Critical-Evaluation of Adult Treatment Panel III Criteria in Identifying Insulin Resistance With Dyslipidemia

Liao Y, Hutto A, Kwon S, Jenkins AJ, Shaughnessy S, Klein RL, Wallace P, Garvey WT. Diabetes Care. 2004;27:978-983

The efficacy of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults ATP III criteria to identify individuals with insulin resistance was compared with maximally insulin-stimulated glucose disposal rate (GDR) with a euglycemic-hyperinsulinemic glucose clamp. Lower GDR values indicate higher insulin resistance. Insulin resistance is thought to cause both type 2 diabetes and atherosclerosis. Cardiovascular disease risk factors in insulin-resistant individuals who did not meet ATP III criteria were also assessed. Seventy-four Caucasian subjects were studied to avoid well-known ethnic variations in patterns of insulin resistance, triglyceride levels, and HDL cholesterol levels. No subjects had diabetes, cardiovascular, renal, hepatic, or thyroid disease; all subjects had fasting glucose <110 mg/dL. Since there is no established level of GDR defining insulin resistance, arbitrary cutoff levels from 9-14 mg/kg/min were assessed. A total of 12.2% of subjects met the ATP III criteria for metabolic syndrome. Twelve patients (16.4%) met the criteria for impaired glucose tolerance (IGT) by 2-hr OGTT. The sensitivity and specificity of the ATP III criteria to predict insulin resistance varied from 50% and 94%, respectively, at a GDR cutoff of 9.5-10 mg/kg/min to 20% and >90%, respectively, at 12 mg/kg/min. ATP III criteria failed to identify many insulin-resistant subjects with adverse cardiovascular risk factors. The use of fasting glucose, rather than IGT, in the ATP III criteria contributes to their diminished sensitivity to detect insulin resistance. The ATP III criteria will fail to identify many individuals at increased risk of developing type 2 diabetes and cardiovascular disease, and may even more profoundly underdiagnose insulin resistance in African Americans and younger patients.