Acta Diabetol (2008) 45:31–35 DOI 10.1007/s00592-007-0015-6
ORIGINAL ARTICLE
Metabolic syndrome in a large chemical company: prevalence in a screened worksite sample Christoph Oberlinner Æ Per M. Humpert Æ Peter P. Nawroth Æ Andreas Zober Æ Michael Morcos
Received: 13 June 2007 / Accepted: 6 July 2007 / Published online: 20 September 2007 Springer-Verlag 2007
Abstract The metabolic syndrome (MS) leads to serious health problems like diabetes and has serious economic consequences for multinational companies. Thus, the workplace is an important setting for primary prevention. Aim of this study was to evaluate the prevalence of MS in a mixed working population to provide a basis for interventional strategies. In 2006, 1,594 employees attended a screening program at BASF Ludwigshafen, the number of employees with MS was determined and the distribution of impaired glucose tolerance (IGT), type 2 diabetes and cardiovascular disease (CVD) analyzed. The study-population consisted of 1,075 men and 519 women, aged 17–64. 374 individuals (23.5%) were classified to be affected by MS, of which 86.9% were male (prevalence MS in men 30%, in women 9.7%). Subjects with MS had higher BMI (P \ 0.01), blood pressure (P \ 0.01), heart rate (P \ 0.01), liver enzymes (P \ 0.01), uric acid (P \ 0.01) and LDL (P \ 0.01), while HDL was significantly lower (P \ 0.01). (Pre)-Diabetes and CVD were found more frequently in subjects with MS. There were no significant differences between individuals with different types of employment (‘‘white collar vs. blue collar’’ workers) or smoking status. We found a high prevalence of MS in our working population, thus interventional programmes
C. Oberlinner (&) A. Zober Occupational Medical and Health Protection Department, BASF Aktiengesellschaft, 67056 Ludwigshafen, Germany e-mail:
[email protected] P. M. Humpert P. P. Nawroth M. Morcos Department of Internal Medicine, Endocrinology, Metabolism and Clinical Chemistry, University of Heidelberg, INF 410, 69129 Heidelberg, Germany
should be implemented. The workplace-setting can be used to promote long-term prevention strategies in this adult working population. Keywords Metabolic syndrome Diabetes Prevention Working population
Introduction The metabolic syndrome is a cluster of cardiovascular risk factors and is a major public health challenge worldwide [1, 2]. Early diagnosis and intensive management of the various risk factors of the metabolic syndrome are needed to reduce the long-term risk of diabetes and cardiovascular disease [3]. In addition, companies are affected by the reduced productivity and increased costs caused by chronic disease amongst employees. Obese workers, for example, have the highest prevalence of work limitations (6.9% vs. 3.0% among normal-weight workers), hypertension (35.3% vs. 8.8%), dyslipidemia (36.4% vs. 22.1%), type 2 diabetes (11.9% vs. 3.2%), and the metabolic syndrome (53.6% vs. 5.7%) [4]. The new International Diabetes Federation (IDF) Definition of the Metabolic Syndrome provides a tool to identify individuals at risk [5, 6]. Employees of a company are a large, discrete population who are relatively easy to target. The active workforce also represents a large percentage of the global population (approximately 54%) [7]. Working adults spend more time at work—approximately one-third of their day—than in any other setting. Therefore, the workplace is a promising focal point for conducting disease screening and prevention programs based on the proximity of occupational medical services to the employee.
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As part of its employee health commitments, the BASF Occupational Medical and Health Protection Department in Ludwigshafen, Germany, performs routine health examinations for occupational health and safety reasons and all data is stored in an occupational medical information system. In addition, the department performs annual worksite health promotion campaigns for common diseases. In 2006, a IGT and diabetes screening was conducted at BASF’s Ludwigshafen site. Employees with metabolic syndrome were identified, and the differences in several parameters such as age, blood pressure and the distribution of chronic diseases were compared between individuals with and without the metabolic syndrome. The findings of this study will help to design prevention programmes in occupational settings.
Research design and methods The BASF Occupational Medical and Health Protection Department initiated a worksite diabetes-screening campaign in 2006 at the Ludwigshafen site in Germany. The campaign took place over a two-week period at our site clinic. Participation was open to all employees and not just for those assigned to jobs requiring routine examinations, and was voluntary in each aspect of the initiative. Brochures regarding the initiative were distributed to employees and the campaign was also advertised via the local media. Each participant was interviewed and had a medical check by an occupational physician. Height, weight, waist circumference and blood pressure were documented. Blood tests were taken using standardized methods and consisted of a complete blood count, triglycerides, total cholesterol, low-density and high-density lipoprotein (HDL and LDL), random glucose, uric acid, hepatic transaminases, and creatinine. Blood pressure and pulse rate were measured in sitting position and a single measurement was taken. The participants were questioned about their personal and family history of diabetes and cardiovascular diseases, the presence of cardiovascular risk factors like hypertension, the use of prescription medications, and their physical activity and eating habits.
Metabolic syndrome Based on these examinations, the cases of employees with MS, as defined by the International Diabetes Federation (IDF), were determined [5]. This classification was based on central obesity (men [ 94 cm, women [ 80 cm waist circumference) plus any two of the following factors: (1) raised triglycerides levels (‡150 mg/dl (1.7 mmol/l)), (2)
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reduced HDL cholesterol (men: \40 mg/dl (1.03 mmol/l); women: \50 mg/dl (1.29 mmol/l)), (3) raised blood pressure (systolic: [130 mmHg, diastolic: [85 mmHg or treated hypertension) or (4) raised fasting plasma glucose level ([100 mg/dl (5.6 mmol/l)).
Employees ‘‘at risk’’ for type 2 diabetes Risk for diabetes was evaluated using the FINDRISKScore (German Modification [8]). Individuals with 12 or more score points were offered an oral glucose tolerance test (OGTT). The standardized OGTT was performed by oral administration of 75 g glucose followed by measuring blood glucose concentrations after 60 and 120 min. The findings were classified according to the World Health Organization criteria for overt diabetes or impaired glucose tolerance.
Data analysis Differences in the distribution of impaired glucose tolerance (IGT), type 2 Diabetes and coronary artery disease in individuals with, as compared to those without the metabolic syndrome were examined using t tests and v2 tests. Individuals at risk for IGT or type 2 diabetes were offered an oral glucose tolerance test (OGTT) done. The standard OGTT was performed with 75 g of glucose followed by measurement of blood glucose concentrations at 60 and 120 min. For IGT, the following criteria were used: 1) 2 h values of 140–199 mg/dl, fasting glucose values of 100–125 mg/dl, or random glucose between 130 mg/dl and 199 mg/dl (defined by the American Diabetes Association (ADA) in 2003 and the Center for Disease Control (CDC) in 2005 [9, 10]. The corresponding limits for diabetes were as follows: OGTT 2 h ‡ 200 mg/dl, fasting glucose ‡ 126 mg/dl, or random glucose ‡ 200 mg/dl.
Results Within a workforce of 33,000 employees at BASF’s Ludwigshafen site in Germany, 1,594 individuals (*4.7%) participated in the worksite diabetes-screening campaign (1,075 men and 519 women) aged 17–64 years (mean age: 41.8 years). 247 (15.5%) of the study population were cigarette smokers at the time. 631 of the 1,075 men (59%) had a waist circumference larger than 94 cm, and 281 of the 519 women (54%) measured larger than 80 cm. A total of 375 employees (23.5% of the study population; 325 men and 50 women) were classified as having the metabolic syndrome.
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Table 1 The presence or absence of the metabolic syndrome as a factor of age, sex, type of employment (blue-collar workers (BCW), service workers (SW), white-collar workers (WCW), and senior executives (SE)) and smoking status Metabolic syndrome: (+) n = 374
Metabolic syndrome: (–) n = 1,220
P value
Age (mean)
46
41
\0.01
Male (%)
86.9
47.1
\0.01
Type of employment BCW SW WCW/ SE Others Current smokers (%)
76
213
217
713
79 2
267 27
16.6
15.2
0.51
The prevalence of the metabolic syndrome was significantly higher in men (30%) than in women (9.7%). Interestingly, there was no significant difference in prevalence of MS between different types of occupation (‘‘bluecollar workers’’ vs. service workers vs. ‘‘white-collar workers’’), nor was there a correlation between cigarette smoking and the presence of the MS (see Table 1). However, it was found that MS was significantly more prevalent with increasing age (mean age of 46 years vs. 41 years, average age of study group). Employees with the metabolic syndrome presented with a higher BMI (28.9 kg/m2 vs. 24.7 kg/m2) and an elevated mean pulse rate (76 beats per min. vs. 72 beats per min) (Table 2). All relevant risk markers were elevated in the MS group (see Table 3). Within the whole study sample, we identified 285 individuals ‘‘at risk’’ for developing type 2 diabetes using the FINDRISK score (German modification [8]). To these individuals we offered to perform an OGTT, but only 50.5% (n = 157) accepted this offer. Within this group we identified 7 individuals with type 2 diabetes and 73 with impaired fasting glucose (IFG).
Table 2 Distribution of selected characteristics according to the presence/ absence of the metabolic syndrome
Conclusion and discussion MS has received increasing attention as a significant health concern and cost driver for employers. There is a strong correlation between lifestyle and the presence of MS. About 23% of the US adult populations are classified as having the metabolic syndrome, with a high prevalence in the working age population [11, 12]. Although the majority of individuals meeting metabolic syndrome criteria in this population do not have IGT, diabetes or a cardiovascular disease, the prevalence of risk factors was significantly higher in the metabolic syndrome cohort, placing these persons at increased risk for chronic diseases. Particular attention needs to be given to educate this population on reducing their risk for disease. The workplace can furthermore be used to promote long-term behavioral changes for the prevention of the metabolic syndrome and related chronic diseases in this adult population. The 2006 screening initiative was available to all employees at the site. Considering the total employee population of 33,000, we expected a higher response rate than 1,594 participants. According to the 2006 German national health report, health initiatives reach only a fraction of the population, and people of a lower social status are less likely to participate [13]. In addition, men tend to be less interested in prevention and health promotion than women. They take advantage of preventive measures only when they do not have to face inconveniences, for example when the initiatives are carried out at the workplace [14]. However, not all employees at risk for IGT or diabetes accepted the offer to have an OGTT done. It seems likely, that there are additional cases of IGT and diabetes in the study group. Prevention must be understood as a task that involves the entire society and spans through all areas of life. Especially in the early diagnosis of diseases, innovative strategies need to be conceived to increase participation in the programs. For example, obesity intervention programs were carried out in 2005 by the BASF medical department in cooperation with the companies’ health insurance provider (Fortisnova), the on-site food
Metabolic syndrome: (+) n = 374 Body mass index (mean)
28.9
Metabolic syndrome: (–) n = 1,220 24.7
P value
\0.01
Medical treatment of hypertension (n)
112
118
\0.01 \0.01
Systolic blood pressure (mean), mmHg
143
129
Diastolic blood pressure (mean), mmHg
90
80
\0.01
Pulse (mean), beats/min
76
72
\0.01
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Table 3 Distribution of selected blood values according to the presence/absence of the metabolic syndrome
Metabolic syndrome: (+) n = 374
P Value
GOT (mean), mg/dl
26
22
\0.01
GPT (mean), mg/dl
33
21
\0.01
GGT (mean), mg/dl
44
27
\0.01
Uric Acid (mean), mg/dl Total Cholesterol (mean), mg/dl
6.24 211
5.13
\0.01
192
\0.01
HDL cholesterol (mean), mg/dl
50
65
\0.01
LDL cholesterol (mean), mg/dl Triglycerides (mean), mg/dl
135 256
118 127
\0.01 \0.01
services provider, the BASF Health Promotion Center, and the local clinic. The intervention included access to medical check-ups and consultations, weight-loss and exercise programs, balanced meals and information about caloric intake for all meals served in the on-site food facilities and volunteer ‘‘weight loss helpers’’ for encouragement. The obesity intervention program enrolled a total of 1,313 overweight participants and 749 normal weight ‘‘weight loss helpers’’. After 10 months, 658 individuals were successful in reducing their body weight (average weight loss: 7.1 kg, reduction of mean weight from 95 kg to 88 kg). Preventive strategies can only be successful and sustainable when the relevant target groups are reached and motivated. People who participate voluntarily in prevention campaigns are often those who are already motivated and maintain a healthier lifestyle. Thus, data generated from settings on a voluntary base, may have a bias in terms of an underestimation of risk factors and diseases linked to a sedentary life style. As with previous health initiatives to screen for various diseases (gastric disorders due to H. Pylori [15], colon cancer [16], obesity), we have found that programs offered to employees that have been broadly advertised, were able to reach a decidedly different subset of employees than programs targeted to employees during individual clinic visits. Female employees and those assigned to supervisory positions are relatively more likely to take advantage of a self-initiative program. In the 2006 screening program, female employees participated 2.6 times more often than their male counterparts. In addition, participants were relatively less overweight compared to the overall target population, but participation was non-differential relative to age. It appears that inviting employees to participate in a preventive health program when they are already at a routine examination would be an effective way to reach those individuals who could benefit most from such a program. The timelines of our early detection initiatives for common diseases is all the more important considering the expected aging of the workforce projected for Germany in
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Metabolic syndrome: (–) n = 1,220
the coming years. While 19% of its workforce is currently aged 50 or older, this is predicted to rise to 33% by the year 2015 [17]. People with metabolic syndrome are older than average [18]. The average age of working age people with metabolic syndrome in the NHANES (National Health and Nutrition Examination Survey) 1999–2000 and 2001–2002 data sets was 46, and the average age of those without metabolic syndrome was 40 (in our worksite screening population, the averages were 46 and 41, respectively—see Table 1). Prevention programs can be viewed as a benefit to employee and employer alike. The employees’ are healthier, and employers benefit from a reduction of lost productivity costs. There has been recent focus on the economic aspect of chronic diseases both in terms of direct medical costs and indirectly in terms of lost productivity costs. After diagnosis of type 2 diabetes, sooner or later, patient’s treatment requires often sulfonylureas and/or insulin. Last not least the economic success of a company is highly dependent on the performance, work satisfaction and innovativeness of the employees. A healthy workforce is the basis for productivity and profitability. Workplace health promotion has a significant role to play in reducing health risks and providing the resources to promote health as an ongoing process. References 1. Eckel RH, Grundy SM, Zimmet PZ (2005) The metabolic syndrome. Lancet 365:1414–1428 2. Cameron AJ, Shaw JE, Zimmet PZ (2004) The metabolic syndrome: prevalence in worldwide populations. Endocrinol Metabo Clin N Am 33:351–376 3. Isomaa B, Almgren P (2001) Cardiovascular morbidity and mortality associated with the metabolic syndrome. Diabetes Care 24(4):683–689 4. Hertz RP, Unger AN (2004) The impact of obesity on work limitations and cardiovascular risk factors in the US workforce. J Occup Environ Med 46(12):1196–1203 5. International diabetes federation (2005) The IDF consensus worldwide definition of the metabolic syndrome. Brussels: IDF.
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