Diabetes Ther https://doi.org/10.1007/s13300-018-0446-9 ORIGINAL RESEARCH Agreement Between the JCDCG, Revised NCEP-ATPIII, and IDF Deﬁnitions of Metabolic Syndrome in a Northwestern Chinese Population . . . . . . Fei Sun Bin Gao Li Wang Ying Xing Jie Ming Jie Zhou . . . . Jianfang Fu Xiaomiao Li Shaoyong Xu Guocai Liu Qiuhe Ji Received: April 6, 2018 The Author(s) 2018 Methods: This population-based cross-sectional ABSTRACT study was a part of the China National Diabetes and Metabolic Disorders Study conducted in Introduction: The Joint Committee for Devel- Shaanxi province. We included 3243 partici- oping Chinese Guidelines (JCDCG) introduced pants aged C 20 years. The age-adjusted MS the Chinese deﬁnition for metabolic syndrome prevalence was assessed per the 2007 Chinese (MS), which has been veriﬁed in southern Chi- population structure. The agreement between nese people but not in northwestern Chinese different deﬁnitions was assessed by the kappa people. We evaluated the MS deﬁnition pro- statistic. posed by the JCDCG in a northwestern Chinese Results: The standardized prevalence of population, in comparison with those of the JCDCG-MS, revised ATPIII-MS, and IDF-MS was revised National Cholesterol Education Pro- 22.4%, 29.4%, and 24.9%, respectively. Among gram Adult Treatment Panel III (NCEP-ATPIII) women, the agreement of the JCDCG deﬁnition and the International Diabetes Federation (IDF). with the revised ATPIII and the IDF deﬁnition was not good (j = 0.599 and 0.601, respec- tively); 54.6% of the revised ATPIII-MS and 56% of the IDF-MS were deﬁned as MS according to Fei Sun and Bin Gao contributed equally to this work. the JCDCG deﬁnition. Among men, the agree- Enhanced digital features To view enhanced digital ment of JCDCG deﬁnition with the revised features for this article go to https://doi.org/10.6084/ ATPIII and IDF deﬁnitions was very good m9.ﬁgshare.6264902. (j = 0.863) and substantial (j = 0.741), Electronic supplementary material The online respectively. version of this article (https://doi.org/10.1007/s13300- Conclusion: The agreement of the JCDCG def- 018-0446-9) contains supplementary material, which is inition with the revised ATPIII and IDF deﬁni- available to authorized users. tions was insufﬁcient in women. Compared with the other two deﬁnitions, the JCDCG F. Sun B. Gao L. Wang Y. Xing J. Ming J. Zhou J. Fu X. Li S. Xu G. Liu Q. Ji (&) deﬁnition underestimates MS prevalence in Department of Endocrinology, Xijing Hospital, northwestern women. Fourth Military Medical University, Xi’an, Shaanxi, China e-mail: email@example.com Keywords: Agreement; Cardiovascular diseases; Chinese; Diabetes; Metabolic syndrome; G. Liu Prevalence; Waist circumference The Third Department of Internal Medicine, The 273 Hospital of Chinese PLA, Korla, Xinjiang, China Diabetes Ther ATPIII (Deﬁnition proposed by AHA/NHLBI), INTRODUCTION and IDF for the diagnosis of MS. We also investigated the agreement between the JCDCG Metabolic syndrome (MS) has attracted deﬁnition and the two aforementioned deﬁni- increased attention due to its signiﬁcant impact tions that are widely used. on cardiovascular diseases (CVD) and diabetes [1–3]. In the past few decades, different deﬁni- tions of MS have been proposed by several METHODS organizations. For example, the World Health Organization (WHO) , the US National Participants Cholesterol Education Program Adult Treat- ment Panel III (NCEP-ATPIII) , and Interna- This study was a subsection of the second stage tional Diabetes Federation (IDF)  have put of the CNDMDS, a representative cross-sec- forward their interpretations. Before long, the tional cohort of Chinese adults from June 2007 American Heart Association/National Heart, to May 2008. The details of the CNDMDS can be Lung, and Blood Institute (AHA/NHLBI) revised found in a previous study . In brief, a mul- the ATPIII deﬁnition . However, there is no tistage, stratiﬁed sampling method was used to consensus on the deﬁnition of MS worldwide. select a representative cohort aged C 20 years Studies revealed that the impact of different from the general population in Shaanxi pro- deﬁnitions of MS on the risk of future CVD and vince (more details can be found in our previous diabetes is discrepant [8, 9]. study) . In China, the Joint Committee for Develop- A total of 3930 individuals who had lived in ing Chinese Guidelines (JCDCG) suggested a their residence for C 5 years were randomly Chinese deﬁnition for MS . The JCDCG chosen and invited to participate in the study. version has been applied as a useful tool to Of them, 3298 individuals completed the survey investigate MS and predict the risk of CVD in and examination (overall response rate, 83.9%). the Chinese population [11–14]. A community- After excluding 55 individuals who had missing based cohort study in southeast China revealed data for waist circumference (WC), fasting that only MS deﬁned by the JCDCG, not those serum glucose levels, 2-h postprandial glucose proposed by IDF and ATPIII, was associated with levels, serum triglyceride levels, serum high- an increased risk of CVD events in Chinese density lipoprotein cholesterol (HDL-C) levels, women . However, in China, different or blood pressure (BP), we ﬁnally included 3243 regions have their own lifestyles, and differ- subjects with complete data in the study. ences are especially between the south and the north, which may inﬂuence the metabolic sta- Compliance with Ethics Guidelines tus [16–18]. Accordingly, some studies had a different conclusion that the JCDCG’s deﬁni- tion was not appropriate for deﬁning MS and The Institutional Review Boards of Xijing predicting acute coronary syndrome among Hospital, Fourth Military Medical University Chinese people [19, 20]. Therefore, there is an approved this study. Written informed consent urgent need to determine whether the JCDCG was obtained from each participant prior to data deﬁnition is more appropriate than other deﬁ- collection. nitions used effectively in the world, especially in northwestern Chinese people. Measurements In order to provide solid proof for the determination, we conducted a population- A standard questionnaire was administered by based study by using data from the China well-trained staff to obtain information includ- National Diabetes and Metabolic Disorders ing the demographic characteristics, lifestyle Study (CNDMDS) in Shaanxi province, north- risk factors, personal medical history, family west China, and evaluated the JCDCG, revised history of diseases, educational level, cigarette Diabetes Ther smoking, alcohol drinking, and physical activ- 80 cm for women of Asian origin; (2) Triglyc- ity. Height and body weight were measured in eride level of 1.7 mmol/L or receipt of drug an upright position, to the nearest 0.5 cm and treatment for elevated triglyceride levels; (3) 0.1 kg, respectively. The WC measurements HDL-C level of 1.03 mmol/L in men and were taken at the end of a normal exhalation 1.29 mmol/L in women or receipt of drug and were measured to the nearest 0.1 cm from treatment for reduced HDL-cholesterol level; (4) the midpoint between the lower borders of the High blood pressure of 130/85 mmHg or receipt rib cage and the anterior superior iliac spine. of drug treatment for hypertension; (5) Body mass index (BMI) was calculated as weight Impaired fasting PG level of 5.6 mmol/L or in kilograms divided by the square of height in receipt of drug treatment for elevated glucose meters. The mean of two BP measurements was level . used. Readings of systolic BP and diastolic BP According to the IDF deﬁnition, MS is were taken 5 min apart in the resting state. deﬁned as central obesity (WC C 90 cm for An oral glucose-tolerance test was performed Chinese men and C 80 cm for Chinese women) for each subject. All participants were required along with two or more of the following to fast for at least 8 h beforehand, the partici- abnormalities: (1) Triglyceride level of pants without history of diabetes were subject 1.7 mmol/L or receipt of speciﬁc treatment for to a 75-g oral glucose tolerance test, and those this lipid abnormality; (2) HDL-C level of with a history of diabetes were given a bread 1.03 mmol/L in men and 1.29 mmol/L in meal test for safety reasons. Vein blood samples women or receipt of speciﬁc treatment for this were drawn at 0, 30, and 120 min after glucose lipid abnormality; (3) BP of 130/85 mmHg or or carbohydrate load. The plasma glucose (PG) receipt of treatment of previously diagnosed levels including fasting PG and 2 h PG (2hPG) hypertension; (4) Fasting PG level of 5.6 mmol/ were measured. Furthermore, high-density L or previously diagnosed type 2 diabetes . lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), total choles- Statistical Analysis terol (TC), and triglyceride (TG) levels in the serum were measured using commercially Continuous variables were expressed as the available reagents at the clinical biochemical mean ± standard deviation, and categorical laboratory, Xijing Hospital, Xi’an, China. variables are presented as proportions. P val- ues \ 0.05 were considered statistically signiﬁ- Diagnosing Standard cant. To compare continuous variables between groups, a t test was used. To compare categorical According to the JCDCG, MS is deﬁned if there are variables between groups, the chi-square test more than three of the following abnormalities: was used. Linear trends for sex- and age-speciﬁc (1) Central obesity (WC [ 90 cm for men and mean or proportion were tested using analysis [ 85 cm for women); (2) Elevated triglyceride of variance linear test (polynomial) or chi- level (C 1.7 mmol/L) or receipt of speciﬁc treat- square test for linear-by-linear association, ment for this lipid abnormality; (3) Reduced HDL- respectively. A binary logistic regression analy- Clevel (\ 1.04 mmol/l) or speciﬁc treatment for sis was adopted to compare the prevalence of this lipid abnormality; (4) Elevated BP (C 130/ MS between genders after adjusting for age. 85 mmHg or current treatment for hypertension) Agreement between different MS deﬁnitions or previously diagnosed hypertension; (5) Ele- was evaluated by the j value (poor, j B 0.20; vated PG level (fasting PG C 6.1 mmol/L or 2 h fair, j = 0.21–0.40; moderate, j = 0.41–0.60; postprandial PG C 7.8 mmol/L) or previously substantial, j = 0.61–0.80; very good, j [ 0.80) diagnosed diabetes mellitus . . As our study was conducted in 2007–2008, The revised ATPIII deﬁnition was deﬁned as the percentage values of MS prevalence were three or more of the following abnormalities: standardized by the direct method according to (1) WC of 90 cm for men of Asian origin and the Chinese population structure in 2007 . Diabetes Ther A database was established using EpiData 3.1 men/women 0.721; age of men software. Statistical analyses were carried out 44.3 ± 14.0 years, women 44.1 ± 13.7 years), using the International Business Machines with a mean BMI of 23.9 kg/m . Men had a Corporation Statistical Package of Social Science signiﬁcantly higher BMI, WC, triglyceride level, for Windows version 22.0 (IBM Corp., Armonk, LDL-C level, education level, and proportion of NY, USA). alcohol drinking and cigarette smoking, whereas women had signiﬁcantly higher HDL-C levels. The mean level of HDL-C was higher in RESULTS women than in men. The systolic BP, diastolic BP, TC, fasting PG, 2hPG, and proportion of Characteristics of Study Population subjects who performed physical activity showed no signiﬁcant differences between the The baseline characteristics of the study subjects two genders. are shown in Table 1. This study included 3243 individuals (1359 men, 1884 women; Table 1 Characteristics of the study population Variables Total (n = 3243) Men (n = 1359) Women (n = 1884) P value Age (years) 44.2 ± 13.8 44.3 ± 14.0 44.1 ± 13.7 0.615 Educational level (n %) Elementary school or below 730 (22.5) 209 (15.4) 521 (27.7) \ 0.001 Middle school 1601 (49.4) 710 (52.2) 891 (47.3) 0.007 Collage or above 912 (28.1) 442 (32.5) 470 (24.9) \ 0.001 Physical activity (n %) 1224 (37.7) 534 (39.3) 690 (36.6) 0.139 Alcohol drinking (n %) 801 (24.7) 694 (51.1) 107 (5.7) \ 0.001 Cigarette smoking (n %) 770 (23.7) 745 (54.8) 25 (1.3) \ 0.001 BMI (kg/m ) 23.9 ± 1.40 24.3 ± 4.37 23.6 ± 3.88 \ 0.001 WC (cm) 81.9 ± 10.2 85.8 ± 9.72 79.1 ± 9.50 \ 0.001 SBP (mmHg) 120.9 ± 20.2 121.3 ± 20.7 120.5 ± 19.9 0.241 DBP (mmHg) 76.7 ± 11.6 76.6 ± 11.8 76.7 ± 11.5 0.836 TC (mmol/L) 4.71 ± 1.03 4.72 ± 1.02 4.70 ± 1.03 0.570 TG (mmol/L) 1.56 ± 1.28 1.75 ± 1.50 1.43 ± 1.07 \ 0.001 HDL-C (mmol/L) 1.29 ± 0.31 1.21 ± 0.28 1.35 ± 0.31 \ 0.001 LDL-C (mmol/L) 2.64 ± 0.80 2.68 ± 0.76 2.61 ± 0.82 0.020 FPG (mmol/L) 5.23 ± 1.40 5.25 ± 1.43 5.21 ± 1.39 0.288 2hPG (mmol/L) 6.52 ± 3.29 6.44 ± 3.23 6.58 ± 3.32 0.244 P values are from t tests between genders BMI body mass index, WC waist circumference, SBP systolic blood pressure, DBP diastolic blood pressure, TC total cholesterol, TG triglycerides, HDL-C high-density lipoprotein cholesterol, LDL-C low-density lipoprotein cholesterol, FPG fasting plasma glucose, 2hPG 2-h plasma glucose Diabetes Ther Standardized Prevalence of MS 18.0%, 30.8%, and 27.0% in women, respec- tively. As compared to men, more women had MS according to the IDF deﬁnition (27.9% vs. The standardized MS prevalence rates of the 30.8%, P = 0.012) and revised ATPIII deﬁnition study population as per the JCDCG-MS, revised (22.7% vs. 27.0%, P \ 0.001). In contrast, more ATPIII-MS, and IDF-MS were 22.4%, 29.4%, and men than women were diagnosed with MS as 24.9%, respectively (Table 2). The prevalence per the JCDCG deﬁnition (27.0% vs. 18.0%, rates of JCDCG-MS, revised ATPIII-MS, and IDF- P \ 0.001). Linear trends in the prevalence of MS were 27.0%, 27.9%, and 22.7% in men and Table 2 Standardized proportion (95% conﬁdence interval) of metabolic syndrome using the JCDCG, revised ATPIII, and IDF deﬁnition JCDCG-MS Revised ATPIII-MS IDF-MS a a a Overall 22.4 (21.0–23.8) 29.4 (27.8–31.0) 24.9 (23.4–26.4) b b b Men 27.0 (24.6–29.4) 27.9 (25.5–30.3) 22.7 (20.5–24.9) b b b Women 18.0 (16.3–19.7) 30.8 (28.7–32.9) 27.0 (25.0–29.0) P \ 0.001 0.012 \ 0.001 Men age (years) 20–29 12.9 (8.6–17.2) 12.4 (8.2–16.6) 10.3 (6.4–14.2) 30–39 28.5 (23.6–33.4) 31.5 (26.5–36.6) 27.0 (22.2–31.8) 40–49 33.8 (28.5–39.1) 35.2 (29.9–40.5) 28.4 (23.4–33.4) 50–59 39.4 (33.6–45.2) 38.5 (32.7–44.3) 26.6 (21.3–31.9) 60–69 42.6 (34.7–50.5) 40.6 (32.7–48.5) 32.6 (25.1–40.1) C 70 26.7 (16.5–37.0) 26.7 (16.5–37.0) 24.2 (14.3–34.1) P \ 0.001 \ 0.001 \ 0.001 Women age (years) 20–29 3.2 (1.2–5.2) 8.7 (5.6–11.9) 7.7 (4.7–10.7) 30–39 6.7 (4.4–9.0) 16.7 (13.3–21.2) 13.8 (10.6–17.0) 40–49 17.8 (14.4–21.2) 37.1 (32.8–41.5) 29.9 (25.8–34.0) 50–59 34.8 (30.0–39.6) 54.1 (49.1–59.1) 49.2 (44.2–54.2) 60–69 40.4 (33.5–47.3) 57.9 (51.0–64.8) 49.8 (42.8–56.8) C 70 43.1 (32.1–54.1) 49.3 (38.2–60.4) 49.3 (38.2–60.4) P \ 0.001 \ 0.001 \ 0.001 JCDCG Joint Committee for Developing Chinese Guidelines, ATPIII Adult Treatment Panel III, IDF International Diabetes Federation Age- and sex-adjusted percentages Age-adjusted percentages for men or women. The percentage values were standardized by the direct method according to the Chinese population structure in 2007 Adjusted for age using binary logistic analysis P value for linear trend from the chi-square test for linear-by-linear association Diabetes Ther MS showed a signiﬁcant increase with age in other two deﬁnitions. According to the JCDCG both genders according to all three deﬁnitions deﬁnition, 54.6% of ATPIII-MS and 56.0% of (Table 2). IDF-MS were deﬁned as MS; 14.4% and 17.0% of non-MS subjects according to the JCDCG deﬁ- nition were deﬁned as MS by the IDF deﬁnition Crude Prevalence of Metabolic and revised ATPIII deﬁnition, respectively Abnormalities According to JCDCG, (Fig. 2). Revised ATPIII, and IDF Criteria Agreement Between JCDCG, Revised In men, except for the elevated PG and central ATPIII, and IDF Criteria for MS Diagnosis obesity, the prevalence of the other metabolic abnormalities according to the revised ATPIII (IDF) criteria was similar in either MS group or To verify the agreement between the different non-MS group. About 74.0% of JCDCG-MS and deﬁnitions of MS for both genders, we used the 81% of ATPIII-MS were deﬁned as MS by the IDF j statistic. A substantial overall agreement deﬁnition, 91.0% of JCDCG-MS and all the IDF- (j = 0.712) was observed between the JCDCG MS were deﬁned as MS by the revised ATPIII and revised ATPIII deﬁnitions, and a moderate deﬁnition, and 87.9% of ATPIII-MS and 88.3% overall agreement (j = 0.648) was observed of IDF-MS were deﬁned as MS by the JCDCG between the JCDCG and IDF deﬁnitions deﬁnition (Fig. 1). (Table 3). When analyzed by gender, very good In women, according to JCDCG criteria, the agreement (j = 0.863) was observed between crude prevalence of elevated TG, elevated BP, the JCDCG and revised ATPIII deﬁnitions for elevated PG, central obesity, and reduced HDL- men, but only a moderate agreement C was higher in JCDCG-MS subjects. In addi- (j = 0.599) was observed for women. A sub- tion, the prevalence rates of the metabolic stantial agreement was found for both genders abnormalities mentioned above were not lower between the JCDCG and IDF deﬁnitions (over- in non-MS subjects deﬁned by the JCDCG def- all, j = 0.648; men, j = 0.741; women, inition than the non-MS subjects deﬁned by the j = 0.601). Fig. 1 Crude prevalence of metabolic abnormalities according to JCDCG, revised ATPIII, and IDF criteria in men Diabetes Ther Fig. 2 Crude prevalence of metabolic abnormalities according to JCDCG, revised ATPIII, and IDF criteria in women participants, the prevalence of MS according to DISCUSSION the JCDCG deﬁnition was 21.9% . Varied prevalence was observed in different regions of We conducted a population-based study in China. A community-based study conducted in Shaanxi province, northwest China, to compare Shanghai, southeast China, revealed that 24.4% the JCDCG deﬁnition of MS with the IDF and of study subjects met the MS deﬁnition of the revised ATPIII deﬁnitions. We found that JCDCG. The varied prevalence of MS between the agreement between the JCDCG deﬁnition northern and southern areas of China may be and the revised ATPIII or the IDF deﬁnitions was partially explained by different lifestyles, e.g., not good enough, especially in northwestern physical exercise, education level, and eco- Chinese women. JCDCG only recognized 56.0% nomic status [16, 25]. In addition to these fac- of IDF-MS and 54.6% of revised ATP-MS; also, tors, studies have also revealed that the MS there were still 14.4% of IDF-MS and 17.0% of prevalence depends on the deﬁnition used revised ATP-MS deﬁned as non-MS according to [26–28]. The community-based study in JCDCG. These results indicated that the JCDCG Shanghai also revealed moderate to good deﬁnition may underestimate the prevalence of agreement between the JCDCG deﬁnition with MS in women compared with the other two the IDF and ATPIII deﬁnition, with kappa value deﬁnitions. Hence, we should consider the between 0.635 and 0.825 in both women and gender difference and further verify the relia- men. In spite of all these studies, there was lack bility of the JCDCG deﬁnition in assessing MS of data evaluating JCDCG compared with other in northwestern Chinese women. deﬁnitions in northern Chinese populations. As Our results showed that 22.4% of Shaanxi we acknowledged, we ﬁrst revealed the agree- adults met the MS criteria according to the ment of the JCDCG deﬁnition with other deﬁ- JCDCG deﬁnition, which is slightly higher than nitions in northwestern Chinese people. the national level. In a nationwide study per- formed in 2007–2008, which enrolled 46,024 Diabetes Ther Table 3 Agreement of the JCDCG with the revised ATPIII and IDF criteria for the diagnosis of MS JCDCG J value 12 Total Revised ATPIII Overall ? 748 330 1078 0.712 - 59 2106 2165 Total 807 2436 3243 Men ? 386 43 429 0.863 - 38 892 930 Total 424 935 1359 Women ? 362 287 649 0.599 - 21 1214 1235 Total 383 1501 1884 IDF Overall ? 635 273 908 0.648 - 171 2164 2335 Total 806 2437 3243 Men ? 312 111 423 0.741 - 32 904 936 Total 344 1015 1359 Women ? 240 23 263 0.601 - 180 976 1156 Total 420 999 1419 Agreement between the different MS deﬁnitions was evaluated by the j statistic (poor, j B 0.20; fair, j = 0.21–0.40; moderate, j = 0.41–0.60; substantial, j = 0.61–0.80; very good, j [ 0.80) JCDCG Joint Committee for Developing Chinese Guidelines, ATPIII Adult Treatment Panel III, IDF International Diabetes Federation Diabetes Ther In the current study, the agreement between according to JCDCG and other widely used the JCDCG deﬁnition and the other two was deﬁnitions in northwestern Chinese women. not very good in women. As we observed In men, the agreement between JCDCG, IDF, JCDCG only recognized 56.0% of IDF-MS and and revised ATPIII deﬁnition was good. The 54.6% of revised ATP-MS; also, there were still prevalence of MS deﬁned by IDF was slightly 14.4% of IDF-MS and 17.0% of revised ATP-MS lower than the prevalence of MS deﬁned by deﬁned as non-MS according to JCDCG. Fur- JCDCG and revised ATPIII deﬁnitions, possibly thermore, according to JCDCG criteria of the because central obesity has been regarded as a metabolic abnormalities, the crude prevalence requisite criterion of the IDF deﬁnition. How- of the ﬁve metabolic abnormalities was higher ever, the prevalence of MS deﬁned by JCDCG in both MS and non-MS subjects by JCDCG and revised ATPIII was close (JCDCG-MS: than the subjects deﬁned by revised ATPIII and 27.0%, revised ATPIII-MS: 27.9%), because the IDF deﬁnitions. These results all proved the only difference between the two deﬁnition is poor agreement between JCDCG and the other the cutoff of elevated PG. The prevalence rates two deﬁnitions in northwestern Chinese of JCDCG-MS we observed in our present study women. Comparison of the three criteria of MS were similar to the nationwide study (27.0% vs. shows that the different cutoffs of central obe- 25.8%) and the community-based study in sity (waist circumference, 80 vs 85 cm), reduced Shanghai (27.0% vs. 26.1%) which was men- HDL-C (1.04 vs. 1.29 mmol/l), and hyper- tioned above [13, 15]. Based on the results glycemia (FPG 5.6 mmol/l vs. FPG 6.1 mmol/l, above, the agreement between JCDCG and the 2hPG 7.8 mmol/l) may lead to the different other two deﬁnitions was good in men. It was prevalence. Among those above, the most very different from what we had observed in important criteria of metabolic syndrome women for these three deﬁnitions. should be based upon the visceral adiposity Despite our important ﬁndings, our study which controls the micro-inﬂammation, adi- has some limitations. First, as it was a cross- ponectin, and adipocytokines that induce sectional study, future prospective studies insulin resistance. The waist circumference of should be conducted to examine which deﬁni- 85 cm for women was derived from visceral fat tion of MS has better predictive power for the area (VFA) measured by magnetic resonance risk of CVD and diabetes. Second, as the study imaging in a southeastern Chinese population was conducted in northwest China, the con- in Shanghai. Similarly, the cutoff point of waist clusions from this study may not be generaliz- circumference was also 85 cm in Japanese able to other areas. Finally, we cannot exclude women, and it was determined by the visceral the possibility of selection bias. For example, level area obtained by CT scan . Recently an the prevalence of MS decreased in the group of intervention trial based on a large population subjects aged 70 or older. It may because there conﬁrmed the validity of this criterion . But were few subjects in this group. There are also it remains unclear whether the waist circum- strengths in our study: our present study not ference of 85 cm for women is adapted to only observed the prevalence of MS according northwestern Chinese women; a prospective to JCDCG but also compared JCDCG with the study should be conducted to verify this. Pre- IDF and the revised ATPIII deﬁnitions in the vious study has revealed that agreement northwestern Chinese population. In addition, between the JCDCG deﬁnition and other deﬁ- our study assessed the deﬁnitions of MS in men nitions (the WHO, IDF, and ATPIII deﬁnitions) and women separately. was moderate to good in southeastern Chinese women . With such different results in dif- CONCLUSIONS ferent regions, we should be cautious when using the JCDCG deﬁnition, and the JCDCG The agreement of the JCDCG deﬁnition with deﬁnition need to be veriﬁed by prospective the revised ATPIII and the IDF deﬁnitions was study in northwestern Chinese women. So far, insufﬁcient in women. The JCDCG deﬁnition no study has observed such differences Diabetes Ther may underestimate MS in the northwestern are in agreement with the content of the female population when compared with the manuscript. other two deﬁnitions, most likely because of the Disclosures. Qiuhe Ji has attended advisory loose cutoffs of central obesity in women. boards and received travel support, and been a Therefore, the cutoffs of central obesity in speaker of Eli Lilly, Novo Nordisk, Merck & Co., northwestern Chinese women need to be veri- Merck Sharp & Dohme China, Sanoﬁ Aventis, ﬁed, and we should be aware of the difference Huadong Pharmaceuticals Company, and between the JCDCG deﬁnition and the other Medtronic, and received research grants from MS deﬁnitions when evaluating MS in north- Novo Nordisk, Merck Sharp & Dohme China, western Chinese women. Prospective studies and AstraZeneca. The remaining authors (Fei may be needed to prove the capability of the Sun, Bin Gao, Li Wang, Ying Xing, Jie Ming, Jie deﬁnitions for predicting future cardiovascular Zhou, Jianfang Fu, Xiaomiao Li, Shaoyong Xu, disease and diabetes. Guocai Liu) have nothing to disclose. Compliance with Ethics Guidelines. The ACKNOWLEDGEMENTS Institutional Review Boards of Xijing Hospital, Fourth Military Medical University approved We thank all of the physicians and participants this study. Written informed consent was of the study for their co-operation and generous obtained from each participant prior to data participation. collection. Funding. This study was supported by grants Data Availability. The data sets generated from Shaanxi Natural Science Foundation of and/or analyzed during the current study are China (2014JM2-8198), the National Natural available from the corresponding author on Science Foundation of China (81300696), and reasonable request. the National Key R&D Program of China (2017YFC1309803). The grants also funded the Open Access. This article is distributed journal’s article processing charges. under the terms of the Creative Commons Attribution-NonCommercial 4.0 International Authorship. All named authors meet the License (http://creativecommons.org/licenses/ International Committee of Medical Journal by-nc/4.0/), which permits any non- Editors (ICMJE) criteria for authorship for this commercial use, distribution, and reproduction article, take responsibility for the integrity of in any medium, provided you give appropriate the work as a whole, and have given their credit to the original author(s) and the source, approval for this version to be published. provide a link to the Creative Commons license, and indicate if changes were made. Authorship Contributions. All the authors have made a signiﬁcant contribution to this manuscript. Fei Sun and Bin Gao contributed equally to this work. Qiuhe Ji was responsible REFERENCES for the study design. Fei Sun, Bin Gao, and Li Wang participated in the design of the study 1. Alberti KG, Eckel RH, Grundy SM, et al. Harmo- and drafted the manuscript. 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Published: May 28, 2018