Body Mass Index, Waist Circumference and Waist:hip Ratio As Predictors of Cardiovascular Risk-A Review of The Literature
Body Mass Index, Waist Circumference and Waist:hip Ratio As Predictors of Cardiovascular Risk-A Review of The Literature
Body Mass Index, Waist Circumference and Waist:hip Ratio As Predictors of Cardiovascular Risk-A Review of The Literature
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REVIEW
Body mass index, waist circumference and waist:hip
ratio as predictors of cardiovascular risk—a review of
the literature
R Huxley1, S Mendis2, E Zheleznyakov2, S Reddy3 and J Chan4
1
Renal and Metabolic Division, The George Institute for International Health, The University of Sydney, Sydney, Australia;
2
Department of Nutrition for Health and Development, World Health Organization, Geneva, Switzerland; 3President, Public Health
Foundation of India, India and 4Department of Medicine and Therapeutics, The Chinese University of Hong Kong, The Prince of Wales
Hospital, Hong Kong, Hong Kong
Overweight and obesity have become a major public health problem in both developing and developed countries as they are
causally related to a wide spectrum of chronic diseases including type II diabetes, cardiovascular diseases and cancer. However,
uncertainty regarding the most appropriate means by which to define excess body weight remains. Traditionally, body mass
index (BMI) has been the most widely used method by which to determine the prevalence of overweight in, and across,
populations as well as an individual’s level of risk. However, in recent years, measures of central obesity, principally waist
circumference and the waist:hip ratio and to a lesser extent the waist:height ratio, which more accurately describe the
distribution of body fat compared with BMI, have been suggested to be more closely associated with subsequent morbidity and
mortality. There is also uncertainty about how these measures perform across diverse ethnic groups; earlier, most of the
evidence regarding the relationships between excess weight and risk has been derived chiefly from Caucasian populations, and
hence, it remains unclear whether the relationships are consistent in non-Caucasian populations. The purpose of this review,
therefore, is to provide an overview of the current evidence-base focusing predominantly on three main questions: (1) Which, if
any, of the commonly used anthropometric measures to define excess weight is more strongly associated with cardiovascular
risk? (2) Which of the anthropometric measures is a better discriminator of risk? and (3) Are there any notable differences in the
strength and nature of these associations across diverse ethnic groups?
European Journal of Clinical Nutrition (2010) 64, 16–22; doi:10.1038/ejcn.2009.68; published online 5 August 2009
Table 1 Pooled relative risk for BMI, WC and WHR with incident diabetes stratified by age, gender and geographical region
Body mass index 32 1.87 1.7 2.0 2.4 2.0 2.4 1.7 2.0
Waist circumference 18 1.87 1.6 2.0 2.3 2.9 2.4 1.9 2.1
Waist : hip ratio 25 1.88 2.1 1.7 3.0 2.7 1.4 1.7 1.9
Diabetes
Asian
BMI 1.26 (1.20 –1.33) 0.006
Waist 1.35 (1.28 –1.43) 0.057 0.20
Waist:Hip
1.47 (1.35 –1.60) 0.002 0.44
Caucasian
BMI 1.39 (1.33 –1.46)
Waist 1.42 (1.36 –1.50) 0.49
Waist:Hip 1.41 (1.33 –1.50) 0.63
P-values for
heterogeneity
WOMEN
Odds Ratio BMI vs Asian vs
Hypertension
(95% CI) Other Caucasian
Asian
1.33 (1.28 –1.39) <0.001
BMI
1.37 (1.31 –1.43) 0.33 0.02
Waist
1.25 (1.20 –1.30) 0.034 0.29
Waist:Hip
Caucasian
1.22 (1.20 –1.25)
BMI
1.24 (1.20 –1.29) 0.44
Waist
1.20 (1.16 –1.24) 0.41
Waist:Hip
Diabetes
Asian
1.23 (1.19 –1.28) 0.004
BMI
1.40 (1.32 –1.47) <0.001 0.042
Waist
1.40 (1.29 –1.52) 0.006 0.006
Waist:Hip
Caucasian
1.32 (1.28 –1.37)
BMI <0.001
1.50 (1.44 –1.58)
Waist <0.001
1.62 (1.52 –1.72)
Waist:Hip
Figure 1 Age-adjusted odds ratios and 95% confidence intervals for prevalent type II diabetes and hypertension associated with 0.5 s.d.
increment in each anthropometric measure: body mass index (BMI), waist circumference (WC) and waist:hip ratio (WHR). Results are shown
separately by sex (a, for men; b, for women) and ethnic group (Asian, Caucasian). The strength of the association between WC and diabetes or
hypertension and between WHR and diabetes or hypertension are compared against the strength of the association between BMI and diabetes or
hypertension. For each variable, the strength of the association with diabetes or hypertension is compared between Asian and Caucasian
individuals. P-values for the differences are shown. Figure 1(a, b) is reproduced through kind permission of Wiley–Blackwell (Huxley et al. 2008).
dyslipidaemia. In both men and women, measures of central prevalent diabetes associated with a 0.5 s.d. increment in
obesity were superior to BMI as discriminators of cardio- each of the three indices of body weight with prevalent
vascular risk factors, although the differences were small diabetes were consistently stronger in Caucasians. By
and unlikely to be of clinical relevance (Table 3). Further, the comparison, for the same standard increment in anthropo-
study showed that combining BMI with any measure of metric indices, the odds of hypertension were stronger
central obesity did not improve the discriminatory capability (although not always statistically significantly so) in Asians
of the individual measures. compared with Caucasians for both men and women
(Figures 1a and b). Findings from the APCSC substudy of
six longitudinal cohorts showed that the strength of the
Ethnic differences in association between anthropometric associations between BMI, WC, WHR and HC with cardio-
measures and CVD risk vascular risk was similar in the Asian and non-Asian cohorts.
Recently, evidence has accumulated to suggest that the However, as discussed earlier, these analyses are based on a
increasing prevalence of type II diabetes and CVD in Asian relatively small number of events and require validation
countries is occurring at levels of BMI much lower than the from future prospective studies.
WHO BMI cut-point of 25.0 kg/m2. One potential explana-
tion that has been suggested to explain the diabetes
epidemic across large parts of Asia is that ethnic differences Summary
may exist in the strength of the relationships between body
size and metabolic and cardiovascular risk factors. For This review attempted to summarize the evidence for three
example, several studies have shown that, for a given BMI, main questions. The first of these asked if there was evidence
adiposity can be substantially greater in Asian compared to indicate which of the commonly used measures to assess
with Caucasian individuals. Moreover, there is evidence to body size is more strongly associated with subsequent
suggest that within Asian populations there is significant cardiovascular risk. In totality, the evidence was conflicting;
variation in the association between adiposity and BMI. For for diabetes, there was some evidence to indicate that
example, Hong Kong Chinese, Indonesians, Singaporeans measures of central obesity were more strongly associated
and urban Thai have been shown to have lower BMI’s at a with risk compared with BMI, but this was not the case for
given percentage of body fat compared with Europeans, hypertension and dyslipidaemia where the relationships
whereas individuals from Northern China (Beijing) and rural with BMI, WC and WHR were similar. For cardiovascular
Thailand had similar values to Europeans (Deurenberg and outcomes, the evidence again was conflicting, with most
Deurenberg-Yap, 2003). Further studies have reported ethnic studies (with the notable exception of INTERHEART),
differences in the slopes of the associations between BMI and suggesting that the magnitude of the relationships between
CVD risk factors. For example, Bell and colleagues observed BMI and central obesity with cardiovascular mortality is
a stronger association between BMI and hypertension in broadly consistent. However, much of the evidence is based
Chinese compared with Caucasians, and in non-Hispanic on cross-sectional studies and there is a clear need for further
Blacks compared with Caucasians and Mexican Americans data from large-scale longitudinal studies. Perhaps not
(Bell et al., 2002). Similarly, the relationship between body surprisingly, given the general consistency in associations
build with fasting insulin concentration has been shown between measures of body size and cardiovascular risk, there
to be significantly steeper in South Asian compared with was limited evidence to support the superior discriminatory
Caucasian children (Whincup et al., 2002). capability of any of the measures. Furthermore, the differ-
Data from the OAC suggested that there was no evidence ences in discriminatory capability that were reported were
that the strength of the associations between BMI, WC or too small to be of any clinical relevance. Finally, despite the
WHR and diabetes were stronger in Asians compared with often considerable differences in body size and fat distribu-
Caucasians in both sexes (Figures 1a and b). Rather, the tion between different ethnic groups, there was little
reverse was true, particularly in women, where the odds of evidence to indicate that the magnitude of the associations