular disease in individuals with the metabolic syndrome [7]. Metabolic syndrome even predicts the occurrence of sudden death, independent of the presence of other cardiovascular risk factors [8]. Metabolic syndrome also predicts the incidence and progression of carotid atherosclerosis [9].
As reviewed recently, worldwide prevalence of metabolic syndrome ranges from <10%>to as much as 84%, depending on age, region, urban or rural environment, ethnicity, and the definition of metabolic syndrome used [10-12]. In the United States, between 1994 and 2000, prevalence
of metabolic syndrome in adults increased from 23% to 27% along with an increase in obesity and physical inactivity [13]. Developing regions like Latin America, undergoing
sea change in the lifestyle factors contributing to the metabolic syndrome, may see even greater increases in prevalence over a relatively short span of time. Local public health and clinical efforts to stem morbidity and mortality from the metabolic syndrome must be based on the
relevant local prevalence of its components. The Cardiovascular Risk Factor Multiple Evaluation in Latin America (CARMELA) study investigated risk factors for cardiovascular isease in 7 Latin American cities, as reported elsewhere [14]. With cardiovascular risk and clinical interventions in mind, the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) criteria [2] were used to assess metabolic syndrome prevalence in CARMELA cities. The association of metabolic syndrome with mean common carotid artery intimamedia thickness (CCAIMT), as a marker of carotid atherosclerosis, was also investigated.
Methods
Study Design
CARMELA was a multistage, cross-sectional epidemiologic study conducted between September 2003 and August 2005, in Barquisimeto, Venezuela; Bogota, Colombia; Buenos Aires, Argentina; Lima, Peru; Mexico City, Mexico; Quito, Ecuador; and Santiago, Chile. The study was conducted according to the Declaration of Helsinki and the Guides for Good Clinical Practice. Approximately 1,600 participants per city between the ages of 25 and 64 years were included, stratified by sex and age (10- year groups). The study was approved by an institutional review committee in all participating cities, and all subjects gave informed consent. Study methods are described in detail elsewhere [14].
Anthropometry
Waist circumference was measured at the midpoint between the last rib and the iliac crest with participants standing and wearing only undergarments.
Blood Glucose and Lipids
Participants were asked to refrain from using laxatives containing glycerin for 48 hours and from consuming glycerin-containing products and other sweets for 24 hours prior to blood sampling. Blood was drawn in the fasting state; only water, black coffee, or unsweetened tea and medications other than antidiabetic medications were permitted during the 12 hours prior to sampling. Following the sampling, participants were allowed to resume their usual antidiabetic medication. Plasma glucose was assayed within 6 hours. Serum was assayed for high density lipoprotein cholesterol and triglycerides.
Blood Pressure
Blood pressure (at rest) was measured with the participant seated. Two readings were taken 5 minutes apart; if different by >5 mm Hg, measurements were repeated until 2
concordant readings were obtained.
Measurement of CCAIMT
Far wall CCAIMT was evaluated according to the Mannheim intima-media thickness consensus [15]. Both common carotid arteries were examined by B-mode ultrasonography with participants in the supine position, using phased array 7.5 MHz transducers and ultrasound apparatus no older than 7 years. M'AthStd® software (Intelligence in Medical Technologies, Paris, France) automatically measured the CCAIMT; measurements were taken over a 10 mm length and averaged, and quality of acquisition was evaluated. Data were analyzed at a central
laboratory at Intelligence in Medical Technologies, Paris, France.
Definitions
Diabetes was defined as a fasting plasma glucose level ≥ 7.0 mmol/l (126 mg/dL) [16] or self-reported diabetes. Metabolic syndrome was defined by NCEP ATP III criteria as the presence of 3 or more of the following: waist >102 cm in men, >88 cm in women; triglycerides ≥ 1.70 mmol/
l (150 mg/dL); high density lipoprotein cholesterol (HDL-C) <1.03>Statistical Analysis
Statistical processing addressed the nonequal probability character of the sample and the structure of the design to generate data adjusted for the age and sex distribution of the population of each city. Means and prevalence along with their 95% confidence intervals were estimated by survey analysis procedures (SAS Software, Release 9.1, Cary, North Carolina, USA), taking into account the multistage stratified sampling design via CLUSTER and STRATA statements.

Results
A total of 11,550 participants between the ages of 25 and 64 years were enrolled in CARMELA between September 2003 and August 2005. Data for 11,502 participants were evaluable for metabolic syndrome: Barquisimeto, n = 1,836; Bogotá, n = 1,550; Buenos Aires, n = 1,476; Lima, n = 1,645; Mexico City, n = 1,720; Quito, n = 1,627; and Santiago, n = 1,648. Per the study design, age and sex distribution was relatively even for each city.
Prevalence of the Metabolic Syndrome in the Overall CARMELA Population
Metabolic syndrome was most prevalent in Mexico City (27%) and Barquisimeto (26%), followed by Santiago (21%) and Bogota (20%); lower prevalence was found in Lima (18%), Buenos Aires (17%), and Quito (14%). Overall, metabolic syndrome was more prevalent in women than men (22% vs 20%, respectively), with the exception of Buenos Aires and Barquisimeto where more men than women had metabolic syndrome. As expected, the prevalence of metabolic syndrome increased with age. In all cities, women showed markedly greater increase in metabolic syndrome with increasing age than men; in the oldest age group, female prevalence (range 25% to 49%) was greater than male prevalence (range 13% to 38%) in all cities except Buenos Aires (See Table 1 and Figure S1 in additional file 1). Of components of metabolic syndrome, the abdominal obesity was notably more prevalent in women than men, and the difference was accentuated in successively older age groups.
Prevalence of Specific Components of the Metabolic Syndrome
reports the prevalence of each component of the metabolic syndrome within the population of all participants with metabolic syndrome (with or without a history of diabetes mellitus). Overall, 86% had high triglycerides, 86% had low HDL-C, and 60% were hypertensive. Across cities, abdominal obesity was present in 81% to 93% of women, and in 46% to 73% of men with metabolic syndrome.
Prevalence of the Metabolic Syndrome in Participants With Specific Components
Prevalence of the metabolic syndrome in subsets of the overall population with specific components of the syndrome. Overall, approximately twothirds of men with abdominal obesity or glucose abnormalities, and approximately 60% to 70% of women with high triglycerides, hypertension, or glucose abnormalities had the full metabolic syndrome. In all cities except Mexico City, the prevalence of metabolic syndrome among participants with low HDL-C was fairly low. Prevalence of the syndrome among women with high triglycerides was notably higher than among men in all cities except Barquisimeto and Buenos Aires.
Prevalence of Metabolic Syndrome Among Participants Without Diabetes
reports the prevalence of the number of components of the metabolic syndrome among CARMELA participants without a history of diabetes mellitus. In all cities, >60% of the participants had at least 1 component of the metabolic syndrome. As in the overall CARMELA
population, the prevalence of metabolic syndrome in the nondiabetic population was higher in women than men, except in Barquisimeto and Buenos Aires.
Metabolic Syndrome and Carotid Atherosclerosis
In both men and women overall, mean CCAIMT increased steeply with increasing numbers of metabolic syndrome components . Similarly, the prevalence of carotid plaque
also increased with increasing numbers of components and overall, was approximately 50% more prevalent in both men and women with metabolic syndrome than those without. In all cities, mean CCAIMT and prevalence of plaque were higher in participants with metabolic syndrome than those without.

Discussion
The CARMELA study reports overall prevalence of 21% of metabolic syndrome by NCEP ATP III criteria in the 7 Latin American cities studied. Profiles of the metabolic syndrome according to sex varied among cities. Among the overall population and the nondiabetic population, the highest prevalence of metabolic syndrome was found in Barquisimeto and Mexico City. Women of Bogota, Lima, Quito, and Santiago had greater prevalence of metabolic syndrome than their male counterparts, while the opposite was true in Buenos Aires. Not surprisingly, prevalence
of metabolic syndrome increased with age, strikingly so in women. Participants with metabolic syndrome had higher mean CCAIMT and prevalence of carotid plaque than those without the syndrome.
The prevalence of metabolic syndrome found in CARMELA approximates prevalence estimates (23% to 27%) in the United States [6,13]. Direct comparison with other Latin America studies using NCEP ATP III criteria show CARMELA prevalence to be consistent with prevalence in
Mexico [17,18]. Also by NCEP ATP III criteria, 31% of a population of Zulia State, Venezuela [19], and 12% and 26% of men and women of Lima [18], respectively, were found to have metabolic syndrome. CARMELA reports lower prevalence in Barquisimeto than elsewhere in Venezuela, and prevalence that is less disparate between the sexes of Lima; however, CARMELA targeted a much broader population base than in the aforementioned
study in Lima. In the Peruvian Study of the Prevalence of Cardiovascular Risk Factors (PREVENCION) study in another urban region of Peru, 14% and 23% of men and women, respectively, were found to have the syndrome [20].
Whereas it has been suggested that the burden of metabolic syndrome is growing in younger populations, especially in developing regions [21], metabolic syndrome increases with age as CARMELA results confirm. Elevated body weight, waist circumference, and low HDL-C levels have been found to be more common contributors to metabolic syndrome in women, while blood pressure and apolipoprotein B have been found to be more common contributors in men [22]. Obesity in women is increasing faster than in men [23] and the metabolic syndrome
increases in a parallel manner. In many women, menopause is accompanied by the emergence of features of the metabolic syndrome and increased cardiovascular risk, whether as a direct result of ovarian failure or indirectly related to central adipose redistribution [23,24]. With this constellation of factors, it has even been suggested that the metabolic syndrome should be defined by different criteria in men and women [22]. CARMELA results illustrate the amplified increase in metabolic syndrome in women as opposed to men as women reach menopausal age. A study of post-menopausal Ecuadorian women [25] revealed an overall prevalence of metabolic syndrome of 42%, similar to that found in CARMELA, with prevalence of hypertension, abdominal obesity, and low HDL-C similar to that in women in the older 2 CARMELA age groups.
In a broader study of postmenopausal Latin American women, rates of metabolic syndrome in women of Bue-nos Aires were higher and those of Bogota, Lima, and Santiago, similar to those of women in the oldest 2 CARMELA age groups [26]. Although in all CARMELA cities, older
women showed strikingly higher abdominal obesity rates than men, high rates of abdominal obesity were found in women of all age groups. In designing targeted programs for detection and treatment of metabolic syndrome, CARMELA provides crucial data on the sensitivity and predictive value of each component. On the one hand, of the general population of men in CARMELA cities (except for Quito where lower prevalence of metabolic syndrome in men is noted), approximately 70% of those with glucose abnormalities, approximately two-thirds of those with abdominal obesity, and half with hypertension, will have the full syndrome. Of the general population of women in CARMELA cities, nearly three-quarters of those with glucose abnormalities, and approximately 50% to 60% with abdominal obesity, high triglycerides, or hypertension, will have the full metabolic syndrome. On the other hand,
once metabolic syndrome is diagnosed, the shape of the syndrome is characterized by predominance of hypertension, low HDL-C and high triglycerides in men, and predominance
of abdominal obesity, high triglycerides, and a remarkable predominance of low HDL-C in women. Thus, hypertension, low HDL-C, and high triglycerides in men and low HDL-C in particular, along with high triglycerides and abdominal obesity in women, are highly specific indicators of the syndrome. CARMELA provides data which confirms the likelihood of finding other specific components, once metabolic syndrome is diagnosed. Although the metabolic syndrome predicts diabetes along with cardiovascular risk, glucose abnormalities in and of themselves are not particularly specific to the full syndrome. This notion is confirmed by the similar prevalence of metabolic syndrome in CARMELA populations that both include and exclude diabetes. Since the metabolic syndrome is epitomized by the development of diabetes,
its presence in the nondiabetic population is of particular importance.
To our knowledge, this is the first study that provides evidence
of a relationship between the occurrence of the metabolic
syndrome and the presence of carotid
atherosclerosis in the Latin American population. A large study in Italy reported increased incidence of carotid plaques and stenosis over 5 years of follow-up in participants with metabolic syndrome [9]. Metabolic syndrome has also been associated with incident stroke in both
black and white populations in the United States [6] and with higher carotid intima-media thickness and prevalence of plaques in elderly French individuals [27]. Metabolic syndrome has also been associated with tissue characteristics of the intima-media complex in the carotid
artery [28], and the increasing number of components of the metabolic syndrome have also been related to higher carotid artery stiffness [29]. In other studies, the association between metabolic syndrome and carotid atherosclerosis has been reported to be stronger in women than men [30], however, in the CARMELA study it seems to be quite similar for men and women. Carotid intima-media thickening
as an indicator of atherosclerosis in other vascular beds [31] is a strong predictor of future cardiovascular events [32]. The relationship between metabolic syndrome
and carotid atherosclerosis noted in CARMELA enhances previous findings of metabolic syndrome as a cardiovascular disease predictor [3,7,9].
The value of CARMELA lies in its carefully constructed
sampling of populations by age and sex to elucidate prevalence of metabolic syndrome components. Urban vs rural and ethnic differences in prevalence of metabolic syndrome have been reported in a variety of Latin American settings [33] and should be investigated further.
Genetic predispositions to the metabolic syndrome [34], along with cultural and nutritional variations, also need investigation given Latin America's unique conglomeration of indigenous and immigrant populations. The obesity epidemic clearly affects the prevalence of metabolic
syndrome among women but also extends to the young; CARMELA's lowest age range (25 to 34 years) may not have fully encompassed populations at risk, nor did CARMELA include increasingly older populations, which until now have borne the brunt of chronic disease. Rigorous studies like CARMELA should aid in designing targeted solutions to increasing rates of metabolic syndrome and its consequences.
In the Shape of the Nations Survey, 39% of participants worldwide who visited primary care physicians were overweight or obese, but only 58% of primary care physicians recognized that abdominal obesity was a significant risk factor for cardiovascular disease, and 45% reported that
they never measured waist circumference [35]. As alarming as these statistics are, CARMELA findings reinforce the notion that metabolic syndrome is prevalent in urban Latin America and should be sought in the presence of even 1 component of the syndrome. Likewise, carotid
atherosclerosis in Latin American individuals should spur healthcare providers to seek evidence of metabolic syndrome components and effect appropriate interventions. Guidelines for treatment of specific components in the context of the full metabolic syndrome are being developed [2] and should be promoted by healthcare educators and providers. The chronic disease burden consequent to metabolic syndrome will be extensive and expensive in
Latin America if studies like CARMELA are ignored.

Conclusion
CARMELA reports high prevalence of metabolic syndrome in 7 Latin American cities. Although rates varied between cities, there was a striking increase in the prevalence of metabolic syndrome with age, especially in women. CARMELA provides evidence for the association
of metabolic syndrome with evidence of carotid atherosclerosis-- namely increasing mean CCAIMT and plaque with increasing numbers of components of the syndrome,
and overall higher mean CCAIMT and plaque in participants with the syndrome compared with those without. It is incumbent on government agencies and the medical community to address current prevalence of metabolic syndrome in order to prevent the dire consequences of
increased burden of disease.

Competing interests
RV is a permanent employee of Pfizer Inc, makers of a
cholesterol-regulating drug, and has shares in the company.
HS was an employee of Pfizer, Inc. during the conduct
of the study (now retired). All other authors declare
no competing interests.

Authors' contributions
JE participated in the design and coordination of the study
and drafted the manuscript. HSc conceived of the study,
and participated in its design and coordination and
helped to draft the manuscript. BC conceived of the study,
and participated in its design and coordination and
helped to draft the manuscript. HSi conceived of the
study, and participated in its design and coordination and
helped to draft the manuscript. CPB participated in the
design and coordination of the study and helped to draft
the manuscript. RV participated in the design and coordination
of the study and helped to draft the manuscript.
MT carried out the lab standardization. RH conceived of
the study, and participated in its design and coordination
and helped to draft the manuscript. EW conceived of the
study, and participated in its design and coordination and
helped to draft the manuscript.
All authors read and approved the final manuscript.

Acknowledgements
The authors would like to thank participating institutions, coordinators, and
investigators: Asociación Cardiovascular Centro Occidental (Barquisimeto)
- Lic. Elizabeth Infante, Luis Rocha; Pontificia Universidad Javeriana
de Bogota (Bogota) - Álvaro Ruíz Morales, Esperanza Peña, Felipe Uriza;
Centro de Educación Medica e Investigaciones Clinicas "Norberto
Quirno"(Buenos Aires) - Carlos Boissonnet, Juan Fuselli, Víctor Torres;
Universidad Cayetano Heredia (Lima) - Raúl Gamboa-Aboado, Carlos
Kiyán, Mario Vargas; Instituto Mexicano del Seguro Social (Mexico City) -
Jorge Escobedo-de la Peña, Luisa Virginia Buitrón, Jesús Ramírez-Martínez;
Hospital Metropolitano de Quito (Quito) - Francisco Benítez, María
Velasco, Luis Falcóni; Pontificia Universidad Católica de Santiago de Chile
(Santiago) - Ximena Berrios-Carrasola, Beatriz Guzmán, Mónica Acevedo.

References
1. Cornier MA, Dabelea D, Hernandez TL, Lindstrom RC, Steig AJ, Stob
NR, Van Pelt RE, Wang H, Eckel RH: The metabolic syndrome.
Endocrine Rev 2008, 29:777-822.
2. National Cholesterol Education Program (NCEP) Expert Panel on
Detection, Evaluation, and Treatment of High Blood Cholesterol in
Adults (Adult Treatment Panel III): 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. Circulation
2002, 106:3143-3421.
3. Eberly LE, Prineas R, Cohen JD, Vazquez G, Zhi X, Neaton JD, Kuller
LH, for the Multiple Risk Factor Intervention Trial Research Group:
Metabolic syndrome. Risk factor distribution and 18-year
mortality in the Multiple Risk Factor Intervention Trial. Diabetes
Care 2006, 29:123-130.
4. Malik S, Wong ND, Franklin SS, Kamath TV, L'Italien GJ, Pio JR, Williams
GR: Impact of the metabolic syndrome on mortality
from coronary heart disease, cardiovascular disease, and all
causes in United States adults. Circulation 2004, 110:1245-1250.
5. Nilsson PM, Engstrom G, Hedblad B: The metabolic syndrome
and incidence of cardiovascular disease in non-diabetic subjects--
a population-based study comparing three different
definitions. Diabet Med 2007, 24:464-472.
6. McNeill AM, Rosamond WD, Girman CJ, Golden SH, Schmidt MI,
East HE, Ballantyne CM, Heiss G: The metabolic syndrome and
11-year risk of incident cardiovascular disease in the Atherosclerosis
Risk in Communities Study. Diabetes Care 2005,
28:385-390.
7. Ford ES: Risks for all-cause mortality, cardiovascular disease,
and diabetes associated with the metabolic syndrome: a
summary of the evidence. Diabetes Care 2005, 28:1769-1778.
8. Empana JP, Duciemetiere P, Balkau B, Jouven X: Contribution of
the metabolic syndrome to sudden death risk in asymptomatic
men: the Paris Prospective Study I. Eur Heart J 2007,
28:1149-1154.
9. Bonora E, Kiechl S, Willeit J, Oberhollenzer F, Egger G, Bonadonna
RC, Muggeo M: Carotid atherosclerosis and coronary heart
disease in the metabolic syndrome. Prospective data from
the Bruneck Study. Diabetes Care 2003, 26:1251-1257.
10. Desroches S, Lamarche B: The evolving definitions and increasing
prevalence of the metabolic syndrome. Appl Physiol Nutr
Metab 2007, 32:23-32.
11. Kolovou GD, Anagnostopoulou KK, Salpea KD, Mikhailidis DP: The
prevalence of metabolic syndrome in various populations.
Am J Med Sci 2007, 333:362-371.
12. Procopiou M, Philippe J: The metabolic syndrome and type 2
diabetes: epidemiological figures and country specificities.
Cerebrovasc Dis 2005, 20(Suppl 1):2-8.
13. Ford ES, Giles WH, Mokdad AH: Increasing prevalence of the
metabolic syndrome among U.S. adults. Diabetes Care 2004,
27:2444-2449.
14. Schargrodsky H, Hernandez-Hernandez R, Champagne BM, Silva H,
Vinueza R, Silva-Ayçaguer LC, Touboul PJ, Boissonnet CP, Escobedo
J, Pellegrini F, Macchia A, Wilson E, for the CARMELA Study Investigators:
CARMELA: assessment of cardiovascular risk in seven
Latin American cities. Am J Med 2008, 121:58-65.15. Touboul PJ, Hennerici MG, Meairs S, Adams H, Amarenco P, Bornstein
N, Csiba L, Desvarieux M, Ebrahim S, Fatar M, Hernandez Hernandez
R, Jaff M, Kownator S, Prati P, Rundek T, Sitzer M, Schminke
U, Tardif JC, Taylor A, Vicaut E, Woo KS, Zannad F, Zureik M: Mannheim
carotid intima-media thickness consensus (2004-
2006). An update on behalf of the Advisory Board of the 3rd
and 4th Watching the Risk Symposium, 13th and 15th European
Stroke Conferences, Mannheim, Germany, 2004, and
Brussels, Belgium, 2006. Cerebrovasc Dis 2007, 23:75-80.
16. Expert Committee on the Diagnosis and Classification of Diabetes
Mellitus: Report of the expert committee on the diagnosis and
classification of diabetes mellitus. Diabetes Care 2003, 26(Suppl
1):S5-S20.
17. Aguilar-Salinas CA, Rojas R, Gomez-Perez FJ, Valles V, Rios-Torres
JM, Franco A, Olaiz G, Rull JA, Sepulveda J: High prevalence of
metabolic syndrome in Mexico. Arch Med Res 2004, 35:76-81.
18. Lorenzo C, Serrano-Rios M, Martinez-Larrad MT, González-Sánchez
JL, Seclén S, Villena A, González-Villalpando C, Williams K, Haffner
SM: Geographic variations of the International Diabetes Federation
and the National Cholesterol Education Program-
Adult Treatment Panel III definitions of the metabolic syndrome
in nondiabetic subjects. Diabetes Care 2006, 29:685-691.
19. Florez H, Silva E, Fernandez V, Ryder E, Sulbaran T, Campos G,
Calmon G, Clavel E, Castillo-Florez S, Goldberg R: Prevalence and
risk factors associated with the metabolic syndrome and dyslipidemia
in White, Black, Amerindian and Mixed Hispanics
in Zulia State, Venezuela. Diabetes Res Clin Pract 2005, 69:63-77.
20. Medina-Lezama J, Zea-Diaz H, Morey-Vargas OL, Bolaños-Salazar JF,
Muñoz-Atahualpa E, Postigo-MacDowall M, Corrales-Medina F, Valdivia-
Ascuña Z, Cuba-Bustinza C, Paredes-Díaz S, Villalobos-Tapia P,
Chirinos-Pacheco J, Goldberg RB, Chirinos JA: Prevalence of the
metabolic syndrome in Peruvian Andean hispanics: The
PREVENCION study. Diabetes Res Clin Pract 2007, 78:270-281.
21. Rodgers A, Ezzati M, Vander Hoorn S, Lopez AD, Lin RB, Murray CJ:
Comparative Risk Assessment Collaborating Group. Distribution
of major health risks: findings from the Global Burden
of Disease study. PLoS Med 2004, 1:e27.
22. Dallongeville J, Cottel D, Arveiler D, Tauber JP, Bingham A, Wagner
A, Fauvel J, Ferrières J, Ducimetière P, Amouyel P: The association
of metabolic disorders with the metabolic syndrome is different
in men and women. Ann Nutr Metab 2004, 48:43-50.
23. Mitrakou A: Women's health and the metabolic syndrome.
Ann N Y Acad Sci 2006, 1092:33-48.
24. Pramparo P, Schargrodsky H, Boissonnet C, Champagne BM, Silva H,
Acevedo M, Wilson E: Cardiovascular risk factors for heart disease
and stroke in women by age and time since menopause,
in seven Latin American cities: The CARMELA Study. CVD
Prev Control 2008, 3:181-189.
25. Hidalgo LA, Chedraui PA, Morocho N, Alvarado M, Chavez D, Huc
A: The metabolic syndrome among postmenopausal women
in Ecuador. Gynecol Endocrinol 2006, 22:447-454.
26. Royer M, Castelo-Branco C, Blumel JE, Chedraui PA, Danckers L,
Bencosme A, Navarro D, Vallejo S, Espinoza MT, Gómez G, Izaguirre
H, Ayala F, Martino M, Ojeda E, Onatra W, Saavedra J, Tserotas K,
Pozzo E, Manriquez V, Prada M, Grandia E, Zuniga C, Lange D, Sayegh
F, Collaborative Group for Research of the Climacteric in Latin
America: The US National Cholesterol Education Programme
Adult Treatment Panel III (NCEP ATP III): prevalence
of the metabolic syndrome in postmenopausal Latin
American women. Climacteric 2007, 10:164-170.
27. Empana JP, Zureik M, Gariepy J, Courbon D, Dartigues JF, Ritchie K,
Tzourio C, Alperovitch A, Ducimetiere P: The metabolic syndrome
and the carotid artery structure in noninstitutionalized
elderly subjects: the three-city study. Stroke 2007,
38:893-899.
28. Katakami N, Kaneto H, Matsuhisa M, Umayahara Y, Kosugi K, Yamasaki
Y: Clustering of several cardiovascular risk factors affects
tissue characteristics of the carotid artery. Atherosclerosis 2008,
198:208-213.
29. Martens FM, van der Graaf Y, Dijk JM, Olijhoek JK, Visseren FL:
Carotid arterial stiffness is marginally higher in the metabolic
syndrome and markedly higher in type 2 diabetes mellitus
in patients with manifestations of arterial disease.
Atherosclerosis 2008, 197:646-653.
30. Iglseder B, Cip P, Malaimare L, Ladurner G, Paulweber B: The metabolic
syndrome is a stronger risk factor for early carotid
atherosclerosis in women than in men. Stroke 2005,
36:1212-1217.
31. Bots ML, Baldassarre D, Simon A, de Groot E, O'Leary DH, Riley W,
Kastelein JJ, Grobbee DE: Carotid intima-media thickness and
coronary atherosclerosis: weak or strong relations? Eur Heart
J 2007, 28:398-406.
32. Lorenz MW, Markus HS, Bots ML, Rosvall M, Sitzer M: Prediction
of clinical cardiovascular events with carotid intima-media
thickness: a systematic review and meta-analysis. Circulation
2007, 115:459-467.
33. Gregory CO, Dai J, Ramirez-Zea M, Stein AD: Occupation is more
important than rural or urban residence in explaining the
prevalence of metabolic and cardiovascular disease risk in
Guatemalan adults. J Nutr 2007, 137:1314-1319.
34. Albala C, Villarroel A, Santos JL, Angel B, Lera L, Liberman C, Sanchez
H, Pérez-Bravo F: FABP2 Ala54Thr polymorphism and diabetes
in Chilean elders. Diabetes Res Clin Pract 2007, 77:245-250.
35. Smith SC Jr, Haslam D: Abdominal obesity, waist circumference
and cardio-metabolic risk: awareness among primary care
physicians, the general population and patients at risk--the
Shape of the Nations survey. Curr Med Res Opin 2007, 23:29-47.