REGULAR ARTICLE
Abdominal circumference should not be a required criterion
for the diagnosis of metabolic syndrome
Kiyoshi Shibata • Sadao Suzuki • Juichi Sato •
Isao Ohsawa • Shinichi Goto • Masaru Hashiguchi •
Shinkan Tokudome
Received: 23 July 2009 / Accepted: 25 December 2009 / Published online: 4 February 2010
 The Japanese Society for Hygiene 2010
Abstract
Background Metabolic syndrome (MetS) is an estab-
lished concept. However, it is characterized by a number of
different definitions as well as different cut-off points
(COPs) for waist circumference (WC) and different modes
for incorporating WC into the diagnostic criteria.
Methods Abdominal ultrasonography was performed in
2,333 subjects who also underwent comprehensive medical
examinations between April and July 2006. The odds ratios
for the number of MetS components were calculated by
taking central obesity status into account and considering
concurrent fatty liver as an independent variable. We
compared the areas under the receiver operating charac-
teristic (ROC) curves for fatty liver and MetS using several
MetS criteria.
Results Regardless of the WC criterion selected, we
observed a strong linear trend for an association (trend
P \ 0.0001) between MetS and the number of components.
The odds ratio (OR) of subjects without central obesity but
with all three MetS components was 9.69 (95% confidence
interval 3.11–30.2) in men and 55.3 (6.34–483) in women.
The COP for the largest area under the curve in men and
women was C82 cm (OR 0.701) and C77 cm (OR 0.699),
respectively, when WC was considered as a component.
When WC distribution is taken into consideration, practical
and appropriate COPs should be C85 cm for men and
C80 cm for women.
Conclusion We suggest that a WC of C85 cm for men
and C80 cm for women would be optimal COPs for the
central obesity criteria in the Japanese population. In
addition, central obesity should be incorporated as a
component of MetS rather than an essential requirement for
the diagnosis of MetS.
Keywords Central obesity  Diagnostic criteria 
Metabolic syndrome  ROC curve
Introduction
The prevention of metabolic syndrome (MetS), for which
visceral fat accumulation and insulin resistance are con-
sidered upstream factors, has recently attracted the atten-
tion of the medical world as a useful approach to protect
against lifestyle-related diseases typified by arteriosclerotic
diseases [1–8]. Visceral fat accumulates for many reasons,
including hyperalimentation and inadequate exercise,
among others, and causes the abnormal functioning of fat
cells and excessive secretion of hormones that are involved
in various pathological conditions [9, 10]. Excessive
K. Shibata (&)  M. Hashiguchi
Kasugai City Medical Center, 1-1-7 Chuodai,
Kasugai, Aichi 487-0011, Japan
e-mail: s-kiyoshi@mvc.biglobe.ne.jp
K. Shibata  S. Suzuki  S. Tokudome
Department of Public Health, Nagoya City University
Graduate School of Medical Sciences, Nagoya, Japan
J. Sato
Department of General Medicine,
Nagoya University Hospital, Nagoya, Japan
I. Ohsawa
Department of Health Science,
Aichi Gakuin University, Nisshin, Aichi, Japan
S. Goto
Department of Medical Laboratory,
Kasugai Municipal Hospital, Kasugai, Japan
S. Tokudome
National Institute of Health and Nutrition, Tokyo, Japan
123
Environ Health Prev Med (2010) 15:229–235
DOI 10.1007/s12199-009-0132-7

secretion of these hormones is thought to act in combina-
tion with other factors to cause arteriosclerotic and other
serious diseases, such as renal failure, blindness, lower
limb amputation, cerebral apoplexy, cardiac arrest, and
cerebrovascular diseases. The progression of conditions,
from obesity into serious diseases, is sometimes referred as
the metabolic domino effect [11, 12], and includes fatty
liver disease.
Diagnostic criteria for MetS have been published by the
World Health Organization [13], American National Cho-
lesterol Education Programs, Adult Treatment Panel III
(NCEP–ATP III) [14], and International Diabetes Federa-
tion (IDF) [15] for Asian countries, including Japan [16]. In
Japan, the Examination Committee for Criteria of MetS
introduced diagnostic criteria for Japanese metabolic syn-
drome (JMetS) [16], which are similar to the ones defined
by IDF. The criteria essentially include central obesity and
several other components, such as hypertension, hyper-
glycemia, and abnormal lipid metabolism. In Japan, the
most prominent difference between the IDF and Exami-
nation Committee criteria for evaluating central obesity is
in the cut-off point (COP) for waist circumference (WC),
especially that for women: in all countries of the world,
with the exception of Japan, the COP for WC is larger for
men than that for women.
The relative newness of the MetS concept necessitates
that the diagnostic criteria be updated as and when needed.
The association between the diagnosis of MetS and
downstream diseases in the metabolic domino needs to be
addressed in prospective studies. In the study reported here,
we applied several criteria to examine the association
between metabolic status and concurrent fatty liver, which
we used as a specific example of a disease in the metabolic
domino. Our aim was to identify preliminary criteria and
COPs for WC that can be used in diagnosing MetS.
Subjects and methods
Height, weight, and WC were measured, and abdominal
ultrasonography was performed in 2,333 subjects (1,195
men and 1,138 women) of 2,428 subjects aged 40–
79 years. These subjects underwent comprehensive
medical examinations at the Kasugai City Medical Center
during a 3-month period between April and July 2006.
Patients receiving drug treatment(s) for liver diseases,
hypertension, diabetes mellitus, or hyperlipidemia were
excluded from the study. Height and weight were measured
using an automatic scale (Tanita BF-220). The WC was
measured in standing subjects with a tape measure placed
horizontally at the level of the navel while the subject was
gently exhaling. If the abdomen was protuberant and the
navel was deviated downwards, the tape measure was
placed at the midpoint level between the lower intercostal
border and the anterior superior iliac spine.
Fatty liver was diagnosed after discussion with medical
technologists (including ultrasound technicians), radiology
technologists, and physicians and by taking fatty liver
scores (as shown in Table 1) obtained at Kasugai City
Medical Center into consideration. These scores were
based on previous studies [17–20].
Blood pressure was measured on the right arm using a
mercury sphygmomanometer; the subject was in a lying
position and had rested for at least 5 min prior to the mea-
surement. Venous blood samples were collected in the
morning from subjects after a fasting period of 12 h. Tri-
glyceride (TG) and serum high-density lipoprotein choles-
terol (HDL-C) were measured by the direct enzymatic
method, and fasting plasma glucose (FPG) was measured by
the glucose oxidase method. Their concentrations were
measured using an automated analyzer (model 7170S;
Hitachi, Japan).
Current JMetS criteria require a central obesity (visceral
adipose tissue area C100 cm2 or WC C85 cm for men and
C90 cm for women) and two or more of the following
three components: (1) high blood pressure, based on a
systolic blood pressure C130 mmHg and/or diastolic blood
pressure C85 mmHg; (2) hyperglycemia, based on FPG
C110 mg/dl; (3) abnormal lipid metabolism, based on TG
C150 mg/dl and/or HDL-C \40 mg/dl [16]. The Exami-
nation Committee for Criteria of MetS in Japan also
defined a ‘‘risk group for MetS’’ (yobi-gun) consisting of
people who have central obesity and one of the three
components listed above (high blood pressure, hypergly-
cemia, or abnormal lipid metabolism). In our study, as in
most epidemiological studies, only WC was considered in
our evaluation of central obesity; the visceral adipose tissue
area was not assessed.
Our primary aim was to identify and propose new MetS
criteria based on our results. Our suggested criteria (our
criterion 1) considers central obesity not to be an essential
requirement for MetS but as only one of the components of
MetS. Accordingly, we defined our patients as having MetS
when they demonstrated three or more components of
Table 1 Fatty liver score
Condition Points
Bright echo pattern 0 or 1
Hepatorenal or hepatosplenic contrast 0 or 1 or 2
Unclear vessels 0 or 1
Deep attenuation 0 or 1 or 2
Fatty bandless sign 0 or 1
Liver swelling 0 or 1
A total score of C3 points is considered to indicate fatty liver
230 Environ Health Prev Med (2010) 15:229–235
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