The hypertriglyceridemic waist phenotype versus the National Cholesterol Education Program–Adult Treatment Panel III and International Diabetes Federation clinical criteria to identify high-risk men with an altered cardiometabolic risk profile
Introduction
The metabolic syndrome is recognized as a cluster of cardiometabolic risk factors that includes an atherogenic dyslipidemic state, insulin resistance, elevated blood pressure, impaired fibrinolysis, and a prothrombotic profile and an inflammatory state [1]. The association between these cardiometabolic risk markers and cardiovascular disease (CVD) or cardiovascular mortality is well recognized [2], [3], [4]. However, controversy remains around the underlying pathophysiologic processes leading to the development of the metabolic syndrome (insulin resistance and/or hyperinsulinemia vs abdominal obesity) [5].
Guidelines encouraged identification of patients with features of the metabolic syndrome in clinical practice [6], [7], [8]. In this regard, several clinical criteria to aid detection of individuals characterized by features of the metabolic syndrome have been developed [1], [6], [8], [9], [10], [11], [12]. However, it is very important to point out that clinical criteria are not the definition of the metabolic syndrome per se but that they are proposed as screening tools with the hope that they will help physicians to identify patients with a cluster of atherogenic cardiometabolic risk abnormalities largely resulting from the presence of abdominal obesity [13].
The criteria of the National Cholesterol Education Program–Adult Treatment Panel III (NCEP-ATP III) guidelines are widely used in clinical practice to identify subjects likely to have the metabolic syndrome [1]. With the NCEP-ATP III clinical criteria, a diagnosis of the metabolic syndrome is made when 3 or more of 5 criteria are met: (1) enlarged waist circumference, (2) elevated triglycerides (TG), (3) low high-density lipoprotein (HDL) cholesterol, (4) impaired fasting glucose, and (5) elevated blood pressure [1], [11]. More recently, the International Diabetes Federation (IDF) has attempted to provide a global approach to identify men and women characterized by the metabolic syndrome worldwide [8]. The IDF criteria have been built upon the NCEP-ATP III 5 screening tools but differ in 2 aspects. First, the waist circumference cutoff has been lowered (102 to 94 cm); and the cutoff is also population specific. Second, an elevated waist circumference is a mandatory clinical criterion and must be present along with 2 additional criteria to diagnose the metabolic syndrome [8]. Both the NCEP-ATP III and IDF criteria have been associated with similar relative increase in the risk of CVD [14].
We have also been interested in the development of a simple screening approach to identify men at increased cardiometabolic risk. In 2000, Lemieux et al [12] proposed that the hypertriglyceridemic waist phenotype (waist girth ≥90 cm combined with fasting plasma TG levels ≥2.0 mmol/L) was predictive of a very high probability for men to be characterized by the simultaneous presence of some cardiometabolic risk markers. It has also been suggested that the hypertriglyceridemic waist phenotype could be helpful in the assessment of risk of coronary artery disease and type 2 diabetes mellitus [12], [15].
More recently, Tankó and colleagues [16] have compared the ability of the hypertriglyceridemic waist phenotype and of the NCEP-ATP III clinical criteria to estimate cardiovascular risk in postmenopausal women. They found that the combined presence of an elevated waist circumference (≥88 cm) and increased TG levels (≥1.45 mmol/L) was the best indicator of progression rate of aortic calcification over an 8.5-year follow-up period [16]. However, although many prevalence studies have been published comparing numbers obtained with the NCEP-ATP III and IDF criteria, no study has simultaneously compared the ability of hypertriglyceridemic waist, NCEP-ATP III, and IDF screening tools to identify men characterized by deteriorated cardiometabolic risk markers such as hyperinsulinemia, elevated apolipoprotein B levels, small low-density lipoprotein (LDL) particles, increased C-reactive protein (CRP) concentrations, and low adiponectin levels.
Section snippets
Study sample and measurements
Two hundred seventy-two men, aged 25 to 63 years (mean age ± SD, 44.9 ± 7.6 years), were recruited from the Québec City metropolitan area by solicitation through the media. Participants were selected to cover a wide range of body mass index values (18.7-39.1 kg/m2). Subjects gave their written consent to participate in the study, which was approved by the Medical Ethics Committee of Université Laval. All subjects were sedentary but healthy, nonsmoking, and nondiabetic volunteers; and they were
Results
In the present sample, the prevalence of men with the NCEP-ATP III criteria, IDF criteria, or hypertriglyceridemic waist phenotype was 59.2%, 64.0%, and 51.1%, respectively. A large proportion of men having the hypertriglyceridemic waist phenotype also met the NCEP-ATP III (82.7%) or the IDF (89.2%) criteria. Physical characteristics and fasting cardiometabolic risk profile of men with or without the NCEP-ATP III, the IDF, or the hypertriglyceridemic waist criteria are presented in Table 1.
Discussion
The NCEP-ATP III guidelines have recognized the metabolic syndrome as a cluster of abnormalities increasing the risk of CVD and type 2 diabetes mellitus [1]. Indeed, studies have shown that the risk of CVD is increased by about 2-fold, whereas the risk of type 2 diabetes mellitus could be increased by about 3- to 5-fold among subjects diagnosed with the clinical markers of the metabolic syndrome [2], [30], [31], [32]. Because the metabolic syndrome is a prevalent condition [33], it is important
Acknowledgment
Angelo Tremblay holds a Canada Research Chair in Physical Activity, Nutrition, and Energy Metabolism. Benoît Lamarche holds a Canada Research Chair in Nutrition, Functional Foods, and Cardiovascular Health. Jean-Pierre Després is Scientific Director of the International Chair on Cardiometabolic Risk, which is supported by an unrestricted grant from Sanofi Aventis awarded to Université Laval. We would like to thank the staff of the Physical Activity Sciences Laboratory for the data collection
References (51)
- et al.
The metabolic syndrome—a new worldwide definition
Lancet
(2005) Quantitative estimation of proteins by electrophoresis in agarose gel containing antibodies
Anal Biochem
(1966)- et al.
Increase in plasma high density lipoprotein concentration following complete androgen blockage in men with prostatic carcinoma
Metabolism
(1987) - et al.
Metabolic risks identified by the combination of enlarged waist and elevated triacylglycerol concentration
Am J Clin Nutr
(2003) - et al.
The hypertriglyceridemic waist phenotype among women
Atherosclerosis
(2003) - et al.
Postprandial hyperlipidemia: another correlate of the “hypertriglyceridemic waist” phenotype in men
Atherosclerosis
(2003) - et al.
Clustering of metabolic abnormalities in adolescents with the hypertriglyceridemic waist phenotype
Am J Clin Nutr
(2006) - et al.
Features of the metabolic syndrome of “hypertriglyceridemic waist” and transplant coronary artery disease
J Heart Lung Transplant
(2005) 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)- et al.
The metabolic syndrome and total and cardiovascular disease mortality in middle-aged men
JAMA
(2002)
Cardiovascular morbidity and mortality associated with the metabolic syndrome
Diabetes Care
The metabolic syndrome in older individuals: prevalence and prediction of cardiovascular events: the Cardiovascular Health Study
Diabetes Care
Abdominal obesity and metabolic syndrome
Nature
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) final report
Circulation
European guidelines on cardiovascular disease prevention in clinical practice. Third Joint Task Force of European and Other Societies on Cardiovascular Disease Prevention in Clinical Practice
Eur Heart J
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
Comment on the provisional report from the WHO consultation. European Group for the Study of Insulin Resistance (EGIR)
Diabet Med
Definition of metabolic syndrome: report of the National Heart, Lung, and Blood Institute/American Heart Association conference on scientific issues related to definition
Circulation
Hypertriglyceridemic waist: a marker of the atherogenic metabolic triad (hyperinsulinemia; hyperapolipoprotein B; small, dense LDL) in men?
Circulation
Abdominal obesity and the metabolic syndrome: contribution to global cardiometabolic risk.
Arterioscler Thromb Vasc Biol
The importance of waist circumference in the definition of metabolic syndrome: prospective analyses of mortality in men
Diabetes Care
Prevalence of “hypertriglyceridemic waist” in men who participated in the Quebec Health Survey: association with atherogenic and diabetogenic metabolic risk factors
Can J Cardiol
Enlarged waist combined with elevated triglycerides is a strong predictor of accelerated atherogenesis and related cardiovascular mortality in postmenopausal women
Circulation
Techniques for the measurement of visceral fat: a practical guide
Int J Obes Relat Metab Disord
Cited by (54)
Triglycerides and glycated hemoglobin for screening insulin resistance in obese patients
2018, Clinical BiochemistryCitation Excerpt :Several indices where triglycerides or lipids might be used to screen IR were proposed. Blackburn et al. argued hypertriglyceridemia is a screening approach to identify individuals with deteriorated cardio-metabolic risk markers, when associated with waist circumference [31,32]. This phenotype was called “hypertriglyceridemic waist” but was not studied specifically in obese patients.
Fatty acid oxidation in normotriglyceridemic men
2016, Journal of Clinical LipidologyCitation Excerpt :The association of hypertriglyceridemia with the metabolic syndrome suggests important roles for obesity (particularly abdominal obesity), elevated nonesterified fatty acids (NEFA), and accumulation of ectopic fat in the liver. This is exemplified by the so-called “hypertriglyceridemia-waist” syndrome.2 One defense against ectopic fat accumulation and hypertriglyceridemia may be increased oxidation of fatty acids in the liver.
Serum nitric oxide metabolites are associated with the risk of hypertriglyceridemic-waist phenotype in women: Tehran Lipid and Glucose Study
2015, Nitric Oxide - Biology and ChemistryHypertriglyceridemic waist phenotype and associated factors in individuals with arterial hypertension and/or diabetes mellitus
2021, Journal of Nutritional ScienceHypertriglyceridemic waist phenotype is associated with left ventricular hypertrophy in Chinese hypertension patients
2023, Journal of Clinical Hypertension