Modification of the NCEP ATP III definitions of the metabolic syndrome for use in Asians identifies individuals at risk of ischemic heart disease


      The association between the metabolic syndrome (MS) to ischemic heart disease (IHD) has not been established prospectively in Asian populations. We carried out registry linkage, using unique national identity numbers, to identify incident IHD events in subjects without diabetes mellitus or IHD from two cross-sectional studies of Chinese, Malays and Asian Indians living in Singapore. The risk of IHD associated with the MS (NCEP ATP III criteria) was determined by Cox-proportional hazards regression before and after adjustment for age, sex, ethnic group and current cigarette smoking. We also assessed the utility of modified Asian criteria (reducing the waist circumference (WC) used to define central obesity to 90 cm in men and 80 cm in women) on the risk of IHD associated with the MS. This study provided 38157.4 person-years in 4042 subjects who experienced 93 incident IHD events. MS (as defined by the NCEP ATP III criteria) was associated with increased risk of IHD (HR3.09; 95% CI 1.96–4.88). Those who satisfied only the modified Asian criteria, but not the NCEP ATP III criteria, were also at increased risk of IHD (HR 2.13; 95% CI 0.99–4.58). It would be appropriate to lower the cut-off for WC used for the diagnosis of the MS in such populations.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Atherosclerosis
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Reaven G.M.
        Role of insulin resistance in human disease.
        Diabetes. 1988; 37: 1595-1607
      1. Executive summary of the Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (adult treatment Panel III). JAMA 2001; 285(16 May (19)):2486–97.

        • Alberti K.G.
        • Zimmet P.Z.
        Definition, diagnosis and classification of diabetes mellitus and its complications. Part 1. Diagnosis and classification of diabetes mellitus provisional report of a WHO consultation.
        Diabet Med. 1998; 15: 539-553
        • Tan C.E.
        • Ma S.
        • Wai D.
        • et al.
        Can we apply the National Cholesterol Education Program Adult Treatment Panel definition of the metabolic syndrome to Asians?.
        Diabetes Care. 2004; 27: 1182-1186
        • Resnick H.E.
        • Jones K.
        • Ruotolo G.
        • et al.
        Insulin resistance, the metabolic syndrome, and risk of incident cardiovascular disease in nondiabetic American Indians: the Strong Heart Study.
        Diab Care. 2003; 26: 861-867
        • Issa B.G.
        • Hanna F.W.
        Insulin resistance, the metabolic syndrome and risk of cardiovascular disease: a complex story.
        Curr Opin Lipidol. 2003; 14: 405-407
        • Tan C.E.
        • Emmanuel S.C.
        • Tan B.Y.
        • et al.
        Prevalence of diabetes and ethnic differences in cardiovascular risk factors. The 1992 Singapore National Health Survey.
        Diab Care. 1999; 22: 241-247
        • Hughes K.
        • Aw T.C.
        • Kuperan P.
        • et al.
        Central obesity, insulin resistance, syndrome X, lipoprotein(a), and cardiovascular risk in Indians, Malays, and Chinese in Singapore.
        J Epidemiol Commun Health. 1997; 51: 394-399
        • Heng D.M.
        • Lee J.
        • Chew S.K.
        • et al.
        Incidence of ischaemic heart disease and stroke in Chinese, Malays and Indians in Singapore: Singapore Cardiovascular Cohort Study.
        Ann Acad Med Singapore. 2000; 29: 231-236
        • Lee J.
        • Heng D.
        • Chia K.S.
        • et al.
        Risk factors and incident coronary heart disease in Chinese, Malay and Asian Indian males: the Singapore Cardiovascular Cohort Study.
        Int J Epidemiol. 2001; 30: 983-988
        • Ford E.S.
        • Giles W.H.
        • Dietz W.H.
        Prevalence of the metabolic syndrome among US adults: findings from the third National Health and Nutrition Examination Survey.
        JAMA. 2002; 287: 356-359
        • Isomaa B.
        • Almgren P.
        • Tuomi T.
        • et al.
        Cardiovascular morbidity and mortality associated with the metabolic syndrome.
        Diab Care. 2001; 24: 683-689
        • Lawlor D.A.
        • Ebrahim S.
        • Davey Smith G.
        The metabolic syndrome and coronary heart disease in older women: findings from the British Women's Heart and Health Study.
        Diab Med. 2004; 21: 906-913
        • Onat A.
        • Ceyhan K.
        • Basar O.
        • et al.
        Metabolic syndrome: major impact on coronary risk in a population with low cholesterol levels-a prospective and cross-sectional evaluation.
        Atherosclerosis. 2002; 165: 285-292
        • Hu G.
        • Qiao Q.
        • Tuomilehto J.
        • et al.
        Prevalence of the metabolic syndrome and its relation to all-cause and cardiovascular mortality in nondiabetic European men and women.
        Arch Intern Med. 2004; 164: 1066-1076
        • Lakka H.M.
        • Laaksonen D.E.
        • Lakka T.A.
        • et al.
        The metabolic syndrome and total and cardiovascular disease mortality in middle-aged men.
        JAMA. 2002; 288: 2709-2716
        • Alexander C.M.
        • Landsman P.B.
        • Teutsch S.M.
        • et al.
        NCEP-defined metabolic syndrome, diabetes, and prevalence of coronary heart disease among NHANES III participants age 50 years and older.
        Diabetes. 2003; 52: 1210-1214
        • Kip K.E.
        • Marroquin O.C.
        • Kelley D.E.
        • et al.
        Clinical importance of obesity versus the metabolic syndrome in cardiovascular risk in women: a report from the Women's Ischemia Syndrome Evaluation (WISE) study.
        Circulation. 2004; 109: 706-713
        • Lin R.T.
        • Lee W.J.
        • Jeng C.Y.
        • et al.
        Metabolic syndrome and its contribution to coronary artery disease in non-diabetic subjects.
        J Formos Med Assoc. 2004; 103: 317-320
        • Girman C.J.
        • Rhodes T.
        • Mercuri M.
        • et al.
        The metabolic syndrome and risk of major coronary events in the Scandinavian Simvastatin Survival Study (4S) and the Air Force/Texas Coronary Atherosclerosis Prevention Study (AFCAPS/TexCAPS).
        Am J Cardiol. 2004; 93: 136-141
        • Hunt K.J.
        • Resendez R.G.
        • Williams K.
        • et al.
        National Cholesterol Education Program Versus World Health Organization Metabolic Syndrome in Relation to All-Cause and Cardiovascular Mortality in the San Antonio Heart Study.
        Circulation. 2004; 110: 1251-1257
        • Ridker P.M.
        • Buring J.E.
        • Cook N.R.
        • et al.
        C-reactive protein, the metabolic syndrome, and risk of incident cardiovascular events: an 8-year follow-up of 14 719 initially healthy American women.
        Circulation. 2003; 107: 391-397
        • Sattar N.
        • Gaw A.
        • Scherbakova O.
        • et al.
        Metabolic syndrome with and without C-reactive protein as a predictor of coronary heart disease and diabetes in the West of Scotland Coronary Prevention Study.
        Circulation. 2003; 108: 414-419
        • Schillaci G.
        • Pirro M.
        • Vaudo G.
        • et al.
        Prognostic value of the metabolic syndrome in essential hypertension.
        J Am Coll Cardiol. 2004; 43: 1817-1822
        • Pyorala K.
        • Ballantyne C.M.
        • Gumbiner B.
        • et al.
        Reduction of cardiovascular events by simvastatin in nondiabetic coronary heart disease patients with and without the metabolic syndrome: subgroup analyses of the Scandinavian Simvastatin Survival Study (4S).
        Diab Care. 2004; 27: 1735-1740
        • Oh J.Y.
        • Hong S.H.
        • Sung Y.A.
        • et al.
        Prevalence and factor analysis of metabolic syndrome in an urban Korean population.
        Diab Care. 2004; 27: 2027-2032
        • Murray C.J.
        • Lopez A.D.
        Alternative projections of mortality and disability by cause1990–2020: Global Burden of Disease Study.
        Lancet. 1997; 349: 1498-1504
        • Deurenberg-Yap M.
        • Chew S.K.
        • Deurenberg P.
        Elevated body fat percentage and cardiovascular risks at low body mass index levels among Singaporean Chinese, Malays and Indians.
        Obes Rev. 2002; 3: 209-215
        • Deurenberg P.
        • Deurenberg-Yap M.
        • Guricci S.
        Asians are different from Caucasians and from each other in their body mass index/body fat percent relationship.
        Obes Rev. 2002; 3: 141-146
        • Lin W.Y.
        • Lee L.T.
        • Chen C.Y.
        • et al.
        Optimal cut-off values for obesity: using simple anthropometric indices to predict cardiovascular risk factors in Taiwan.
        Int J Obes Relat Metab Disord. 2002; 26: 1232-1238
        • Unwin N.
        • Harland J.
        • White M.
        • et al.
        Body mass index, waist circumference, waist-hip ratio, and glucose intolerance in Chinese and Europid adults in Newcastle, UK.
        J Epidemiol Community Health. 1997; 51: 160-166
        • Snehalatha C.
        • Viswanathan V.
        • Ramachandran A.
        Cutoff values for normal anthropometric variables in asian Indian adults.
        Diab Care. 2003; 26: 1380-1384