METABOLIC SYNDROME AND RELATED DISORDERS ORIGINAL ARTICLE

Volume 14, Number 2, 2016

 Mary Ann Liebert, Inc.
Pp. 1–7
DOI: 10.1089/met.2015.0067

C-Peptide Is a Sensitive Indicator for the Diagnosis

of Metabolic Syndrome in Subjects from Central Mexico

M. Elba Gonzalez-Mejia, MD, PhD,1 Leonardo M. Porchia, PhD,2

Enrique Torres-Rasgado, PhD,1 Guadalupe Ruiz-Vivanco, MS,1 Patricia Pulido-Pérez, MS,2
Blanca G. Báez-Duarte, PhD,1 and Ricardo Pérez-Fuentes, MD, PhD1,2

Abstract
Background: Metabolic Syndrome (MetS) is associated with elevated risk for developing diabetes and car-
diovascular disease. A key component of MetS is the development of insulin resistance (IR). The homeostatic
model assessment (HOMA) model can determine IR by using insulin or C-peptide concentrations; however, the
efficiency of insulin and C-peptide to determine MetS has not been compared. The aim of the study was to
compare the efficiency of C-peptide and insulin to determine MetS in Mexicans.
Methods: Anthropometrics, glucose, insulin, C-peptide, triglycerides, and high-density lipoproteins were de-
termined in 156 nonpregnant females and 114 males. Subjects were separated into normal or positive for MetS.
IR was determined by the HOMA2 calculator using insulin or C-peptide. Correlations were calculated using the
Spearman correlation coefficient (r). Differences between correlations were determined by calculating Steiger’s
Z. The sensitivity was determined by the area under receiver operating characteristics curve (AUC) analysis.
Results: Independent of the MetS definition [Adult Treatment Panel III (ATP III), International Diabetes
Federation (IDF), or World Health Organization (WHO)], C-peptide and insulin were significantly higher in
MetS subjects (P < 0.05). C-peptide and insulin correlated with all components of MetS; however, for waist
circumference, waist-to-hip ratio, and fasting plasma glucose, C-peptide correlated better than insulin
(P < 0.05). Moreover, C-peptide (AUC = 0.72–0.78) was a better marker than insulin (AUC = 0.62–0.72) for
MetS (P < 0.05). Finally, HOMA2-IR calculated with C-peptide (AUC = 0.80–0.84) was more accurate than
HOMA2-IR calculated with insulin (AUC = 0.68–0.75, P < 0.05) at determining MetS.
Conclusion: C-peptide is a strong indicator of MetS. Since C-peptide has recently emerged as a biomolecule
with significant importance for inflammatory diseases, monitoring C-peptide levels will aid clinicians in pre-
venting MetS.

Introduction Since its first description in the 1920s, MetS has been as-
sociated with hypertension and hyperglycemia, with the ad-

I n Mexico, with a large obesity problem and more pop-

ulation living an inactive lifestyle, Metabolic Syndrome
(MetS) is rapidly becoming a major health concern.1 A cur-
rent report suggested that 54.8% of the Mexican population is
positive for MetS,2 which has increased twofold since 1993.3
Moreover, MetS is associated with a fivefold increased risk
for developing type 2 diabetes and a twofold increased risk
for developing cardiovascular disease,4 thus making the
correct identification of MetS more beneficial for disease
prevention.
dition of central adiposity, hypertriglyceridemia, and insulin
resistance (IR) in later reports.5,6 Lacking any specific genetic
or physical markers,7,8 many organizations have developed
their own definitions, which are based around these central
concepts9; however, the use of any of them can inappropri-
ately misidentify subjects with or without MetS.
Even though the World Health Organization’s (WHO)
definition, which mainly focuses on IR and impaired glucose
tolerance,7 is the preferred definition for MetS, the National
Cholesterol Education Program Adult Treatment Panel III’s

1
Facultad de Medicina, Benemérita Universidad Autónoma de Puebla, Puebla, México.
2
Laboratorio de Fisiopatologı́a en Enfermedades Crónicas, Centro de Investigación Biomédica de Oriente, Instituto Mexicano del Seguro
Social, Puebla, México.

1
2 GONZALEZ-MEJIA ET AL.
(NCEP ATP III) definition is typically used in Mexico. The
ATP III focuses on using clinical and laboratory measure-
ments,10 which, for developing countries, is easier to apply.
However, due to the difficulties of applying the WHO and
ATP III definitions between different ethnicities, the Inter-
national Diabetes Federation (IDF) developed their own
definition4 that uses ethnic specific cutoff values.9 In Mexico,
many reports have compared these criteria yielding conflict-
ing results.
A key component of MetS is the development of IR or
impaired glucose tolerance. The ‘‘Gold Standard’’ to mea-
sure IR is the time-consuming, expensive hyperinsulinemic-
euglycemic clamp; moreover, its use in a large-scale study is
impractical.11 Therefore, using simpler, cheaper surrogate
indices, such as the homeostatic model assessment (HOMA)
and the Quantitative Insulin Sensitivity Check Index, has
become ideal. Typically, these indices require knowing the
fasting plasma glucose and insulin concentrations and, in
some cases, the C-peptide concentration.
Currently, there are two versions of HOMA, the equation-
based model (HOMA1), which focuses mainly on hepatic
IR, and the updated computer model (HOMA2), which fo-
cuses on hepatic and peripheral IR.11–13 Recent evidence
suggests that the HOMA2 model is more accurate at de-
termining IR.14,15 However, there are few reports that use
HOMA2 and determine its cutoff value for MetS, especially
in the Mexican population.16,17
Insulin and C-peptide are produced by the pancreas’ b-cells
and released in equimolar amounts in response to plasma
glucose concentrations. Due to impaired insulin action, plasma
C-peptide concentrations have been better correlated with
b-cell function.17 Furthermore, insulin and C-peptide are
cleared from the plasma by different mechanisms, leading
to different concentrations.17 Recently, C-peptide, which
was believed to be an inert biomolecule, was discovered
to be a part of the immune response by regulating inflam-
matory cytokines.18 In addition, MetS has been linked to
low-grade inflammation.19 Since MetS is influenced by a
chronic low-grade inflammation, this would insinuate that
C-peptide concentrations might correlate with components
of MetS.
This study was undertaken to determine the efficiency of
C-peptide and insulin to determine components of MetS in
subjects from the State of Puebla, Mexico, using three
definitions of MetS (ATP III, IDF, and WHO). In addition,
we propose cutoff values for C-peptide, insulin, and IR in-
dices for MetS.
Materials and Methods
Subjects and settings
Two hundred seventy subjects were recruited from the
Family Medicine Unit Clinic #2 of the Mexican Social Se-
curity Institute, located in the city of Puebla, Mexico, be-
tween March 2012 and February 2014 for a cross-sectional
study (males: n = 114 and nonpregnant females: n = 156).
The cohort, whose ages ranged from 18 to 80 years old,
consisted of healthy individuals with or without type 2 di-
abetes. The protocol was approved by the Scientific Re-
search Committee of the Mexican Social Security Institute.
All participants provided informed consent to participate in
the study, conducted in accordance with the Declaration of
Helsinki.
Clinical characterization
Subjects were clinically evaluated according to a stan-
dardized protocol, which included personal and family clin-
ical history. With the subjects in fasting conditions, wearing
light clothing and without shoes, their height (m) and weight
(kg) were measured using the body composition analyzer
(TBF-215; Tanita, Tokyo, Japan). Body mass index (BMI)
was calculated as weight divided by the height squared
(kg/m2).20 Waist circumference was measured at the mid-
point between the highest point of the iliac crest and the
lowest point of the costal margin at the midaxillary line with a
nonstretching anthropometric measuring tape. Hip circum-
ference was measured at the widest part of the buttocks. The
waist circumference was used to calculate the waist-to-hip
ratio by dividing it by the hip circumference. Diastolic and
systolic blood pressures were taken on the left arm of the
seated subject with a mercury-column sphygmomanometer
with an appropriately sized cuff. The data are the average of
two physician-obtained measurements.
Biochemical assays
Following a 10-12h overnight fast, whole blood samples
were collected from the antecubital vein into a Vacutainer
Plus plastic sterile tube with BD Hemogard closure con-
taining sodium fluoride and potassium oxalate (Catalog
#367925; BD Mexico City, Mexico) or containing EDTA
(Catalog #367863; BD Mexico City, Mexico) and kept at
room temperature to allow clotting. Samples were used for
the following endpoints: fasting plasma glucose, fasting
plasma insulin, HbA1c, C-peptide, high-density lipoprotein,
and triglycerides. The serum fraction was recovered and
frozen at -20C until used. Glucose levels were determined,
in duplicate, using plasma samples and the enzymatic meth-
od/spectrophotometric glucose oxidation (Beckman Instru-
ments, Brea, CA). Insulin levels were determined by an
automated immunoassay (Access; Beckman Instruments).
C-peptide levels were determined by the chemiluminescence
assay. The erythrocytes’ HbA1c percentage was determined
by the turbidimetric inhibition immunoassay. Triglycerides
and high-density lipoprotein levels were enzymatically
measured using the spectrophotometric method.
Calculation of insulin resistance
IR was assessed by either the HOMA equation: HOMA1-
IR = (fasting glucose · fasting insulin)/405 (units = mg/dL) or
the online calculator (HOMA2-IR) from www.dtu.ox.ac.uk/
homacalculator/index.php (downloaded on April 2014).
Defining metabolic syndrome
To classify subjects as normal [MetS(-)] or having Meta-
bolic Syndrome [MetS(+)], three definitions for MetS were
used. The ATP III definition required three of the following
five criteria: (1) waist circumference: ‡102 cm for men or
‡88 cm for women; (2) triglycerides ‡150 mg/dL; (3) high-
density lipoprotein: <40 mg/dL for men or <50 mg/dL
for women; (4) hypertension (systolic blood pressure:
‡130 mmHg or diastolic blood pressure: ‡85 mmHg); or (5)
impaired glucose tolerance (fasting plasma glucose ‡110 mg/
dL) or diabetes. The IDF definition required central adiposity
(waist circumference: ‡90 cm for men or ‡80 cm for women,
C-PEPTIDE AND METABOLIC SYNDROME 3

or BMI ‡30 kg/m2) and two of the following four criteria: (1)
triglycerides ‡150 mg/dL or using triglycerides lowering
medication; (2) high-density lipoprotein: <40 mg/dL for men,
<50 mg/dL for women, or using high-density lipoprotein
augmenting medication; (3) hypertension (systolic blood
pressure: ‡130 mmHg or diastolic blood pressure: ‡85 mmHg)
or treatment for hypertension; or (4) impaired glucose toler-
ance (fasting plasma glucose ‡100 mg/dL) or diabetes. The
WHO definition required impaired glucose tolerance or
diabetes and two of the following four criteria: (1) central
adiposity (waist-to-hip ratio: ‡0.90 for men or ‡0.85 for wo-
men, or BMI ‡30 kg/m2); (2) triglycerides ‡150 mg/dL; (3)
high-density lipoprotein: <35 mg/dL for men, <39 mg/dL
for women; or (4) hypertension (systolic blood pressure:
‡140 mmHg or diastolic blood pressure: ‡90 mmHg). Dia-
betes was defined according to the American Diabetes Asso-
ciation’s recommendations: type 2 diabetics (fasting glucose
‡126 mg/dL or HbA1c ‡6.5%), impaired glucose tolerance
(fasting glucose 100–125 mg/dL or HbA1c 5.7%–6.4%), or
normal glucose tolerance (fasting glucose <100 mg/dL or
HbA1c <5.7%).21
Statistical analyses
Statistical analyses were performed using the Statistical
Package for the Social Sciences program for Windows, ver-
sion 19 (SPSS, Chicago, IL), or MedCalc Statistical Software
version 13.3.3 (MedCalc, Ostend, Belgium). The data were
determined to be not normally distributed by the Shapiro–
Wilk Test (SPSS). The differences between MetS(-) and
MetS(+) groups were evaluated by the Mann–Whitney U Test
(SPSS). The association between parameters was determined
by calculating the Spearman’s correlation coefficient (r).
Comparisons between Spearman’s correlations were deter-
mined by calculating Steiger’s Z. Receiver operating char-
acteristic curve was used to determine the sensitivity and
specificity. The area under the receiver operating character-
istic curve (AUC) was calculated using the method described
by Hanley and McNeil (MedCalc).22 Comparisons between
receiver operating characteristic curves were also determined
using the Hanley and McNeil method (MedCalc).22,23 Using
the sensitivity and specificity, the Youden’s index (sensitivity
+ specificity – 1) was calculated and the highest Youden’s
index score was considered the optimal cutoff value (Med-
Calc). P values <0.05 were considered statistically signifi-
cant. Results are expressed as the mean – standard error.
Results
Using the three different definitions for MetS for our
cohort, we determined that between 56.3% and 63.3% of the
subjects were MetS(+). It is worthy to note that, even though
both ATP III and WHO had the same number of MetS(+)
subjects, only 125 of the subjects were shared between the
two definitions. The anthropometric and metabolic charac-
teristics are summarized in Table 1. For each definition, for
all parameters assayed, the MetS(+) subjects were signifi-
cantly higher than MetS(-) subjects (P < 0.05).
Given that, C-peptide and insulin are produced in equi-
molar amounts, but with different metabolic clearance rates
affecting their accumulation, we determined how well insulin
and C-peptide correlated with each component of MetS. For
C-peptide, there was a strong positive correlation for waist
circumference, BMI, fasting plasma glucose, and HbA1c

Table 1. Clinical and Metabolic Characteristics of the Study

ATP III IDF WHO
Category Total MetS(-) MetS(+) MetS(-) MetS(+) MetS(-) MetS(+)
Sample (m/f) 270 118 152 99 171 118 152
Age (years) 47.0 – 0.9 40.5 – 1.3 52.0 – 1.1* 40.9 – 1.5 50.5 – 1.1* 40.1 – 1.3 52.3 – 1.1*
Height (m) 1.59 – 0.01 1.61 – 0.01 1.58 – 0.01* 1.61 – 0.01 1.58 – 0.01* 1.61 – 0.01 1.57 – 0.01*
Weight (kg) 69.9 – 0.9 64.2 – 1.1 74.3 – 1.3* 62.0 – 1.1 74.5 – 1.2* 67.1 – 1.4 72.1 – 1.2*
Waist circumference (cm) 93.5 – 0.8 86.2 – 0.9 99.2 – 0.9* 84.1 – 0.9 98.9 – 0.8* 88.6 – 1.1 97.3 – 0.9*
Hip circumference (cm) 100.5 – 0.6 95.7 – 0.7 104.3 – 0.9* 94.0 – 0.7 104.3 – 0.8* 97.5 – 0.8 102.9 – 0.9*
Waist-to-hip ratio 0.93 – 0.01 0.90 – 0.01 0.92 – 0.01* 0.90 – 0.01 0.95 – 0.01* 0.91 – 0.01 0.95 – 0.01*
BMI (kg/m2) 27.7 – 0.3 24.8 – 0.3 29.9 – 0.4* 23.9 – 0.3 29.8 – 0.4* 25.8 – 0.4 29.1 – 0.4*
Systolic blood pressure 117 – 1 112 – 1 121 – 1* 112 – 1 119 – 1* 114 – 1 119 – 1*
(mmHg)
Diastolic blood pressure 77 – 1 74 – 1 79 – 1* 74 – 1 78 – 1* 75 – 1 78 – 1*
(mmHg)
Fasting plasma glucose 128 – 4 95 – 1 153 – 6* 103 – 4 142 – 5* 93 – 1 154 – 6*
(mg/dL)
HbA1c (%) 6.5 – 0.1 5.3 – 0.1 7.4 – 0.2* 5.7 – 0.2 7.0 – 0.2* 5.2 – 0.1 7.4 – 0.2*
Triglyceride (mg/dL) 189 – 8 136 – 8 230 – 11* 140 – 9 218 – 10* 148 – 9 221 – 11*
High-density lipoprotein 26.5 – 1.0 33.4 – 1.7 21.1 – 0.9* 35.1 – 1.9 21.5 – 0.9* 31.7 – 1.8 22.4 – 0.9*
(mg/dL)
C-peptide (mg/dL) 2.7 – 0.1 2.1 – 0.1 3.1 – 0.1* 2.0 – 0.1 3.0 – 0.1* 2.2 – 0.1 3.0 – 0.1*
Insulin (mg/dL) 10.2 – 0.4 8.1 – 0.4 11.9 – 0.5* 7.7 – 0.4 11.7 – 0.5* 8.9 – 0.5 11.3 – 0.5*
HOMA1-IR 3.24 – 0.15 1.94 – 0.10 4.25 – 0.22* 1.96 – 0.13 3.99 – 0.20* 2.07 – 0.12 4.16 – 0.22*
HOMA2-IR by C-peptide 2.23 – 0.07 1.56 – 0.06 2.75 – 0.10* 1.56 – 0.08 2.62 – 0.09* 1.63 – 0.07 2.70 – 0.10*
HOMA2-IR by insulin 1.44 – 0.05 1.07 – 0.05 1.73 – 0.07* 1.03 – 0.06 1.68 – 0.07* 1.16 – 0.07 1.67 – 0.07*
Data are average – standard error. Differences between groups were calculated by the Mann–Whitney U Test.
ATP III, Adult Treatment Panel III; BMI, body mass index; HOMA, homeostatic model assessment; IDF, International Diabetes
Federation; IR, insulin resistance; WHO, World Health Organization.
*P < 0.05 MetS(-) versus MetS(+).
4 GONZALEZ-MEJIA ET AL.

Table 2. Correlation Between C-Peptide and Insulin with Components of Metabolic Syndrome
C-peptide Insulin
Category q P q P Z-score
Waist circumference 0.488 <0.01 0.410 <0.01 2.12
Waist-to-hip ratio 0.265 <0.01 0.130 <0.05 3.31
BMI 0.496 <0.01 0.471 <0.01 0.70
Systolic blood pressure 0.234 <0.01 0.201 <0.01 0.81
Diastolic blood pressure 0.237 <0.01 0.176 <0.01 1.50
Fasting plasma glucose 0.371 <0.01 0.183 <0.01 4.72
HbA1c 0.356 <0.01 0.136 <0.05 5.46
Triglyceride 0.251 <0.01 0.184 <0.01 1.65
High-density lipoprotein -0.211 <0.01 -0.139 <0.05 1.76
Associations between variables were determined by calculating Spearman’s r. P values <0.05 were considered significant. Steiger’s Z
was calculated to compare between two correlations. Z-score >1.96 was considered significant.

(r = 0.356–0.496, P < 0.01) and a moderate correlation with HOMA2-IRinsulin, independent of the MetS definition used
waist-to-hip ratio, diastolic and systolic blood pressures, tri- (P < 0.0001).
glyceride, and high-density lipoprotein (r = 0.211–0.251, The optimal cutoff values for C-peptide, Insulin, HOMA1-
P < 0.01, Table 2). A similar result was seen with insulin, IR, HOMA2-IRc-peptide, and HOMA2-IRinsulin to determine
except fasting plasma glucose and HbA1c were weakly cor- MetS were calculated using the MedCalc software. The
related (r = 0.136–0.471, P < 0.05). However, when the cor-
relations between C-peptide and insulin for the components C-peptide
of MetS were compared, C-peptide’s correlation was signif- A 1.0
icantly better than insulin for waist circumference, waist-to-
hip ratio, fasting plasma glucose, and HbA1c (P < 0.05).
0.8
Since, C-peptide better correlated with certain compo-
nents of MetS than insulin, receiver operating characteristic
Sensitivity

analysis was used to compare the effectiveness of insulin 0.6

and C-peptide to indicate MetS. For C-peptide, the AUC
was 0.76 (95% CI: 0.73–0.83, P < 0.0001) for the ATP III
0.4
definition, 0.78 (95% CI: 0.73–0.83, P < 0.0001) for the IDF
definition, and 0.72 (95% CI: 0.66–0.77, P < 0.0001) for the ATP-III
WHO definition (Fig. 1A). For insulin, the AUC was 0.68 0.2 IDF
(95% CI: 0.62–0.74, P < 0.0001) for the ATP III definition, WHO
0.72 (95% CI: 0.66–0.77, P < 0.0001) for the IDF definition,
0
and 0.62 (95% CI: 0.56–0.68, P < 0.0005) for the WHO
definition (Fig. 1B). Comparing AUCs between C-peptide 0 0.2 0.4 0.6 0.8 1.0
and insulin, we determine that the AUC for C-peptide was 1-Specificity
significantly larger, suggesting that C-peptide is a better
indicator for MetS, independent of the definition used (ATP Insulin
B 1.0
III: P > 0.0001; IDF: P = 0.0043; WHO: P < 0.0001).
MetS is associated with the development of IR. With
multiple indices available, we examined the validity of the 0.8
HOMA indices to determine MetS by receiver operating
characteristic analysis. For HOMA1-IR, the AUC was 0.82
Sensitivity

(95% CI: 0.77–0.89, P < 0.0001) for the ATP III definition, 0.6
0.79 (95% CI: 0.74–0.84, P < 0.0001) for the IDF definition,
and 0.79 (95% CI: 0.73–0.83, P < 0.0001) for the WHO 0.4
definition (Fig. 2A). For HOMA2-IR determined with C-
peptide (HOMA2-IRC-peptide), the AUC was 0.84 (95% CI: ATP-III
0.80–0.89, P < 0.0001) for the ATP III definition, 0.81 (95% 0.2 IDF
CI: 0.76–0.86, P < 0.0001) for the IDF definition, and 0.80 WHO
(95% CI: 0.75–0.85, P < 0.0005) for the WHO definition 0
(Fig. 2B). For HOMA2-IR determined with Insulin
0 0.2 0.4 0.6 0.8 1.0
(HOMA2-IRinsulin), the AUC was 0.74 (95% CI: 0.68–0.79,
P < 0.0001) for the ATP III definition, 0.75 (95% CI: 0.70– 1-Specificity
0.80, P < 0.0001) for the IDF definition, and 0.68 (95% CI: FIG. 1. Receiver operating characteristic curve for C-peptide
0.63–0.74, P < 0.0005) for the WHO definition (Fig. 2C). (A) and insulin (B) for determining MetS. ATP III (blue), IDF
Comparing AUCs between HOMA1-IR, HOMA2-IRc-peptide, (green), and WHO (red) definitions for MetS were assessed.
and HOMA2-IRinsulin, HOMA1-IR and HOMA2-IRc-peptide MetS, Metabolic Syndrome; WHO, World Health Organiza-
were equal at determining MetS and both were superior to tion. Color images available online at www.liebertpub.com/met
C-PEPTIDE AND METABOLIC SYNDROME 5

HOMA1-IR highest Youden’s Index was considered to be the optimal

A 1.0 value. The proposed cutoff values, sensitivity, specificity, and
positive likelihood ratios are listed in Table 3. For C-peptide
and insulin, there was large variability between the cutoff
0.8
values, ranging between 1.9–2.4 mg/dL and 9.8–12.7 mU/mL,
respectively. For HOMA1-IR and HOMA2-IRc-peptide, the
Sensitivity

0.6 cutoff values are similar for the ATP III and IDF definitions,
2.4 and 2.0, respectively. However, for HOMA1-IRinsulin,
there was no consistency between the three definitions (range:
0.4
1.2–1.5). Overall, these results suggest that C-peptide is a
ATP-III better marker of MetS; furthermore, C-peptide-derived IR
0.2 IDF was more dependable than its insulin counterpart was when
WHO using the HOMA2 model.
0
Discussion
0 0.2 0.4 0.6 0.8 1.0
1-Specificity In Mexico, the prevalence of MetS is rapidly increasing.
With our cohort, we assessed the predictive capabilities of
B HOMA2-IRinsulin C-peptide, insulin, and their derivative IR indices for MetS.
1.0 In this study, the prevalence of MetS ranged between 56.3%
and 63.3%, depending on the MetS definition used. Other
0.8
studies have confirmed this result, ranging from 21.4% in
2004 to 54.8% in 2014 in the total population and up to
73.8% in only obese subjects, however focusing on other
Sensitivity

0.6 regions of Mexico.2,3,24–26

Within the past two decades, the biological importance of
0.4
C-peptide has emerged as a regulator of low-grade inflam-
mation.18 Furthermore, the effect of C-peptide on MetS de-
ATP-III velopment has just begun to be deduced. In a study of young
0.2 IDF Arab females, C-peptide was shown to moderately correlate
WHO with diastolic blood pressure, waist circumference, as well as
0
high-density lipoprotein, and not systolic blood pressure, in
obese subjects. Even though the Pearson’s correlation coef-
0 0.2 0.4 0.6 0.8 1.0 ficient suggested the presence of an association, the lack of a
1-Specificity significant correlation could be due to a small sample size.
Furthermore, the authors did not examine the correlation with
C HOMA2-IRc-peptide other components of MetS.27 Our results are in agreement
with this study; moreover, we included other components of
1.0
MetS (i.e., fasting plasma glucose, triglycerides, and so on),
independent of obesity. We concluded that insulin and
0.8 C-peptide correlated with all components of MetS, but
C-peptide better correlated with waist circumference, waist-
to-hip ratio, fasting plasma glucose, and HbA1c.
Sensitivity

0.6
The use of surrogate indices is more practical for large
studies. Most of these indices are based on fasting plasma
0.4 glucose and insulin levels.28 However, since C-peptide cor-
related better to glucose function, we postulated if an index
ATP-III based on C-peptide levels was more efficient to determine
0.2 IDF MetS. Indeed, IR values calculated by C-peptide by the
WHO HOMA2 model were significantly superior to IR values cal-
0 culated by insulin, using the same model. The HOMA1-IR
index is the most preferred surrogate index. Interestingly,
0 0.2 0.4 0.6 0.8 1.0
when we compared the C-peptide derived IR index to the
1-Specificity standard, the HOMA1-IR (calculated only using fasting
FIG. 2. Receiver operating characteristic curve for IR plasma glucose and insulin) and HOMA2-IR calculated by C-
indices to determine MetS. HOMA1-IR (A), HOMA2-IR- peptide were both equal at determining MetS and superior
insulin (B), and HOMA2-IRC-peptide (C) were evaluated using
than HOMA2-IR calculated by insulin. This result could be
the ATP III (blue), IDF (green), and WHO (red) defini- explained by the fact that HOMA1 only measures hepatic IR,
tions for MetS. HOMA, homeostatic model assessment; IR, whereas HOMA2 measures hepatic and peripheral IR.29
insulin resistance. Color images available online at www This does suggest that C-peptide is a better indicator of
.liebertpub.com/met overall IR. The mechanism of this effect remains unclear.
Two possible mechanisms could explain this result. First, C-
peptide can regulate the expression of inflammatory
6 GONZALEZ-MEJIA ET AL.

Table 3. Proposed Cutoff Values to Determine Metabolic Syndrome for Central Mexicans
ATP III IDF WHO
Parameter Cutoff Sn Sp LR(+) Cutoff Sn Sp LR(+) Cutoff Sn Sp LR(+)
C-peptide 1.9 0.887 0.551 2.0 2.4 0.677 0.758 2.8 2.2 0.750 0.581 1.8
Insulin 12.7 0.378 0.890 3.4 9.8 0.547 0.779 2.5 10.6 0.461 0.735 1.7
HOMA1-IR 2.4 0.689 0.771 3.0 2.4 0.659 0.808 3.4 2.9 0.586 0.846 3.8
HOMA2-IRC-peptide 2.0 0.722 0.814 3.9 2.0 0.665 0.818 3.7 1.8 0.757 0.692 2.5
HOMA2-IRinsulin 1.2 0.649 0.678 2.0 1.5 0.488 0.869 3.7 1.4 0.513 0.761 2.1
Cutoff value was determined by the highest Youden’s Index value (sensitivity + specificity -1).
Sn, sensitivity (%); Sp, specificity (%); LR(+), positive likelihood ratio.

cytokines.17 Increases in proinflammatory cytokines aug-
ment IR in the muscle tissue and the conversion of macro-
phages to foam cells, which also promote elevated
triglyceride levels and IR.17 Another possible mechanism is
C-peptide regulates insulin activity. Inactive hexamer insu-
lin becomes active monomeric insulin in the presence of C-
peptide, leading to increased glucose utilization.30
The currently used cutoff for IR in Mexico for HOMA1-IR
is 2.6.13 Here the ATP III and IDF gave values close to the
suggested cutoff, and the WHO proposed that the cutoff was
much higher (2.9). At this time, there are no proposed cutoff
values for the HOMA2-IR models for Mexico. In Brazil, the
BRAMS demonstrated a HOMA2-IR cutoff value, calculated
by glucose and insulin levels, of 1.8 using the 90th percentile
of the healthy subjects and 1.4 for MetS, using the IDF
definition.31 In this study, using the multiple definitions for
MetS, we determined the HOMA2-IR cutoff value, calculated
by insulin, to be 1.2, 1.5, and 1.4 for ATP III, IDF, and WHO,
respectively. A proposed cutoff value for HOMA2-IR cal-
culated by C-peptide has not been determined for Mexico or
any other country. We determined a cutoff value of 2.0, 2.0,
and 1.8 for ATP III, IDF, and WHO, respectively. Using the
higher positive likelihood ratio, we suggest 2.0 and 1.5 cutoff
values for the HOMA2-IR models when calculated by C-
peptide and insulin, respectively. This does suggest that our
value is similar to the BRAMS and supports its validity.
In this study, we demonstrate the superior efficiency of
C-peptide over insulin to determine IR and MetS; however,
its inclusion into the criteria for MetS determination remains
unadvisable. This result has mainly been shown in two
populations with key caveats—Central Mexicans and obese
Arab women.27 There is a substantial need to reproduce this
study among many different populations before it is even
to be considered. Furthermore, the costs associated with
C-peptide testing are, in most places, 10%–30% more ex-
pensive than insulin. To that end, C-peptide’s diagnostic
potential recently has been posited and has not undergone
the comprehensive optimization that other biomarkers have,
such as insulin and glucose, which will decrease its cost and
interlaboratory viability.
The current conception of using few biomarkers to
identify a disease, or the increased potential of developing a
disease, does lead to the miscategorization of many subjects
that could benefit from early interventions. Moreover, nu-
merous studies are demonstrating that the development of
one pathology can occur by many different mechanisms, all
of which could require different treatments. All this does
suggest that the future of medicine will require the use of
many biomarkers for the correct identification and selection
for the prevention or treatment of a disease. At the current
date, this remains unfeasible, especially for poor countries,
but not impossible to overcome. Nonetheless, identification
of possible biomarkers remains the first most important step.
This study had a few limitations. First, postprandial glu-
cose tolerance was not included in the diagnosis of type 2
diabetes and impaired glucose tolerance. It is possible few
subjects would have been classified as MetS(+) if we included
this parameter, minimally affecting the results. Second, IR
and its correlation to the proposed cutoff values could not be
determined using the hyperinsulinemic-euglycemic clamp.
However, many reports have demonstrated that the methods
used in this study correlated well with the hyperinsulinemic-
euglycemic clamp. Third, this is a cross-sectional study and
does not indicate any causal relationships. Further studies are
required to determine the effect C-peptide has on the com-
ponents of MetS and MetS development. Finally, the sample
comprised both male and female. It is possible that separation
by gender would affect the proposed cutoff values, but mostly
not the significance of the correlations.
Conclusion
In conclusion, in subjects from Central Mexico, we
demonstrate that C-peptide is a strong indicator of MetS.
Since C-peptide has recently emerged as a biomolecule with
significant importance with inflammatory diseases, moni-
toring C-peptide levels may aid clinicians in preventing
MetS development.
Acknowledgments
The authors would like to express their gratitude to the
participants of this study, to Maria del Carmen Sanchez-
Guillen, who contributed to the development of this project,
and to Ricardo Villegas-Tovar from BUAP Libraries-
Department. This study was supported by grants from the
Programa de Mejoramiento del Profesorado’’ (PROMEP-
SEP)’’ and the ‘‘Vicerrectorı́a de Investigación (VIEP)’’ of the
Benemérita Universidad Autónoma de Puebla, Mexico (to
ETR, MEGM, and RPF).
Author Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Ricardo Pérez-Fuentes, MD, PhD
Laboratorio de Fisiopatologı́a de Enfermedades Crónicas
Centro de Investigación Biomédica de Oriente
Instituto Mexicano del Seguro Social
HGZ No. 5 Km 4.5 Carretera Federal Atlixco-Metepec
Puebla 42730
México
E-mail: rycardoperez@hotmail.com