ORIGINAL ARTICLE

European Journal of Medical and Health Sciences

www.ejmed.org

A Clinical Profile of Metabolic Syndrome and Its

Determinants among Police Officers in Bali
Febyan, Krisnhaliani Wetarini, Rendy, Chintia Septiani Thintarso, and Ketut Suastika

ABSTRACT
Introduction: Metabolic syndrome is defined as a cluster of cardiovascular
risk factors which includes hyperglycemia, central obesity, hypertension Published Online: December 28, 2020
and dyslipidemia. This study aimed to describe the clinical profile of ISSN: 2593-8339
metabolic syndrome among police officers.
DOI: 10.24018/ejmed.2020.2.6.619
Material and Methods: A cross-sectional study was conducted among the
police officers who performed the screening program at Bhayangkara Febyan*
Hospital Denpasar. The data was obtained by anamnesis, physical Department of Medicine, Bhayangkara
examination from anthropometric measurements and blood pressure, and Hospital Denpasar, Bali, Indonesia.
laboratory findings. All data was computerized and analyzed using SPSS (e-mail: febyanmd@ gmail.com)
v.24. Criteria of metabolic syndrome was established using modified 3rd Krisnhaliani Wetarini
Adult Treatment Panel, International Diabetes Federation. Department of Medicine, Bhayangkara
Hospital Denpasar, Bali, Indonesia.
Results: The prevalence of metabolic syndrome among the police officers Rendy
who performed the screening program in the period of January-June 2019 Department of Medicine, Kalideres
was 68.7%. Males (87.3%) were found to be more frequent than females General Public Hospital, Jakarta,
(12.7%), and the most prevalent age were ranging from 36-45 years old Indonesia.
(62.7%). A significant association was found between the metabolic Chintia Septiani Thintarso
syndrome event and gender (OR=0.169, 95% CI=0.078-0.366, p-value Department of Medicine, Ciputra
Hospital, Citra Garden City, Jakarta,
<0.001).
Indonesia.
Conclusions: The prevalence of metabolic syndrome among the police Ketut Suastika
officers was high, especially in male. The most frequent component of Department of Internal Medicine,
Division of Endocrine and Metabolic
metabolic syndrome found in both male and female was central obesity.
Diseases, Sanglah General Hospital
Association was found between metabolic syndrome and gender. Denpasar, Bali, Indonesia.

Keywords: Metabolic Syndrome, Obesity, Police, Indonesia. *Corresponding Author

I. INTRODUCTION A report from Franke states that the police officers have an
Metabolic syndrome (MetS) is defined as a cluster of increased prevalence of MetS compared to civilians in Indian
cardiovascular risk factors that includes hyperglycemia, population. They also reported that it is strongly suggest that
central obesity, hypertension and dyslipidemia [1]. It affects MetS likely resulted from inappropriate lifestyle choices and
more than 1 in 4 United States (US) adults and increases the modifiable behaviors. Poor eating habits and physical
risk of diabetes mellitus (DM) by 5-fold and the risk of inactivity are major contributors to both MetS and the
atherosclerotic cardiovascular disease (ASCVD) by 1.5 to 3- component risk factors that make up the MetS [4].
fold in over 5-10 years [2]. In US, study showed that this Unfortunately, there is no epidemiological data on the
occupational group has a high risk for development of MetS prevalence of DM and MetS among police officers from
and causing mortality at an earlier age compared to other Indonesia, especially in Bali. Therefore, this study was
groups [3]. The increase in risk is related to the lifestyle and conducted among the Denpasar police officers to describe the
working environment of the police that frequently under clinical profile of MetS and its determinants in Bhayangkara
constant stress with a high rate of smoking and alcohol Hospital, Denpasar, Bali.
addiction [3]. Some policemen are often lead a physically
inactive life, have irregular diet and limited choice of foods
while on duty, take overtime and shift work, suffer from II. MATERIAL AND METHODS
disrupted sleep patterns, stress and have high rates of tobacco A. Study Design and Patients
and alcohol consumption than the general population, they This study was a cross sectional study with purposive
have been found to have an increased prevalence of MetS risk sampling method. The subjects were 268 police officers who
factors and DM than any other occupational group and among performed the screening program at Bhayangkara Hospital
the general population in many countries [3]. Denpasar in the period of January to June 2019. The data were

DOI: http://dx.doi.org/10.24018/ejmed.2020.2.6.619 Vol 2 | Issue 6 | December 2020 1

 ORIGINAL ARTICLE
European Journal of Medical and Health Sciences
www.ejmed.org

obtained by anamnesis, physical examination including As shown in Table 3, there was significant association
anthropometric measurements of weight, height, and waist between gender and MetS. Male police officers were found
circumference, done by using standardized techniques. The to be 5.93% higher at risk of developing MetS compared to
blood pressure was recorded in the sitting position, from the female police officers (OR=5.930, 95% CI=2.731-12.878).
right upper arm with the cuff at the level of right atrium and However, we also found that there was no significant
antecubital fossa facing upward. Measurement was carried association between MetS and the years of service or age.
out using the mercury sphygmomanometer. The overnight The most frequent component of MetS found in both male
fasting blood samples were taken after at least eight hours of and female police officers was central obesity, which is
overnight fasting to estimate the fasting blood glucose, lipid defined based on waist circumference of male ≥ 90 cm and
profiles, and liver enzymes. female ≥ 80 cm (Table 4). In fact, we found that all police
officers with MetS were having central obesity.
B. Definition of Metabolic Syndrome
Metabolic syndrome (MetS): The MetS was diagnosed TABLE I: CHARACTERISTIC OF SUBJECTS
using modified 3rd Adult Treatment Panel (ATP III), Characteristic Variable Frequency Percentage (%)
Gender
International Diabetes Federation (IDF) criteria based on Male 234 87.3
presence of any of the following three out of five criteria [5]- Female 34 12.7
[7]: Age (y)
a. Fasting blood glucose ≥ 100 mg/dL and/or on diabetic < 40 166 61.9
≥ 40 102 38.1
sugar-lowering drugs; Years of Service (y)
b. Blood pressure ≥ 130/85 mmHg and/or hypertensive ≤ 10 27 10.1
patients on drugs; > 10 241 89.9
Body Mass Index (kg/m2)
c. Triglyceride level ≥ 150 mg/dL or on lipid-lowering Normal 34 12.7
drugs; Overweight 0 0.0
d. High density lipoprotein cholesterol ≤ 40 mg/dL in male Obese 1 35 13.1
Obese 2 199 74.3
and ≤ 50 mg/dL in female; Waist Circumference (cm)
e. Waist circumference ≥ 90 cm in male and ≥ 80 cm in Male (234)
female. ≥ 90 217 92.7
< 90 17 7.3
C. Statistical Analysis Female (34)
≥ 80 16 47.1
A computerized database was created for all the records. A < 80 18 52.9
statistical package for the International Business Machines Blood Pressure (mmHg)
Statistical Package for the Social Sciences (IBM SPSS ® Normal 127 47.4
Hypertension 141 52.6
version 24.0) was used for statistical analysis. All data were Fasting Blood Glucose (mg/dL)
expressed in categorical parameters to divide them closely for < 100 99 36.9
the clinical study. The statistical significance was assumed at ≥ 100 169 63.1
Triglyceride (mg/dL)
p-value <0.05. Chi-square test was performed to find an < 150 93 34.7
association between two categorical variables. ≥ 150 175 65.3
High Density Lipoprotein (mg/dL)
Male (234)
≤ 40 8 3.0
III. RESULT > 40 226 84.3
Female (34)
Among the police officers who performed the screening ≤ 50 1 0.4
program in the period of January to June 2019, the male group > 50 33 12.3
(87.3%) were found to be more frequent than female group Metabolic Syndrome
Absent 84 31.3
(12.7%). The prevalence of MetS among the police officers Present 184 68.7
who performed the screening program in the period of
January to June 2019 was 68.7% (Table 1). TABLE II: AGE DISTRIBUTION OF METABOLIC SYNDROME SUBJECTS
In both male and female police officers who were having ACCORDING TO GENDER
Gender
MetS, we found that the most subjects were within the age Age (y)
Male (N=173) Female (N=11)
less than 40 years old. Among that group, most of them < 40 100 (57.8%) 8 (72.7%)
consisted of 100 (57.8%) males rather than females (Table 2). ≥ 40 73 (42.2%) 3 (27.3%)

TABLE III: ASSOCIATION OF YEARS OF SERVICE, AGE, AND GENDER WITH METABOLIC SYNDROME
Metabolic Syndrome Odds Ratio Confidence Interval
Variable p-value
Present (N=184) Absent (N=84) Total (N=268) (OR) (95% CI)
Gender
Male 173 (94.0%) 61 (72.6%) 234 (87.3%) 5.930 2.731-12.878 <0.001
Female 11 (6.0%) 23 (27.4%) 34 (12.7%)
Age (y)
< 40 108 (58.7%) 58 (69.0%) 166 (61.9%) 0.637 0.368-1.102 0.105
≥ 40 76 (41.3%) 26 (31.0%) 102 (38.1%)
Years of Service (y)
≤ 10 16 (8.7%) 11 (13.1%) 27 (10.1%) 0.632 0.280-1.428 0.267
> 10 168 (91.3%) 73 (86.9%) 241 (89.9%)
* p-value is significant based on α = 0,05.

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 ORIGINAL ARTICLE
European Journal of Medical and Health Sciences
www.ejmed.org

TABLE IV: DISTRIBUTION OF METABOLIC SYNDROME COMPONENTS ACCORDING TO GENDER

Gender
Components of Metabolic Syndrome Total (N=184)
Male (N=173) Female (N=11)
Central Obesity 173 (100%) 11 (100%) 184 (100%)
Hypertriglyceridemia 151 (87.3%) 11 (100%) 162 (88.0%)
Hyperglycemia 144 (83.2%) 9 (81.8%) 153 (83.2%)
Hypertension 121 (69.9%) 9 (81.8%) 130 (70.7%)
Low HDL-C 7 (4.0%) 1 (9.1%) 8 (4.3%)
HDC-L: high-density lipoprotein cholesterol.

the police are expected to be in an ideal physical condition to

IV. DISCUSSION be able to work strong and agile in their daily professional
This study was conducted as part of an early detection activities. The other MetS components, including
program made for the police officers in order to prevent the hypertension, hyperglycemia, and hypertriglyceridemia were
occurrence of non-communicable diseases, especially the also found to dominate the study population.
metabolic syndrome. Estimation of global MetS prevalence Among the police officers who had MetS, it was found that
by IDF shows a number of 20-25%, while the prevalence of the most subjects consisted of males rather than females, with
MetS in Indonesia is known to be at 21.66% [5]. Several the age mostly less than 40 years old. Male police officers
studies have shown that the incidence of MetS tends to be were also found to be 5.93% higher at risk of developing
higher in police population, allegedly it was related to high MetS compared to female police officers (OR=5.930, 95%
work-related stress [6], and high risk of alcohol consumption CI=2.731-12.878; p-value <0.01). The prevalence study by
and smoking in this population [7]-[9]. Suastika and colleagues, conducted in Bali, found a 16.6%
The prevalence of MetS among police officers in our study prevalence of MetS among males and a prevalence of 20.0%
was 68.7%. Although our study did not directly compare the among females in general population. Although they found
prevalence of MetS among police officers and general no differences in the prevalence of nutritional state between
population, this finding roughly indicated that the MetS male and female subjects, but central obesity was more
prevalence were quite high among police officers in compare frequently in female subjects than in male (43.4% vs. 27.5%,
to the general population in Bali (15.94%) and Indonesia p-value <0.001) [13]. In other words, compared to the prior
(21.66%) [5]. Several other studies have found the prevalence study done by Suastika and colleagues, our study found a
of MetS to be in between 16.8-57.3% [7]-[10]. Thus, the different result. This may be caused by the difference in
finding in our study indicated a higher prevalence compared gender characteristic among police officers and general
to the previous studies. A recent longitudinal study confirmed population, where in our study the male groups were
that the incidence of dyslipidemia in police officers can be dominantly included.
predicted by psychological distress [11]. Kumar and Matic and colleagues stated that males are found to be
colleagues also stated that the police officers have been found related to MetS because it may be decreased levels of
to be at high risk for MetS and coronary heart diseases. aromatase enzyme, the principal enzyme of estrogen
Previous cross-sectional study showed that MetS-related production, develop abdominal obesity, elevated blood lipids
parameters, such as impaired fasting glucose, and impaired and insulin resistance that developing MetS [14]. Yan H and
glucose tolerance, are more frequent in police officers than in colleagues also found the prevalence of MetS is higher in
other workers [12]. males than in females. These are influenced by the estrogen
Many other elements such as dietary factors, lifestyle, which improves insulin sensitivity and suppresses hepatic
atypical work hours, reduced sleep duration, lack of physical gluconeogenesis through activation of estrogen receptor (ER)
activity, or a combination of all these factors can play as a alpha phosphoinositide 3-kinase-Akt-Foxo1 signaling, which
causative role in MetS among police officers. One cohort can be independent of insulin receptor substrates 1 and 2 (Irs1
study had been able to rule out the role of dietary factors, shift and Irs2) that revealing an important of mechanism for
and night work, lack of physical activity, and depression or estrogen in the regulation of glucose homeostasis. These may
other common mental disorders in their relation with MetS help explain why young females have lower incidence of
[6]. Instead, the effect of smoking and sleep habits among MetS [15].
police officers were found to be related to MetS, so that the Meanwhile, the age and years of service variables were not
latter proved to be a very important factor. A further study found to have a significant relationship. This result showed
about the significant relation between smoking, sleep habits, an accordance with the research conducted by Zhang and
work stress, and MetS would be useful to clarify their mutual colleagues, in which policemen were found to be significantly
effects. related to MetS (OR=11.3; 95% CI=7.2-17.8; p-value <0.01).
The research carried out by Garbarino and colleagues In contrast to the results of our study, Zhang and colleagues
shows the characteristics that resemble our study, which found that older age (OR=1.6; 95% CI=1.4-1.7; p-value
found that the male police officers were more frequent than <0.01) increased the risk of MetS events among police
female police officers. Most of the police officers were less officers [8]. Study by Tharkar and colleagues also showed
than 40 years old in age and had more than 10 years of service that older age was associated with the event of DM
[6]. The majority of subjects were found to be categorized as (OR=10.4; 95% CI=3.5-30.3; p-value <0.01) and MetS
having obesity, based on body mass index (BMI) > 30.0 (OR=3.9; 95% CI=1.3-11.9; p-value=0.015) [9].
kg/m2. The percentage of obesity found in this study was The different findings were probably caused by the
much higher compared to other studies (87.4% vs. 47.9- differences in characteristics between two studies, with the
72.64%) [6]-[10]. This becomes a problem because generally different age criteria were shown in study done by Zhang and

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 ORIGINAL ARTICLE
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colleagues [8]. Whereas in the study done by Thankar and evidences demonstrated that shortened leukocyte telomere
colleagues, the mean age of police officers were 44.3±12.1 length had a significant association with MetS [22].
years, meaning that the majority of study population was A prospective study from Multi-ethnic Dallas Heart Study
dominated by older age [9]. Nestel and colleagues reported by Mani and colleagues found that among 1,120 participants
that the age group of 40-60 years had a higher prevalence of without DM or MetS at baseline (57% females, 45% black,
MetS [16]. The result in our study, contrary showed mean age 43), were followed up with the total percentage of
difference findings from Ogbera and colleagues, with the 22.8% new incident of MetS. In that study, the low result of
prevalence of MetS being 43.5% in females and 34.1% in high-density lipoprotein particle (HDL-P) and HDL-C levels
males in general population [17]. Another study also reported were modestly correlated with MetS incident (r=0.54, p-value
an overall MetS prevalence of 51%, consisted of 56% females <0.0001). However, adjustment for visceral adiposity did not
and 44% males [18]. A retrospective study in Southern Brazil attenuate the inverse association between HDL-P and MetS
from Marchi and colleagues found that MetS was observed in incident, suggesting that the pathways by which low HDL-P
18.5% of general population, consisted of 9.4% the young confers increased metabolic risk is distinct from the pathways
females and 22.2% of the elderly females displayed MetS reflected by metabolically dysfunctional fat depots [23,24].
[19]. Suastika and colleagues, found that the elderly group (>
60 years) had a significantly higher prevalence of MetS than
in younger aged group (< 60 years) {22.9% vs. 17.3%, p- V. CONCLUSION
value =0.026; prevalence risk 1.423 [CI=1.043-1.944]} in the The prevalence of MetS was high among the police
population of Bali [20]. Moreover, there was a statistically officers. Male gender is one of the unmodifiable risk factors
significant relationship between postmenopausal stage and that found to be significantly related to MetS. A marked
increased age with the presence of MetS. Older females number of central obesities, hypertriglyceridemia,
(older than 56 years) were 5.95 (CI=3.03-11.64) times more hyperglycemia, and hypertension were found among the
likely than younger females to be diagnosed with MetS [21]. police officers who experience MetS. Only a small number of
We found that the most frequent component of MetS found police officers that were found to be having low HDL
in both male and female police officers was central obesity. cholesterol. Community programs in the public health setting
In our study it was found that all police officers suffering are crucial to promote awareness of components MetS. Thus,
from MetS had central obesity. The findings by Ogbera and such programs should focus on encouraging lifestyle changes
colleagues also showed that the high prevalence of the police to prevent health problems among the police officers in
group with MetS had abdominal obesity which is one of the Denpasar, Bali.
components of MetS according to the IDF criteria [17].
Similar to the findings of Kelliny and colleagues, they also
found that abdominal obesity was one of the MetS ACKNOWLEDGMENT
components that occurred frequently [18]. Other MetS
Authors thank to all the staffs of the Bhayangkara Hospital
components that were also found to be high includes
Denpasar, who contributed to data collection.
hypertriglyceridemia, hyperglycemia, hypertension. While
low HDL-C was only found in 4.3% of police officers with
MetS. Thus, preventing and controlling obesity as a major
REFERENCES
health problem in the MetS police officer population are
essential steps for preventing MetS-related morbidities and [1] P.C. Negi, S. Sondhi, R. Merwaha, and S. Asotra, “Prevalence and risk
determinants of metabolic syndrome in obese worksite workers in hill
mortality. city of Himachal Pradesh, India,” Indian Heart J., vol. 71, pp. 45-51,
Cheng and colleagues found that the high triglyceride was 2019.
significantly associated with a decrease of the mean [2] H. Beltrán-Sánchez, M.O. Harhay, M.M. Harhay, S. McElligott,
“Prevalence and trends of metabolic syndrome in the adult U.S.
leukocyte telomere length (LTL) in fully adjusted models (p- population, 1999-2010,” J Am Coll Cardiol., vol. 62, no. 8, pp. 697-
value <0.001) that furtherly developing to be MetS. A higher 703, 2013.
score of waist circumference was also found to be associated [3] D.R. Smith, S. Devine, P.A. Leggat, T. Ishitake, “Alcohol and tobacco
consumption among police officers,” Kurume Med J., vol. 52, pp. 63-
with 4.8 times increased risk of developing the MetS 5, 2005.
(OR=4.76, 95% CI=3.71-6.10). In both the male and female [4] W.D. Franke, “What is the risk for metabolic syndrome in police
groups, waist circumference was significantly associated officers?,” North Am J Med Sci., vol. 4, pp. 636-637, 2012.
[5] E.H. Herningtyas, T.S. Ng, “Prevalence and distribution of metabolic
with a decrease of mean LTL (p-value <0.05) [22]. syndrome and its components among provinces and ethnic groups in
Pathogenesis of MetS and other related diseases involves the Indonesia,” BMC Public Health, vol. 19, no. 1, pp. 377, 2019.
excess of reactive oxygen species, which damage [6] S. Garbarino, N. Magnavita, “Work stress and metabolic syndrome in
police officers: a prospective study,” PLoS One, vol. 10, no. 12, pp.
mitochondrial components and trigger cellular lysis. Such e0144318, 2015.
toxic reactions lead to the aging process [23]. In a [7] J. Thayyil, T.T. Jayakrishnan, M. Raja, J.M. Cherumanalil, “Metabolic
longitudinal study reported by Lee and colleagues, telomere syndrome and other cardiovascular risk factors among police officers,”
length was shorter in an obese population. Their study was N Am J Med Sci., vol. 4, no. 12, pp. 630-635, 2012.
[8] J. Zhang, Q. Liu, S. Long, C. Guo, H. Tan, “Prevalence of metabolic
conducted of 5,598 participants, and they stated that a shorter syndrome and its risk factors among 10,348 police officers in a large
LTL was associated with multiple measures of obesity in both city of China: A cross-sectional study,” Medicine (Baltimore), vol. 98,
males and females with MetS. Shorter telomere length is a no. 40, pp. e17306, 2019.
[9] S. Tharkar, S. Kumpatla, P. Muthukumaran, V. Viswanathan, “High
sign of cellular marker for biological age, and was associated prevalence of metabolic syndrome and cardiovascular risk among
with a higher metabolic risk profiles, which remains police personnel compared to general population in India,” J Assoc
unfavorable even after a period of 6 years. Accumulating Physicians India, vol. 56, pp. 845-849, 2008.

DOI: http://dx.doi.org/10.24018/ejmed.2020.2.6.619 Vol 2 | Issue 6 | December 2020 4

 ORIGINAL ARTICLE
European Journal of Medical and Health Sciences
www.ejmed.org

[10] R.T. Filho, A. J. D'Oliveira, “The prevalence of metabolic syndrome

among soldiers of the military police of Bahia State, Brazil,” Am J
Mens Health, vol. 8, no. 4, pp. 310-315, 2014.
[11] T.A. Hartley, C.M. Burchfiel, D. Fekedulegn, M.E. Andrew, S.S.
Knox, M. Violanti, “Associations between police officer stress and the
metabolic syndrome,” Int J Emerg Ment Health, vol. 13, no. 4, pp. 243-
256, 2011.
[12] P. Kumar, D. Mallik, D.K. Mukhopadhyay, A. Sinhababu, B.S.
Mahapatra, P. Chakrabarti, “Prevalence of diabetes mellitus, impaired
fasting glucose, impaired glucose tolerance, and its correlates among
police personnel in Bankura District of West Bengal,” Indian J Public
Health, vol. 57, no. 1, pp. 24-28, 2013.
[13] K. Suastika, P. Dwipayana, I.M.R. Saraswati, et al., “Prevalence of
obesity, metabolic syndrome, impaired fasting glycemia, and diabetes
in selected villages of Bali, Indonesia,” JAFES, vol. 26, no. 2, pp. 159-
162, 2011.
[14] M. Matic, G. Bryzgalova, H. Gao, et al., “Estrogen signalling and the
metabolic syndrome: targeting the hepatic estrogen receptor alpha
action,” PloS One, vol. 8, no. 2, pp. e57458, 2013.
[15] H. Yan, W. Yang, F. Zhou, et al., “Estrogen improves insulin
sensitivity and suppresses gluconeogenesis via the transcription factor
Foxo1”, Diabetes, vol. 68, no. 2, pp. 291-304, 2019.
[16] P. Nestel, R. Lyu, L.P. Low, et al., “Metabolic syndrome: Recent
prevalence in East and Southeast Asian populations,” Asia Pac J Clin
Nutr., vol. 16, no. 2, pp. 362-367, 2007.
[17] A.O. Ogbera, “Prevalence and gender distribution of the metabolic
syndrome,” Diabetol Metab Syndr., vol. 2, pp. 1, 2010.
[18] C. Kelliny, J. William, W. Riesen, et al., “Metabolic syndrome
according to different definitions in a rapidly developing country of the
African region,” Cardiovasc Diabetol., vol. 7, pp. 27, 2008.
[19] R.D. Marchi, C.M. Dell’Agnolo, T.C.R. Lopes, et al., “Prevalence of
metabolic syndrome in pre-and postmenopausal women,” Arch
Endocrinol Metab., vol. 61, no. 2, pp. 160-166, 2017.
[20] K. Suastika, P. Dwipayana, I.M.R. Saraswati, et al., “Relationship
between age and metabolic disorders in the population of Bali,”
Journal of Clinical Gerontology & Geriatrics, vol. 2, no.2, pp. 47-52,
2011.
[21] M. Nakhjavani, M. Imani, M. Larry, et al., “Metabolic syndrome in
premenopausal and postmenopausal women with type 2 diabetes: loss
of protective effects of premenopausal status,” J Diabetes Metab
Disord., vol. 13, no. 1, pp. 102, 2014.
[22] Y.Y. Cheng, T.W. Kao, Y.W. Chang, et al., “Examining the gender
difference in the association between metabolic syndrome and the
mean leukocyte telomere length,” PLoS One, vol. 2, no. 7, pp.
e0180687, 2017.
[23] M. Lee, H. Martin, M.A. Firpo, E.W. Demerath, “Inverse association
between adiposity and telomere length: The Fels Longitudinal Study,”
Am J Hum Biol., vol. 23, no. 1, pp. 100-106, 2011.
[24] P. Mani, H.Y. Ren, I.J. Neeland, et al., “The association between HDL
particle concentration and incident metabolic syndrome in the multi-
ethnic Dallas Heart Study,” Diabetes Metab Syndr, vol. 11, no. 1, pp.
175-179, 2017.

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