Metabolic Syndrome and CVD Risk in College Students?
29
Journal of Exercise Physiologyonline
(JEPonline)
Volume 13 Number 4 August 2010
Managing Editor
Tommy Boone, PhD, MPH
Editor-in-Chief
Jon K. Linderman, PhD
Review Board
Todd Astorino, PhD
Julien Baker, PhD
Tommy Boone, PhD
Eric Goulet, PhD
Robert Gotshall, PhD
Alexander Hutchison, PhD
M. Knight-Maloney, PhD
Len Kravitz, PhD
James Laskin, PhD
Derek Marks, PhD
Cristine Mermier, PhD
Chantal Vella, PhD
Ben Zhou, PhD
Official
Research Journal of
the American Society of
Exercise Physiologists
(ASEP)
ISSN 1097-975
Exercise and Health
Fitness and Fatness: Indicators of Metabolic Syndrome and
Cardiovascular Disease Risk Factors in College Students?
JANELLE SCHILTER1, LANCE DALLECK1,2
1Department
of Human Performance / Minnesota State University,
Mankato, MN, USA, 2Department of Sport and Exercise Science, The
University of Auckland, Auckland, New Zealand
ABSTRACT
Schilter JM, Dalleck LC. Fitness and Fatness: Indicators of Metabolic
Syndrome and Cardiovascular Disease Risk Factors in College
Students? JEPonline 2010;13(4):29-39. The purpose of this study was
to identify which health related behaviors including fatness, amount of
physical activity, and cardiorespiratory fitness, correlate with increased
cardiovascular disease and metabolic syndrome risk factors in college
students. There were 203 men and women (20.3  2.2 yr) who
participated in a two day collection period. Height, weight, waist
circumference, blood pressure, blood lipid profile, and cardiorespiratory
fitness were measured. Each participant also filled out a questionnaire in
regards to their physical activity habits and other demographic
information. Multiple linear regression was used to determine the
independent relation of fatness (body mass index and waist
circumference), amount of physical activity, intensity of physical activity,
and cardiorespiratory fitness to metabolic syndrome and cardiovascular
disease risk factors. Thirty-four percent of the sample population had no
cardiovascular risk factors, 28.6%, 22.7% and 14.8% had one, two, and
three or more risk factors respectively. Physical activity and fatness were
predictive of low cardiorespiratory fitness and dyslipidemia. Individuals
that self-reported vigorous (n=55) rather than moderate (n=134) physical
activity levels had significantly (p<0.05) higher VO2max, lower resting
heart rate, higher HDL, and lower fasting blood glucose. These findings
suggest that multiple cardiovascular risk factors are present in a college
aged population. The relationship between physical activity and fatness
suggest that future prevention programs should focus on modifying
these behaviors
Key Words: Physical activity, Obesity, Prevention, Young adults
Metabolic Syndrome and CVD Risk in College Students?
30
INTRODUCTION
In 2006, according to the American Heart Association (AHA), about 80 million people in the United
Stated had some sort of cardiovascular disease (CVD), while claiming 35.3% of all cause death (24).
As of 2007, the AHA also notes that 35.7% of the U.S. population has Metabolic Syndrome (MetS),
which is defined as a grouping of metabolic abnormalities including glucose intolerance, insulin
resistance, central obesity, dyslipidemia, and hypertension. In 2004, MetS affected 34.6%, 76 million
individuals, of the population (24). Over nine percent, about 2.9 million of adolescents, ages 12–19,
have MetS. Forty-four percent of children who are overweight or obese have MetS (24).
Consequently, risk factors for MetS are known to increase the risk of CVD (11).
While researching prevalence of MetS, Huang et al. discovered a low prevalence among college
aged students, but it was shown that 26-40% of students had at least one risk factor. High-density
lipoprotein (HDL) cholesterol, impaired fasting glucose, and hypertriglyceridemia had increased
prevalence among this population. While females in Huang et al.’s study were more likely to show
impaired glucose tolerance, men showed more cases of obesity, hypertension, and
hypertriglyceridemia (17). A major problem with young people and risk is their overall lack of
awareness. For example, Collins et al. and Green et al. discovered that most college students do not
accurately perceive their risk of heart disease and would rate their own risk less than their peer’s risk.
Additionally, lack of knowledge among college students in regards to risk factors is an issue (7,15).
Becker and colleagues discovered that college students were unsure which risk factors will develop
into MetS (2). Due to the fact that college students are unaware and have lack of knowledge on MetS
and CVD risk factors, it is likely that they will go undiagnosed until cardiovascular problems occur.
Physical activity is important in aiding in the prevention process of CVD and MetS. With age, college
students tend to see a decrease in physical activity (16, 38); nationally 22.4% of 18-24 year olds
report participating in no physical activity, but Huang et al. only saw 16.1% of their subjects
participating in no physical activity (16). After follow up of a nine year longitudinal study, Xiaolin and
colleagues found that both men and women, aged 15-39, had a linear relationship between leisure
time physical activity and MetS for all definitions (42). Spencer found that lack of cardiovascular
exercise increases cholesterol levels (40). MetS may be prevented or delayed with physical activity
throughout a lifespan (42). Diseases that are associated with physical inactivity can be reduced by
slightly increasing the amount of physical activity above the minimal recommendations (39). The
American College of Sports Medicine states that participation in regular physical activity can decrease
the risk of both fatal and nonfatal cardiovascular disease events and “the benefits of regular physical
activity outweigh its risks” (1). A sedentary lifestyle, along with poor cardiorespiratory fitness has been
shown to be associated with an increased risk of MetS in middle aged men (22). Janssen and
colleagues discovered that adolescent individuals with high cardiorespiratory fitness levels were
associated with lower MetS prevalence (19). With implementation of exercise, risk factors of MetS
can be reversed and prevented (12).
Hypertension, renal dysfunction, unhealthy lipid profiles, metabolic dysfunction, and impaired insulin
resistance are just some of the problems that are occurring in obese individuals (21). Colleges across
the United States are seeing increasing obesity rates (35). Fifty percent of children who are
overweight tend to be overweight as an adult; these children also have a tendency to have a
collection of risk factors for CVD (21). Elevated risk for MetS and CVD are being seen in the younger
population, which may in turn cause many health problems later in their lives. College students who
were overweight had a threefold increased risk of obtaining at least one MetS risk factor (18).
Likewise, obesity has been shown to increase hypertension, which is a risk factor for both CVDand
MetS (33). Due to sedentary lifestyle choices, there is a growing prevalence of childhood
Metabolic Syndrome and CVD Risk in College Students?
31
obesity.Obesity, along with insulin resistance, has been shown to play a vital role in the development
of MetS (5). Due to increased visceral fat, insulin resistance and elevated lipid levels accelerate the
atherosclerosis process (10,23,30). In addition, the association between waist to hip ratio/waist girth
was directly associated with an increased occurrence of coronary calcification fifteen years later (23).
As illustrated above, increased body weight increases the risk factors associated with MetS and CVD.
There is evidence that suggests that the presence of MetS is a strong predictor of CVD development
(9,10,13,14,15,25,26,28,36). Lloyd-Jones and colleagues, found that the lifetime cardiovascular risk
was very low if no risk factors were present (25). Identification and management of MetS is an
extremely important piece in the prevention of coronary heart disease (24). The association between
MetS and CVD are strongly related because they share many of the same risk factors; the risks that
define MetS tend to lead to development of CVD (36).
The focus of both students and universities should be on preventing risk factors from occurring in the
first place. Regardless of their young age, college students are at risk for developing risk factors of
MetS and CVD diseases (17,18). The lifestyle choices that are made during the college years may be
influencing development of risk factors. Therefore, the purpose of this study was to identify which
behavior-related risk factors including fatness, amount of physical activity, and cardiorespiratory
fitness correlate with increased CVD and MetS risk factors in college students.
METHODS
Subjects
The subjects recruited in this study consisted of 203 college students (78 male and 125 female) from
an upper Midwest university, where the total student body population is about 10,000. Of the
participating students 95.2% were Caucasian, 1.0% Hispanic American, 2.4% Asian American and
1.4% were from other ethnicities. A majority, 67.1%, of the sample were college freshman. Students
were recruited by class announcements and further details were given to those who were interested.
All of the subjects understood the terms of the study and signed a consent form agreeing to the
procedures. This study was approved by the University Subjects Institutional Review Board.
Procedures
During the data collection the following measurements were taken: height, weight, waist
circumference, resting HR, blood pressure, blood lipid profile, blood glucose, and aerobic fitness. The
evaluation was performed by junior and senior level students, who were trained by a PhD-level
exercise physiologist. On the first day of data collection, height, weight, waist circumference, resting
HR, blood pressure, blood lipid profile, and blood glucose were collected. First, height was measured
in centimeters and inches using the Seca stadiometer. Subjects were instructed to remove their
shoes and step with their back against the wall under the stadiometer hinged lever. Subjects stood
as tall as possible with their feet together; the subject deeply inhaled, and the technician positioned
the hinged level to the crown of the head to find the height reading to the nearest 0.1 centimeter.
Female subjects were asked to wear their hair down or in a low ponytail. To find the subject’s weight,
a standard Detecto scale was used. Participants were instructed to remove shoes, jewelry,
accessories, and anything in their pockets. They then stood on the scale with their arms down at their
side. The technician recorded weight to the closest 0.1 kilogram.
Body mass index was calculated by dividing weight in kg by height in meters squared. Waist
circumference was measured around the smallest portion of the waist, above the umbilicus and below
the xiphoid process. The measurement was taken on bare skin with the tape directly on the skin
without pulling too tightly to create skin compressions. The reading was recorded to the nearest 0.1
centimeter. ACSM guidelines for resting blood pressure were followed (1). Participants were seated
Metabolic Syndrome and CVD Risk in College Students?
32
quietly for about five minutes in a chair with their arms rested and relaxed at heart level. Blood
pressure was measured twice on the left arm brachial artery with the use of a sphygomomanomter.
Each measurement was separated by one minute, and the mean of the measurements was recorded.
Fasting blood lipids and blood glucose tests were
performed. Participants were instructed to fast for
Table 1. Risk factors/defining levels.
twelve hours prior to testing, as well as to refrain from
Risk Factor
Defining level
exercise, caffeine, and smoking. Participants’ hands
Body mass index (kg/m2)
≥ 30
were washed with soap and water, and then wiped with
an alcohol swab and allowed to dry. Following a 10
Waist circumference (cm)
minute upright sitting rest, skin was punctured using
> 102
Men
lancets. Blood from the fingerstick sample was
> 88
Women
collected into a heparin-coated 40l capillary tube.
Blood pressure (mmHg)
≥ 130/ ≥ 85
Blood was then dispensed onto test cassettes for
Physical activity (min/week)
< 90
analysis with a LDX Cholestech analyzer, which
measured total cholesterol, high density lipoprotein
LDL (mg/dL)
≥ 130
(HDL) cholesterol, low density lipoprotein (LDL)
cholesterol, triglycerides, and blood glucose). The
HDL (mg/dL)
analyzer was checked prior to use for that day with an
Men
< 40
Women
<50
optics check.
Triglycerides (mg/dL)
≥ 150
As participants were leaving, they were given a short
questionnaire investigating their family health history,
personal health history, amount of physical activity
completed and intensity, and current medication usage. Amount of physical activity (minutes/week)
completed by each subject was obtained by multiplying numbers of days completed and minutes per
exercise session. Demographic information such as age, gender, ethnicity, and year in school was
also collected within the questionnaire. All subjects brought questionnaire back to their second data
collection session. The second day of data collection, within a six week collection period, consisted of
a cardiorespiratory fitness test. Participants completed a one mile walk test around the track. Based
on the subject’s heart rate, VO2 max was estimated. The cut off values for each of the independent
variables are shown in Table 1. These were obtained from the ATP III (Adult Treatment Panel III)
definition of MetS, while the remaining independent variables including body mass index, physical
activity, and LDL cholesterol cut off levels were taken from the American College of Sports Medicine
which is outlined elsewhere (1).
Fasting blood glucose
≥ 100
Statistical Analyses
All analyses were performed using Statistical Package for the Social Sciences, Version 15.0. (SPSS
Inc., Chicago, IL). Measures of centrality and spread are presented as frequency and mean ± SD.
MetS guidelines, according to the NCEP-ATP III, were used to determine cut off values for risk factor
stratification; these are outlined in Table 1. Use of a multiple linear regression analyses was used to
determine the independent relation of fatness (body mass index and waist circumference),
participation in physical activity, and cardiorespiratory fitness level to MetS risk factors. MetS risk
factors were entered as the dependent variable, while amount of physical activity, cardiorespiratory
fitness level, and fatness were entered as independent variables. Residual analyses to test the
validity of regression model assumptions were performed for all developed regression models. An
independent t-test was used to analyze the differences between vigorous and moderate intensity
exercise. The probability of making a Type I error was set at p <0.05 for all statistical analyses.
Metabolic Syndrome and CVD Risk in College Students?
33
RESULTS
College aged students, 18-24 years of age, were assessed for presence of MetS and CVD risk
factors. Age, height, weight, body mass index, waist circumference, resting HR, systolic and diastolic
blood pressure, lipid
Table 2. Descriptive data of the subjects (n = 203).
profile, physical activity
Component
Women
Men
Combined
(min/week), and VO2
(n =125)
(n = 78)
(n = 203)
max were measured and
Age, year
20.2  1.9
20.7  2.5
20.3  2.2
shown in Table 2.
Height, cm
Weight, kg
Body mass index, kg/m2
Waist circumference, cm
Resting HR, beats/min
SBP, mmHg
DBP, mmHg
LDL, mg/dL
HDL, mg/dL
Triglycerides, mg/dL
Fasting blood glucose, mg/dL
Physical activity, min/week
VO2max, mL/kg/min
166.1  6.9
66.7  12.5
24.2  4.1
75.7  11.4
72.8  10.2
112.8  9.2
69.0  7.5
91.9  31.6
55.3  15.9
102.9  53.0
88.1  10.9
147.0  117.8
39.1  8.5
180.5  7.2
81.5  13.8
25.0  3.9
83.2  9.3
70.8  10.0
119.3  11.1
73.0  8.3
100.4  31.4
48.6  16.7
119.9  52.4
90.8  10.1
167.3  123.2
38.3  7.9
171.6  9.9
72.4  14.8
24.5  4.0
78.6  11.2
72.1  10.2
115.3  10.4
70.5  8.0
95.0  31.7
52.7  16.5
109.2  53.3
89.2  10.6
154.8  120.0
38.8  8.3
BMI
Waist
Circumference
High Blood
Pressure
Physical
Inactivity
0
1
2
1
3
6
2
1
0
0
2
4
4
5
2
1
Thirty-four percent of the
sample population had
no cardiovascular risk
factors, 28.6%, 22.7%
and 14.8% had one, two,
and three or more risk
factors respectively as
shown in Table 3.
Dyslipidemia,
physical
inactivity, and fatness
were among the risk
factors that were most
Values are mean ± SD
commonly found within
the sample population.
Physical activity (R2 = .64) and fatness (R2 = .40) were shown to be predictive of low cardiorespiratory
fitness and dyslipidemia. Individuals that self-reported vigorous (n = 55) rather than moderate (n =
134)
physical
activity Table 3. Prevalence of MetS and CVD individual risk factors by
levels had significantly (p< number of components.
0.05) higher VO2max, Conditions
Number of Total Positive Risk Factors
lower resting heart rate,
0
1
2
3
4
5
6
7
higher HDL, and lower
fasting blood glucose as n=
69
58
46
12
8
6
3
1
shown in Figure 1.
DISCUSSION
Considering the rising
0
5
2
2
1
3
2
1
amount of individuals who
0
9
28
9
6
6
3
1
are experiencing CVD and
MetS throughout their Elevated LDL
0
4
8
2
3
1
2
1
lifetime (24), it is crucial to
Depressed HDL
0
18
35
8
8
6
3
1
implement healthy lifestyle Elevated
practices at an early age Triglycerides
0
13
5
7
4
2
3
1
(31). Understanding which Impaired Fasting
0
8
10
3
3
1
1
1
health risks most greatly Glucose
affect risk for CVD and
MetS in college aged adults is yet to be determined. Therefore, the main purpose of this study was to
examine which health related behaviors including fatness, amount of physical activity, and
cardiorespiratory fitness, correlate with increased CVD and MetS risk factors in college students. The
results of this study suggest that there are lifestyle behaviors that will hinder one’s cardiovascular
Metabolic Syndrome and CVD Risk in College Students?
34
health.
The findings of this study suggest that multiple CVD risk factors are present in the college aged
population. Most notably found were dyslipidemia, physical inactivity, and obesity. Only 34% of the
sample population had no risk factors, leaving almost two-thirds with one or more risk factors. Similar
to this study, previous research has shown that CVD and MetS risk factors are present in college
students (17,18,40). Huang and colleagues reported 33% of students obtained at least one risk factor
for MetS; abnormal HDL cholesterol was seen in 24% and impaired fasting glucose in nine percent of
the participants (17), this is comparable to what was found in the present study.
A.
B.
* p < 0.05
60
VO2max (mL/kg/min)
HDL-chol (mg/dL)
80
70
60
50
40
50
40
30
20
moderate
vigorous
moderate
vigorous
D.
C.
100
110
* p < 0.05
Blood glucose (ml/dL)
Resting HR (beats/min)
* p < 0.05
90
80
70
60
* p < 0.05
100
90
80
moderate
vigorous
moderate
vigorous
Figure 1. Comparison of risk factors for those who
completed moderate versus vigorous exercise.
With 38% of the sample population having low HDL levels, it is important to highlight the various
cardioprotective mechanisms of HDL. In both genders, at all ages and at all levels of risk, HDL
cholesterol protects against cardiovascular disease by increasing reverse cholesterol transport,
inhibiting inflammation, and reducing oxidation (8). A significantly strong inverse relationship has
previously been reported between HDL cholesterol and CVD within both genders (8). Young adults
with low HDL cholesterol levels have been shown to have 28-fold higher odds of having a myocardial
infarction (34). In conclusion, low HDL is a significant indicator of future CVD, and with appropriate
lifestyle modifications, increases in HDL may play a crucial role in CVD prevention (8,34).
In this study, individuals who self-reported higher amounts of physical activity and had decreased
fatness were significantly associated with elevated cardiorespiratory fitness levels and reduced
dyslipidemia. Huang discovered that dyslipidemia was associated with being overweight in college
aged students; even at a young age, being overweight and having a poor metabolic profile contribute
to a major health threat (18). Due to sedentary lifestyles, obesity has become a large health problem;
abdominal obesity is strongly related to development of CVD (10). A 15 year longitudinal study
Metabolic Syndrome and CVD Risk in College Students?
35
completed by Lee and colleagues discovered that abdominal obesity was associated with early
atherosclerosis development (23). This demonstrates the importance of decreased fatness, especially
abdominal fatness, on cardiovascular health. An increased amount of physical activity was shown to
be beneficial on a lipid profile and prevention of metabolic decline (20,39). The American College of
Sports Medicine states that both fatal and nonfatal cardiovascular events can be decreased by
regular exercise, and the risk is outweighed by the many benefits (1). Implementation of a prevention
program, concentrating on increasing amount of physical activity completed and decreasing amount
of body fatness, in college universities, may be crucial in prevention of future CVD and MetS.
Participants who self-reported vigorous intensity exercise showed a significant association with higher
VO2max values, lower resting HR, higher HDL, and lower SBP. Therefore, this study suggests that
vigorous intensity exercise is associated with a healthier cardiovascular risk factor profile. This finding
may have long term positive implications for the college aged student, as Swain and Franklin recently
found that vigorous intensity exercise had a greater cardioprotective benefit when compared to
moderate intensity exercise. Those who exercised at a more vigorous intensity had higher
cardiorespiratory fitness levels which may have contributed to the decreased risk for CVD. When
energy expenditure is held constant, individuals who exercised at a higher intensity saw a more
favorable risk profile. The reason why there is a cardioprotective effect with vigorous intensity
exercise remains unclear, but it is known that while exercising at a higher intensity, there is an
increase in the sympathetic drive which may in turn effect blood pressure and thrombosis (41). Both
adult and adolescent individuals, with low cardiorespiratory fitness, were shown to have an increased
prevalence of CVD risk factors (6). Moderate levels of cardiorespiratory fitness are shown to have
beneficial effects on CVD and MetS risk profiles (4). Poor cardiorespiratory fitness has been shown to
be associated to MetS (22). Individuals were less likely to die from all cause mortality and CVD if
they maintained or improved physical fitness (3).
Due to the findings of this study, it may be beneficial for universities to require all students to
complete a health and wellness course that focuses on behavior modification to improve risk factor
profiles. College students’ perception of what the risk factors are for heart disease and who is at risk
is not accurate (7, 37); therefore, educational courses also need to address not only what heart
disease is but which populations are effected. In order to monitor the progression of the disease risk,
the universities should offer health risk assessments upon entrance and exiting of the university. With
the findings of the risk assessment, a personalized program can be set up to aid students in making
the proper changes to improve their risk profile. The education will help students to learn what CVD
and MetS are, who they affect, and what risk factors compose each disease. Since these risk factors
have been shown to be present among college student, it is important to start surveillance and
correction of the various chronic disease risk factors (17,18,40). College students may be able to
delay or prevent CVD with the implementation of screening and education at the age of 20 (31). Little
research has been completed on the effects of implementation of a screening and educational based
program for college students. Programs implemented in worksites have seen success in lowering
CVD risk and making healthy lifestyle modifications (28,29,32). Although these environments are not
identical, similar results may occur on a college campus.
Several limitations of the present study warrant further discussion. Self-selection bias is a concern
because participants volunteered for the study. Future investigations aimed at confirmation of finding
from the present study should incorporate random sampling. Our sample was 95.2% Caucasian and
obtained from one school in the upper Midwest of the U.S., therefore, this limits the generalizability. A
single sample of blood pressure and blood lipids/glucose was obtained for each participant due to
time and resource considerations. Duplicate measures of these parameters would have strengthened
our findings.
Metabolic Syndrome and CVD Risk in College Students?
36
Future research is required to determine whether implementation of a prevention program would
result in a positive risk factor modification. Prevalence of CVD and MetS in a population with ethnic
diversity should also be investigated. Other health risk behaviors should be looked at such as dietary
habits, smoking habits, alcohol intake, and stress levels. Future research should also concentrate on
the young to middle aged adult population to determine whether or not these characteristics become
more predictive of CVD and MetS risk factors throughout age.
The present study provides evidence that college aged students possess risk factors of CVD and
MetS. Intervention needs to take place in order to decrease the risk of various cardiovascular events
in today’s college aged populations. It has been shown that increased amounts of physical activity
and decreased fatness can cause an increase in cardiorespiratory fitness and decrease in
dyslipidemia. The cardioprotective benefits of elevated cardiorespiratory fitness levels, a healthy lipid
profile, both of which are affected by amount and intensity of exercise, should be a main focus of the
intervention program. Due to the findings of this study, it should be considered that all college
universities implement some sort of risk assessment and educational program that will assist future
generations in prevention of CVD, MetS, and other chronic diseases.
Address for correspondence: Dalleck LC, PhD, Department of Human Performance, Minnesota
State University Mankato, Mankato, MN, USA, 56001. Phone (507) 389-6715; FAX: (507) 389-5618;
Email. lance.dalleck@mnsu.edu.
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