Objective   To investigate the relationship between socioeconomic status (SES) and the incidence of metabolic syndrome (MS) among adult residents in Guizhou province, and to provide references for the prevention and control of MS in the population.

  Methods  Totally 9 280 permanent residents aged ≥ 18 years were recruited from 12 counties/prefectures/ districts of Guizhou province with multistage cluster random sampling. Among the participants, a baseline survey including face-to-face interview with the National Chronic Disease Surveillance Questionnaire developed by Chinese Center for Disease Control and Prevention, physical examination and laboratory testing was conducted from November 2010 through December 2012; follow-up visits were carried out from December 2016 through June 2020. After excluding those who did not meet the inclusion criteria, lost to follow-up and died, 2 956 participants were finally included in the analysis on the impact of SES on the incidence of MS.

  Results  Individual follow-up periods ranged 5.05 − 9.52 years and the mean period was 6.96 ± 1.10 years. Of the participants followed up, 611 MS cases were identified, with an incidence rate of 20.67% and an incidence density of 29.68/1 000 person-years. After adjusting for sex, age, place of residence, smoking, alcohol consumption, sedentary time, physical activity, sleep duration, body mass index (BMI), family history of hypertension and family history of diabetes, the results of multivariate Cox proportional hazard regression analysis showed that the MS incidence risk increased (hazard risk HR = 1.542, 95% confidence interval 95% CI: 1.126 − 2.110) among the participants being engaged in farm work, forestry, animal husbandry, fishery and water conservancy industry compared to those being unemployed; but MS incidence risk decreased among the participants with regular education in comparison to those with informal education (primary school: HR = 0.699, 95%CI = 0.512 − 0.956; middle school: HR = 0.612, 95%CI: 0.449 − 0.835; high school/secondary specialized school/technical school: HR = 0.563, 95%CI: 0.375 − 0.847; junior college and above: HR = 0.434, 95%CI: 0.236 − 0.798), with higher annual household income per capita contrasting to those with the income of less than 2 000 CNY (5 225 − 8 332 CNY: HR = 0.705, 95%CI: 0.502 − 0.992; 8 333 − 13 757 CNY: HR = 0.655, 95%CI: 0.457 − 0.938; ≥ 13 758 CNY: HR = 0.628, 95%CI: 0.436 − 0.903), and with higher SES scores compared to those with the SES scores of less than 7 (SES score of 9 − 10: HR = 0.682, 95%CI: 0.493 − 0.944 , the score of 10: HR = 0.618, 95%CI: 0.421 − 0.909, the score of 11: HR = 0.578, 95%CI: 0.407 − 0.821).

  Conclusion  There is a inverse correlation between SES and MS risk among adult residents in Guizhou province, and the residents with low SES are the key population for MS prevention and control in the province.