Diabetes Care
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

Published online April 27, 2007
Diabetes Care 30:2128-2134, 2007
DOI: 10.2337/dc06-2402
© 2007 by the American Diabetes Association
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow All Versions of this Article:
dc06-2402v1
30/8/2128    most recent
Right arrow Purchase Article
Right arrow View Shopping Cart
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow Request Permissions
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by He, Y.
Right arrow Articles by Hu, F. B.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by He, Y.
Right arrow Articles by Hu, F. B.
Social Bookmarking
Add to CiteULike   Add to Del.icio.us   Add to Digg   Add to Reddit   Add to Technorati  
What's this?

Cardiovascular and Metabolic Risk
Original Article

BMI Versus the Metabolic Syndrome in Relation to Cardiovascular Risk in Elderly Chinese Individuals

Yao He, MD, PHD1,2, Bin Jiang, MD, PHD3, Jie Wang, MD, PHD4, Kang Feng, MD1, Qing Chang, MD1, Shanxiang Zhu, MPH1, Li Fan, MD5, Xiaoying Li, MD5 and Frank B. Hu, MD, PHD2

1 Institute of Geriatrics, Chinese PLA General Hospital, Beijing, China
2 Nutrition, Harvard School of Public Health, Boston, Massachusetts
3 Acupuncture, Chinese PLA General Hospital, Beijing, China
4 Clinic of PLA Communication, Beijing, China
5 Geriatric Cardiology, Chinese PLA General Hospital, Beijing, China

Address correspondence and reprint requests to Dr. Yao He, Institute of Geriatrics, Chinese PLA General Hospital, 28 Fuxing Road, Beijing 100853, China. E-mail: yhe301{at}sina.com or fhu{at}hsph.harvard.edu


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 RESEARCH DESIGN AND METHODS
 RESULTS
 CONCLUSIONS
 References
 
OBJECTIVE—The purpose of this study was to evaluate the associations of BMI versus metabolic syndrome with cardiovascular diseases (CVDs) in elderly Chinese individuals.

RESEACH DESIGN AND METHODS—We conducted a population-based cross-sectional study in an urban sample of 2,334 elderly subjects (943 men and 1,391 women). Subjects were classified by BMI (≤18.5, <24, <28, and ≥28 kg/m2) and the presence or absence of metabolic syndrome, which was defined by International Diabetes Federation (IDF) criteria. CVDs included clinically diagnosed coronary heart disease (CHD), stroke, and peripheral arterial disease (PAD).

RESULTS—The prevalence rates of overweight (BMI ≥25 kg/m2) and metabolic syndrome according to the IDF criteria were 56.3% (53.9% in men and 57.9% in women) and 46.3% (34.8% in men and 54.1% in women), respectively. Increasing BMI was strongly associated with a higher risk of CHD, stroke, and PAD even after adjustments for metabolic syndrome and other CVD risk factors. Stratified analysis of participants with or without metabolic syndrome showed that BMI was independently associated with CHD, stroke, and PAD.

CONCLUSIONS—Both overweight and metabolic syndrome are highly prevalent in this elderly Chinese population. BMI, as a measure of overall adiposity, is strongly associated with increased prevalence of CVD independent of metabolic syndrome.

Abbreviations: CHD, coronary heart disease • CVD, cardiovascular disease • ECG, electrocardiogram • IDF, International Diabetes Federation • PAD, peripheral artery disease • WHO, World Health Organization


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
RESEARCH DESIGN AND METHODS
 RESULTS
 CONCLUSIONS
 References
 
China is experiencing rapid economic growth and aging of its population. Resulting changes in lifestyle and longer life expectancy have led to an increased burden of cardiovascular diseases (CVDs) and other chronic diseases (1,2). A nationwide study from China indicates that >30% of adults are overweight, and the prevalence of metabolic syndrome is 13.7% (3). Obesity and metabolic syndrome frequently coexist, and both are associated with CVD risk (4–9). In our recent report in elderly individuals in urban China, the prevalence rates of metabolic syndrome by the National Cholesterol Education Program (10) and new International Diabetes Federation (IDF) (11) criteria were 30.5 and 46.3%, and the individuals with metabolic syndrome defined by either criteria had significantly elevated risks for CVD (12). However, the role of obesity as an independent etiologic factor for CVD remains controversial (13,14). Previous studies have suggested that the association between BMI and risk of CVD became nonsignificant after adjustment for metabolic syndrome (14). In this study, we examined the relative associations of BMI versus metabolic syndrome with the prevalence of CVD in a population-based survey of elderly Chinese individuals in Beijing, China.


   RESEARCH DESIGN AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 RESEARCH DESIGN AND METHODS
RESULTS
 CONCLUSIONS
 References
 
This study was a population-based cross-sectional survey of individuals aged ≥60 years living in the Wanshoulu Community of Haidian District, a metropolitan area representative of the geographic and economic characteristics in Beijing, China. A two-stage stratified sampling method was used. First, nine residential communities or streets (about 300–600 households) were randomly selected from a total of 94 residential communities in the Wanshoulu area in Beijing. Second, all households were chosen from the selected streets, but only one eligible participant was randomly selected from each household. Between April 2001 and March 2002, 2,680 people aged 60–95 years were selected and invited for screening. The 2,334 subjects (943 men and 1,391 women) attended five clinics where detailed health evaluations were completed, yielding a response rate of 87.1% (83.5% in men and 89.7% in women); these subjects accounted for 11.4% of elderly residents in the Wanshoulu area.

The details of data collection have been reported elsewhere (12). Height was measured in meters (without shoes) and weight in kilograms (with heavy clothing removed and 1 kg deducted for remaining garments). Waist circumference was measured while subjects were standing with a soft tape midway between the lowest rib and the iliac crest. Two blood pressure recordings were obtained from the right arms of patients in a sitting position after 30 min of rest; measurements were taken in 5-min intervals, and mean values were calculated. We also performed other physical examinations and tests (including an electrocardiogram [ECG], an ankle-arm systolic blood pressure index, and typical symptoms) to diagnose coronary heart disease (CHD) and peripheral artery disease (PAD).

Classification of BMI
BMI was calculated as body weight in kilograms divided by the square of height in meters. According to World Health Organization (WHO) criteria (4), overweight was defined as a BMI ≥25.0 kg/m2. However, WHO-recommended cut points for BMI may be inappropriate for Asian populations (e.g., Chinese). In the present study, BMI was classified into four categories: ≤18.5, 18.6–23.9, 24.0–27.9, and ≥28.0 kg/m2. These categories are based on the criteria of the Cooperative Meta-Analysis Group of the Working Group on Obesity in China (15).

Definition of metabolic syndrome
We used the 2005 IDF definition of metabolic syndrome. This definition includes central obesity (≥90 and ≥80 cm in Chinese men and women, respectively) plus any two of the following four factors: 1) high blood pressure (≥130/85 mmHg or known treatment for hypertension); 2) hypertriglyceridemia (fasting plasma triglycerides ≥1.7 mmol/l); 3) fasting HDL cholesterol <1.0 mmol/l in men and <1.3 mmol/l in women; and 4) hyperglycemia (fasting glucose level of ≥ 5.6 mmol/l (≥100 mg/dl) or known treatment for diabetes) (11).

Diagnosis of CVD
Hypertension was defined as diastolic blood pressure of ≥90 mmHg, systolic blood pressure of ≥140 mmHg, or current medication for hypertension. CHD and stroke were defined using the WHO Multinational Monitoring of Trends and Determinants in Cardiovascular Diseases (MONICA) criteria (16). Major CHD events included myocardial infarction (n = 68) and confirmed angina (n = 715). Myocardial infarction was diagnosed by a representative set of ECGs, cardiac enzyme values, and typical symptoms. Angina was defined as use of nitroglycerin, experience of typical chest pain, and ECG changes compatible with ischemic heart disease (58% of the cases were validated by an exercise test or B-mode ultrasonography but were not randomly selected). There were 365 cases of stroke (235 ischemic, 70 hemorrhagic, and 60 other types). Strokes were defined as events requiring hospitalization; this information was verified from local hospital records and 83% of the cases were confirmed by computed tomography scans and magnetic resonance imaging. Subjects with a fasting plasma glucose ≥7.0 mmol/l and/or a 2-h plasma glucose ≥11.1 mmol/l during an oral glucose tolerance test and/or who were receiving antidiabetic medications were diagnosed with diabetes. PAD was assessed as positive intermittent claudication by a WHO/Rose questionnaire or an ankle-arm systolic blood pressure index <0.9 (17).

Statistical analysis
Data were entered (double entry) and managed by Microsoft Access (Microsoft, Redmond, WA). We calculated sex-specific prevalence rates of overweight and metabolic syndrome. We used logistic regression to calculate odds ratios (ORs) and their 95% CIs. We also conducted both stratified analyses and multiple logistic regression analyses to examine the independent and combined effects of BMI and the metabolic syndrome. The statistical package used was SPSS (version 11; SPSS, Chicago, IL). We adjusted for potential confounders (age, marital status, years of education, smoking and alcohol drinking, physical exercise, and family histories of CHD or stroke).


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 RESEARCH DESIGN AND METHODS
 RESULTS
CONCLUSIONS
 References
 
According to the WHO definition for overweight (BMI ≥25.0 kg/m2) and the IDF criteria for metabolic syndrome, prevalence rates for overweight and metabolic syndrome in this elderly Chinese population were 56.3% (53.9% in men and 57.9% in women) and 46.3% (34.8% in men and 54.1% in women), respectively.

General characteristics of the 2,334 subjects (943 men and 1,391 women) categorized by BMI are shown in Table 1. We found a clear increasing trend in risk factors for CVD and clinical outcomes from subjects with lower BMI to those with higher BMI. The Pearson correlation coefficient between BMI and waist circumference was 0.78 (P < 0.0001).


View this table:
[in this window]
[in a new window]

  		Table 1— Clinical and metabolic characteristics in subjects with BMI ≤18.5, <24, <28, and ≥28 kg/m2

 
Table 2 shows the proportion of metabolic syndrome components (i.e., hyperglycemia, high blood pressure, hypertriglyceridemia, low HDL cholesterol level, and central obesity) and the number of components in the four BMI groups (i.e., ≤18.5, <24, <28, and ≥28 kg/m2). Table 3 shows the ORs (95% CI) for CHD, stroke, PAD, and total CVD for the subjects with BMI ≤18.5, <24, <28, and ≥28 kg/m2. Increasing BMI was strongly associated with increased risk of CHD, stroke, PAD, and total CVD, and these associations were somewhat attenuated but remained statistically significant even after adjustments for the presence or absence of metabolic syndrome.


View this table:
[in this window]
[in a new window]

  		Table 2— Prevalence of individual metabolic syndrome components and component numbers in subjects with BMI ≤18.5, <24, <28, and ≥28 kg/m2

 

View this table:
[in this window]
[in a new window]

  		Table 3— ORs of CHD, stroke, PAD, and total vascular diseases (CVD) according to BMI categories

 
Table 4 shows the result of stratified analysis of the relative association of BMI versus metabolic status on CHD, stroke, PAD, and total CVD. Both elevated BMI and the metabolic syndrome were associated with increased risk of CVD. Among those who were obese (BMI ≥28.0 kg/m2), the risk of CHD and CVD was similar between those with and without metabolic syndrome. Interestingly, the ORs for stroke and PAD in underweight individuals with the metabolic syndrome were the highest of all groups (OR 2.10 [95% CI 0.21–21.26] and 2.79 [0.37–21.15]).


View this table:
[in this window]
[in a new window]

  		Table 4— Stratified analysis of the ORs for CHD, stroke, PAD, and total vascular diseases (CVD) in subjects with BMI ≤ 18.5, < 24, < 28, and ≥28 with or without metabolic syndrome (MS)

 
The interactions between BMI and metabolic syndrome in CHD, stroke, PAD, and CVD were tested in multivariate logistic models by adjusting for sex, age, marital status, education, and other covariates. None of the interaction terms was statistically significant (P = 0.09, 0.70, 0.73, and 0.16, respectively).

Figure 1 shows multivariate adjusted ORs of CHD, stroke, PAD, and CVD in subjects in all BMI groups (i.e., ≤18.5, <24, <28, and ≥28 kg/m2) with or without metabolic syndrome; 95% CIs are shown in Table 4. There was a significant dose-response relation between the increasing categories of BMI and risk of CHD, PAD, and CVD in subjects without metabolic syndrome.


Figure 1
View larger version (30K):
[in this window]
[in a new window]

  		Figure 1— Multivariate-adjusted ORs of CHD, stroke, PAD, and CVD in subjects with BMI ≤18.5, <24, <28, and ≥28 kg/m2 with ({blacksquare}) or without (blk12) metabolic syndrome (MS).

 

   CONCLUSIONS
TOP
 ABSTRACT
 INTRODUCTION
 RESEARCH DESIGN AND METHODS
 RESULTS
 CONCLUSIONS
References
 
Overweight and obesity are rapidly growing threats to public health worldwide (4), especially in economically developing countries such as China. In the past two decades, prevalence rates of overweight and obesity in China have increased dramatically (6), which has led to increased occurrence of chronic diseases, especially type 2 diabetes and CVD in Chinese populations.

According to the WHO definition of overweight and the IDF criteria for metabolic syndrome, prevalence rates of overweight and metabolic syndrome in this study were 56.3 and 46.3%, respectively. These figures are lower than those in the same age-group in the U.S. (18,19) but higher than those seen in other studies conducted in Chinese populations (3,6,20–22). The relatively high prevalence rates of CHD (32% in men and 35% in women) and stroke (17% in men and 15% in women) in this population are probably due to the higher average age of our participants (69 years for men and 67 years for women) and our selection of an urban elderly population in Beijing.

Because the WHO-recommended BMI cut points may be inappropriate for the Chinese population, we used the BMI cut point criteria of the Cooperative Meta-Analysis Group of the Working Group on Obesity in China (i.e., ≤18.5 kg/m2, underweight; 18.6–23.9 kg/m2, normal weight; 24.0–27.9 kg/m2, overweight; and ≥28.0 kg/m2, obese) (15). The respective corresponding prevalence rates of overweight and obesity in this study were 46.4 and 22.2%. As expected, there was a strong positive correlation between increasing BMI and the prevalence of metabolic syndrome (Table 2).

The relation of BMI to metabolic syndrome and its role as an independent risk factor for CVD have been recent topics of debate (9,13). In 2004, the Women's Ischemia Syndrome Evaluation (WISE) study reported that metabolic syndrome but not BMI predicted future cardiovascular risk in women referred for coronary angiography (14). Other epidemiological studies, however, have reported that obesity and metabolic syndrome are independent cardiovascular risk factors (4–9). The present study shows that both BMI and the metabolic syndrome are independently associated with CHD, stroke, PAD, and total CVD. In particular, among those who did not meet the diagnostic criteria for the metabolic syndrome, there was a dose-response relationship between increasing BMI and higher prevalence of CVD. Interestingly, among those who were obese (BMI ≥28.0 kg/m2), the risk of CHD and CVD was similar between those with and without the diagnosis of metabolic syndrome (Table 4). These data suggest that assessment of CVD risk cannot depend completely on the diagnosis of metabolic syndrome. Obese subjects who do not meet the criteria for metabolic syndrome should be evaluated and managed for CVD risk assessment and reduction as aggressively as those who have metabolic syndrome. The positive association between BMI and CVD was weaker among those with metabolic syndrome, and this finding is probably due to the fact that BMI and waist circumference are highly correlated and that the effects of waist circumference were already taken into account in the definition of the metabolic syndrome. This pattern of BMI as an independent risk factor for both CHD and stroke in Chinese adults is consistent with data from other Chinese prospective studies (23–25).

BMI is a measure of overall adiposity, whereas waist circumference is a marker of central obesity. In our and other studies, there was a strong correlation between BMI and waist circumference. However, BMI was strongly correlated with the metabolic syndrome in our population, a correlation that was not completely accounted for by waist circumference. It has been suggested that waist circumference may be more strongly correlated with insulin resistance and chronic inflammation, the underlying mechanism for the metabolic syndrome (26). This observation has served as the rationale for including waist circumference instead of BMI as one of the diagnostic criteria for the metabolic syndrome. However, the measures of BMI and waist circumference do not completely overlap (r = 0.78). Numerous epidemiological studies have shown that BMI and fat distribution independently predict various metabolic disorders (27). Our data suggest that BMI can provide an additional predictive value for CVD risk beyond the metabolic syndrome. Therefore, in clinical practice, both BMI and waist circumference should be measured and monitored for CVD risk assessment, especially in high-risk populations.

To the best our knowledge, this report is the first to evaluate the relative effects of body weight versus metabolic syndrome on CVD in a population-based study in China. As an independent risk factor of CVD, BMI is easier to measure in primary intervention settings than the diagnosis of metabolic syndrome and, thus, is of clinical importance. It is also easily accepted by clinicians and the general public and, thus, is well-suited for use in health education and promotion in primary care settings.

The cross-sectional nature of this study did not allow us to assess the temporal relationship between the metabolic syndrome and CVD and, thus, limits causal inference. However, the temporal associations of BMI and metabolic syndrome with CVD have been well established in previous studies. The higher OR of stroke and PAD in underweight subjects with metabolic syndrome might be due to the fact that elderly individuals with metabolic syndrome were more likely to lose weight. This was a random cluster–selected sample with a relatively high response rate. Of the eligible subjects, ~13% dropped out of the study (e.g., left original residence or did not complete interviews or examinations), but no statistically significant differences in demographic characteristics such as age, sex, education, and marital status were detected between responders and nonresponders. Because our study population might not be a representative sample, the prevalence of metabolic syndrome may not generalize to other parts of China.

In summary, the present study indicates that both overweight and metabolic syndrome are highly prevalent in urban China. Our findings support a strong association of the metabolic syndrome and CVD, as well as an independent role of BMI in predicting the risk of CVD in elderly Chinese individuals. BMI can be more easily applied in clinical practice than the diagnosis of the metabolic syndrome. Developing effective public health strategies for the prevention and treatment of overweight and metabolic syndrome should be an urgent priority to reduce the social and public health burden of CVD in China.


   Acknowledgments
 
This study was supported by research grants from the National Natural Science Foundation of China (30057006) and Beijing Natural Science Foundation (7062063). F.B.H. is partly supported by an American Heart Association Established Investigator Award.


   Footnotes
 
Published ahead of print at http://care.diabetesjournals.org on 27 April 2007. DOI: 10.2337/dc06-2402.

A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances.

The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked "advertisement" in accordance with 18 U.S.C. Section 1734 solely to indicate this fact.

Received for publication November 23, 2006. Accepted for publication April 23, 2007.


   References
TOP
 ABSTRACT
 INTRODUCTION
 RESEARCH DESIGN AND METHODS
 RESULTS
 CONCLUSIONS
 References
 

  1. Wu Z, Yao C, Zhao D, Wu G, Wang W, Liu J, Zeng Z, Wu Y: Sino-MONICA project: a collaborative study on trends and determinants in cardiovascular diseases in China. Part I: morbidity and mortality monitoring. Circulation 103:462–468, 2001[Abstract/Free Full Text]
  2. Yao C, Wu Z, Wu Y: The changing pattern of cardiovascular diseases in China. World Health Stat Q 46:113–118, 1993[Medline]
  3. Gu D, Reynolds K, Wu X, Chen J, Duan X, Reynolds RF, Whelton PK, He J: Prevalence of the metabolic syndrome and overweight among adults in China. Lancet 365:1398–405, 2005[Medline]
  4. World Health Organization: Obesity: preventing and managing the global epidemic: report of a WHO consultation. World Health Org Tech Rep Ser 894:1–253, 2000
  5. Han TS, van Leer EM, Seidell JC, Lean ME: Waist circumference action levels in the identification of cardiovascular risk factors: prevalence study in a random sample. BMJ 311:1401–1405, 1995[Abstract/Free Full Text]
  6. Zhou B, Wu Y, Yang J, Li Y, Zhang H, Zhao L: Overweight is an independent risk factor for cardiovascular disease in Chinese populations. Obes Rev 3:147–156, 2002[Medline]
  7. Isomaa B, Almgren P, Tuomi T, Forsen B, Lahti K, Nissen M, Taskinen MR, Groop L: Cardiovascular morbidity and mortality associated with the metabolic syndrome. Diabetes Care 24:683–689, 2001[Abstract/Free Full Text]
  8. Lakka HM, Laaksonen DE, Lakka TA, Niskanen LK, Kumpusalo E, Tuomilehto J, Salonen JT: The metabolic syndrome and total and cardiovascular disease mortality in middle-aged men. JAMA 288:2709–2716, 2002[Abstract/Free Full Text]
  9. Krauss RM, Winston M, Fletcher BJ, Grundy SM: Obesity: impact on cardiovascular disease. Circulation 98:1472–1476, 1998[Medline]
  10. Nation Institutes of Health: 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 285:2486–2497, 2001[Free Full Text]
  11. Alberti KG, Zimmet P, Shaw J: The metabolic syndrome-a new worldwide definition. Lancet 306:1059–1062, 2005
  12. He Y, Jiang B, Wang J, Feng K, Chang Q, Fan L, Li XY, Hu FB: Prevalence of the metabolic syndrome and its relation to the risk of cardiovascular disease in an elderly Chinese population. J Am Coll Cardiol 47:1588–1594, 2006[Abstract/Free Full Text]
  13. Pradhan AD, Skerrett PJ, Manson JE: Obesity, diabetes, and coronary risk in women. J Cardiovasc Risk 9:323–330, 2002[Medline]
  14. Kip KE, Marroquin OC, Kelley DE, Johnson BD, Kelsey SF, Shaw LJ, Rogers WJ, Reis SE: 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 109:706–713, 2004[Abstract/Free Full Text]
  15. Zhou BF: Predictive values of body mass index and waist circumference for risk factors of certain related diseases in Chinese adults—study on optimal cut-off points of body mass index and waist circumference in Chinese adults. Biomed Environ Sci 15:83–96, 2002[Medline]
  16. WHO MONICA Project: Multinational Monitoring of Trends and Determinants in Cardiovascular Diseases (MONICA Project) and Manual of Operation. Geneva, World Health Organization, Cardiovascular Disease Unit, 1983
  17. He Y, Jiang Y, Wang J, Fan L, Li XY, Hu FB: Prevalence of peripheral arterial disease and its association with smoking in a population-based study in Beijing, China. J Vasc Surg 44:333–338, 2006[Medline]
  18. Overweight Obesity and Health Risk: National Task Force on the Prevention and Treatment of Obesity. Arch Intern Med 160:898–904, 2000[Abstract/Free Full Text]
  19. Ford ES, Giles WH, Dietz WH: Prevalence of the metabolic syndrome among US adults: findings from the third National Health and Nutrition Examination Survey. JAMA 287:356–359, 2002[Abstract/Free Full Text]
  20. Wang JJ, Hu G, Miettinen ME, Tuomilehto J: The metabolic syndrome and incident diabetes: assessment of four suggested definitions of the metabolic syndrome in a Chinese population with high post-prandial glucose. Horm Metab Res 36:708–715, 2004[Medline]
  21. Wang JJ, Qiao Q, Miettinen ME, Lappalainen J, Hu G, Tuomilehto J: The metabolic syndrome defined by factor analysis and incident type 2 diabetes in a Chinese population with high postprandial glucose. Diabetes Care 27:429–2437, 2004[Abstract/Free Full Text]
  22. Wang JJ, Li HB, Kinnunen L, Hu G, Jarvinen TM, Miettinen ME, Yuan S, Tuomilehto J How well does the metabolic syndrome defined by five definitions predict incident diabetes and incident coronary heart disease in a Chinese population? Atherosclerosis 192:161–168
  23. Zhou BF: Effect of body mass index on all-cause mortality and incidence of cardiovascular diseases—report for meta-analysis of prospective studies open optimal cut-off points of body mass index in Chinese adults. Biomed Environ Sci 15:245–252, 2002[Medline]
  24. Yuan JM, Ross RK, Gao YT, Yu MC: Body weight and mortality: a prospective evaluation in a cohort of middle-aged men in Shanghai, China. Int J Epidemiol 27:824–832, 1998[Abstract/Free Full Text]
  25. Gu D, He J, Duan X, Reynolds K, Wu X, Chen J, Huang G, Chen CS, Whelton PK: Body weight and mortality among men and women in China. JAMA 295:776–783, 2006[Abstract/Free Full Text]
  26. Eckel RH, Grundy SM, Zimmet PZ: The metabolic syndrome. Lancet 365:1415–1428, 2005[Medline]
  27. Douketis JD, Sharma AM: Obesity and cardiovascular disease: pathogenic mechanisms and potential benefits of weight reduction. Semin Vasc Med 5:25–33, 2005[Medline]

Add to CiteULike CiteULike   Add to Del.icio.us Del.icio.us   Add to Digg Digg   Add to Reddit Reddit   Add to Technorati Technorati    What's this?



This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow All Versions of this Article:
dc06-2402v1
30/8/2128    most recent
Right arrow Purchase Article
Right arrow View Shopping Cart
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow Request Permissions
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by He, Y.
Right arrow Articles by Hu, F. B.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by He, Y.
Right arrow Articles by Hu, F. B.
Social Bookmarking
Add to CiteULike   Add to Del.icio.us   Add to Digg   Add to Reddit   Add to Technorati  
What's this?

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
Diabetes Diabetes Care Clinical Diabetes Diabetes Spectrum