We are concerned that Dr. Rizvi feels our recent report will sidetrack and confuse health care professionals. Obviously, that was not our intent. The purpose of our analysis was to make the important clinical point that not all overweight or obese individuals are at equal risk for serious health consequences (1), particularly type 2 diabetes mellitus and CVD. Given this difference in risk, the current obesity epidemic, and the difficulty in achieving weight loss, we thought it would be helpful to describe a relatively simple way to identify the apparently healthy overweight or obese person who would benefit most from weight loss. We do not believe that it represents an "undue obsession" with insulin resistance for us to indicate that insulin resistance or compensatory hyperinsulinemia increases the risk for type 2 diabetes and CVD (2-4).

The purpose of our paper was not to evaluate the pros and cons of the metabolic syndrome as defined by the ATP III report (5). However, since Dr. Rizvi feels that the ATP III criteria "offer a more inclusive and broader risk assessment," it should be noted that these criteria define the metabolic syndrome as a "constellation of lipid and non-lipid risk factors of metabolic origin" and state that "this syndrome is closely related to insulin resistance" (5). All of this, however, is beside the point. At no place in our article do we even imply that appropriate intervention should not be initiated when clear-cut CVD risk factors have been identified in overweight or obese individuals. It is obvious that if a patient has met the diagnostic criteria for essential hypertension, antihypertensive treatment should be initiated regardless of whether he or she has the metabolic syndrome. What is not so obvious is how best to help the enormous number of individuals who are overweight or obese but do not have "conventional" CVD risk factors. In that context, we feel that it is of great clinical importance to identify the subset of such individuals that would benefit most from weight loss. The approach we outlined may not be perfect, but it has reasonable diagnostic accuracy, is inexpensive and easy to use, is based on laboratory tests that are reasonably well standardized and frequently obtained, and identifies a preclinical stage of several serious clinical syndromes for which there is an essentially risk-free and effective intervention. Thus, we argue that overweight or obese persons who have a triglyceride concentration greater than 1.47 mmol/L (>130 mg/dL), a ratio of triglyceride to high-density lipoprotein cholesterol concentrations greater than 1.8 in SI units (>3.0 in traditional units), or both are likely to be both insulin resistant and at increased CVD risk. We believe that use of these values will help achieve our goal: identification of overweight or obese individuals who will benefit most from weight loss.