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Background Considering the fact that both alanine aminotransferase (ALT) and the triglyceride (TG)/high-density lipoprotein cholesterol (HDL-C) ratio are useful markers for cardiovascular disease, insulin resistance (IR), and metabolic syndrome (MetS), the possible association of ALT and TG/HDL-C ratio is conceivable, but the association is not well studied. Moreover, assessment of IR and MetS by a combination lipid and liver biomarkers has rarely been carried out. Methods A total of 11,808 Japanese subjects who underwent an annual hea