Clinical Endocrinology (2013) 78, 874–881 doi: 10.1111/j.1365-2265.2012.04487.

ORIGINAL ARTICLE

Neck circumference as a simple tool for identifying the metabolic

syndrome and insulin resistance: results from the Brazilian
Metabolic Syndrome Study
Christiane Stabe*, Ana Carolina Junqueira Vasques*, Marcelo Miranda Oliveira Lima*,
Marcos Antonio Tambascia*, Jose Carlos Pareja†, Ademar Yamanaka‡ and Bruno Geloneze*

*Laboratory of Research in Metabolism and Diabetes, Department of Medical Clinic, State University of Campinas UNICAMP,
†Laboratory of Research in Metabolism and Diabetes, Department of Surgery, State University of Campinas UNICAMP and
‡Department of Medical Clinic, State University of Campinas UNICAMP, Campinas, São Paulo, Brazil

tion with high-density lipoprotein (HDL). NC and IS showed a

Summary
Objective To investigate the relationship of the neck circumfer-
ence (NC) with the metabolic syndrome (MetS) and insulin
resistance (IR) in a large Brazilian population-based sample,
within a wide range of adiposity and glucose tolerance, and to
establish cut-off values of the NC for MetS and IR.
Context The NC correlates with cardiovascular risk factors, IR
and components of MetS. Upper-body subcutaneous (sc) fat, as
estimated by the NC, is associated with cardiovascular risk
factors as much as abdominal fat, which is usually estimated by
the waist circumference (WC). There are few epidemiological
population-based studies on the clinical significance of the NC
to MetS and IR.
Design This is a cross-sectional study.
Patients About 1053 Brazilian adults (18–60 years).
Measurements Patients with BMI 18
5–40
0 kg/m2, with nor-
mal glucose tolerance or type 2 diabetes (T2DM), were submitted
to anthropometric measurements including waist circumference
(WC), NC and BMI. Abdominal visceral fat (VF) was assessed by
ultrasound. Insulin sensitivity (IS) was assessed by euglycaemic–
hyperinsulinaemic clamp (10% of total sample) and HOMA-IR.
Spearman correlations were used to evaluate the association
between NC and IR and MetS risk factors. Receiver operating
characteristic (ROC) curves were used for gender-specific cut-off
values for the prediction of IR and MetS. Binary logistic regression
analysis was used to assess the chance of developing IR or MetS
according to the enlargement of NC and WC.
Results The sample consisted of 28
6% men, with a mean age
of 39
4 (12 years). T2DM diagnosis was present in 306 individu-
als, of whom 34% were men. NC correlated with WC and BMI
in both men and women (P < 0
001). In both genders, NC
showed a positive correlation with triglycerides, fasting glucose,
fasting insulin and HOMA-IR, and NC had a negative associa-
Correspondence: Christiane Stabe, Av. Pioneiros, 750 (227) – Pq Villa
Flores – Sumaré – 13175-668; E-mail: chrisstabe@hotmail.com
moderate negative correlation. A significant correlation was
demonstrated between VF and NC. In the ROC curves, NC pre-
sented the largest AUC for IR in women (P < 0
001), while NC
presented a large AUC for MetS in both genders.
Conclusions Neck circumference measurements are an alterna-
tive and innovative approach for determining body fat distribu-
tion. The NC is positively associated with MetS risk factors, IR
and VF, with established cut-off values for the prediction of
MetS and IR.
(Received 29 February 2012; returned for revision 01 April 2012;
finally revised 13 June 2012; accepted 26 June 2012)
Introduction
Body distribution of adiposity is a stronger predictor of meta-
bolic dysfunctions and cardiovascular risk than whole-body
adiposity, which is measured as the body mass index (BMI).1
The wide use of the waist circumference (WC) relies on its
correspondence to abdominal visceral fat (VF), which is
thought to have a major role in cardiometabolic risk.2–5 How-
ever, upper-body subcutaneous fat (SF) relates to cardiometa-
bolic risk as much as abdominal VF.6 The neck circumference
(NC) is an alternative measure of upper-body SF that corre-
lates with whole-body adiposity (BMI), abdominal adiposity
(WC and waist-to-hip ratio), abdominal VF and components
of the metabolic syndrome (MetS), such as systolic and dia-
stolic blood pressures, total cholesterol, triglycerides, fasting
glucose and insulin resistance (IR).1–6
Despite the established use of the WC in the evaluation of
health risk, it has a number of limitations.7 First, different
anatomical landmarks have been used to determine the exact
location for measuring WC in different clinical studies. The
specific site used to measure the WC influences the absolute
WC value that is obtained.8 Second, it is subject to variations
during the day and under health conditions affecting either

874 © 2012 John Wiley & Sons Ltd


the structure of the abdominal wall (e.g. severe obesity, lipo-
abdominoplasty, great weight loss) or abdominal organs and
cavity. Third, it may not be practical for large population
studies, especially in cold weather and heavy clothing.
Measuring the NC is easier than measuring the WC,
which presents a large variability in its procedure. Addition-
ally, the NC measurements can be useful in clinical screen-
ings for persons with an increased risk for IR and MetS.
Furthermore, developing simple tools for quantifying insulin
sensitivity (IS) in humans, such as NC, is of clinical interest
to accurately appropriately investigate the epidemiology,
pathophysiological mechanisms, therapeutic intervention out-
comes and clinical courses of patients with IR.9 There are
few epidemiological population-based studies on the clinical
significance of the NC to MetS and IR because most studies
on the NC focus on its correlation with obstructive sleep
apnoea syndrome.10
The aims of this study were to investigate the relationship of
the NC with MetS and IR in a large population-based sample of
Brazilian adults with a wide range of adiposity and glucose toler-
ance and to establish cut-off values of the NC for the prediction
of MetS and IR.
Subjects and methods
This study was performed as part of the Brazilian Metabolic
Syndrome Study (BRAMS), a population survey on metabolic
disorders, which included subjects from different regions of Bra-
zil. Currently, BRAMS is being conducted in five cities: Campin-
as and Itu, SP; Três Corações, MG; Fortaleza, CE; and Natal,
RN.
From 1998 to 2011, a total of 3498 subjects were included
in the study. The sample was selected using an intentional
nonprobabilistic sampling. The patients were selected from out-
patient clinics of type 2 diabetes, metabolic syndrome and
obesity. The data from 1053 subjects met the criteria for the
desired analyses: adult (aged 18–60 years), adiposity in a wide
range (BMI 18
5 to 40
0 kg/m2) and either normal glucose tol-
erance or type 2 diabetes according to the ADA criteria (those
with abnormal glucose tolerance but no diabetes were
excluded). None of the subjects were using any medicine that
affected plasma glucose levels or insulin sensitivity, except the
diabetic individuals. As our diabetic group was composed by
patients with well-controlled mild diabetes, they were receiving
nonpharmacological approach (diet plus lifestyle changes rec-
ommendations) or metformin that could be stopped for 3 days
before clamp studies without significant worsening of the pre-
vailing glycaemic control. The exclusion criteria were as fol-
lows: clinical or laboratory evidence of cardiac, renal, liver or
endocrine disease, severe systemic disease (e.g. cancer, heart
failure) or AIDS as well as patients who were bodybuilders or
pro-/amateur athletes, pregnant or lactating.
The Ethics Committee of the Medical School of the University
of Campinas (UNICAMP) approved the study. The subjects pro-
vided informed written consent.
© 2012 John Wiley & Sons Ltd
Clinical Endocrinology (2013), 78, 874–881
Neck circumference as a simple tool 875
Anthropometry
All the subjects underwent a detailed anthropometrical examina-
tion while wearing light clothes and no shoes. Body weight was
assessed using an electronic scale to the nearest 0
1 kg. Height
was measured to the nearest 0
1 cm, and body mass index
(BMI) was calculated as weight (kg) divided by height (m)
squared. Waist circumference was measured using an inelastic
tape at the umbilicus level after normal exhalation to the nearest
0
1 cm, without clothes in the measurement area. Hip circum-
ference was measured at the most salient point between the
waist and the thigh,11 and the waist-to-hip and height-to-waist
ratios were calculated. The thigh circumference was measured at
the right side, midway between the inguinal crease and the prox-
imal border of the patella, with the tape perpendicular to the
vertical axis. The individual remained standing with his or her
right leg slightly bent.12 NC was measured at the base of the
neck, below the cricothyroid cartilage. The reading circle was
held in front of the collarbone, in the external extremity, and
the neck-to-thigh ratio was determined.13
Abdominal visceral fat assessment
The abdominal VF was assessed by ultrasound using a
3
5-MHz probe located 1 cm from the umbilicus (GE) in 10%
of the whole sample, in one study site only. The same observer
took two ultrasound measurements of the thickness of the
intra-abdominal (‘visceral’) fat. VF was defined as the distance
between the internal face of the same muscle and anterior wall
of the aorta.14 The reliability analysis showed a strong intra-
class correlation coefficient (r = 0
98; IC 95%: 0
98–0
99;
P < 0
001).
Insulin sensitivity
Insulin sensitivity (IS) was assessed by a 180-min euglycaemic–
hyperinsulinaemic clamp,15 which is the gold standard method
for measuring IS, in a 10% of the whole sample, in one study site
only. A primed continuous intravenous insulin infusion (40 mU/
m2/min) was administered. Fasting glycaemia was maintained
(variation 5%) by a variable rate glucose infusion, and blood
glucose was determined (glucose oxidase) every 5 min by a YSI
2700 biochemistry analyzer (Yellow Springs Inc., Yellow Springs,
OH, USA). If fasting hyperglycaemia was present, it was corrected
to a target of 100 mg/dl by an initial i.v. insulin infusion. IS was
calculated as the glucose infusion rate (GIR) at 80–120 min
(steady state), corrected for the glucose distribution space and
adjusted to fat-free mass (FFM), resulting in the M value.
Insulin sensitivity was also assessed using the homoeostasis
model assessment IR index (HOMA-IR).16 HOMA-IR was calcu-
lated using the following formula: HOMA-IR = [fasting glucose
(mg/dL) 9 fasting insulin (lU/ml)]/405.
The subjects were classified with IR if the HOMA-IR > 2
71,
which is the cut-off value that was determined for the Brazilian
population.17
876 C. Stabe et al.

Definition of metabolic syndrome method) and ultra-sensitive C-reactive protein (CRP) (chemilu-
minescence) were measured. Plasma insulin was measured using
Metabolic syndrome was defined using the International Diabe-
an ELISA kit for human insulin with negligible cross-reactivity
tes Federation criteria,18 which considers central obesity based
with proinsulin (Linco Research, St. Louis, MO, USA). The
on waist circumference plus any two of the following four fac-
intra-assay and interassay CVs were 2
9–9
4% and 5
5–8
5%,
tors: raised triglyceride levels (=1
695 mM) or current treatment
respectively. Free fatty acids (FFA) and adiponectin concentra-
for this condition; reduced HDL cholesterol (<1
036 mM in men
tions were measured using an ELISA kit (R&D Systems, Minne-
and <1
295 mM in women) or current treatment for this lipid;
apolis, MN, USA).
raised blood pressure (systolic blood pressure = 130 or diastolic
blood pressure = 85 mmHg) or current treatment with an anti-
hypertensive drug (for a previously diagnosed hypertension); or Statistical analysis
raised fasting plasma glucose (=5
55 mM) or previously diag-
Statistical analysis was performed with the SPSS program for
nosed type 2 diabetes. The cut-off for waist circumference was
Windows (version 18.0). A P value <0
05 was considered statisti-
to set Europids (e.g. WC  94 cm to men; WC  80 cm for
cally significant. The Kolmogorov–Smirnov test was applied to
women).
assess the assumption of normality for the data. Data were
reported as mean ± standard deviation (SD) or median/inter-
Blood biochemical assays quartile range, according to the normal distribution status. Spear-
man correlations were performed to assess associations of
Blood samples were obtained after a 12-h overnight fast and
interest. Receiver operating characteristic (ROC) curves were
were stored at 20 °C for later evaluation. Plasma glucose (glu-
constructed to evaluate the performance of anthropometric
cose oxidase method), glycated haemoglobin (HPLC method),
parameters to identify the conditions IR and MetS. The areas
lipid profile (total cholesterol, high-density lipoprotein choles-
under the ROC curves were calculated, using a range of 95%. For
terol (HDL-C), low-density lipoprotein cholesterol (LDL-C) and
the comparison of curves, Z-test was performed with multiple
triglycerides), uric acid, liver enzymes (enzymatic colorimetric
comparisons two by two – MedCalc program version 9.3. The
sensitivity and specificity of anthropometric indicators were cal-
culated for each cut-off point in the sample. The cut-off point
Table 1. Baseline study sample characteristics

Men Women
Table 2. Age-adjusted Spearman correlation between the neck circum-
Parameters n = 301 n = 752 P-value
ference and certain risk factors

Age (years) 42
7 ± 12
1* 38
1 ± 12
8 0
001

Neck circumference
Weight (kg) 79
1 ± 14
6 71
2 ± 15
1 0
001
Height (m) 1
70 ± 0
08 1
56 ± 0
07 0
001
BMI (kg/m2) 27
3 ± 4
3 28
3 ± 5
5 0
001 Men Women
Waist circumference (cm) 94
5 ± 12
9 93
4 ± 13
9 NS
Hip circumference (cm) 99
9 ± 10
1 104
9 ± 11
1 0
001 r P r P
Waist-to-hip ratio 0
9 ± 0
1 1
0 ± 0
4 NS
Waist-to-height ratio 0
5 ± 0
1 0
6 ± 0
1 0
001 BMI (kg/m2) 0
67 0
001 0
62 0
001
Neck circumference (cm) 39
7 ± 2
9 35
9 ± 2
8 0
001 Waist circumference (cm) 0
71 0
001 0
64 0
001
Thigh circumference (cm) 51
2 ± 5
7 54
2 ± 7
0 0
001 Waist-to-hip ratio 0
33 0
001 0
02 0
56
Neck-to-thigh ratio 0
7 ± 0
1 0
6 ± 0
1 0
001 Systolic blood pressure (mmHg) 0
07 0
23 0
25 0
001
Systolic blood pressure (mmHg) 125 ± 16 117 ± 15 0
001 Diastolic blood pressure (mmHg) 0
05 0
35 0
13 0
001
Diastolic blood pressure 80 ± 11 77 ± 32 0
001 Total cholesterol (mM) 0
04 0
47 0
09 0
01
(mmHg) HDL cholesterol (mM) 0
22 0
001 0
27 0
001
HDL cholesterol (mM) 1
1 ± 0
2 1
2 ± 0
3 0
001 Triglycerides (mM) 0
25 0
001 0
30 0
001
Triglycerides (mM) 1
4 ± 0
8 1
2 ± 0
7 0
001 Fasting glucose (mM) 0
17 0
001 0
15 0
001
Fasting glucose (mM) 5
7 ± 2
5 5
2 ± 2
0 0
001 Uric acid (lM) 0
11 0
08 0
22 0
001
Uric acid (μM) 333 ± 136 276 ± 148 0
001 GGT (U/l) 0
01 0
97 0
13 0
001
GGT (U/l) 39
9 ± 44
5 25
8 ± 31
3 0
001 ALT (U/l) 0
02 0
79 0
06 0
10
ALT (U/l) 32
1 ± 39
1 21
6 ± 30
5 0
001 AST (U/l) 0
07 0
23 0
06 0
10
AST (U/l) 25
2 ± 21
6 19
7 ± 18
1 0
001 C-reactive protein (mg/l) 0
01 0
93 0
20 0
001
C-reactive protein (mg/dl) 0
3 ± 0
1 0
5 ± 0
1 NS Free fatty acids (mM) 0
02 0
87 0
05 0
42
Free fat acids (mM) 0
03 ± 0
02 0
03 ± 0
02 NS Adiponectin (lg/ml) 0
23 0
05 0
20 0
001
Fasting insulin (pM) 80
7 ± 11
8 75
07 ± 7
0 NS Glycated haemoglobin (PTHemogl.) 0
21 0
001 0
20 0
001
Adiponectin (μg/ml) 5
1 ± 4
8 4
9 ± 5
2 NS Fasting insulin (pM) 0
21 0
001 0
30 0
001
Homa-IR 3
5 ± 5
9 2
9 ± 3
9 NS Log HOMA-IR 0
30 0
001 0
42 0
001

*Mean ± SD (all such values). GGT, gamma glutamyltransferase; ALT, alanine transferase; AST, aspar-
NS, not significant. tate transferase; PTHemogl., proportion of total haemoglobin.

© 2012 John Wiley & Sons Ltd

Clinical Endocrinology (2013), 78, 874–881
 Neck circumference as a simple tool 877

that resulted in a higher sum of sensitivity and specificity was

chosen to optimize the relationship between these two parameters
with higher accuracy (fewer false negatives and false positives). In
parallel, looked up so that the minimum values of sensitivity and
specificity were  60%, obtaining a balance between sensitivity
and specificity. Binary logistic regression analysis was performed,
considering the HOMA-IR and MetS as dependent variables and
the neck and waist circumference as independent variables. Anal-
yses were performed separately for each gender.
Results
The study sample consisted of 1053 individuals, 301 (28
6%)
men and 752 women, with a mean age of 39
4 ± 12 years. MetS
was identified in 94 (31
2%) men and 243 (32
3%) women, and
IR was found in 77 (34%) men and 177 (31%) women. T2DM
diagnosis was present in 306 individuals (29%), of whom 34%
were men. The main characteristics of the study population are
presented in Table 1. All variables, except for WC, waist-to-hip

Fig. 1 Relationship between NC (cm) and MetS risk factors in men (●) and women (○). Correlation assessed by Spearman analysis. Systolic and
diastolic blood pressure were measured in mmHg; total cholesterol, uric acid, HDL-cholesterol, fasting glucose and fasting insulin were measured in
mg/dl.

© 2012 John Wiley & Sons Ltd

Clinical Endocrinology (2013), 78, 874–881
878 C. Stabe et al.

Fig. 2 Relationship between NC (cm) and M value, LogHOMA-IR and adiponectin (μg/ml) in men (●) and women (○).Correlation assessed by
Spearman analysis.

Fig. 3 Receiver operating characteristics (ROC) curves comparing anthropometric variables as discriminators of insulin resistance and metabolic
syndrome in men and women. *Areas under the curve for each anthropometric measure (P < 0
001. CI, confidence interval).

Table 3. Cut-off levels for determining the individuals with IR and MetS according to ROC analysis

Men Women

Cut-off Sensitivity (95% CI) Specificity (95% CI) Cut-off Sensitivity (95% CI) Specificity (95% CI)

IR >39
6 64
1 (52
4–74
7) 66
9 (58
8–74
3) >36
1 65
9 (58
4–72
9) 71
3 (66
6–75
7)
MS >39
6 71
5 (61
4–80
9) 62
6 (55
6–69
2) >36
1 63
5 (57
1–69
6) 69
7 (65
5–73
7)

IR, insulin resistance; MS, metabolic syndrome; CI, confidence interval.

© 2012 John Wiley & Sons Ltd

Clinical Endocrinology (2013), 78, 874–881

ratio (WHR), CRP, FFA, adiponectin and HOMA-IR, were sig-
nificantly different between the genders.
Correlations between the NC, obesity and MetS markers,
adjusted for age, are presented in Table 2. The NC was associ-
ated with the obesity markers, WC and BMI, in men and
women, while the NC correlated with WHR only in men.
Among the traditional markers of MetS, the NC showed a posi-
tive correlation with fasting triglycerides and fasting glucose and
showed a negative association with HDL cholesterol in both
men and women. However, only women showed an association
between the NC and blood pressure, uric acid, GGT and CRP
levels.
The NC was positively correlated with glycated haemoglobin,
fasting insulin, adiponectin and HOMA-IR levels in both groups.
The main associations of the NC with MetS risk markers and VF
are shown in Fig. 1. Figure 2 shows a negative association of the
NC with adiponectin and with the clamp-derived IS index as well
as a positive association of the NC with HOMA-IR.
The ROC curves are presented in Fig. 3, along with their anal-
yses. The AUC for different anthropometric measures were sta-
tistically significant (P < 0
001). After performing Fisher’s Z-test,
we observed that NC is not statistically different from WC, when
compared between both gender, for IR (P = 0
992, for men;
P = 0
885 for women). In women, the NC presented the largest
AUC for IR compared with men, which is similar to the WC.
For MetS, the WC showed the largest AUC in both genders
(0
81 and 0
87 in men and women, respectively), followed by
the BMI (0
78 and 0
84) and the WHR (0
79 and 0
78),
although the NC also presented a large AUC (0
73 and 0
74).
Table 3 shows the optimal cut-off values of the NC for IR and
MetS. For men, the optimal NC cut-off values were >40 cm for
both IR and MetS. For women, the optimal cut-off NC values
were >36
1 cm for both IR and MetS (P < 0
001).
After a binary logistic regression analysis, considering the
HOMA-IR and MetS as dependent variables and the NC and
WC as independent variables, the results were as follows: for
women, the enlargement of NC increased by 1
21 times the
chance of IR (β=0
20; P < 0
001) and 1
13 times the chance of
MetS (β=0
12; P < 0
01), whereas the enlargement in WC
increased by 1
04 times the chance of IR (β = 0
04; P < 0
001)
and 1
08 times the chance of MetS (β = 0
08; P < 0
001). For
men, the enlargement of NC increased by 1
20 times the chance
of having IR (β = 0
18; P < 0
001) and was not related to the
increased chance of MetS, while the enlargement in WC
increased by 1
16 times the chance of having MetS (β = 0
15;
P < 0
001) and 1
06 times the chance of having for IR
(β = 0
06; P < 0
001).
Discussion
In this cross-sectional analysis of population-based data among
Brazilian adults, the NC was an indicator of central obesity, IR
(assessed by both euglycemic-hyperinsulinemic clamp and
HOMA-IR), MetS and related biochemical parameters. Further-
more, gender-specific cut-off values of the NC for IR and MetS
were established.
© 2012 John Wiley & Sons Ltd
Clinical Endocrinology (2013), 78, 874–881
Neck circumference as a simple tool 879
The age-adjusted NC measurements were significantly asso-
ciated with WC, which is often used as a surrogate marker of
abdominal (subcutaneous and intra-abdominal) fat mass4 as well
as with markers of MetS and IR. Compared with WC, the NC
also showed association with VF and IS. NC and WC measure-
ments shared significant and independent association with IR
risk, although the NC was a better marker for women than for
men. The WC shows the best correlation for determining MetS,
followed by BMI and W-HR; however, the NC was also closely
associated with MetS.
This current study is the first to show a significant association
between the NC and IR using the euglycemic-hyperinsulinemic
clamp, which is considered the gold standard method for mea-
suring IS. Our findings are also in agreement with previous stu-
dies, in which the NC and neck fat have been associated IR
(measured by HOMA-IR), impaired glucose homeostasis, hyper-
lipidemia and hypertension.6,10,19–24 Moreover, a previous analy-
sis of the Framingham Heart Study demonstrated that the NC is
associated with IR, elevated hypertension, and dyslipidemia,
independent of VF.25 Another previous study observed a signifi-
cant relationship between NC and carotid intima-media thick-
ness, which is a direct measure of subclinical atherosclerosis, in
the general population.24
The NC is considered a surrogate marker of upper-body SF,
which is an important contributor to circulating FFA and is
more lipolytically active than lower body SF.26 Because FFA con-
centrations are directly associated with IR,27 hepatic VLDL pro-
duction,28 and endothelial dysfunction, upper body SF may have
an important cardiovascular and metabolic impact.29
The regression procedure indicated that, for both gender, the
enlargement of NC increases the chance to developing IR in 1·2
times. And only in women, was observed the relationship
between the enlargement of NC and the chance to developing
MetS.
Another novelty of this study was determining the cut-off
value of the NC for the prediction of IR, regardless of the pre-
sence of MetS. Our study established that, for men, the NC cut-
off value of >40 cm are suitable for assessing the likelihood of
both the same cutoff value for both IR and MS, either for men
and women, considering the balance between specificity and sen-
sitivity, respecting the assumption that there was less than 60%.
Thus we become the information with practical use. WC cutoffs
are clearly superior to NC regarding MetS but comparable with
respect to IR. It could be due to a weak association between
WC and IR among diabetic individuals (data not show).
One previous study10 determined cut-off values of the NC for
the prediction of MetS (but not for IR) that were very close to
those of our study: NC > 39 cm for men and NC > 35 cm for
women. Another study30 presented NC cut-off values of >39 cm
for men and >35 cm for prediction of MetS in women with type
2 diabetes.
Our study has a few limitations, none of which affects the
findings. First, the effects of life style and race were not assessed.
Racial classification might be inaccurate due to the admixture of
races in the Brazilian population. Second, we did not assess sleep
apnea, which might link the NC to some metabolic markers. A
880 C. Stabe et al.
third question is that our study includes a high prevalence of
T2DM and there is a lack of adjustment for MetS components.
Anthropometry is a simple evaluation tool with a well-
established relationship with body fat distribution and metabolic
complications that overcomes the cost and availability limita-
tions of the gold-standard methods (computed tomography,
magnetic resonance).31–33 The NC requires a single measurement
site with low bias of anatomical and observer variations,
although there is no established guideline for measurement of
NC. Several studies show different positions for measurement of
NC. [above the cricothyroid cartilage;2 at the level of the upper
margin of the thyroid cartilage;3 just below the laryngeal promi-
nence;4–7 at the upper margin of the laryngeal prominence
(Adam’s apple)8]. We choose to measure the NC below the cri-
cothyroid cartilage in order to standardize both for men and
women, independent of the laryngeal prominence. It offers an
alternative to WC, especially in health conditions that affect the
abdominal wall, organs and cavity (lipoabdominoplasty, volumi-
nous skin folds and pendulous abdomen in obese subjects or
after great weight loss, hernia and ascitis).3 In addition, different
anatomic landmarks also have been used to determine the exact
location for measuring the WC in different clinical studies,
which influences the absolute WC value that is obtained.7,8 The
specific site used to measure the WC influences the absolute
WC value that is obtained and can limit the evaluation of fat
body distribution.
The NC is an alternative and innovative approach for the
determination of body fat distribution, which is associated with
visceral fat, Metabolic Syndrome components and insulin resis-
tance, specially in women. It is easily measured and has popula-
tion-based cut-off values for metabolic risk evaluation.
Therefore, NC is a useful screening tool in clinical and research
settings.
Acknowledgement
This research was supported by Foundations that support
research in the State of Sao Paulo (FAPESP – Fundação de
Amparo a Pesquisa do Estado de São Paulo – 2007/58638-0).
Conflict of interests
Nothing to declare.
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