Experimental Gerontology 106 (2018) 132–136

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Experimental Gerontology
journal homepage: www.elsevier.com/locate/expgero

The associations between liver enzymes and the risk of metabolic syndrome T
in the elderly
⁎
Cun-Fei Liua,b, Wei-Ning Zhouc, Zheng Lua, Xue-Ting Wanga, Zhao-Hui Qiua,
a
Department of Cardiology, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200336, China
b
Department of Cardiology, Linyi People's Hospital, Linyi, Shandong 276000, China
c
Department of Pathology, East Hospital, Tongji University School of Medicine, Shanghai 200120, China

A R T I C LE I N FO A B S T R A C T

Section Editor: Holly M. Brown-Borg Background: Studies have demonstrated that liver enzymes are associated with metabolic syndrome (MetS).
Keywords: However, little information is available regarding these relationships in elderly populations. Our present study
Liver enzyme aimed to explore the associations between liver enzymes and the risk of MetS in elderly populations.
Metabolic syndrome Methods: This cross-sectional study included 1444 elder participants (970 men and 474 women) who attended
Elderly annual physical examinations. Univariate and multivariate logistic regressions were performed to estimate the
associations between liver enzymes and the risk of MetS and its components according to quartiles of the
concentration of each liver enzyme.
Results: The prevalence of MetS and its components increased remarkably with increasing quartiles of alanine
aminotransferase (ALT), gamma-glutamyltransferase (GGT) and alkaline phosphatase (ALP) but not with as-
partate aminotransferase (AST) in the elderly. Compared with subjects in the bottom quartile, the adjusted odds
ratio for MetS in the highest ALT, GGT and ALP quartiles were 1.78 (95% CI 1.21–2.61), 2.58 (95% CI
1.77–3.78) and 1.85 (95%CI 1.27–2.70) respectively. No statistically significant increases in the odds ratio for
MetS according to increased quartiles of AST were found in either the univariate or multivariate logistic re-
gression analyses.
Conclusions: Elevated liver enzymes levels (mainly ALT, GGT and ALP but not AST) are positively associated
with the prevalence of MetS in elderly populations.

1. Background elevated liver enzymes such as alanine aminotransferase (ALT), aspar-

Metabolic syndrome (MetS) is a complicated disorder characterized
by several risk factors, including abdominal obesity, high blood pres-
sure, hyperglycemia, and dyslipidemia (including hypertriglyceridemia
and reduced lower high-density lipoprotein cholesterol). MetS is asso-
ciated with significant increased risk of cardiovascular related diseases
including diabetes, myocardial infarction, stroke, cardiovascular re-
lated mortality and all-cause mortality (Grundy, 2007; Mottillo et al.,
2010). MetS has now become not only a clinical issue but also become
an important global public health challenge with its significant in-
creasing prevalence all over the world (Alberti et al., 2009). Hence,
early detection and intervention against MetS are very important for
preventing the progression of cardiovascular related diseases and re-
ducing the public health burden.
Nonalcoholic fatty liver disease (NAFLD) is thought to be the he-
patic manifestation of MetS (Adams et al., 2009; Kotronen and Yki-
Jarvinen, 2008; Yki-Jarvinen, 2014). NAFLD is usually associated with
tate aminotransferase (AST), gamma-glutamyltransferase (GGT) and
alkaline phosphatase (ALP) (Clark et al., 2003; Hossain et al., 2016;
Pantsari and Harrison, 2006; Salman et al., 2016; Schindhelm et al.,
2006). To date, several epidemiological studies have explored the as-
sociations between liver enzymes and MetS in different populations
(Hanley et al., 2005; Koskinen et al., 2012; Lee and Yang, 2013; Perera
et al., 2008; Villegas et al., 2011). However, these results are not con-
sistent, and little information is available regarding these relationships
in elderly populations. Because the prevalence of MetS is closely related
with age, and the incidence of MetS is much higher in elderly popula-
tions (Ford et al., 2002; Gu et al., 2005; Xi et al., 2013), we conducted a
cross-sectional study to investigate the relationships of liver enzymes
with MetS and its components in elderly people.

⁎
Corresponding author.
E-mail address: QCH3503@shtrhospital.com (Z.-H. Qiu).

https://doi.org/10.1016/j.exger.2018.02.026
Received 19 August 2017; Received in revised form 28 October 2017; Accepted 25 February 2018
Available online 27 February 2018
0531-5565/ © 2018 Published by Elsevier Inc.
C.-F. Liu et al. Experimental Gerontology 106 (2018) 132–136

2. Methods Table 1
Characteristics of the study populations.
2.1. Study populations
MetS(n = 524) Non-MetS(n = 920) P value

The present cross-sectional study enrolled 1680 Han Chinese elderly Sex (men, %) 358 (68.32%) 612 (66.52%) 0.484
participants (aged 60–93 years) who visited the health examination Age (year) 69.58 ± 7.01 70.04 ± 7.65 0.255
BMI (kg/m2) 26.81 ± 2.60 23.30 ± 2.83 < 0.001
center of Tongren hospital for annual physical check-ups from March
WC (cm) 93.16 ± 10.62 80.81 ± 11.26 < 0.001
2016 to October 2016. All participants completed a health ques- Current smoking (%) 26 (4.96%) 59 (6.41%) 0.616
tionnaire and health check-up according to a standardized protocol. SBP (mm Hg) 139.02 ± 16.23 130.67 ± 17.23 < 0.001
Because serum liver enzyme levels can be significantly affected by al- DBP (mm Hg) 82.51 ± 10.31 78.02 ± 9.66 < 0.001
cohol consumption and hepatitis viruses, those who were currently TG (mg/dl) 217.75 ± 135.10 127.72 ± 83.10 < 0.001
TC (mg/dl) 201.11 ± 41.20 196.37 ± 36.78 0.024
drinking and those who were currently suffering from viral hepatitis
HDL-C (mg/dl) 58.18 ± 15.92 69.35 ± 17.37 < 0.001
were excluded from our present study. Ultimately, 1444 elderly parti- LDL-C (mg/dl) 102.81 ± 31.63 99.48 ± 27.93 0.039
cipants (970 men and 474 women) with complete data were included in FPG (mmol/L) 6.31 ± 1.97 5.35 ± 1.21 < 0.001
our study. Written informed consent was obtained from all eligible ALT (IU/L) 26.98 ± 15.51 22.01 ± 12.58 < 0.001
AST (IU/L) 23.37 ± 8.85 23.25 ± 8.66 0.796
participants, and this study was approved by the Ethics Committee of
GGT (IU/L) 29.80 ± 19.54 23.42 ± 18.93 < 0.001
Tongren Hospital, Shanghai Jiao Tong University School of Medicine. ALP (IU/L) 86.25 ± 16.25 81.41 ± 12.80 < 0.001
Total bilirubin 14.50 ± 5.27 14.65 ± 5.53 0.617
2.2. Data collection and laboratory measurements Albumin 37.01 ± 4.31 36.98 ± 4.13 0.906
Uric acid (mg/dl) 6.26 ± 1.52 5.67 ± 1.36 < 0.001
Creatinine (umol/l) 81.48 ± 25.71 80.16 ± 24.25 0.331
A standardized questionnaire was used to obtain the general in-
No of MetS components 3.31 ± 0.46 1.38 ± 0.68 < 0.001
formation of the subjects, including age, medical history, history of
drug treatment, cigarette smoking, etc. Standing height and weight Abbreviation: BMI: body mass index; WC: waist circumference; TG: triglyceride; TC: total
were measured without shoes to the nearest 0.1 cm and 0.1 kg, re- cholesterol; HDL-C: high-density lipoprotein cholesterol; LDL-C: low-density lipoprotein
spectively. Waist circumference (WC) was measured to the nearest cholesterol; FPG: fasting plasma glucose; ALT: alanine aminotransferase; AST: aspartate
0.1 cm between iliac crest and the rib cage with a non-elastic tape. The aminotransferase; GGT: gamma-glutamyltransferase. ALP: alkaline phosphatase.

body mass index (BMI) was assessed by the formula weight (kg)/
height2 (m2). Resting blood pressure was measured two times with an
electronic sphygmomanometer (HEM-741C; Omron, Tokyo, Japan) in
the seated position after at least 5 min of rest in a quiet room.
Venous blood samples after an overnight fast were obtained from
the antecubital vein and were then sent to the laboratory center for
analysis. Fasting plasma glucose (FPG), total cholesterol (TC), high-
density lipoprotein cholesterol (HDL-C), low-density lipoprotein cho-
lesterol (LDL-C), triglycerides (TG), creatinine, uric acid and liver en-
zymes were measured enzymatically on an automatic analyzer
(Architect Ci8200, Abbott Co., Illinois, USA). All laboratory assays were
measured without knowledge of the information of the participants.
2.3. Definition of MetS
In our present study, we chose the definition of MetS according to
the 2009 harmonizing definition criteria as including three or more of
the following factors (Alberti et al., 2009): abdominal obesity, i.e.,
WC ≥ 90 cm in Asian men or ≥80 cm in Asian women; systemic hy-
pertension, i.e., a systolic blood pressure (SBP) ≥ 130 mm Hg, a dia-
stolic blood pressure (DBP) ≥ 85 mm Hg, or the use of antihypertensive
drugs; hypertriglyceridemia, i.e., TG ≥ 150 mg/dl; reduced HDL-C, i.e.,
HDL-C < 40 mg/dl in men or < 50 mg/dl in women; hyperglycemia,
i.e., FPG ≥ 100 mg/dl or the use of antidiabetic agents.
2.4. Statistical analysis
Continuous variables are summarized as the means with the stan-
dard deviations (SDs), and categorical variables are expressed as the
numbers and percentages. Independent t-tests and chi-square tests were
used to compare the differences in characteristics difference between
the MetS group and non-MetS group. To evaluate the odds ratio (ORs)
for MetS according to varying levels of liver enzymes, the subjects were
divided into quartiles according to their liver enzymes levels. Pearson's
correlation coefficients were used to calculate the associations of liver
enzyme levels with each component of MetS. Univariate and multi-
variate logistic regression were performed to evaluate the ORs of MetS
and its components according to the quartiles of the liver enzymes
levels. All statistical tests were two-sided, and a P-value < 0.05 was
considered to be statistically significant. All statistical analyses were
performed with SPSS software 18.0 (SPSS Inc., Chicago, IL, USA).
3. Results
3.1. Characteristics of the study populations
The main characteristics of subjects are presented in Table 1.
Among the included 1444 participants, 524 subjects were diagnosed
with MetS, and the prevalence of MetS was 36.3% across all subjects
(35.0% of the women and 36.9% of the men). There were no significant
differences in age, gender or smoking status between the MetS and non-
MetS groups (P > 0.05). However, the subjects in MetS group had
significantly higher WC, BMI, SBP, DBP, TC, TG, LDL-C, FPG, and uric
acid levels but lower HDL-C values than the subjects in the non-MetS
groups. Additionally, the mean number of MetS components was much
higher in the MetS group than non-MetS group (3.31 ± 0.46 vs
1.38 ± 0.68; P < 0.01).
3.2. Correlations of liver enzyme levels and MetS components
Pearson's correlation coefficients were calculated to evaluate the
correlations between liver enzyme levels and MetS components after
adjustments for sex and age (Table 2). ALT was positively associated
with WC, FPG and TG and negatively correlated with HDL-C. GGT was
positively correlated with WC, FPG, TG, SBP and DBP. ALP was posi-
tively associated with WC, FPG and TG and negatively correlated with
HDL-C. However, there were no statistically positive or negative cor-
relations of AST with any MetS components.
3.3. Odds ratios for MetS according to the quartiles of the liver enzyme
levels
Univariate and multivariate logistic regression analyses were con-
ducted to evaluate the liver enzyme levels and the risk of MetS. As
presented in Table 3, compared with the subjects in the bottom ALT

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Table 2
Correlation coefficients between liver enzyme and each MetS component.

ALT AST GGT ALP

Pearson's coefficients P value Pearson's coefficients P value Pearson's coefficients P value Pearson's coefficients P value

WC 0.190 < 0.001 −0.008 0.751 0.128 < 0.001 0.169 < 0.001
FPG 0.150 < 0.001 −0.004 0.890 0.090 0.001 0.140 < 0.001
SBP 0.012 0.654 −0.021 0.420 0.080 0.002 0.004 0.866
DBP 0.025 0.347 0.000 0.985 0.102 < 0.001 0.028 0.289
TG 0.119 < 0.001 0.025 0.352 0.184 < 0.001 0.105 < 0.001
HDL-C −0.097 < 0.001 0.042 0.113 −0.045 0.087 −0.099 < 0.001

Abbreviation: ALT: alanine aminotransferase; AST: aspartate aminotransferase; GGT: gamma-glutamyltransferase; ALP: alkaline phosphatase; WC: waist circumference; FPG: fasting
plasma glucose; SBP: systolic blood pressure; DBP: diastolic blood pressure; TG: triglyceride; HDL-C: high-density lipoprotein cholesterol.

quartile, the unadjusted OR of the MetS patients increased from 1.37
(95% CI 0.99–1.88) for the second quartile group to 3.17 (95% CI
2.30–4.36) for the highest quartile group (P for trend < 0.001), and
the OR increased from 1.23 (95% CI 0.89–1.72) to 3.75 (95% CI
2.75–5.12) across the GGT quartiles (P for trend < 0.001). As to ALP,
the unadjusted OR of the MetS increased from 1.07 (95% CI 0.77–1.48)
for the second quartile group to 2.75 (95% CI 2.01–3.77) for the highest
quartile group (P for trend < 0.001). The ORs for MetS were atte-
nuated, but they remained significant after adjustments for several
covariates (i.e., age, sex, BMI, current smoking, uric acid and creati-
nine) in regard ALT, GGT and ALP levels. The adjusted OR for the
highest quartiles of ALT, GGT and ALP were 1.78 (95% CI 1.21–2.61),
2.58 (95% CI 1.77–3.78) and 1.85 (95%CI 1.27–2.70) respectively.
However, no statistically significant increase in the risk of MetS ac-
cording to increased concentrations of AST was found in either the
univariate or multivariate logistic regression analyses.
3.4. Association between liver enzymes concentration and each component
of MetS
We further investigated the association between liver enzymes and
the risk of MetS components after adjustments for age and sex. The
detailed results are provided in Table 4. Generally, the prevalence of
MetS components increased from the bottom quartiles to the highest
quartiles of ALT, GGT and ALP (P for trends < 0.05) with the exception
of hypertension prevalence in ALT (P for trend = 0.593) and ALP (P for
trend = 0.868). ALT was positively associated with increased ORs for
all MetS components except hypertension (1.43 (95% CI 0.99–2.06),
P = 0.127). GGT was positively associated with increased ORs for all
MetS components, including central obesity, dyslipidemia, hypergly-
cemia and hypertension. ALP was positively associated with increased
ORs for all MetS components but not with hypertension (1.21 (95% CI
0.83–1.76), P = 0.316). However, no significant positive associations
between the AST levels and any of the MetS components were found.
4. Discussion
The prevalence of MetS is increasing with the economic and social
development in the world and much more common in the elderly
people. For example, the incidence of MetS has been reported to be
21.3% in the China Health and Nutrition Survey according to NCEP
ATPIII criteria, but the prevalence of MetS is dramatically increased to
36.7% among elderly people (60 years or older) (Xi et al., 2013).
Moreover, the risk of MetS in elderly populations is 4.41 times higher
(95%CI 3.69–5.29) than that in people < 40 years old (Xi et al., 2013).
In our present study, we investigated the association between hepatic
enzyme concentrations and the risk of MetS in elderly people. Our re-
sults revealed that elevated ALT, GGT and ALP concentrations were
positively associated with MetS and its components in elderly subjects.
Compared with the subjects in the bottom quartiles of ALT, GGT and
ALP, the unadjusted ORs for MetS were 3.17 (95% CI 2.30–4.36), 3.75
(95% CI 2.75–5.12) and 2.75 (95% CI 2.01–3.77), respectively, in the

Table 3
Odds ratios (95% CIs) of MetS according to quintiles of each liver enzyme.

Q1 Q2 Q3 Q4 P for trend

ALT (IU/L) ≤15 16–21 22–28 > 28

Case/number at risk 89/366 129/422 134/315 172/341 < 0.001
Model 1 1 1.37(0.99–1.88) 2.30(1.66–3.20) 3.17(2.30–4.36) < 0.001
Model 2 1 1.37(0.99–1.88) 2.31(1.66–3.20) 3.18(2.30–4.41) < 0.001
Model 3 1 1.07(0.74–1.55) 1.26(0.86–1.87) 1.78(1.21–2.61) 0.002
AST (IU/L) ≤18 19–22 23–26 > 26
Case/number at risk 130/361 165/458 104/297 125/328 0.12
Model 1 1 1.00(0.75–1.33) 0.96(0.70–1.32) 1.09(0.80–1.49) 0.646
Model 2 1 1.01(0.76–1.34) 0.97(0.70–1.34) 1.11(0.81–1.51) 0.585
Model 3 1 1.01(0.72–1.53) 1.04(0.71–1.53) 1.04(0.71–1.52) 0.811
GGT (IU/L) ≤15 16–20 21–30 > 30
Case/number at risk 106/402 116/344 138/348 164/350 < 0.001
Model 1 1 1.23(0.89–1.72) 2.34(1.71–3.20) 3.75(2.75–5.12) < 0.001
Model 2 1 1.27(0.91–1.77) 2.40(1.75–3.31) 3.87(2.81–5.32) < 0.001
Model 3 1 1.05(0.71–1.56) 1.61(1.10–2.35) 2.58(1.77–3.78) < 0.001
ALP (IU/L) ≤74 75–78 79–86 > 86
Case/number at risk 98/363 102/361 152/379 172/341 < 0.001
Model 1 1 1.07(0.77–1.48) 1.81(1.33–2.47) 2.75(2.01–3.77) 0.001
Model 2 1 1.07(0.77–1.48) 1.81(1.33–2.47) 2.76(2.00–3.80) < 0.001
Model 3 1 1.15(0.78–1.68) 1.31(0.90–1.87) 1.85(1.27–2.70) 0.001

Model 1: unadjusted OR.

Model 2: adjusted for age and sex.
Model 3: adjusted for age, sex, BMI, current smoking, uric acid and creatinine.

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Table 4
Age and sex adjusted odds ratios (95% CIs) of each MetS component according to quintiles of each liver enzyme.

Q1 Q2 Q3 Q4 P for trend

ALT ≤15 16–21 22–28 > 28

Central obesity (case/number at risk) 112/366 162/422 172/315 198/328 < 0.001
Age and sex adjusted OR 1 1.33(0.99–1.80) 2.56(1.86–3.51) 2.82(2.06–3.86) < 0.001
Dyslipidemia (case/number at risk) 129/366 161/422 140/315 183/341 < 0.001
Age and sex adjusted OR 1 1.16(0.87–1.56) 1.73(1.27–2.37) 2.07(1.52–2.82) < 0.001
Hypertension (case/number at risk) 280/366 338/422 243/315 270/341 0.593
Age and sex adjusted OR 1 1.31(0.92–1.85) 1.12(0.78–1.61) 1.43(0,99–2.06) 0.127
Hyperglycemia (case/number at risk) 131/366(35.8%) 161/422(38.2%) 149/315(47.3%) 171/341(50.1%) < 0.001
Age and sex adjusted OR 1 1.16(0.88–1.56) 1.73(1.27–2.37) 2.07(1.52–2.82) < 0.001
AST ≤18 19–22 23–26 > 26
Central obesity (case/number at risk) 166/361 202/458 125/297 151/328 0.715
Age and sex adjusted OR 1 0.95(0.72–1.26) 0.90(0.66–1.23) 1.08(0.80–1.47) 0.717
Dyslipidemia (case/number at risk) 167/361 185/458 116/297 145/328 0.191
Age and sex adjusted OR 1 0.78(0.59–1.03) 0.73(0.53–1.00) 0.88(0.65–1.19) 0.376
Hypertension (case/number at risk) 251/361 308/458 198/297 215/328 0.967
Age and sex adjusted OR 1 0.91(0.65–1.28) 0.90(0.61–1.31) 0.95(0.65–1.37) 0.770
Hyperglycemia (case/number at risk) 97/361 131/458 73/297 87/328 0.875
Age and sex adjusted OR 1 1.01(0.76–1.33) 1.06(0.78–1.45) 0.93(0.68–1.26) 0.714
GGT ≤15 16–20 21–30 > 30
Central obesity (case/number at risk) 125/402 135/344 178/348 206/350 < 0.001
Age and sex adjusted OR 1 1.35(0.99–1.84) 2.14(1.58–2.90) 2.83(2.08–3.84) < 0.001
Dyslipidemia (case/number at risk) 118/402 126/344 159/348 210/350 < 0.001
Age and sex adjusted OR 1 1.61(1.17–2.20) 2.36(1.72–3.22) 4.25(3.10–5.84) < 0.001
Hypertension (case/number at risk) 292/402 258/344 274/348 307/350 < 0.001
Age and sex adjusted OR 1 1.12(0.80–1.58) 1.48(1.04–2.10) 3.05(2.04–4.55) < 0.001
Hyperglycemia (case/number at risk) 153/402 137/344 153/348 169/350 0.025
Age and sex adjusted OR 1 1.12(0.83–1.51) 1.37(1.01–1.84) 1.68(1.24–2.27) < 0.001
ALP (IU/L) ≤74 75–78 79–86 > 86
Central obesity (case/number at risk) 125/363 125/361 196/379 198/341 < 0.001
Age and sex adjusted OR 1 0.98(0.72–1.33) 1.96(1.45–2.64) 2.40(1.76–3.28) < 0.001
Dyslipidemia (case/number at risk) 130/363 137/361 163/379 183/341 < 0.001
Age and sex adjusted OR 1 1.08(0.80–1.47) 1.34(1.00–1.81) 2.00(1.47–2.73) < 0.001
Hypertension (case/number at risk) 288/363 279/361 284/379 270/341 0.868
Age and sex adjusted OR 1 0.94(0.66–1.35) 0.98(0.68–1.39) 1.21(0.83–1.76) 0.316
Hyperglycemia (case/number at risk) 138/363 131/361 172/379 171/341 < 0.001
Age and sex adjusted OR 1 0.96(0.71–1.30) 1.44(1.07–1.93) 1.86(1.37–32.53) < 0.001

highest quartile groups. The ORs for MetS according to ALT, GGT and
ALP levels were attenuated but remained significant after adjustments
for several covariates (age, sex, BMI, current smoking, uric acid and
creatinine). However, no significant associations were found between
the AST level and MetS or MetS components.
Liver enzymes have been widely explored as markers of MetS and its
components among different populations (Koskinen et al., 2012; Lee
and Yang, 2013; Villegas et al., 2011). However, these studies have
provided inconsistent results. For example, Koskinen et al. (2012) found
no association between increased enzyme levels (mainly ALT and GGT)
and the atherogenicity of MetS in young adults. Villegas et al. (2011)
found that elevated ALT and AST were associated with the prevalence
of MetS in middle-aged Chinese men. Lee and Yang (2013) demon-
strated that ALT and GGT were associated with MetS in adolescents.
Hanley et al. (2005) showed significant cross-sectional associations of
ALT and ALP with MetS in American aged 40–69 years. Our present
study revealed that elevated ALT, GGT and ALP were positively asso-
ciated with MetS in an elderly population. Based on the above research
results, it seems that age might be an influential factor in the associa-
tion of liver enzymes with the incidence of MetS. Indeed, there are
significant different liver enzymes levels when the elderly subjects were
further grouped according to quintiles of age (data was shown in sup-
plemental material).
ALT is regarded as the most specific biomarker of hepatic function
and is used as an indirect marker of liver injury. GGT is an enzyme that
is involved in the extracellular catabolism of the antioxidant glu-
tathione and is thought to be a marker of oxidative stress and sub-
clinical inflammation (Anderson et al., 1982; Lee et al., 2004). ALP is
responsible for hydrolysis of phosphate esters and is a biomarker for
liver function. However, AST is a less specific marker of liver injury
because it can also be secreted by other organs and cells, such as the
heart, skeletal muscle, kidneys, pancreas, lungs, leukocytes, and ery-
throcytes (Pratt and Kaplan, 2000), and this may partially explain why
no significant associations were found between MetS and AST in our
present study. The exact mechanisms that link liver enzymes with MetS
are still not fully understood. Possible explanations are described
below. Elevated ALT, GGT and ALP are closely associated with liver fat
deposition (Clark et al., 2003) and are considered to be biomarkers of
NAFLD (Hossain et al., 2016; Pantsari and Harrison, 2006; Schindhelm
et al., 2006), whereas NAFLD is considered to be a mediator of MetS
(den Boer et al., 2004) and insulin resistance, and abdominal obesity
may be a pathophysiological distinction between NAFLD and MetS
(Bugianesi et al., 2010; Finucane et al., 2014). Moreover, studies have
demonstrated that ALT and GGT are also positively associated with
insulin resistance and MetS in obese subjects (Marchesini et al., 2005;
Wallace et al., 2007).
Several limitations of our present study should be noted. First, our
study design was cross-sectional; therefore, we are unable to elucidate
causal relationships between liver enzymes and MetS. However, the
available studies in general adults indicate that elevated liver enzymes
may be a predictor of the future development of MetS (Goessling et al.,
2008; Nakanishi et al., 2004). Second, the single measurements of he-
patic enzyme concentrations may have led to some misclassifications of
the subjects, but several prospective studies have confirmed that
longitudinal increases in the liver enzymes are positively associated
with MetS (Patel et al., 2007; Ryu et al., 2010). Finally, we adjusted for
several potential confounding factors during our evaluations of the
associations of liver enzymes with MetS in our statistical models;
however, residual confounding effects may still exist.

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5. Conclusion
In summary, our present study demonstrated that elevated ALT,
GGT and ALP levels are positively associated with the prevalence of
MetS in an elderly population. Because ALT, GGT and ALP are closely
related to NAFLD, further random control trials are needed to elucidate
the influence of treating NAFLD on the prevalence of MetS.
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