Insulin Resistance Differential Diagnoses

Updated: Jul 08, 2020
  • Author: Samuel T Olatunbosun, MD, FACP, FACE; Chief Editor: George T Griffing, MD  more...
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Diagnostic Considerations

In an effort to clinically identify patients with insulin resistance, various organizations have developed diagnostic criteria. The most commonly used criteria in the United States are those of the National Cholesterol Education Program/Adult Treatment Panel III (NCEP/ATP III).

NCEP/ATP III criteria for metabolic syndrome

NCEP/ATP III criteria for the diagnosis of the metabolic syndrome include the following (diagnosis is made when three or more are present):

  • Waist circumference of more than 102 cm in men or more than 88 cm in women

  • Fasting triglyceride level of 150 mg/dL or higher

  • Blood pressure level of 130/85 mm Hg or higher

  • High-density lipoprotein cholesterol (HDL-C) level of less than 40 mg/dL in men or less than 50 mg/dL in women

  • Fasting glucose level of 110 mg/dL or higher (which has been changed to 100 mg/dL to reflect revised criteria for impaired fasting glucose [IFG])

WHO criteria for metabolic syndrome

The World Health Organization (WHO) has also developed criteria for the diagnosis of the metabolic syndrome, as follows:

  • IFG level of 101-125 mg/dL

  • Impaired glucose tolerance (IGT) (glucose level of 140-199 mg/dL 2 h after administration of 75 g of glucose)

  • Glucose uptake level of less than the lowest quartile for ethnic population under hyperinsulinemic, euglycemic conditions if the fasting glucose level is normal

In addition to the aforementioned criteria, the diagnosis must also include two of the following:

  • Use of antihypertensive medication; blood pressure of 140 mm Hg systolic or higher, 90 mm Hg diastolic or higher, or both

  • Triglyceride level of 150 mg/dL or higher

  • HDL-C level of less than 35 mg/dL in men or less than 39 mg/dL in women

  • Body mass index (BMI) of more than 30 kg/m2, waist-to-hip ratio of more than 0.9 in men or more than 0.85 in women, or both

  • Urinary albumin excretion level of 20 mcg/min or higher or albumin-creatinine ratio of 30 mg/g or higher

AACE clinical criteria for insulin resistance syndrome

The American Association of Clinical Endocrinologists (AACE) has formulated clinical criteria for the diagnosis of insulin resistance syndrome, as follows [7] :

  • BMI of 25 kg/m2 or higher

  • Triglyceride level of 150 mg/dL or higher

  • HDL-C level of less than 40 mg/dL in men or less than 50 mg/dL in women

  • Blood pressure of 130/85 mm Hg or higher

  • Glucose level of more than 140 mg/dL 2 hours after administration of 75 g of glucose

  • Fasting glucose level of 110-126 mg/dL

Additional risk factors include the following:

Differences in diagnostic criteria

Whereas the NCEP/ATP III criteria use fasting glucose level as the only measurement of glucose tolerance, the WHO and AACE criteria include the option of performing a 2-hour oral glucose tolerance test (OGTT). The OGTT better identifies individuals at risk for endothelial damage due to hyperglycemia, because IGT has been shown to be independently associated with endothelial dysfunction and, hence, cardiovascular risk. [16]

IDF global consensus statement on metabolic syndrome

In a global consensus statement, an International Diabetes Federation (IDF) panel presented a worldwide definition of the metabolic syndrome aimed at facilitating early detection and more intensive management of the condition, with the hope of reducing the long-term risk of cardiovascular disease (CVD) and diabetes.

According to the definition by the IDF panel, the diagnostic criteria for the metabolic syndrome include central obesity (defined as waist circumference ≥94 cm in men or ≥80 cm in women in Europid persons and in ethnic-specific levels in Chinese, Japanese, and South Asian persons) together with two of the following:

  • Triglyceride level of 1.7 mmol/L (150 mg/dL) or higher

  • Low HDL-C level (defined as < 1.04 mmol/L [40 mg/dL] in men or < 1.29 mmol/L [50 mg/dL] in women)

  • Blood pressure of 130/85 mm Hg or higher

  • Fasting hyperglycemia (defined as glucose level ≥5.6 mmol/L [100 mg/dL]) or previous diagnosis of diabetes or IGT.

The scientific basis for the definition of the metabolic syndrome and its clinical utility have been debated. [50, 51, 52] The debate was accentuated by a joint statement from the American Diabetes Association and the European Association for the Study of Diabetes. [8]

Both sides of the debate, however, generally agree that the risk factors commonly coexist in the same patient and that insulin resistance is the major underlying mechanism. Moreover, the metabolic syndrome serves as a clinical tool to raise awareness among health care providers, thus assisting in identifying high-risk individuals.

Differential Diagnoses