The metabolic syndrome is currently defined by various combinations of insulin resistance, obesity, dyslipidaemia and hypertension. The tendency for these risk factors to appear simultaneously suggests a single aetiologic basis. A low level of circulating adiponectin is associated with the appearance of each metabolic syndrome risk factor. The following review summarizes a large body of evidence that suggests a low level of circulating adiponectin represents an independent risk factor and a possible biomarker for the metabolic syndrome. An association between the metabolic syndrome and low adiponectin supports the view that the development of the metabolic syndrome may be triggered by a single underlying mechanism. Clinical studies in the future may show that a low level of circulating adiponectin is a primary biomarker for a specific cluster of metabolic syndrome risk factors rather than all the possible combinations of risk factors currently used to identify the metabolic syndrome. The significance of low circulating adiponectin in risk assessment models should ultimately be compared against insulin resistance, obesity, dyslipidaemia, hypertension and other metabolic syndrome risk factors presently under consideration. Adiponectin can be measured reliably in a clinical setting; circulating values of adiponectin do not fluctuate on a diurnal basis as much as insulin, glucose, triglycerides or cholesterol and only 2-4 microl of blood are currently needed for its measurement.