BACKGROUNDThe prevalence of metabolic syndrome varies widely by ethnicity and by the criteria used in its definition.OBJECTIVETo identify the optimal cutoff values for waist circumference (WC), waist-to-hip ratio (WHR) and body mass index (BMI) for identifying metabolic syndrome among the Saudi population.DESIGNNationwide household cross-sectional population-based survey.SETTINGThirteen health sectors in Saudi Arabia.SUBJECTS AND METHODSWe used data for subjects in the Saudi Abnormal Glucose Metabolism and Diabetes Impact Study (SAUDI-DM), which was conducted from 2007 to 2009. Using International Diabetes Federation (IDF) criteria, metabolic syndrome and its different components were assessed using anthropometric measurements, blood pressure, fasting plasma glucose, triglycerides and HDL cholesterol. Receiver operating characteristic (ROC) curves were generated to assess sensitivity and specificity for different cutoff values of WC, WHR, and BMI. The Youden index was used to calculate the optimal cutoff value for each anthropometric measurement.MAIN OUTCOME MEASURE(S)Optimal cutoff value for WC, WHR, and BMI for identifying the risk of metabolic syndrome.RESULTSThe prevalence of two or more risk factors for metabolic syndrome was observed in 43.42% of the total cohort of 12 126 study participants ≥18 years of age. The presence of two or more risk factors were significantly higher among men (46.81%) than women (40.53%) (P<.001). The optimal cutoff values for WC, WHR, and BMI were 92 cm, 0.89, and 25 kg/m2 for men and 87 cm, 0.81 and 28 kg/m2 for women for identifying the risk of metabolic syndrome. The prevalence of elevated triglycerides, blood pressure, and fasting plasma glucose significantly increased with age for both genders.CONCLUSIONSThe proposed WC cutoff values were better than WHR and BMI in predicting metabolic syndrome and could be used for screening people at high risk for metabolic syndrome in the Saudi population.LIMITATIONSNo direct measure of body fatness and fat distribution, cross-sectional design.

Objective: To describe a case of primary amenorrhea in a young woman.Methods: We describe the case of a 19-year-old Saudi woman with type 1 diabetes for 6 years and primary hypothyroidism. She had presented to the endocrinology clinic in July 2013 with primary amenorrhea associated with cyclical abdominal pain for 4 years.Results: Our patient was finally diagnosed to have the rarest form of Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome (V5b, C0, U0, A0, M0), as she had isolated vaginal atresia with normal uterus.Conclusion: The patient's complaints (e.g., amenorrhea, etc.) must be taken seriously, as subsequent examination, work-up, and the ultimate diagnosis depend on them. Our patient was unique in the sense that she had the rarest type of MRKH syndrome, with vaginal atresia and normally functioning uterus along with type 1 diabetes and hypothyroidism. The diagnosis of MRKH syndrome entails ethical and management challenges that should be discussed with the patient and his or her family. The patient's future marital and reproductive life is based upon such decisions. (AACE Clinical Case Rep. 2017;3:e93-e95) Abbreviation: MODY = maturity-onset diabetes of the young; MRKH = Mayer-Rokitanski-Küster-Hauser

Hypoglycemia can be the presenting symptom of Type 2 diabetes.The patients may experience hypoglycemic symptoms,post-prandially(3-5 hrs post-meals),preceded by fasting & post-meals hypoglycemia. We are describing a patient of Type 2 diabetes, who was initially managed with diet and metformin.Later on he presented with symptomatic post-meals, delayed hypoglycemia. CLINICAL CASE: 58yrs old Saudi gentleman had Type 2 diabetes for 5 yrs, dyslipidemia,Mitral valve disease, Bronchial asthma, GERD,vitamin D deficiency, BPH and depressive illness.He had presented to the outpatient Diabetes clinic in November,2015 with post-prandial hypoglycemic symptoms, 2-3 hrs post-meals esp. lunch & supper(with sympathetic symptoms and Whipple's triad).SMBG during hypoglycemia was never below 70 mg/dl.He denied any neurological symptoms.The minimum recorded RBS at home was 70 mg/dL.He had intermittent retrosternal burning.His weight & the bowel habits were usual.Rest of the systemic review was unremarkable.His deceased father had diabetes.Our patient was initially on Metformin that was later discontinued.Other medications included Simvastatin, Cholecalciferol, Mebeverine, Pantoprazole, Fluoxetine, Symbicorte inhaler and Ibuprofen. He was fully alert,oriented and cooperative .Vitals were preserved. BMI 28.09 kg/m 2. There was Lt hallux valgus deformity. CVS examination revealed a Grade 1,non-radiating systolic murmur in the mitral area.Rest of the general & systemic exam was unremarkable. The complete blood count, ESR, liver and renal parameters were well within normal limits. Bone profile, Vitamin D,PTH were normal.HbA1c was 42mols/mols IFCC. Serum testosterone, LH,FSH,Prolactin and PSA levels were normal.(C-peptide and insulin levels-pending).Echocardiogram showed mitral valve prolapse and mild MR.U/S Abdomen & prostate were normal. Upper GI endoscopy was consistent with gastro-esophageal reflux disease. His fasting blood glucose was 82 mg/dl. The 75 G oral glucose tolerance test showed an RPG of 220 mg/dl,2hrs post glucose, that dropped to 65 mg/dl after 3 hrs.The continuous glucose monitoring system for 7 days revealed postprandial peaks of >250 mg/dl, followed by nadir upto 70 mg/dl(Figure 1) Our patient was diagnosed to have a reactive hypoglycemia, which can be a feature of Mild Type 2 diabetes.He was referred to the nutritionist, advised avoidance of simple sugars,encouraged to take complex carbohydrates and small, frequent meals.The patient's hypoglycemic episodes got settled with the change in his dietary pattern and Metformin 500mg,twice daily. CGMS (Figure1) Patterns of Reactive Hypoglycemia (Figure 2) [1] CONCLUSION: Impaired glucose tolerance and diabetes are the known causes of hyperinsulinemic, delayed(≥3hrs) post-prandial hypoglycemia.Patients may have hypoglycemic symptoms without documented hypoglycemia[2],as in our case.

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