Temporal Sequence of Metabolic Syndrome Components: Abdominal Obesity as the Primary Driver of Progression in a Korean Prospective Cohort Study.

: Metabolic syndrome (MetS) progresses gradually as individual components accumulate. However, there is limited understanding regarding whether the sequence of component appearance influences disease progression. This study sought to determine the most frequent initial MetS component and evaluate whether this component influences the subsequent risk of developing full MetS. : We examined data from 6137 participants in the Korean Genome and Epidemiology Study (KoGES), free of MetS at baseline (2001-2002), followed until 2011-2012. Participants were stratified by the first emerging MetS component: abdominal obesity, elevated blood pressure, high fasting glucose, high triglycerides, or low HDL cholesterol. The primary endpoint was progression to full MetS, defined as the development of three or more components. We also assessed transition probabilities between components and sex-specific sequence differences. : Abdominal obesity was the most frequent initial metabolic abnormality (31.0%), followed by elevated blood pressure (26.3%), low HDL cholesterol (15.3%), high triglycerides (13.7%), and high fasting glucose (4.9%). Over a median 8.2-year follow-up, participants with initial abdominal obesity exhibited the greatest progression rate to full MetS (44.4%), significantly higher than those with elevated blood pressure (24.8%), high triglycerides (23.0%), high fasting glucose (21.6%), or low HDL cholesterol (9.3%) (all < 0.001). After controlling for age, sex, smoking status, and baseline BMI, initial abdominal obesity was associated with a 4.77-fold increased risk (95% CI: 3.68-6.18) of developing full MetS compared to initial low HDL cholesterol. Distinct transition patterns were observed: high triglycerides frequently transitioned to low HDL cholesterol (78.1%), while abdominal obesity most often led to elevated blood pressure (52.1%). Marked sex-related differences were also found: abdominal obesity was more common initially among women (41.7% vs. 25.2%), whereas elevated blood pressure was predominant among men (37.6% vs. 21.2%). : The initial MetS component strongly predicts progression to full syndrome, with abdominal obesity conferring the highest risk. Early identification and targeted interventions addressing abdominal obesity may effectively prevent MetS and its subsequent complications.