European Journal of Cardiovascular Medicine

Metabolic syndrome (MetS) represents a constellation of interrelated metabolic abnormalities, including impaired glucose tolerance or insulin resistance, central obesity, dyslipidaemia, and elevated blood pressure. Collectively, these abnormalities significantly increase the risk of cardiovascular diseases such as myocardial infarction and stroke, as well as neurodegenerative conditions including dementia. Previous epidemiological studies have demonstrated that metabolic syndrome affects approximately one-third of the adult population, with reported prevalence rates of around 35% in the United States and nearly 37% in East Finland.¹˒²

Neck pain is a highly prevalent musculoskeletal complaint, particularly among middle-aged adults. Population-based data from Finland indicate that neck stiffness is reported by nearly one-quarter of men and over one-third of women aged 30 years and above.³ In recent years, obesity has increasingly been recognized as a state of chronic low-grade systemic inflammation. White adipose tissue actively secretes pro-inflammatory cytokines such as tumor necrosis factor-α and interleukin-6, which contribute to inflammatory pathways and worsen insulin resistance. This chronic inflammatory milieu may play a key role in musculoskeletal degeneration and pain syndromes.

Individuals with metabolic syndrome have been shown to carry a higher risk of osteoarthritis and chronic musculoskeletal pain, including cervical spine discomfort.⁴˒⁵ Visceral adiposity, a hallmark feature of metabolic syndrome, may contribute to altered biomechanics and cervical dysfunction. In addition, metabolic syndrome and chronic pain conditions have been hypothesized to share common neuroendocrine mechanisms involving dysregulation of the hypothalamic–pituitary–adrenal axis, which is also closely linked to depressive symptoms.⁶˒⁷ Patients with metabolic disorders, particularly diabetes mellitus, frequently report increased musculoskeletal pain, including neck discomfort.

Given these overlapping biological and clinical pathways, it is plausible that metabolic syndrome and neck pain may be interrelated conditions. However, data exploring this association remain limited. The present study was therefore undertaken to evaluate the prevalence of neck pain among individuals with metabolic syndrome and to examine associated demographic, metabolic, lifestyle, and psychological factors.

A cross-sectional, observational study was conducted between August 2018 and Decemberber 2020 in the departments of Orthopaedics and Physical Medicine and Rehabilitation at a tertiary care teaching hospital. The study was outpatient-based and included patients presenting with complaints of neck stiffness or neck pain. Eligible participants were adults between 20 and 60 years of age at the time of consultation. Written informed consent was obtained from all participants prior to enrolment, and ethical clearance for the study was granted by the institutional research ethics committee. During the study period, 1,350 individuals were screened for eligibility. After applying the predefined inclusion and exclusion criteria, 800 participants were included in the final analysis. Detailed clinical and comorbidity data were available for a subset of participants. The mean age of the study population was 56.2 years with a standard deviation of 15.7 years, and the mean body mass index was 27.7 kg/m² with a standard deviation of 5.6. The study population had an approximately equal gender distribution. Participants aged between 20 and 70 years, of either sex and irrespective of occupation, were eligible for inclusion. Individuals younger than 20 years, those with a history of spinal or pelvic surgery, ankylosing spondylitis, congenital or developmental spinal deformities, scoliosis, poliomyelitis, Pott’s spine, pregnancy, postpartum cervical spine injuries, or conditions causing restricted cervical mobility were excluded from the study. Each participant underwent a comprehensive clinical evaluation, which included assessment of age, sex, body mass index, presenting symptoms, and medical history. Body mass index was calculated using the standard formula of weight in kilograms divided by height in meters squared. Blood pressure measurements were taken twice at five-minute intervals, and the second reading was used for analysis. Smoking status was defined as current smoking at least once per week, while alcohol consumption was considered current if intake occurred at least once per year. Physical activity was defined as exercise lasting at least 30 minutes per session and inducing sweating. Based on frequency, physical activity was categorized as low, moderate, or high. Metabolic syndrome was defined using criteria adapted from the World Health Organization and the National Cholesterol Education Program Adult Treatment Panel III. The diagnosis was established when three or more of the following criteria were present: increased waist circumference, elevated triglyceride levels, reduced high-density lipoprotein cholesterol, elevated blood pressure, and impaired fasting glucose or insulin resistance. Psychological distress was assessed using the 12-item General Health Questionnaire (GHQ-12). Responses were scored using a binary method, and participants were categorized into three groups based on total score: no psychological distress, mild distress, and moderate to severe distress. Neck pain severity was evaluated by asking participants about neck pain experienced during the preceding one month. Neck pain was categorized as either absent or occasional, or as daily or almost daily pain. For the purpose of this study, clinically significant neck pain was defined as pain occurring on a daily or near-daily basis. Continuous variables were expressed as mean values with standard deviations, while categorical variables were presented as proportions and percentages. The independent t-test was used to compare continuous variables, and the chi-square test was applied for categorical variables. A p-value of less than 0.05 was considered statistically significant. Statistical analysis was performed using SPSS software and GraphPad Prism version 8.

A total of 800 participants were included in the final analysis, comprising 402 males (50.3%) and 398 females (49.7%). The mean age of male participants was 46.5 ± 6.4 years, while that of female participants was 45.2 ± 5.7 years, with no statistically significant difference between genders (p = 0.68). Table 1 summarizes the baseline demographic and clinical characteristics of the study participants.

Table 1: Baseline characteristics of study participants (N = 800)

Neck pain occurring on a daily or near-daily basis was reported by 171 participants (21.4%). The prevalence of neck pain was significantly higher among females (20.6%) compared to males (12.4%) (p < 0.001).

Participants reporting neck pain were slightly older than those without neck pain, although the difference was not statistically significant. Among males, the mean age of those without neck pain was 47.0 ± 6.4 years compared to 47.9 ± 6.1 years in those with neck pain (p = 0.30). Among females, the corresponding ages were 45.0 ± 6.2 years and 45.6 ± 6.2 years, respectively (p = 0.06).

Metabolic syndrome was significantly more common among participants reporting neck pain. Gender-wise comparison of neck pain prevalence according to metabolic syndrome status is presented in Table 2.

Table 2: Prevalence of neck pain according to metabolic syndrome status

Overall, participants with metabolic syndrome had a significantly higher prevalence of neck pain compared to those without metabolic syndrome. The relative risk of neck pain associated with metabolic syndrome was 1.6 (95% CI: 1.2–2.2). Alcohol consumption was significantly associated with neck pain among females but not among males. In contrast, higher BMI and increased waist circumference showed a significant association with neck pain in men, whereas these associations were not observed in women. No statistically significant associations were found between neck pain and smoking status, physical activity levels, blood pressure, lipid parameters, fasting glucose, or C-reactive protein levels in either gender. Psychological distress, as assessed by the GHQ-12, was significantly higher among participants reporting neck pain. Table 3 shows the association between GHQ-12 scores and neck pain.

Table 3: Association between GHQ-12 score and neck pain (N = 800)

Participants with a GHQ-12 score of 3 or higher had a markedly increased risk of neck pain. After adjusting for age, gender, BMI, alcohol use, and antihypertensive medication, metabolic syndrome remained independently associated with neck pain. Gender-specific multivariate risk estimates are shown in Table 4.

Table 4: Multivariate analysis of factors associated with neck pain

Males with metabolic syndrome exhibited a higher risk of neck pain compared to females. Psychological distress emerged as the strongest independent predictor of neck pain in both genders.

The concept of metabolic syndrome (MetS) has evolved over the past century, beginning with Kylin’s early observations of clustering of hypertension, hyperglycaemia, and gout. Over time, obesity, insulin resistance, and dyslipidaemia were recognized as interrelated metabolic abnormalities contributing to diabetes and cardiovascular disease, forming the basis of the modern definition of MetS¹⁻⁴. Increasing evidence suggests that these metabolic abnormalities also influence musculoskeletal health, including the development of neck pain.

In the present study, MetS was significantly associated with neck pain in both men and women. Similar associations between MetS and chronic musculoskeletal pain, including neck and back pain, have been reported in population-based studies³⁻⁹. Although women reported a higher overall prevalence of neck pain, the association between MetS and neck pain was stronger among men. This gender difference has also been observed in earlier studies, where metabolic risk factors were more strongly linked to musculoskeletal symptoms in men than in women⁹⁻¹¹.

Obesity, particularly central obesity, is a key component of MetS and has been implicated in musculoskeletal disorders through both mechanical loading and inflammatory mechanisms⁴⁻⁵. In our study, neck pain in men was significantly associated with higher body mass index and waist circumference, supporting previous findings that abdominal adiposity increases the risk of neck discomfort⁹⁻¹⁰. In contrast, women with neck pain did not demonstrate significant differences in BMI or waist circumference, suggesting that adiposity alone may not fully explain the association between MetS and neck pain in females.

Psychological distress emerged as a significant factor associated with neck pain in both genders. Participants with neck pain had higher GHQ-12 scores, indicating greater psychological distress. Previous studies have demonstrated strong links between psychological distress, hypothalamic–pituitary–adrenal axis dysfunction, and chronic musculoskeletal pain²⁻⁷. Depression and chronic stress have also been independently associated with the development of MetS, indicating overlapping biological pathways between metabolic and musculoskeletal disorders⁶⁻¹².

Physical inactivity may represent another shared mechanism linking MetS and neck pain. Low levels of physical activity have been shown to predict the development of metabolic syndrome¹⁴, while long-term inactivity is also associated with chronic musculoskeletal complaints, including neck pain¹⁵. Additionally, stress-related biomarkers have been linked to neck and back pain, further supporting the role of psychosocial stress in musculoskeletal symptom development¹³. Chronic musculoskeletal pain has also been associated with increased long-term cardiovascular and cancer-related mortality, highlighting its broader clinical implications¹⁶.

Overall, the findings of this study suggest that the relationship between MetS and neck pain is multifactorial, involving metabolic disturbances, obesity-related inflammation, psychological distress, and physical inactivity. Although causality cannot be established due to the cross-sectional study design, the consistent associations observed in this and previous studies indicate that neck pain may serve as a clinical marker of underlying metabolic and psychosocial dysfunction.

Limitations of the Study

This study has certain limitations that should be acknowledged. First, the participants were recruited from a limited geographical region, which may restrict the generalizability of the findings to broader populations. Second, although the overall sample size was adequate, the number of participants reporting neck pain was relatively modest, necessitating cautious interpretation of subgroup analyses. Third, neck pain was assessed based on self-reported symptoms, and no detailed clinical or radiological evaluation was performed to characterize the underlying pathology. Finally, the cross-sectional design precludes the establishment of causal relationships between metabolic syndrome and neck pain.

The present study demonstrates a significant association between metabolic syndrome and neck pain in adults. While women reported a higher prevalence of neck pain, the strength of association between metabolic syndrome and neck pain was greater among men. Psychological distress and physical inactivity appear to play important contributory roles in this relationship. These findings underscore the need for an integrated approach addressing metabolic health, mental well-being, and physical activity in individuals presenting with chronic neck pain. Prospective longitudinal studies are warranted to further elucidate the causal pathways linking metabolic syndrome and musculoskeletal pain and to guide targeted preventive strategies.

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