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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 9  |  Issue : 3  |  Page : 167-170

A study of neutrophil-to-lymphocyte ratio in patients with metabolic syndrome


Department of Medicine, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India

Date of Submission11-Dec-2020
Date of Decision27-Feb-2021
Date of Acceptance01-Mar-2021
Date of Web Publication16-Jul-2021

Correspondence Address:
Dr. Manjushree Mohan
#141, Gurukarunya, 1st Cross, Karnataka Layout, Bengaluru - 560 086, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ajim.ajim_102_20

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  Abstract 


Background and Aim of the Study: Numerous studies have shown an association of metabolic syndrome (MS) and insulin resistance with inflammation. The prevalence of MS as defined by the National Cholesterol Education Programme, Adult Treatment Panel III (NCEP, ATP), and other criteria indicates ranges from 11% to 41% in India. Neutrophil-lymphocyte ratio, which is calculated from a routine complete blood count with differential, is an easily obtained, inexpensive, can be used as a widely available marker of inflammation. This ratio can also aid in the risk stratification of patients with various cardiovascular diseases in addition to the traditionally used markers. Materials and Methodology: In this cross-sectional study, 210 patients with and without MS were included after detailed history and examination. Patients were considered as cases based on the NCEP, ATP III criteria for MS. Both groups of patients were subjected to routine investigations which included complete blood counts, total white blood counts, neutrophil and lymphocyte levels, HbA1c levels, serum glucose levels, fasting lipid profile, and electrocardiography. Logistic regression analysis was done to look for the association of neutrophil-lymphocyte ratio with MS. P < 0.05 was considered as statistically significant. Results: It was seen that the neutrophil-lymphocyte ratio in participants without MS was found to be 1.57 ± 0.728 and the ratio in participants with MS fulfilling 3 out of the 5 criteria, 4 out of 5 and 5 out of 5 criteria were, respectively, 2.65 ± 1.003, 3.59 ± 1.258, and 4.79 ± 2.143. This association was statistically significant with a P = 0.00. Conclusion: Participants with MS had increased neutrophil-lymphocyte ratio when compared to participants without MS. Participants fulfilling higher criteria of MS had higher neutrophil-lymphocyte ratio suggesting increasing inflammatory state.

Keywords: Blood glucose, body mass index, cholesterol, glycated hemoglobin A, high-density lipoprotein, insulin resistance, metabolic syndrome, triglycerides, waist circumference


How to cite this article:
Mohan M, Kavya S T, Sanjay Kumar H R. A study of neutrophil-to-lymphocyte ratio in patients with metabolic syndrome. APIK J Int Med 2021;9:167-70

How to cite this URL:
Mohan M, Kavya S T, Sanjay Kumar H R. A study of neutrophil-to-lymphocyte ratio in patients with metabolic syndrome. APIK J Int Med [serial online] 2021 [cited 2021 Jul 29];9:167-70. Available from: https://www.ajim.in/text.asp?2021/9/3/167/321653




  Introduction Top


The prevalence of the metabolic syndrome (MS) varies from place to place around the world, due to the difference in the age and ethnicity of the populations studied and the diagnostic criteria applied.[1] The prevalence as defined by the National Cholesterol Education Program, Adult Treatment Panel III (NCEP, ATP) ranges from 11% to 41% in India.[2] Numerous studies have shown an association of MS and insulin resistance (IR) with inflammation. Two hypotheses have been proposed to explain the relationship of MS with inflammation. The first states that low-grade inflammation going on for a long time leads to metabolic disturbances, which in turn leads to IR.[3] The second suggests that change in the glucose and lipid metabolism causes inflammation which results in IR.[4]

The relationship of systemic inflammatory markers high-sensitivity C-reactive protein (hs-CRP) with MS and IR has been shown in several studies.[5] Prediabetic participants who were insulin resistant had comparatively higher levels of markers of inflammation (hs-CRP). Therefore, a proinflammatory state can contribute to the atherogenic risk profile in prediabetic patients with increased IR.[6] However, most of these markers are time-consuming and expensive.

Recently, it has been shown that there is a strong relationship between the ratio of Neutrophil-Lymphocyte ratio (NLR) and several metabolic diseases, such as diabetes and cardiovascular diseases 5 (CVD).[7] NLR has been shown to be a more valuable marker for CVD than white blood cell (WBC), as it is less likely to be influenced by physiological conditions.[8] NLR, which is calculated from complete blood count with differential, is an inexpensive, easy to obtain, widely available marker of inflammation, which can aid in the risk stratification of patients with various CVD in addition to the traditionally used markers.[9]


  Materials and Methodology Top


A cross-sectional study was conducted on 210 participants seen on the outpatient basis at hospitals attached to Bangalore Medical College and Research Institute, Bangalore, India. Out of the 210 participants, 105 participants were with MS and 105 age- and gender-matched controls were without MS. The study period was between November 2017 and May 2019.

The aim of the present study was to evaluate the neutrophil-lymphocyte ratio in patients with MS and to correlate the same with the severity of MS based on the categories of MS.

The inclusion criteria included patients of age ≥18 years, participants fulfilling the NCEP: ATP III modified criteria of MS and patients with normal cardiovascular system, respiratory system, per abdomen and central nervous system examinations.

MS was diagnosed according to the NCEP ATP 3.[7] Those criteria require the presence of 3 or more of the following:

  1. Abdominal obesity (waist circumference [WC] >102 cm in men and >88 cm in women);
  2. A high triglyceride (TG) level >1.7 mmol/L (>150 mg/dL);
  3. A low high-density lipoprotein (HDL) cholesterol level <1.0 mmol/L for men and <1.3 mmol/L for women (<40 mg/dL for men and <50 mg/dL for women);
  4. A high blood pressure (BP) (systolic BP >130 mm Hg; and/or diastolic BP >85 mm Hg) and
  5. A high fasting blood glucose concentration >5.6 mmol/L (>110 mg/dL).


While the exclusion criteria included patients on any medications (except oral hypoglycemic agents and lipid-lowering agents) that may have affected the results of the study and inflammation parameters, patients with a history of smoking/alcohol, patients on immunosuppressive drugs, and patients with known coronary artery disease.

Detailed history included a history of risk factors, if any, physical examinations and baseline investigations such as complete blood counts, HbA1c levels, serum glucose levels, fasting lipid profile, and electrocardiography. Patients were classified into three groups based on the number of MS criteria: Group 1 (patients with 3 MS criteria), Group 2 (patients with 4 MS criteria), and Group 3 (patients with 5 MS criteria).

Height, weight, and WC were measured while fasting and standing up with the standard measuring tools. The narrowest diameter between the costal arch and anterior superior iliac spine was measured for WC. The BP was measured after at least a 10 min rest in the sitting position. The mean of all three measurements with a 2-min interval was considered BP. 8 Data were analyzed using simple statistical methods and represented categorically in [Table 1], [Table 2], [Table 3], [Table 4] and [Figure 1] and [Figure 2].
Table 1: Gender-wise classification of the participants

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Table 2: Mean age distribution of the participants

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Table 3: Comparison of the mean N/L ratio between the groups using the Mann-Whitney test

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Table 4: Comparison of the mean N/L ration among the groups using Kruskal-Wallis

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Figure 1: Comparison of the mean N/L ratio between the groups using the Mann–Whitney test

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Figure 2: Comparison of the mean N/L ration among the groups using Kruskal–Wallis

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  Results Top


Our study consisted of 102 females and 108 males. Among the cases, there were 50 females (48.54%) and 53 males (51.46%). While among the controls, there were 50 females (46.73%) and 57 males (53.27%).The mean age in our study was found to be 57 ± 9.545 years with minimum being 35 years and maximum being 80 years. In our study, the majority of 210 participants, i.e., 146 (69.5%) participants were between the age group of 46–65 years and 32 (15.2%) were of the younger age between 35 and 45 years and 32 (15.2%) participants were above 65 years of age.

Out of the 210 participants in our study, 103 participants had MS and 107 were without MS. The neutrophil-lymphocyte ratio in participants without MS was found to be 1.57 ± 0.728 and the ratio in subjects with MS fulfilling 3 out of the 5 criteria, 4 out of 5 and 5 out of 5 criteria were respectively 2.65 ± 1.003, 3.59 ± 1.258, and 4.79 ± 2.143. The overall neutrophil-lymphocyte ratio in participants with MS was 3. 66 ± 1.769.


  Discussion Top


MS refers to a group of metabolic abnormalities related to a state of IR which is frequently associated with a high-risk overweight/obesity phenotype. The major characteristics of MS include IR, abdominal obesity, high BP, and lipid abnormality (i.e., increased levels of TGs and low levels of HDL cholesterol).[2] The co-occurrence of these disorders seems to be more frequent than would be expected by chance, and their collection seems to add essential cardiovascular risk above and beyond that of the individual risk factors. Moreover, there are several inklings in favor of a common pathophysiological background for the syndrome, at the center of which lies IR.[10]

In obese conditions in humans and animals, inflammation contributes to the pathogenesis of diabetes through IR. Therefore, anti-inflammation therapy may be proposed as a strategy for the improvement of IR. High-dose salicylates directly suppress inflammation by targeting nuclear factor kappa B, which improves insulin sensitivity and reduces blood glucose in patients with diabetes.[11]

Consistent with the literature, the present study showed that the number of neutrophils increased in MS. The study also showed that the participants with all the five criteria of MS had higher neutrophil-to-lymphocyte ratio when compared to participants with 4 or 3 criteria signifying that as severity of MS increases, neutrophil-to-lymphocyte ratio also increases.

Leukocyte activation occurs during an inflammatory reaction. Leukocytes were detected to have a role in atherogenesis. Along with a high number of leukocytes, there is a significant relationship between neutrophil–lymphocyte ratio (NLR) and severity and prognosis of CVD. Previous studies demonstrated that WBC, leukocyte subtype, and NLR predicted systemic inflammation. Number of neutrophils is considered to be associated with the formation, complexity, and activation of atheromatous plaque.[12]

In a study by Buyukkaya et al. who performed a neutrophil-to-lymphocyte ratio on participants attending the cardiology outpatient clinic in Turkey found similar results with neutrophil-to-lymphocyte ratio. Participants meeting 5 MS criteria had higher NLR than those meeting 3 and 4 criteria, whereas there was no difference between the patients meeting 3 and 4 MS criteria. Participants with NLR above 1.84 had higher hs-CRP levels which in turn predicted inflammation.[12]

There are some limitations that should be noted meanwhile. First, the number of observed events is to some extent small which limits the statistical power of this explorative study. However, the sample size of this research is sufficient to draw a conclusion. Second, neutrophil-lymphocyte ratio was not compared with a known inflammatory marker.


  Conclusion Top


In our study, NLR above approximately 1.57 predicted significant inflammation. Neutrophil-to-lymphocyte ratio is calculated from complete blood count with differential, is an economical, easy to obtain, affordable, accessible marker of inflammation, which can help in the risk stratification of patients with various CVD in addition to the traditionally used markers.

Further prospective studies of larger numbers are required to confirm the findings of the present study and the optimal cutoff value of NLR in inflammation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Eckel RH. The metabolic syndrome. In: Kasper D, Hauser S, Jameson L, Fauci A, Longo D, Loscalzo J, editors. Harrison's Principles of Internal Medicine. 19th ed. Vol. 2. New York: McGraw-Hill Professional Publishing; 2015. p. 2450.  Back to cited text no. 1
    
2.
Misra A. in Metabolic Syndrome. API Textbook of Medicine. Munjal YP, Sharma SK, Agarwal AK, Singal R.K, Gupta P, Sundar S, et al. editors. 9th edition, New Delhi, India.Jaypee Brothers Medical Publishers Ltd, 2012;2.  Back to cited text no. 2
    
3.
Fernández-Real JM, Ricart W. Insulin resistance and chronic cardiovascular inflammatory syndrome. Endocr Rev 2003;24:278-301.  Back to cited text no. 3
    
4.
Shoelson SE, Lee J, Goldfine AB. Inflammation and insulin resistance. J Clin Invest 2006;116:1793-801.  Back to cited text no. 4
    
5.
Prakash K, Mamatha TR, Nirgude D, Prakash B. High sensitivity C-reactive protein inmetabolic syndrome. Int J Adv Med 2016;3:607-10.  Back to cited text no. 5
    
6.
Brownlee M, Aiello L, Cooper M, Vinik A, Nesto R, Boulton A, et al. Complications of diabetes mellitus. In: Melmed S, Polonsky K, Larsen R, Kronenberg H, editors. Williams Textbook of Endocrinology. 12th ed. Philadelphia: Saunders, Elsevier; 2011. p. 1523.  Back to cited text no. 6
    
7.
Bhat T, Teli S, Rijal J, Bhat H, Raza M, Khoueiry G, et al. Neutrophil to lymphocyte ratio andcardiovascular diseases. Expert Rev Cardiovasc Ther 2013;11:55-9.  Back to cited text no. 7
    
8.
Horne BD, Anderson JL, John JM, Weaver A, Bair TL, Jensen KR, et al. Which white bloodcell subtypes predict increased cardiovascular risk? J Am Coll Cardiol 2005;45:1638-43.  Back to cited text no. 8
    
9.
Surendar J, Indulekha K, Mohan V, Pradeepa R. Association of neutrophil-lymphocyte ratio with metabolic syndrome and its components in Asian Indians (CURES-143). J Diabetes Complications 2016;30:1525-9.  Back to cited text no. 9
    
10.
Sarafidisa PA, Nilsson PM. The metabolic syndrome: A glance at its history. J Hypertens 2006;24:621-6.  Back to cited text no. 10
    
11.
Sun Q, Li J, Gao F. New insights into insulin: The anti-inflammatory effect and its clinical relevance. World J Diabetes 2014;5:89-96.  Back to cited text no. 11
    
12.
Buyukkaya E, Karakas MF, Karakas E, Akçay AB, Tanboga IH, Kurt M, et al. Correlation of neutrophil to lymphocyte ratio with the presence and severity of metabolic syndrome. Clin Appl Thromb Hemost 2014;20:159-63.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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