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Published online December 10, 2007
Diabetes Care 31:590-592, 2008
DOI: 10.2337/dc07-0802
© 2008 by the American Diabetes Association
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Cardiovascular and Metabolic Risk
Original Research

Optimal Cut Points of Waist Circumference for the Clinical Diagnosis of Metabolic Syndrome in the Japanese Population

Yuka Matoba, MD1, Toyoshi Inoguchi, MD, PHD1, Shigeru Nasu, MD2, Shizu Suzuki, MD2, Toshihiko Yanase, MD, PHD1, Hajime Nawata, MD, PHD3 and Ryoichi Takayanagi, MD, PHD1

1 Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
2 Human Dry Dock Center Wellness, Fukuoka, Japan
3 Fukuoka Prefectural University, Fukuoka, Japan

Address correspondence and reprint requests to Yuka Matoba, MD, Department of Medicine and Bioregulatory Science, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan. E-mail: ymatoba{at}intmed3.med.kyushu-u.ac.jp

Abbreviations: IDF, International Diabetes Federation • IMT, intima-media thickness • ROC, receiver operating characteristic


   INTRODUCTION
TOP
 INTRODUCTION
RESEARCH DESIGN AND METHODS--
 RESULTS--
 CONCLUSIONS--
 References
 
In 2005, the International Diabetes Federation (IDF) and the Japanese Committee for the Diagnostic Criteria of Metabolic Syndrome (Japanese definition) proposed metabolic syndrome definitions for the Japanese population (1,2). Both definitions included waist circumference as an essential component and adopted cut points of 85 cm for men and 90 cm for women based on the relationship between waist circumference and visceral fat area by computed tomography (3). However, those cut points have been in dispute because of their suboptimal sensitivity and specificity (4–6). Recently, the IDF proposed common cut points for the whole Asian population including the Japanese: 90 cm for men and 80 cm for women (7). In this study, we investigated optimal waist cut points to identify subjects with multiple risk factors in the Japanese population and verified the cut points to predict carotid intima-media thickening in metabolic syndrome subjects as a surrogate marker of early atherosclerosis and cardiovascular disease (8–10).


   RESEARCH DESIGN AND METHODS—
TOP
 INTRODUCTION
 RESEARCH DESIGN AND METHODS--
RESULTS--
 CONCLUSIONS--
 References
 
We reviewed cross-sectional data from 1,658 men and 1,116 women (aged 48.8 ± 9.8 and 46.8 ± 10.4 years, respectively) who had annual medical checkup services provided by their employers. The medical checkup took place from May 2005 to November 2006 at the Human Dry Dock Center Wellness in Fukuoka, Japan. Subjects on antihypertensive and/or antidiabetic medications were included as individuals with hypertension and/or diabetes, respectively. We excluded 158 subjects on medications for dyslipidemia because we were unable to determine whether they were treated for hypercholesterolemia or hypertriglyceridemia. The study protocol was approved by the ethics committee of the related institutes.

Measurements
Waist circumference was measured at the level of the umbilicus. Blood pressure was measured at rest using an automatic sphygmomanometer. All blood samples were withdrawn after an overnight 10-h fast. Mean carotid intima-media thickness (IMT) was measured by ultrasonography (SDU-2200; Shimadzu, Kyoto, Japan) equipped with IMT measurement software (Intimascope; Media Cross, Tokyo, Japan) (8).

Definitions of metabolic syndrome
We diagnosed metabolic syndrome by each waist cut point and two or more of the following risk factors: using the IDF definition, 1) blood pressure, systolic ≥130 and/or diastolic ≥85 mmHg, 2) triglycerides ≥150 mg/dl, 3) HDL cholesterol <40 mg/dl in men and <50 mg/dl in women, and 4) fasting plasma glucose ≥100 mg/dl; and using the Japanese definition, 1) blood pressures, same as the IDF, 2) triglycerides ≥150 mg/dl and/or HDL cholesterol <40 mg/dl, and 3) fasting plasma glucose ≥110 mg/dl.

Statistical analyses
Receiver operating characteristic (ROC) curve analyses were performed using Dr. SPSS II 11.0.1J software (SPSS Japan, Tokyo, Japan), and the optimal cut points were obtained from the Youden index, maximum (sensitivity + specificity – 1) (11) (12). ANOVA and multiple comparisons were used to compare carotid IMT among subject groups for statistical significance and were performed using StatView software (SAS Institute, Cary, NC). Statistical significance was inferred at P < 0.05.


   RESULTS—
TOP
 INTRODUCTION
 RESEARCH DESIGN AND METHODS--
 RESULTS--
CONCLUSIONS--
 References
 
We plotted ROC curves to determine optimal waist cut points (87 cm in men and 80 cm in women) to identify subjects with multiple risk factors with maximum sensitivity and specificity using the Youden index for both of the definitions (Fig. 1A–D). Using the optimal cut point of 87 cm for men, the sensitivity and specificity were 68 and 62% for the IDF and 70 and 57% for the Japanese definition, whereas the cut point of 90 cm, compared with 87 cm, showed lower sensitivity of 51% for the IDF and 53% for the Japanese definition (Fig. 1A and B). Using the optimal cut point of 80 cm for women, the sensitivity and specificity were 74 and 70% for the IDF and 84 and 68% for the Japanese definition. The former IDF and Japanese cut point of 90 cm showed inadequate sensitivity of 33% for the IDF and 38% for the Japanese definition (Fig. 1C and D).


Figure 1
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  		Figure 1— ROC curves for waist circumference and intima-media thickening in metabolic syndrome subjects. ROC curves for waist circumference were plotted (A–D). •, optimal cutpoint with maximum sensitivity and specificity determined using the Yoden Index. {circ}, cut point of the conventional and revised waist cut points. The numbers in parentheses under the waist circumference indicate sensitivity (%)/specificity (%) at each cut point. AUC, area under the curve. Mean IMT were obtained in subgroups using the optimal or conventional or revised waist cut points and the IDF or the Japanese definition (E–H). In subgroups with abdominal adiposity, black bars indicate the metabolic syndrome subjects with significantly increased IMT.

 
Next, we divided the subjects into subgroups by waist circumference. In men, the cut points of 85, 87, and 90 cm identified 25.0, 21.9, and 16.2% of subjects with the metabolic syndrome, respectively, for the IDF definition and 14.9, 13.4, and 10.2%, respectively, for the Japanese definition. In subgroups with abdominal adiposity, IMT increased significantly in metabolic syndrome subjects with multiple risk factors, suggesting feasibility of the cut points of 85, 87, and 90 cm (Fig. 1E and F). With any of the above cut points, the increasing IMT in metabolic syndrome subjects was more specific using the Japanese definition (Fig. 1E and F).

In women, the cut points of 80 and 90 cm identified 7.0 and 3.0% of metabolic syndrome subjects, respectively, for the IDF definition and 2.8 and 1.3% of subjects, respectively, for the Japanese definition. In subjects with waist circumference ≥90 cm, there was no significant difference in IMT using either definition. In contrast, when we used the cut point of 80 cm, the IMT increased significantly in metabolic syndrome subjects (Fig. 1G and H), suggesting the feasibility of the optimal cut points (80 cm) and the revised IDF definition. The increasing IMT in metabolic syndrome subjects was more specific using the IDF definition (Fig. 1G and H).

The optimal cut points obtained in the present study, 87 cm for men and 80 cm for women, predicted increasing IMT in metabolic syndrome subjects. These cut points were equivalent to those in a previous report by Hara et al. (4) that proposed ~85 cm for men and ~80 cm for women.

Finally, a potential limitation of this study is that the subjects were exclusively company employees who may not represent the whole Japanese population. Another metabolic syndrome definition, which includes waist criteria as an optional component, was proposed by the American Heart Association/National Heart, Lung and Blood Institute (13). Including requisiteness of waist circumference, further studies are required to optimize metabolic syndrome definitions in larger populations.


   CONCLUSIONS—
TOP
 INTRODUCTION
 RESEARCH DESIGN AND METHODS--
 RESULTS--
 CONCLUSIONS--
References
 
The optimal waist cut points were 87 cm for men and 80 cm for women. These cut points not only had maximum sensitivity and specificity to identify subjects with multiple risk factors but also predicted increased IMT in metabolic syndrome subjects. In men, both definitions were feasible. However, the Japanese definition (85 cm) surpasses the IDF definition (90 cm), since the cut point of 90 cm decreased sensitivity. In women, only the IDF definition (80 cm) was feasible to identify metabolic syndrome subjects in Japanese population.


   Footnotes
 
Published ahead of print at http://care.diabetesjournals.org on 10 December 2007. DOI: 10.2337/dc07-0802.

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 April 25, 2007. Accepted for publication November 29, 2007.


   References
TOP
 INTRODUCTION
 RESEARCH DESIGN AND METHODS--
 RESULTS--
 CONCLUSIONS--
 References
 

  1. Zimmet P, Magliano D, Matsuzawa Y, Alberti G, Shaw J: The metabolic syndrome: a global public health problem and a new definition. J Atheroscler Thromb 12:295–300, 2005[Medline]
  2. Metabolic syndrome: definition and diagnostic criteria in Japan. J Jpn Soc Intern Med 94:188–203, 2005
  3. The Examination Committee of Criteria for ‘Obesity Disease’ in Japan, the Japan Society for the Study of Obesity: New criteria for ‘obesity disease’ in Japan. Circ J 66:987–992, 2002[Medline]
  4. Hara K, Matsushita Y, Horikoshi M, Yoshiike N, Yokoyama T, Tanaka H, Kadowaki T: A proposal for the cutoff point of waist circumference for the diagnosis of metabolic syndrome in the Japanese population. Diabetes Care 29:1123–1124, 2006[Free Full Text]
  5. Miyawaki T, Hirata M, Moriyama K, Sasaki Y, Aono H, Saito N, Nakao K: Metabolic syndrome in Japanese diagnosed with visceral fat measurement by computed tomography. Proc Japan Acad 81:471–479, 2005
  6. Hayashi T, Boyko EJ, McNeely MJ, Leonetti DL, Kahn SE, Fujimoto WY: Minimum waist and visceral fat values for identifying Japanese Americans at risk for the metabolic syndrome. Diabetes Care 30:120–127, 2007[Abstract/Free Full Text]
  7. The IDF consensus worldwide definition of the metabolic syndrome [article online], 2006. Available from http://www.idf.org/webdata/docs/MetS_def_update2006.pdf. Accessed 11 October 2007
  8. Yanase T, Nasu S, Mukuta Y, Shimizu Y, Nishihara T, Okabe T, Nomura M, Inoguchi T, Nawata H: Evaluation of a new carotid intima-media thicknessn measurement by B-mode ultrasonography using an innovative measurement software, intimascope. Am J Hypertens 19:1206–1212, 2006[Medline]
  9. Dijk JM, van der Graaf Y, Bots ML, Grobbee DE, Algra A: Carotid intima-media thickness and the risk of new vascular events in patients with manifest atherosclerotic disease: the SMART study. Eur Heart J 27:1971–1978, 2006[Abstract/Free Full Text]
  10. Ludwig M, von Petzinger-Kruthoff A, von Buquoy M, Stumpe KO: [Intima media thickness of the carotid arteries: early pointer to arteriosclerosis and therapeutic endpoint]. Ultraschall Med 24:162–174, 2003 [article in German][Medline]
  11. Youden WJ: Index for rating diagnostic tests. Cancer 3:32–35, 1950[Medline]
  12. Perkins NJ, Schisterman EF: The inconsistency of "optimal" cutpoints obtained using two criteria based on the receiver operating characteristic curve. Am J Epidemiol 163:670–675, 2006[Abstract/Free Full Text]
  13. Grundy SM, Cleeman JI, Daniels SR, Donato KA, Eckel RH, Franklin BA, Gordon DJ, Krauss RM, Savage PJ, Smith SC Jr, Spertus JA, Costa F: Diagnosis and management of the metabolic syndrome: an American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement. Circulation 112:2735–2752, 2005[Free Full Text]

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