OBJECTIVE:To investigate the effect of body mass index (BMI) and body fat distribution as measured by waist-to-hip ratio (WHR) on the cardiovascular risk factor profile of the three major ethnic groups in Singapore (Chinese, Malay and Indian people) and to determine if WHO recommended cut-off values for BMI and WHR are appropriate for the different sub-populations in Singapore. DESIGN: Cross-sectional population study. SUBJECTS: A total of 4723 adult subjects (64% Chinese individuals, 21% Malay individuals and 15% Indian individuals) were selected through a multi-staged sampling technique to take part in the National Health Survey in 1998. MEASUREMENTS: Data on socio-economic status (education level, occupation, housing type) and lifestyle habits (smoking and physical activity), body weight, body height, waist and hip circumferences and blood pressure measured using standardised protocols. Fasting venous blood samples were obtained for determination of serum total cholesterol (TC), high density lipoprotein cholesterol (HDL), low density lipoprotein cholesterol (LDL), triglycerides (TG). Venous blood samples were taken for 2 h oral glucose tolerance test (2 h glu). RESULTS: Absolute and relative risks for at least one cardiovascular risk factor (elevated TC, elevated TC=HDL ratio, elevated TG, hypertension and diabetes mellitus) were determined for various categories of BMI and WHR. At low categories of BMI (BMI between 22 and 24 kg=m 2 ) and WHR (WHR between 0.80 and 0.85 for women, and between 0.90 and 0.95 for men), the absolute risks are high, ranging from 41 to 81%. At these same categories the relative risks are significantly higher compared to the reference category, ranging from odds ratio of 1.97 to 4.38. These categories of BMI and WHR are all below the cut-off values of BMI and WHR recommended by WHO. CONCLUSIONS:The results show that, at relatively low BMI and WHR, Singaporean adults experience elevated levels of risks (absolute and relative) for cardiovascular risk factors. These findings, in addition to earlier reported high percentage body fat among Singaporeans at low levels of BMI, confirm the need to revise the WHO cut-off values for the various indices of obesity and fat distribution, viz BMI and WHR, in Singapore.

OBJECTIVE -The International Diabetes Federation (IDF) proposes that central obesity is an "essential" component of the metabolic syndrome, while the American Heart Association/ National Heart, Lung, and Blood Institute (AHA/NHLBI) proposes that central obesity is an "optional" component. This study examines the effect of the metabolic syndrome with and without central obesity in an Asian population with ischemic heart disease (IHD). RESEARCH DESIGN AND METHODS-From the population-based cohort study (baseline 1992-1995), 4,334 healthy individuals were grouped by the presence or absence of the metabolic syndrome and central obesity and followed up for an average of 9.6 years by linkage with three national registries. Cox's proportional hazards model was used to obtain adjusted hazard ratios (HRs) for risk of a first IHD event.RESULTS -The prevalence of metabolic syndrome was 17.7% by IDF criteria and 26.2% by AHA/NHLBI criteria using Asian waist circumference cutoff points for central obesity. Asian Indians had higher rates than Chinese and Malays. There were 135 first IHD events. Compared with individuals without metabolic syndrome, those with central obesity/metabolic syndrome and no central obesity/metabolic syndrome were at significantly increased risk of IHD, with adjusted HRs of 2.8 (95% CI 1.8 -4.2) and 2.5 (1.5-4.0), respectively. CONCLUSIONS -Having metabolic syndrome either with or without central obesity confers IHD risk. However, having central obesity as an "optional" rather than "essential" criterion identifies more individuals at risk of IHD in this Asian cohort.

Objective: To evaluate the specific contact lensrelated or other factors that may contribute to the outbreak of Fusarium keratitis. Methods: A case-control study was conducted of Fusarium keratitis in contact lens users in Singapore from March 1, 2005, to May 31, 2006, and included 61 patients with Fusarium keratitis and 188 populationbased and 179 hospital-based control subjects. Interviewers asked about contact lens solution use and other risk factors. Results: Patients with Fusarium keratitis were more likely to use ReNu contact lens solutions (Bausch & Lomb, Rochester, NY) 58 [95.1%] of 61 cases) than were either population-based (62 [34.3%] of 181) or hospital-based (50 [30.1%] of 166) control subjects. After controlling for age, sex, contact lens hygiene, and other factors, the use of ReNu with MoistureLoc significantly increased the risk of Fusarium keratitis (odds ratio, 99.3; 95% confidence interval, 18.4-535.4; PϽ.001), and the risk was 5 times higher compared with the risk with use of ReNu MultiPlus, a multipurpose solution (odds ratio, 21.5; 95% confidence interval, 4.0-115.5; PϽ.001). Conclusions: The use of ReNu contact lens solutions significantly increased the risk of contact lens-related Fusarium keratitis in Singapore. Our data support the recall of ReNu MultiPlus from the Singapore market and the need for further investigations into the role of ReNu MultiPlus in the development of Fusarium keratitis in other populations.

OBJECTIVE: In 1997, the American Diabetes Association (ADA) recommended a new diagnostic category, impaired fasting glucose (IFG), to describe individuals with borderline glucose tolerance. On the other hand, the World Health Organization (WHO) suggested retaining the category of impaired glucose tolerance (IGT). We studied the prevalence of IFG and IGT in a multiethnic society and compared the cardiovascular risk profiles of subjects with IFG, IGT, or both IFG and IGT. RESEARCH DESIGN AND METHODS: A total of 3,568 subjects were examined from the 1992 National Health Survey of Singapore, which involved a combination of disproportionately stratified sampling and systematic sampling. Anthropometric, blood pressure, insulin, lipid profile, and uric acid measurements were taken, and a standard 75-g oral glucose tolerance test was performed after a 10-h overnight fast. RESULTS: The prevalence rates of IFG only, IGT only, and both IFT and IGT were 3.45, 10.2, and 3.4%, respectively. The degree of agreement (kappa) between the two diagnostic criteria (the ADA IFG and the WHO IGT) was only 0.25. A fasting glucose level of 5.5 mmol/l was the optimal cutoff for predicting a 2-h postload glucose level of > or =7.8 mmol/l. The following cardiovascular risk factors were higher in subjects with both IFG and IGT compared with those with either IFG or IGT alone: systolic blood pressure (131 +/- 20 vs. 125 +/- 21 and 125 +/- 19 mmHg, respectively; P < 0.05 and P < 0.001, respectively); diastolic blood pressure (77 +/- 12 vs. 73 +/- 12 and 74 +/- 12 mmHg, respectively; P < 0.05); BMI (26.2 +/- 4.2 vs. 24.4 +/- 4.0 and 24.6 +/- 4.4 kg/m2, respectively; P < 0.01 and P < 0.001, respectively); waist circumference (84.1 +/- 10.3 vs. 79.3 +/- 10.7 and 79.3 +/- 10.6 cm, respectively; P < 0.001); waist-to-hip ratio (0.84 +/- 0.08 vs. 0.82 +/- 0.09 and 0.81 +/- 0.08, respectively; P < 0.05 and P < 0.001, respectively); fasting insulin (12.1 +/- 9.7 vs. 9.2 +/- 5.3 and 9.9 +/- 7.7 mU/l; P < 0.01); insulin resistance (by homeostasis model assessment [HOMA]) (3.41 +/- 2.77 vs. 2.58 +/- 1.50 and 2.43 +/- 1.83, respectively; P < 0.01 and P < 0.001, respectively); total cholesterol (5.81 +/- 1.1 vs. 5.51 +/- 1.1 and 5.53 +/- 1.1 mmol/l, respectively; P < 0.05) and apolipoprotein(B) [apo(B)] (1.5 +/- 0.38 vs. 1.40 +/- 0.34 and 1.39 +/- 0.35 mmol/l, respectively; P < 0.01). The pattern of difference remained significant only for fasting insulin, insulin resistance (HOMA), and apo(B) (borderline) after adjustment for age, sex, and ethnic differences. CONCLUSIONS: Obvious discordance was evident in the classification of glycemic status when applying the criteria proposed by the ADA (IFG) or WHO (IGT) in a multiethnic society like Singapore. However, subjects with either IFG or IGT had similar cardiovascular risk profiles. Therefore, both criteria identified individuals at high risk for cardiovascular disease. Individuals with both IFG and IGT had a greater incidence of the cardiovascular dysmetabolic syndrome.

E. SHYONG TAI, MD 5OBJECTIVE -To 1) document the change in glucose tolerance for subjects with normal glucose tolerance (NGT) and impaired glucose tolerance (IGT) over time, 2) identify baseline factors associated with worsening of glucose tolerance, and 3) determine whether cardiovascular disease (CVD) risk factors associated with IGT improved in tandem with glucose tolerance.RESEARCH DESIGN -Subjects with IGT and NGT (matched for age, sex, and ethnic group) were identified from a cross-sectional survey conducted in 1992. Subjects with IGT (297) and NGT (298) (65.0%) were reexamined in 2000. Glucose tolerance (assessed by 75-g oral glucose tolerance test), anthropometric data, serum lipids, blood pressure, and insulin resistance were determined at baseline and at the follow-up examination.RESULTS -For NGT subjects, 14.0% progressed to IGT and 4.3% to diabetes over 8 years. For IGT subjects, 41.4% reverted to NGT, 23.0% remained impaired glucose tolerant, and 35.1% developed diabetes. Obesity, hypertriglyceridemia, higher blood pressure, increased insulin resistance, and lower HDL cholesterol at baseline were associated with worsening of glucose tolerance in both IGT and NGT subjects. Those with IGT who reverted to NGT remained more obese and had higher blood pressure than those with NGT in both 1992 and 2000. However, serum triglyceride, HDL cholesterol, and insulin resistance values in 2000 became indistinguishable from those of subjects who maintained NGT throughout the study period.CONCLUSIONS -Some, but not all, CVD risk factors associated with IGT and with the risk of future diabetes normalize when glucose tolerance normalizes. Continued surveillance and treatment in subjects with IGT, even after they revert to NGT, may be important in the prevention of CVD. Diabetes Care 26:3024 -3030, 2003D iabetes is associated with increased risk of microvascular (retinopathy, nephropathy, and neuropathy) and macrovascular complications (1). The latter manifests primarily as cardiovascular disease (CVD) (2). Diabetes is now recognized as a CVD risk equivalent in the National Cholesterol Education Program Adult Treatment Panel III (3). Although microvascular complications have been shown to be associated with the duration of diabetes (4 -6), the same cannot be said of CVD (7).It has been suggested that the lack of association between the duration of diabetes and CVD might be related to the presence of diabetes-associated CVD risk factors (dyslipidemia, hypertension, and obesity-all features of the metabolic syndrome) before the onset of glucose intolerance. As such, the atherosclerotic process is already underway by the time glucose intolerance sets in. In support of this hypothesis, in 1990, Haffner et al. (8) reported the 8-year follow-up of 614 nondiabetic Mexican Americans and compared the baseline characteristics of those who did and did not develop diabetes. Subjects who developed diabetes exhibited an atherogenic pattern of risk factors, including dyslipidemia, obesity, and hypertension, even in the nondiabetic s...