Study on Dynamic Progression and Risk Assessment of Metabolic Syndrome Based on Multi-State Markov Model

Figures & data

Figure 1 Flow chart for participants selection.

Table 1 Baseline Information of 5581 Subjects

Variables	Group	Definition	n(%)
Gender	Female	1	3481(62.4)
	Male	2	2100(37.6)
Age(year)	40~	1	2015(36.1)
	55~	2	2192(39.3)
	≥65	3	1374(24.6)
Marital status	Married	1	4931(88.4)
	Other	2	650(11.6)
Education	Illiteracy	1	2790(50.0)
	Primary school	2	1232(22.1)
	Junior high school	3	1057(18.9)
	≥Senior high school	4	502(9.0)
Exercise	Often	1	1718(30.8)
	Occasionally	2	2139(38.3)
	Little	3	1724(30.9)
Sleep time (h)	<6	1	1674(30.0)
	6~8	2	2285(40.9)
	≥8	3	1622(29.1)
BMI level	Normal	1	2782(49.8)
	Thin	2	357(6.4)
	Overweight/Obesity	3	2442(43.8)
Smoke	No	0	4157(74.5)
	Yes	1	1424(25.5)
Drink	No	0	3753(67.2)
	Yes	1	1828(32.8)
Depression	No	0	3385(60.7)
	Yes	1	2196(39.3)
Functional loss	No	0	4200(75.3)
	Yes	1	1381(24.7)
Hyperuricemia	No	0	5175(92.7)
	Yes	1	406(7.3)
High TC	No	0	4404(78.9)
	Yes	1	1177(21.1)
High LDL-C	No	0	3386(60.7)
	Yes	1	2195(39.3)
High HbA1c	No	0	5196(93.1)
	Yes	1	385(6.9)
High CRP	No	0	4589(91.8)
	Yes	1	408(8.2)

Abbreviations: BMI, body Mass Index; TC, total cholesterol; LDL-C, low density lipoprotein cholesterol; HbA1c, glycated hemoglobin; CRP, C-reactive protein.

Table 2 Transition Frequency Between MetS Disease States During Follow-Up

Original States	Follow-Up States
	FMD	MMD	SMD	MetS	Total
FMD	121(25.42)	188(39.50)	114(23.95)	53(11.13)	476
MMD	142(11.98)	420(35.44)	378(31.90)	245(20.68)	1185
SMD	67(4.65)	340(23.59)	469(32.55)	565(39.21)	1441
MetS	22(0.89)	197(7.95)	551(22.23)	1709(68.93)	2479
Total	352	1145	1512	2572	5581

Abbreviations: FMD, free of metabolic disorder; MMD, mild metabolic disorder; SMD, severe metabolic disorder; MetS, metabolic syndrome.

Figure 2 Transition frequency of MetS states from Baseline to follow-up.

Abbreviations: FMD, free of metabolic disorder; MMD, mild metabolic disorder; SMD, severe metabolic disorder; MetS, metabolic syndrome.

Table 3 The Transition Intensities Estimated by the Multistate Model

Original States	Follow-Up States				Mean Sojourn Time (Years) (95% CI)
	FMD	MMD	SMD	MetS
FMD	−0.19	0.10	0.06	0.03	5.26(4.80–5.89)
MMD	0.03	−0.16	0.08	0.05	6.25(5.74–6.62)
SMD	0.01	0.06	−0.17	0.10	5.88(5.54–6.28)
MetS	<0.01	0.02	0.06	−0.08	12.50(11.94–13.74)

Abbreviations: FMD, free of metabolic disorder; MMD, mild metabolic disorder; SMD, severe metabolic disorder; MetS, metabolic syndrome.

Table 4 Forward Transitions of MetS States by Different Factors: Univariate Models [Hazard Ratios (95% CI)]

Variables	FMD→MMD	FMD→SMD	FMD→MetS	MMD→SMD	MMD→MetS	SMD→MetS
Gender	1.26(0.94,1.68)	1.08(0.75,1.56)	0.67(0.39,1.15)	1.02(0.83,1.24)	1.01(0.79,1.30)	0.95(0.80,1.12)
Age (year)
55~64	1.03(0.75,1.41)	1.02(0.67,1.54)	1.35(0.76,2.39)	1.01(0.80,1.26)	1.23(0.92,1.63)	0.98(0.81,1.19)
≥65	1.05(0.71,1.56)	1.15(0.70,1.89)	0.67(0.27,1.65)	0.98(0.75,1.29)	1.04(0.74,1.48)	1.02(0.82,1.26)
Marital status	0.93(0.49,1.76)	0.76(0.31,1.86)	1.35(0.49,3.74)	0.99(0.71,1.39)	0.79(0.50,1.25)	0.83(0.64,1.08)
Education
Primary school	0.99(0.70,1.43)	1.25(0.79,1.98)	1.01(0.49,2.07)	1.14(0.89,1.46)	1.06(0.77,1.46)	0.99(0.80,1.23)
Junior high school	0.91(0.62,1.32)	0.95(0.57,1.58)	1.44(0.75,2.77)	1.03(0.78,1.36)	1.01(0.71,1.44)	1.16(0.94,1.43)
≥Senior high school	0.72(0.40,1.28)	1.57(0.88,2.79)	0.89(0.31,2.57)	0.93(0.64,1.35)	1.37(0.92,2.05)	1.07(0.80,1.42)
Exercise
Occasionally	1.12(0.83,1.51)	1.27(0.85,1.89)	0.76(0.42,1.38)	0.96(0.77,1.21)	1.33(0.98,1.80)	1.10(0.89,1.37)
Little	0.76(0.45,1.25)	1.33(0.76,2.32)	1.07(0.49,2.35)	0.99(0.75,1.30)	1.91(1.37,2.65)*	1.56(1.27,1.91)*
Sleep time(h)
6–8	1.03(0.72,1.46)	1.05(0.67,1.63)	1.26(0.65,2.47)	1.06(0.84,1.36)	1.09(0.81,1.47)	1.01(0.83,1.24)
≥8	1.10(0.75,1.60)	0.95(0.58,1.56)	1.13(0.54,2.38)	1.03(0.79,1.34)	0.92(0.66,1.28)	1.10(0.89,1.36)
Smoke	1.13(0.84,1.51)	1.16(0.80,1.70)	0.60(0.32,1.13)	1.00(0.81,1.24)	1.40(1.08,1.80)*	1.10(0.92,1.32)
Drink	1.13(0.85,1.51)	1.31(0.91,1.90)	0.68(0.38,1.19)	1.08(0.88,1.32)	1.10(0.85,1.41)	1.21(1.02,1.43)*
Depression	0.91(0.67,1.22)	0.74(0.50,1.10)	1.33(0.77,2.28)	1.05(0.86,1.29)	0.97(0.75,1.26)	1.00(0.85,1.19)
Functional loss	0.69(0.48,0.99)*	1.40(0.95,2.08)	1.50(0.85,2.65)	0.95(0.75,1.20)	0.93(0.69,1.24)	0.95(0.79,1.16)
Hyperuricemia	1.19(0.67,2.09)	1.89(1.04,3.44)*	0.63(0.15,2.59)	1.13(0.72,1.77)	1.51 (0.92,2.46)	1.22(0.90,1.66)
BMI level
Thin	1.15(0.80,1.64)	0.52(0.28,0.97)*	1.04(0.52,2.08)	0.78(0.55,1.10)	0.68(0.41,1.10)	0.67 (0.42,1.07)
Overweight/Obesity	0.83(0.42,1.62)	1.87(1.05,3.35)*	0.63(0.15,2.61)	0.96(0.74,1.24)	1.79(1.36,2.36)*	1.77(1.49,2.09)*
High LDL-C	0.89(0.65,1.23)	0.89(0.59,1.35)	1.34(0.76,2.34)	0.97(0.78,1.20)	1.27 (0.98,1.63)	1.18(1.01,1.40)*
High HbA1c	0.96(0.43,2.16)	0.52(0.13,2.10)	1.14(0.28,4.68)	1.17(0.72,1.90)	0.95 (0.49,1.84)	0.96 (0.64,1.44)
High TC	0.73(0.45,1.19)	1.13(0.67,1.92)	1.42(0.69,2.90)	0.85(0.63,1.16)	0.90 (0.62,1.31)	1.07 (0.87,1.30)
High CRP	1.06(0.50,2.26)	0.99(0.37,2.70)	1.06(0.26,4.38)	1.08(0.73,1.61)	0.85 (0.49,1.46)	1.11 (0.79,1.55)

Note: *P < 0.05.

Abbreviations: FMD, free of metabolic disorder; MMD, mild metabolic disorder; SMD, severe metabolic disorder; MetS, metabolic syndrome; BMI, body Mass Index; LDL-C, low density lipoprotein cholesterol; HbA1c, glycated hemoglobin; TC, total cholesterol; CRP, C-reactive protein; CI, confidence interval.

Table 5 Backward Transitions of MetS States by Different Factors: Univariate Models [Hazard Ratios (95% CI)]

Variables	MMD→FMD	SMD→FMD	SMD→MMD	MetS→FMD	MetS→MMD	MetS→SMD
Gender	0.83(0.60,1.16)	1.40(0.87,2.26)	1.21(0.98,1.49)	2.29(0.99,5.31)	1.73(1.30,2.30)*	1.32(1.11,1.58)*
Age (year)
55~64	1.15(0.80,1.67)	0.78(0.45,1.34)	1.12(0.88,1.43)	0.87(0.37,2.05)	0.81(0.59,1.13)	0.93(0.77,1.14)
≥65	0.97(0.61,1.53)	0.77(0.41,1.45)	1.14(0.86,1.50)	0.11(0.02,0.89)*	0.89(0.63,1.27)	0.94(0.76,1.17)
Marital status	1.05(0.62,1.80)	1.35(0.71,2.57)	1.10(0.81,1.50)	0.31(0.04,2.39)	0.81(0.51,1.27)	0.98(0.77,1.27)
Education
Primary school	0.83(0.55,1.26)	0.91(0.49,1.66)	1.07(0.82,1.39)	0.61(0.17,2.17)	0.99(0.68,1.44)	1.07(0.86,1.33)
Junior high school	0.56(0.33,1.04)	0.61(0.29,1.27)	0.98(0.74,1.30)	1.21(0.42,3.42)	1.42(0.99,2.01)	1.12(0.89,1.40)
≥Senior high school	0.64(0.33,1.23)	1.29(0.62,2.69)	0.88(0.60,1.31)	1.04(0.23,4.64)	1.26(0.77,2.06)	1.16(0.86,1.56)
Exercise
Occasionally	0.87(0.61,1.24)	1.12(0.66,1.90)	0.87(0.69,1.11)	0.82(0.31,2.20)	0.87(0.61,1.23)	0.83(0.67,1.03)
Little	0.58(0.34,0.96)*	0.50(0.25,0.99)*	0.54(0.41,0.72)*	0.52(0.17,1.54)	0.74(0.52,1.05)	0.87(0.71,1.08)
Sleep time (h)
6–8	0.55 (0.37,0.83)	0.99(0.56,1.75)	0.93(0.72,1.20)	0.47(0.18,1.20)	1.00(0.72,1.40)	0.90(0.74,1.10)
≥8	1.02(0.69,1.50)	0.86(0.46,1.61)	0.92(0.70,1.21)	0.38(0.12,1.19)	0.95(0.66,1.37)	0.97(0.79,1.20)
Smoke	0.69 (0.48,1.00)	0.71(0.39,1.28)	0.98(0.77,1.25)	1.30(0.48,3.53)	1.13(0.80,1.60)	1.17(0.95,1.44)
Drink	0.86(0.61,1.21)	0.86(0.52,1.43)	0.85(0.68,1.07)	0.87(0.32,2.36)	0.93(0.67,1.29)	1.17(0.97,1.41)
Depression	1.00(0.71,1.39)	0.99(0.61,1.62)	1.02(0.82,1.2)	1.11(0.48,2.60)	1.03(0.77,1.37)	1.04(0.88,1.24)
Functional loss	1.04(0.72,1.51)	1.09(0.64,1.88)	0.98(0.76,1.25)	0.94(0.35,2.55)	1.27(0.93,1.73)	1.01(0.83,1.23)
Hyperuricemia	1.04 (0.49,2.23)	0.69 (0.22,2.18)	0.67 (0.40,1.12)	0.46 (0.06,3.48)	0.70 (0.40,1.22)	0.77 (0.56,1.06)
BMI level
Thin	1.46(0.97,2.22)*	2.21(1.20,4.08)*	1.44(1.03,2.02)*	2.03(0.26,15.62)	1.29(0.57, 2.94)	1.56(0.91, 2.69)
Overweight/Obesity	0.17(0.07,0.41)	0.14(0.06,0.35)	0.40(0.31,0.53)*	0.38(0.16,0.91)*	0.35(0.26,0.47)*	0.74(0.63,0.88)*
High LDL-C	0.87(0.61,1.23)	0.55(0.32,0.94)*	0.87(0.70,1.08)	0.50(0.20,1.28)	0.80(0.60,1.07)	0.89(0.75,1.06)
High HbA1c	0.72(0.27,1.94)	0.33(0.05,2.35)	0.86(0.49,1.49)	0.41(0.06,3.03)	0.46(0.24,0.86)*	0.42(0.29,0.63)*
High TC	1.10 (0.70,1.74)	0.96(0.53,1.76)	0.93 (0.71,1.22)	0.44 (0.13,1.47)	0.91(0.66,1.26)	0.90 (0.75,1.10)
High CRP	0.49(0.20,1.19)	1.81(0.82,3.98)	1.05(0.67,1.63)	1.96 (0.56,6.81)	0.56 (0.30,1.06)	0.77(0.56,1.07)

Note: *P < 0.05.

Abbreviations: FMD, free of metabolic disorder; MMD, mild metabolic disorder; SMD, severe metabolic disorder; MetS, metabolic syndrome; BMI, body Mass Index; LDL-C, low density lipoprotein cholesterol; HbA1c, glycated hemoglobin; TC, total cholesterol; CRP, C-reactive protein; CI, confidence interval.

Table 6 Forward and Backward Transitions of MetS States by Different Factors: Multivariate Models [Hazard Ratios (95% CI)]

Variables	Forward Transitions			Backward Transitions
	FMD→SMD	MMD→MetS	SMD→MetS	SMD→FMD	SMD→MMD	MetS→MMD	MetS→SMD
Gender	0.74(0.42,1.32)	0.74(0.53,1.05)	0.75(0.59,0.95)*	1.93(1.03,3.64)*	1.40(1.05,1.86)*	2.35(1.60,3.44)*	1.34(1.04,1.72)*
Age
55~64	1.22(0.77,1.91)	1.31(0.97,1.76)	1.08(0.88,1.32)	0.64(0.36,1.15)	1.02(0.79,1.32)	0.77(0.55,1.09)	0.93(0.76,1.15)
≥65	1.33(0.77,2.28)	1.18(0.81,1.72)	1.23(0.98,1.55)	0.43(0.22,0.86)*	0.92(0.68,1.25)	0.81(0.55,1.19)	0.94(0.74,1.18)
Exercise
Occasionally	1.24(0.82,1.89)	1.30(0.95,1.76)	1.06(0.86,1.32)	1.39(0.80,2.41)	0.93(0.73,1.18)	0.93(0.65,1.33)	0.88(0.71,1.09)
Little	1.36(0.74,2.50)	1.60(1.14,2.26)*	1.36(1.10,1.69)*	0.81(0.39,1.6)	0.67(0.50,0.89)*	0.81(0.56,1.16)	0.88(0.71,1.09)
Smoke	1.32(0.81,2.15)	1.66(1.22,2.26)*	1.16(0.93,1.45)	0.56(0.30,1.07)	0.90(0.68,1.18)	0.80(0.53,1.21)	0.97(0.75,1.24)
Drink	1.32(0.87,2.02)	1.10(0.83,1.46)	1.30(1.07,1.57)*	0.75(0.42,1.34)	0.76(0.59,0.98)*	0.70(0.48,1.02)	1.03(0.83,1.28)
Functional loss	1.37(0.91,2.06)	0.95(0.71,1.28)	0.99(0.81,1.20)	1.03(0.60,1.78)	0.95(0.74,1.21)	1.21(0.89,1.66)	0.97(0.80,1.19)
Hyperuricemia	2.01(1.07,3.76)*	1.40(0.84,2.33)	1.08(0.78,1.48)	0.89(0.27,2.90)	0.76(0.45,1.29)	0.71(0.40,1.26)	0.74(0.54,1.03)
BMI level
Thin	0.53(0.28,1.01)	0.65(0.40,1.08)	0.66(0.41,1.06)	2.44(1.29,4.59)*	1.43(1.01,2.01)*	1.28(0.56,2.95)	1.51(0.88,2.61)
Overweight/Obesity	1.93(1.06.3.53)*	1.68(1.25,2.25)*	1.68(1.41,2.00)*	0.15(0.06,0.37)*	0.44(0.33,0.58)*	0.36(0.27,0.48)*	0.76(0.63,0.90)*
High LDL-C	0.90(0.59,1.37)	1.19(0.92,1.55)	1.11(0.94,1.32)	0.67(0.39,1.18)	0.97(0.77,1.22)	1.00(0.74,1.35)	0.98(0.82,1.17)
High HbA1c	0.47(0.11,1.95)	1.07(0.54,2.10)	0.97(0.64,1.46)	0.28(0.04,2.08)	0.79(0.45,1.37)	0.54(0.29,1.03)	0.45(0.30,0.67)*

Note: *P < 0.05.

Abbreviations: FMD, free of metabolic disorder; MMD, mild metabolic disorder; SMD, severe metabolic disorder; MetS, metabolic syndrome; BMI, body Mass Index; LDL-C, low density lipoprotein cholesterol; HbA1c, glycated hemoglobin; TC, total cholesterol; CI, confidence interval.