OBJECTIVE - We aimed to establish optimal definitions for abdominal obesity and metabolic syndrome (MetS) among Andean adults. RESEARCH DESIGN AND METHODS - Among 1,448 Andean adults, we assessed the relationship between waist circumference and subclinical vascular disease assessed by carotid intima-media thickness (cIMT) and manifest cardiovascular disease (M-CVD). RESULTS - Optimal waist circumference cutoffs to classify individuals with abnormal cIMT or M-CVD were >97 and >87 cm in men and women, respectively. With these cutoffs, there was substantial disagreement between the original American Heart Association/National Heart, Lung and Blood Institute (AHA/NHLBI) and the recently updated MetS definition, particularly among men (κ = 0.85). Subjects with MetS identified by the updated definition but not meeting the original AHA/NHLBI MetS criteria demonstrated significantly increased cIMT (P < 0.001) compared with subjects who did not meet the MetS criteria by either definition. CONCLUSIONS - Our findings support the use of ethnic-specific waist circumference cutoffs and the updated MetS definition in Andean adults.