A questionnaire study on knowledge and awareness of metabolic syndrome and it’s components in undergraduate medical students at entry level

Metabolic syndrome is a major and escalating public health crisis among young adults in recent times. Increasing calorie intake, sedentary lifestyle, lack of exercise and chronic stress are the contributing factors for metabolic syndrome. The objective of this study is to evaluate the awareness and knowledge levels of (cid:977)irst-year medical students regarding various aspects in metabolic syndrome. The study was conducted among 74 undergraduate medical students at Apollo institute of medical sciences and research. A stan-dardized questionnaire was given to the students and the students were asked to answer the questionnaire independently and the responses obtained were statistically analyzed. In our study, the participants showed a good level of knowledge about different types, the pattern of inheritance and symptoms of diabetes mellitus. They were cognizant about causes, risk factors and treatment of adiposity and hypertension. The majority knew about ill effects of high cholesterol, stroke and arteriosclerosis. Most of them doesn’t know the underlying mechanism of heart infraction. The study also identi(cid:977)ied areas of de(cid:977)iciencies in the knowledge of students about different components of metabolic syndrome. This effort is done in the beginning of their course because being the force of future medical feternity, they can educate them-selves and the public about ill-effects of metabolic syndrome and means to prevent it as a part of public health. The study also supports the necessity of early clinical exposure for medical students at the entry-level.


INTRODUCTION
Metabolic syndrome (MetS) is a clinical challenge worldwide (Kaur, 2014). Sedentary lifestyle, lack of exercise and chronic stress are the contributing factors for metabolic syndrome (Laaksonen, 2002). It is a state of chronic in lammation, a consequence of the complex interplay between genetic and environmental factors with profound systemic effects such as elevated blood pressure, insulin resistance, visceral adiposity, endothelial dysfunction, hypercoagulable state and atherogenic dyslipidemia. (Grundy et al., 2005;Reaven, 2006). Met syndrome is also known as syndrome X or insulin resistance syndrome (Reaven, 1988;Grundy et al., 2004). Met syndrome confers a greater risk for cardiovascular disease, type 2 diabetes mellitus, and mortality (Galassi et al., 2006;Malik et al., 2004). According to NCEP: ATP III de inition, Met syndrome is identi ied if the subject has three or more of the following criteria. Abdominal obesity: WC≥102 cm in men and ≥88 cm in women, Hypertriglyceridemia: ≥150 mg/dl (1.695 mmol/l), Low HDL-C: <40 mg/dl in men and <50 mg/dl in women, High blood pressure (BP): >130/85 mmHg, High fasting glucose: >110 mg/dl (Parikh and Mohan, 2012;Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults, 2001). Despite the fact that MetS is common in the adult population, it is becoming a major and escalating public health crisis in young adults in recent times. Data from the National Health and Nutrition Examination Survey (NHANES) from 1988 to 2001 shows that the prevalence of metabolic syndrome increased by more than 35% from 1988-1994 to 2007-2012, increasing from 25.3% to 34.2% among US adults aged 18 years or older (Moore et al., 1988). The prevalence of the metabolic syndrome is 23% between the 19-24 age group in Indians (Ithayamalar et al., 2016;Prasad et al., 2012). Increasing calorie intake, sedentary lifestyle, lack of exercise and chronic stress are the contributing factors. Assessing the awareness and pre-existing knowledge of the medical students at undergraduate level gives us an idea about their level of understanding and helps us to educate them as well as enhance students wellness by motivating them to adopt a healthy eating pattern, regular physical activity, weight management which can reduce the prevalence of MeS in young individuals. It also supports the necessity of early clinical exposure to Medical students. The present study provides an insight to the knowledge, and awareness of Metabolic Syndrome in the medical students at the undergraduate level.

MATERIALS AND METHODS
The present study was a cross-sectional study conducted during the academic year 2017-18, among the 1 st year MBBS students of Apollo Institute of Medical Sciences & Research, Jubilee Hills, Hyderabad. Out of 100 students joined in 1 st year MBBS, a total of 74 students (28 male & 46 female), between 18-24 years, were voluntarily enrolled in the present study. The study was approved by the Research Committee of the Apollo Institute of Medical Sciences And Research (AIMSR). Adequate information about the study was given to all the students. After taking written consent from the students agreeing to participate in the study, a self-administered questionnaire, which includes a total of 90 questions, was given to the students. The questions were adapted from previous studies by (Becker et al., 2008;Yahia et al., 2014).The questionnaire was pretested, structured and standardized and was also used among university students in previous studies (Becker et al., 2008;Yahia et al., 2014). Further, the questionnaire was also validated by subject experts. A pilot study was done on a group of 30 students to ensure an adequate understanding of the adapted questions. The questions were about student's knowledge regarding de inition, types, risk factors, physical changes signi icant to Met S, consequences and management of these conditions. These 90 questions related to diabetes (16 questions), hypertension (12 questions), adiposity (9 questions), high blood cholesterol(6 questions), arteriosclerosis(17 questions), stroke(12 questions) and myocardial infarction (18 questions) were given to the students and their response was analyzed (Becker et al., 2008;Yahia et al., 2014). The response options to the questions will be 'True' or 'False'. Students were instructed to ill the questionnaire truthfully. Scores are given based on their correct answers. The "correct" answer was awarded one point and the "incorrect" and "do not know" answers were awarded zero points. The maximum achievable total score for the MetS questions was 90. The percentage of correct answers was calculated. If the scores are between 81 -100% de ined as good knowledge, between 51-80% scores -as fair knowledge and ≤50% scores-considered as poor knowledge (Becker et al., 2008;Yahia et al., 2014). Fisher's exact test was used to examine differences in students' responses to the questionnaire by using "MedCalc Statistical Software version 16.4.3 (Med-Calc Software bvba, Ostend, Belgium)". P values were reported as 2 -sided and the statistical signi icance was de ined by P-value <0.05.

RESULTS
In the present study, we assessed the level of knowledge and awareness of metabolic syndrome in undergraduate MBBS students at entry-level during the academic year 2017-18 at Apollo Institute of Medical Sciences & Research, Jubilee Hills, Hyderabad. Out of 100 students joined in 1 st year MBBS, 74 students, 28 (38%) male 46 (62%) female were voluntarily enrolled in our study. The highest overall individual score obtained was 77 out of 90. The maximum and minimum scores obtained in each component of Metabolic syndrome, Mean & SD, were represented in Table 1 andGraph 1.
The number and percentage of the student's response to a questionnaire for Diabetes mellitus   Table 2 and Graph 2.
The number and percentage of the student's response to a questionnaire for Adiposity was shown in Table 3 and Graph 3. More than ninety percent of the students (78.59% male & 100% female), thought that Adipose individuals are more likely to suffer from arteriosclerosis and the difference in response between male and females, is statistically highly signi icant (P=0.002).
The number and percentage of the student's response to the questionnaire for Hypertension was shown in Table 4 and Graph 4. Only 44.59% (67.86% male and 30.43% female) could relate the association of Hypertension and arteriosclerosis and the difference in response between male and females is statistically signi icant (P=0.003).
The number and percentage of the student's response to a questionnaire for Cholesterol levels Graph 1: Maximum, minimum scores obtained by students was shown in Table 5 and Graph 5.
The number and percentage of the student's response to a questionnaire for Arteriosclerosis was shown in Table 6 and Graph 6.
Most of the students were familiar with the causes, types and consequences of stroke. The number and percentage of the student's response to the Graph 2: Gender-based comparison of percentages of the correct response to a questionnaire for Diabetes questionnaire for stroke was shown in Table 7 and Graph 7. A total of 67.57% (78.57% male and 60.87% female ) acknowledged that stroke is preceded frequently by speech problems ( P=0.008).
The number and percentage of the student's response to the questionnaire for Myocardial infarction was shown in Table 8 and Graph 8.   Around 90.54% of the students (78.57% male and 97.83% of female, P=0.01 ) identi ied radiating pain into the arms as a symptom for a myocardial infraction (MI) and they were also aware of the fact that oxygen supply to the heart is affected by a Myocardial infarction.

DISCUSSION
In our present study, it was observed that students were more knowledgeable about Adiposity, hypertension, atherosclerosis and least knowledgeable about cholesterol and myocardial infarction. More than 90% of the students showed good knowledge about the types of Diabetes, the role of hereditary factors and complications of Diabetes. They also have a better understanding about the increased risk of diabetes during pregnancy. Ninety-four percent of the students correctly identi ied frequent urination as a symptom of Diabetes Mellitus but they were not familiar with other symptoms as 64.86% of the participants identi ied poor appetite also as a common symptom. Whereas half of the students falsely acknowledged increased alertness as a frequent symptom of diabetes. The participants showed an average level of knowledge about the process involved in the absorption and diffusion of glucose across cells and blood. In addition, students also showed some misbeliefs about diet and treatment. Such as 55% of the students have a misbelief that Diabetics may only eat special types of sweets. And 51 % of students, especially male (35.71%), when compared to females (60.87% ), have a correctly understood that all the Diabetic patients must Graph 3: Gender-based comparison of percentages of the correct response to the questionnaire for Adiposity not have insulin shots( P = 0.05). Similar indings were observed in the work done by (Becker et al., 2008;Yahia et al., 2014). Diabetes Mellitus is occurring at a relatively younger age due to changes in lifestyle and the economic boom (Kaveeshwar,   Graph 5: Gender-based comparison of percentages of the correct response to a questionnaire related to Cholesterol levels.
Graph 6: Gender-based comparison of percentages of the correct response to a questionnaire for Arteriosclerosis Graph 7: Gender-based comparison of percentages of the correct response to the questionnaire for Stroke Graph 8: Gender-based comparison of percentages of the correct response to the questionnaire for Myocardial infarction ni icant mortality and morbidity. So, though the students are at entry level, knowledge of the students regarding signs and symptoms, metabolism and treatments aspects should be improvised to avoid the misbeliefs and to reduced the number of cases.
The majority of the students showed a good level of knowledge about adiposity. Most of the students (96%) understood that adiposity is multifactorial and also recognized myocardial infarction, stroke and arteriosclerosis as the long term complications of adiposity, whereas 66.22% of the participants considered cessation of breathing while sleeping as an effect of adiposity. Only 59.75% of students didn't consider 'overweight' and 'adiposity' as synonyms. On the other hand, students didn't acknowledge liposuction as the best possible therapy in adiposity treatment but except few all most all the students thought that obesity can be treated surgically. All of the females were able to understand the link between adiposity and arteriosclerosis when compared to male students (P=0.002). Hypertension is one of the most important modi iable risk factors for cardiovascular disease (Farag et al., 2014). According to the World Health Organization (WHO) data, the global burden of hypertension will increase by 60% to be 1.56 billion individuals worldwide and higher in the developed nations by 2025. The prevalence of hypertension in India has been estimated to be 3% to 34.5% in males and 5.8% to 33.5% of females (Das et al., 2005). According to the Global burden of diseases, the study reports the number of deaths has increased from 0.78 millions in 1990 to 1.63 millions in 2016 in India.
Increasing the awareness of hypertension will help in preventing disease progression. In our study, students' responses show that they were wellinformed about Hypertension. Most of the students (78.28%) identi ied dizziness as a symptom of hypertension. Students showed fair to a good level of knowledge about causes, the role of genetic factors and complications of Hypertension. Around half of the students(51.35% ), including females, didn't show a good understanding of the elevated risk of hypertension in pregnancy. On the other hand, only 44.59% of the students could understand the association between hypertension and arteriosclerosis and the difference in response between male and females is statistically signi icant (P=0.003). Surprisingly, the majority of the students know that after the medication has lowered hypertension, the medication should be continued.
In our present study only about 58%of the students responded correctly for the question asked to understand the association between high blood cholesterol and hereditary factors. This inding is in agreement with the study done by (Becker et al., 2008). Conversely, in the study by (Yahia et al., 2014) more than two-thirds of the students were aware that family history is a risk factor for high serum cholesterol. More than 85% of the participants were aware that high serum cholesterol can be treated with a low cholesterol diet and medication. Interestingly, 94.59% of the students considered high blood cholesterol as a promoting factor for arteriosclerosis. Only a few of the students knew that fatigue is not a symptom of high blood cholesterol. Most of the students have a misconception that fatigue is a frequent symptom of high blood cholesterol. Only very few students (14.86%) knew that high blood cholesterol does not cause acute ailments.
In regard to arteriosclerosis questions, most of the students showed knowledge about the manifestations, complications and treatment of arteriosclerosis. The majority of the participants (93.24% ) responded correctly to the question asked to understand the correlation between High blood pressure and arteriosclerosis. But only 39% of the students identi ied heredity as a risk factor for arteriosclerosis. The participants were knowledgeable about the changes that occur in the blood vessels in arteriosclerosis. Almost all the students answered that with arteriosclerosis, blood platelets accumulate on the arterial walls. On the other hand, most of the students have a misbelieve that with arteriosclerosis, arteries contract, this shows a lack of knowledge about the underlying mechanism. Most of the students were knowledgeable about the precipitating causes, types and complications of a stroke. The majority of them recognized stroke as an end result of arterial obstruction, and they have a clear understanding of stroke affects brain. Almost half of the students considered memory dysfunction as a consequence of stroke and female students when compared to male thought that stroke is preceded frequently by speech problems. ( P=0.008). Unexpectedly very few students know that stroke is not an end result of sudden dysfunction of the heart and only a few (14.86%) of the students correctly interpreted that chest pains is not the indication of stoke. These indings show that the medical students were lacking the clinical knowledge and were confused about stoke and myocardial infarction. In another study by (Becker et al., 2008). more than one-third of the laypersons thought that a stroke announces itself through chest pains. Similar results were observed in the study done by (Yahia et al., 2014) where almost half of the students assumed that a stroke was frequently preceded by chest pain and is characterized by a sudden dysfunction of the heart . Just about twenty-eight percent of the participants understood that stoke is not caused due to over excitation of the cells.
Students showed a better level of knowledge about only a few symptoms of Myocardial infarction. Especially females knew that in most of the cases with myocardial infarctions, chest pain can radiate into the right or left arm (P=0.01 ) and also identi ied shortness of breath as a preceding symptom. All the students were also clear about the fact that MI is due to artery obstruction, which can permanently damage the heart tissue. Most of the students were aware of the importance of anticoagulant administration in MI. Surprisingly only a small number of the students could make out that there is no relation between MI and paralysis and more than half of the participants thought that there will be some degree of paralysis after MI so, this shows that students were not able to differentiate myocardial infarction and stroke. Similar results were observed in the previous studies done by (Becker et al., 2008;Yahia et al., 2014). And very few students know that in MI, pain may radiate to the stomach; this shows inadequate clinical knowledge to identify the emergency condition which requires immediate attention. Students were also not clear about the underlying mechanism.

CONCLUSIONS
This study will help us in the assessment of the adequacy of the present knowledge of the undergraduate MBBS students and could be utilized in designing the curriculum of the MBBS students and also health promotion programs. The study also supports the necessity of early clinical exposure for medical students at the beginning of their medical school. Upgrading the present knowledge of the students at an undergraduate level by conducting Health education programs can motivate them to change their attitude towards the lifestyle so that they can prolong the onset of these diseases and also help in motivating the patients, family and community in future. Thus plays a vital role in early detection and treatment

Limitations of the study
The study included only a small number of participants. It can be done in a large group for effective results. As it is a self-reported questionnaire, biasing is common.