In this cross-sectional study, we studied 313 type 2 diabetic patients from two tertiary referral hospitals in Klang Valley, Malaysia-Kuala Lumpur Hospital and Serdang Hospital. A systematic random sampling method was applied to select patients based on the inclusion and exclusion criteria. The study protocol conforms to the principles of the Malaysian Guideline for Good Clinical Practice [22] which were consistent with the Ethical Guidelines of the Declaration of Helsinki (World Medical Association Declaration of Helsinki) as reflected in priori approvals by the Committees for Medical Research Ethics of the Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, and Ministry of Health Malaysia on the understanding that patients’ data were coded and anonymity guaranteed. Additionally, all patients were aware of the nature of the study and gave informed consent prior to commencement of the interview.

Comprehensive information on patients was collected using structured questionnaire, physical examination and laboratory investigations according to standardised protocols. Patients were personally interviewed on their socio-demographic backgrounds consisting date of birth, age, gender and ethnic group. Investigation of patient’s medical history on the diseases (with T2DM as a prerequisite) was conducted, which includes the presence of hypertension and dyslipidemia, duration of diseases and treatment obtained. Medical records of all patients were reviewed and extracted according to a standardized procedure.

Anthropometric measurements at the study visits included height, weight, WC, hip circumference and waist-to-hip ratio (WHR) were measured by trained personnel according to the standard procedures. Waist circumference was measured using a non-elastic tape made of fiberglass. Patients were asked to stand erect in a relaxed position with both feet together on a flat surface, while one layer of clothing was accepted. Waist girth was measured as the smallest horizontal girth between the costal margins and the iliac crests at minimal respiration, touching but not compressing the skin. For the statistical analysis, mean values of the two consecutive WC measurements were calculated. Hip circumference was measured to the nearest 0.5 cm by using the same nonelastic fiberglass tape over the greater trochanters (the widest portion of the hip) or the widest part of the gluteal region, respectively, with patients wearing light underwear. The WHR is an indicative of regional fat distribution, and it was determined using the formula as WC divided by hip circumference. Body mass index (BMI) was used as a measure of overall obesity. Body weight was measured to the nearest 0.1 kg by the SECA digital scale (THD-360, Tanita Health Equipment Ltd., Tokyo, Japan) with patients dressed in lightweight clothing (with heavy clothing removed and 0.5 kg deducted for remaining garments). Height was measured by a wall-mounted SECA microtoise tape (Model 206, Vogel and Halke GmbH & Co., Hamburg, Germany) which was suspended upright against a smooth wall (with patients barefooted) in centimeters (cm) (to the nearest 0.5 cm) prior to conversion into meters (m). Measurements were taken in duplicate and averaged. As an estimate of relative weight, BMI was computed as weight (kg) divided by standing height squared (m²). The WHO classification of BMI was used to classify the patients as underweight (BMI < 18.5 kg/m²); normal (BMI 18.5 - 24.9 kg/m²); overweight (BMI 25.0 - 29.9 kg/m²); and obese (BMI > 30 kg/m²) [23].

Blood pressure was measured at the sitting position using a calibrated digital Omron Automatic Blood Pressure Monitor (Model T8, Omron Healthcare Singapore Pte Ltd., Alexandra Technopark, Singapore) with an appropriate sized cuff on the left arm after taking rest for at least 10 min. A cuff larger than the standard one was used when arm circumference exceeded 34 cm. Mean values of the resting systolic and diastolic blood pressure were determined from two independent measurements at 5-min intervals. All measurements were taken by the same trained personnel to reduce error.

Information on the routine laboratory investigations involving glycemic control and plasma lipid profiles were retrieved from patients’ medical records. The variables extracted from patients’ records include glycated hemoglobin (HbA_1C), fasting plasma glucose (FPG), serum total cholesterol, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C) and triglycerides. The last available values, i.e. the latest and must be of readings within the last three months were noted. Based on the Management of Type 2 Diabetes Mellitus Clinical Practice Guidelines criteria, HbA_1c and FPG of less than 6.5% and within 4.4 - 8.0 mmol/L respectively were considered as good glycemic control [24].

Table 1 manifests the summary of MetS classification in accordance to WHO, NCEP ATP III, IDF, and Harmonized definitions. The traditional risk factors of MetS were defined as follows: hypertension, dyslipidemia and DM as the use of antihypertensive, lipid lowering or