Metabolic syndrome (MetS) is nowadays a big challenge worldwide, which is characterized by a cluster of several metabolic disorders, i.e. abdominal obesity, atherogenic dyslipidemia, hypertension and dysregulation of glucose1,2. Despite unclear common pathophysiological mechanism, MetS has been recognized to increase the risk of diabetes mellitus (DM) and series atherosclerotic cardiovascular disease(ASCVD), i.e. coronary heart disease3,4, cardiovascular mortality2,5, cognitive impairment6 and all cause mortality7. Lifestyle modification and risk factors management are currently recommended to decrease the risk of subsequent cardiovascular diseases. Previous studies 8,9 have emphasized the importance of dyslipidemia as one component for the diagnosis of MetS and a recent epidemiological study10 has demonstrated that more than one third the Chinese adults younger than 75 years in 2010 suffered from MetS, which was similar to the epidemiological situation in the USA in 2014. Furthermore, the prevalence of MetS in the Americans older than 60 years was 1.6-fold higher11, which has shown that MetS components are more likely to cluster together in the older Americans. Dyslipidemia (hypertriglyceridemia and hypo-high density lipoproteinemia) is an important component for MetS, which plays a critical role in the progression from MetS to DM and ASCVD 8,9. Several studies12,13,14,15,16,17,18 have investigated the potential ability of the total cholesterol to high-density lipoprotein cholesterol (THR) and triglyceride to high-density lipoprotein cholesterol ratio to predict ASCVD, stroke and diabetes in adolescents, young and middle aged population, while few19,20 study has reported this potential association in very elderly until now.

Therefore, this study aimed to investigate the potential association between the THR and MetS in a community very elderly population.


Study population

This study was designed to investigate cardiovascular and metabolic risk factors in general community very elderly (≥ 80 years old) in Chengdu, which locates in the southwest of China21. From 2013 to 2015, a representative sample of very elderly in communities were recruited by using of a stratified three-stage cluster sampling design, which was described previously elsewhere21. Totally, 1056 very elderly from 20 residential communities were enrolled according to registration data from the local government. The study protocol conforms to the ethical guidelines of the 1975 Declaration of Helsinki as reflected in a prior approval by the ethics committee of the second people’s hospital of Chengdu. And all participants have given informed consent.

Demographic data collection and laboratory test

Well trained physicians and nurses were responsible for demographic data collecting (e.g. medical history, lifestyle, cardiovascular and metabolic risk factors) by a questionnaire-based face to face interview with a standardized questionnaire. The body mass index (BMI) was defined as weight in kilograms divided by the square of the height in meters. Blood pressure (BP) were measured three times in a sitting position by using a standardized automatic electronic sphygmomanometer (HEM-7300, Omron, Kyoto, Japan) according to the Chinese Guidelines for the Management of Hypertension22 and average values were calculated and included in the statistical analysis.

After fasting at least for 8 h, blood samples were collected from all participants and biochemical parameters, e.g. fast plasma glucose (FPG), total cholesterol (TC), triglycerides (TG), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), creatinine and serum uric acid were analyzed enzymatically on an auto-analyzer (AU5421 Chemistry Analyzer, Beckman, Brea, California, United States) in the central laboratory of our hospital.

The estimated glomerular filtration rate (eGFR) was calculated by using the Modification of Diet in Renal Disease study equation modified for the Chinese: eGFR = 186 × serum creatinine−1.154 × Age−0.203 × 0.742 (if women).

Diagnostic criteria of MetS

In this study, MetS was defined according to the Chinese guideline for dyslipidemia management23 and the Consensus Worldwide Definition from International Diabetes Federation (IDF)24 respectively as follows.

Chinese criteria: MetS should fulfill any three or more of the following items: abdominal obesity (waist circumference (WC) ≥ 90 cm in men and ≥ 85 cm in women), fasting TG ≥ 150 mg/dL (1.7 mmol/L), fasting HDL-C < 40 mg/dL (1.0 mmol/L), FPG ≥ 110 mg/dL (6.10 mmol/L) or 2 h blood glucose after glycemic load ≥ 140 mg/dL (7.80 mmol/L) or anti-diabetic treatment, and BP ≥ 130/85 mmHg or anti-hypertensive treatment.

IDF criteria: abdominal obesity with ethnic-specific WC cut-points (≥ 90 cm for Chinese men and ≥ 80 cm for women) and fulfills two items of the following: TG ≥ 150 mg/dL (1.7 mmol/L) or treatment for hypertriglycerides, HDL-C < 40 mg/dL (1.03 mmol/L) in men or < 50 mg/dL (1.29 mmol/L) in women or treatment for low HDL-C, FPG ≥ 100 mg/dL (5.6 mmol/L) or previously diagnosed type 2 diabetes, and BP ≥ 130/85 mmHg or treatment for hypertension.

Statistical analysis

All statistical analysis were performed by using SPSS software (Version 22.0, SPSS Inc, Chicago, IL). Continuous variables are expressed as mean ± standard deviation and frequencies are presented as percentages. Statistical comparison of continuous variables between groups was conducted using ANOVA or Kruskal–Wallis test, whereas χ2 test was applied to compare frequencies. Logistic regression models were used to evaluate the potential association between the THR and MetS. The receiver operating characteristic curve (ROC) analysis was used to evaluate the efficiency of the THR in predicting MetS according to different criteria. A two-sided P value < 0.05 was considered statistically significant.

Ethics statement

The study protocol conforms to the ethical guidelines of the 1975 Declaration of Helsinki as reflected in a prior approval by the ethics committee of the second people’s hospital of Chengdu and all participants provided written informed consent to participate in this study.


Baseline characteristics

Totally, there were 1056 participants enrolled in this study and 1038 of them were included in the final statistical analysis. In this study population, more very elderly women suffered from MetS (Women vs. Men: 33.6% vs. 17.3% (IDF criteria), 25.8% vs. 17.8% (Chinese criteria)). The mean THR was 3.25 ± 0.93 (men vs. Women: 3.27 ± 0.93 vs. 3.24 ± 0.92, P = 0.508). Moreover, participants with MetS were relatively younger and more likely to smoke and drink currently. And they had relatively higher WC, body weight, BP, FPG, non-HDL-C, serum uric acid, THR and lower eGFR levels (Table 1).

Table 1 Baseline characteristics of very elderly according to MetS (Chinese criteria).

Participants with lower tertile category of THR had a lower estimated prevalence of MetS and its components (i.e. abdominal obesity, hypertirglyceridemia, low HDL cholesterol and hyperglycemia) according both to the Chinese and the IDF criteria (Table 2).

Table 2 Estimated prevalence of metabolic syndrome and its components.

Logistic regression analysis of the MetS risk

The logistic regression analysis found that FPG, TC, TG, and HDL-C were associated with MetS (Fig. 1). The THR was associated with an increased risk of MetS according both to the Chinese criteria (odds ratio (OR): 3.211, 95% confidence interval (CI) 2.349–4.388, P < 0.001) and the IDF criteria (OR: 2.281, 95% CI 1.742–2.989, P < 0.001) in this very elderly population. After adjustment of sex, BMI, hyperurecima and eGFR, the THR was found to be also associated with an increased risk of MetS according both to the Chinese criteria (OR: 3.107, 95% CI 2.507–3.849, P < 0.001) and the IDF criteria (OR: 2.418, 95% CI 1.981–2.951, P < 0.001). Furthermore, the THR was found to be still associated with the increase of MetS according both to the Chinese criteria (OR: 3.053, 95% CI 2.464–3.782, P < 0.001) and the IDF criteria (OR: 2.458, 95% CI 2.016–2.995, P < 0.001) in this very elderly population after adjustment of sex, age, BMI, hyperurecimia and eGFR, current smoking, current drinking and physical activity (Table 3).

Figure 1
figure 1

Logistic regression results of laboratory parameters for MetS predicting. (A) MetS according to the Chinese criteria. (B) MetS according to the IDF criteria. FPG fast plasma glucose, HDL-C high-density lipoprotein cholesterol, IDF international diabetes federation, MetS metabolic syndrome, TC total cholesterol, TG triglyceride, THR total cholesterol and high density lipoprotein cholesterol ratio.

Table 3 Association between the THR and MetS according to models with different risk factors.

ROC analysis of MetS predicting

ROC analysis found that the area under the ROC curve (AUC) of the THR was 0.800 (95% CI 0.749–0.852, P < 0.001) and 0.727 (95% CI 0.669–0.786, P < 0.001) for predicting MetS in very elderly according to the Chinese and the IDF criteria, respectively. Moreover, the AUC of THR for predicting MetS (Chinese criteria) was similar to that of FPG (0.800, 95% CI 0.745–0.856, P < 0.001), lower than TG (0.843, 95% CI 0.795–0.8961, P < 0.001) and higher than HDL-C (0.744, 95% CI 0.706–0.781, P < 0.001). The AUC of TG was the biggest for predicting MetS according to the Chinese criteria (0.843, 95% CI 0.795–0.891, P < 0.001), while the AUC of FPG was the biggest according to the IDF criteria (0.771, 95% CI 0.715–0.826, P < 0.001) (Fig. 2).

Figure 2
figure 2

ROC curves of different parameters for MetS predicting. (A) ROC analysis of the THR for MetS predicting according to the Chinese criteria. The AUC of THR was 0.800 (95% CI 0.749–0.852). (B) ROC analysis of the THR for MetS predicting according to the IDF criteria. The AUC of the THR was 0.727 (95% CI 0.669–0.786). AUC area under the ROC curve, FPG fast plasma glucose, HDL-C high-density lipoprotein cholesterol, IDF international diabetes federation, MetS metabolic syndrome, ROC Receiver operating characteristic, TC total cholesterol, TG triglyceride, THR total cholesterol and high density lipoprotein cholesterol ratio.


Dyslipidemia and MetS

It is well known that MetS is a cluster or combination of several metabolic abnormalities without fully understood pathogenesis currently25. Framingham Heart Study (FHS)26 has demonstrated that the prevalence of MetS is two to three times higher in Framingham residents aged 50 years and older than in younger ages. Unclassified interaction between genetic and environmental factors may play an important role in the pathological process of MetS. Genetic variants in MetS are associated especially with glucose metabolism or lipid metabolism. And genetic susceptibility may exist within adipose tissue, in insulin signaling pathways, and in regulation of individual components of MetS. Insulin resistance or hyperinsulinaemia may contribute to obesity- and DM related hypertension and possibly also promote dyslipidaemia in MetS. Obesity, lifestyle, chronic inflammation and circadian rhythm disturbances may also contribute to the genesis of MetS27,28. Dyslipidaemia in MetS is mainly characterized by highly atherogenic small dense low-density lipoprotein and small dense high-density lipoprotein particles which can deplete of triglyceride9. One recent study29 has identified more than thirty new lipids contributing to key metabolic risk factors, i.e. obesity, dyslipidemia and dysglycemia in FHS participants. Triglyceride could result in endothelial dysfunction and foam cells formation by accelerating the oxidation of LDL-C. While in contrast, HDL-C play an anti-atherosclerosis role through transporting excess cholesterol to liver. Therefore, hypertriglyceridemia and hypo-high density lipoproteinemia play an important role in the pathogenesis in MetS. A previous study30 has reported that hypertriglyceridemia with a prevalence of 10.8% is the main type of lipid disorders in Chinese older than 60 years, especially in older women, which is in line with results of our previous study 21. In the present study, all levels of LDL-C, TC and TG, WC and BMI were higher in the very elderly participants than in Chinese adults aged 18–74 years, while FPG level was similar to that of general adults10,21. Potential reasons include typical local dietary style rich in oil and physical inactivity in population in this area. Especially, the prevalence of abdominal obesity and hypertriglyceridemia was even higher in this very elderly population than that of Chinese adults aged 18–74 years and middle aged population in this area. Moreover, the prevalence of hypercholesteremia is notably higher than that of hypertriglyceridemia21. Aside from high prevalence of hypertension, these dramatic characteristics and clustering of components mentioned above contribute significantly to the relatively high prevalence of MetS in this very elderly population31. However, different criteria of MetS chosen among studies, different constitution of study population and survey duration may contribute to the prevalence difference of MetS among studies.

THR and MetS

It has been reported that the THR is associated with an increased risk of ischemic stroke of middle aged to elderly community residents in FHS19 and in Chinese men aged 20–80 years18. Also, a study20 including nearly 3000 participants older than 60 years has found that the THR is associated with low ankle brachial index in non-smokers and therefore THR maybe play a role in peripheral arterial disease early screening. In Sweden women aged 50–59 years, the THR has been found to have a predictive ability for ischemic heart disease as well13. Vischer et al.32 has found that low TC and HDL-C levels can predict total mortality in very elderly French. Among very elderly participants in this study, TC level and the THR were significantly higher and HDL-C level was significantly lower in participants with MetS. Previous studies 12,13,33,34 have already demonstrated that the THR and the TG/HDL-C ratio are associated with MetS in general younger population. This current study has also investigated that there is an association between the THR and MetS according both to the Chinese and the IDF criteria in very elderly population. However, statistical analyses have demonstrated that THR has a higher ability for MetS prediction according to the Chinese criteria than the IDF criteria. And interestingly, very elderly women are more likely to suffer from MetS according to both criteria in this very elderly population, which is different from the results of a previous study in young and middle aged Chinese30. Although the Chinese MetS criteria are mainly different from the IDF criteria in WC and HDL cholesterol cut-off points, the prevalence of abdominal obesity, hypercholesterolaemia and hypertriglyceridemia in this very elderly women population are higher than that of young and middle aged women, which may be one of the potential explanations for the difference of MetS predicting according to different MetS criteria.

It’s not surprising that this study has also demonstrated that the ability of the THR for predicting of MetS is similar to that of FPG and it is somewhat inferior to which of TG in this very elderly population. TG and FPG abnormalities are important components of MetS according to different criteria. Moreover, they could be somewhat more easily influenced by diets before testing. Therefore, except for these direct measured parameters for MetS diagnosis, the THR could be a reliable indirect measured parameter for MetS predicting in very elderly before absolute changes of directly measured lipid parameters become apparent or could be consider as an potential alternative marker for MetS in daily clinical practice.

Study limitations

Several limitations should be considered in this study. First, this cross-sectional study could not describe any causality. Second, the study population comes from the southwest of China, whether current findings could be generalized to other very elderly population or younger population in other areas of China needs further clarification from further longitudinal prospective studies, although limited life expectancy of very elderly could restrict the conduction of perspective studies in this special population.


In conclusion, the main finding of this study is that THR is associated with the increase risk of MetS and it could potentially add diagnostic information for MetS in very elderly Chinese population. Based on the high prevalence of abdominal obesity, dyslipidemia and glucose abnormality in this study and the oil rich local daily food style, proper lifestyle modification, especially a dietary modification are still needed to be emphasized in the prevention of MetS and ASCVD in very elderly, although the residual life expectancy of very elderly population is not the same long as that of younger population.