WHO Waist Circumference Protocol

Waist Circumference
and Waist-Hip Ratio

Report of a
WHO Expert Consultation
GENEVA, 811 DECEMBER 2008
Waist Circumference and WaistHip Ratio:

Report of a WHO Expert Consultation
Geneva, 811 December 2008
WHO Library Cataloguing-in-Publication Data

Waist circumference and waisthip ratio: report of a WHO expert consultation, Geneva, 811
December 2008.
1.Body mass index. 2.Body constitution. 3.Body composition. 4.Obesity. I.World Health
Organization.
ISBN 978 92 4 150149 1
(NLM classification: QU 100)
World Health Organization 2011

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ii
A c k n o w l e d g e m e n ts
ThismeetingreportwasoriginallypreparedbyDrPrakashShetty,withsupportfrom
ProfessorShirikiKumanyika(Chairpersonoftheconsultation)andDrGaryTinChoiKo
(Rapporteuroftheconsultation).Itwasfurtherdevelopedandfinalizedwithsubstantial
supportandinputsfromProfessorShirikiKumanyika,ProfessorScottLear,Professor
ThorkildSrensenandProfessorPaulZimmet,andthemembersoftheWHOSecretariat(Dr
ChizuruNishidaandDrFrancescoBranca).
Specialacknowledgementismadetoallthemembersoftheexpertconsultation,in
particulartothosewhopreparedthebackgroundpapersfortheconsultation.WHOis
gratefultotheEuropeanJournalofClinicalNutritionforacceptingandpublishingthese
backgroundpapers(EJCN,vol64,No.1,pp261,January2010)forwiderdissemination.
AcknowledgementisalsomadetotheWHOstafffromthedepartmentsofNutritionfor
HealthandDevelopment,andChronicDiseasesandHealthPromotion,whoprovided
valuablecontributionstotheconsultation.
WHOexpressesdeepappreciationtotheMinistryofHealth,LabourandWelfareofthe
GovernmentofJapanfortheirfinancialsupportforthecommissioningofthebackground
papers,holdingoftheexpertconsultationandproductionofthemeetingreport.
TechnicaleditingofthereportwasundertakenbyDrHilaryCadmanfromCadmanEditing
ServicesinAustraliaandcoverdesignwasundertakenbyMsSueHobbsfromMinimum
GraphicsinNewZealand.
iii
Abbreviations and acronyms

ATP
AdultTreatmentPanel
AUC
areaunderthereceiveroperatingcharacteristiccurve
BMI
bodymassindex
CARDIA
CoronaryArteryRiskDevelopmentinYoungAdults
CVD
cardiovasculardisease
DEXA
dualXrayabsorptiometry
FAO
FoodandAgricultureOrganizationoftheUnitedNations
FPR
falsepositiverate
IDF
InternationalDiabetesFederation
MESA
MultiEthnicStudyofAtherosclerosis
NCD
noncommunicabledisease
NCEP
NationalCholesterolEducationProgram
NHANES
NationalHealthandNutritionExaminationSurvey
NHLBI
NationalHeart,LungandBloodInstitute
NIH
NationalInstitutesofHealth
ROC
receiveroperatingcharacteristic
STEPS
STEPwiseApproachtoSurveillance(WHO)
SWAN
StudyofWomensHealthAcrosstheNation
TPR
truepositiverate
US
UnitedStates
WHO
WorldHealthOrganization
iv
C o n t e n ts
Acknowledgements........................................................................................................... iii
Abbreviationsandacronyms............................................................................................. iv
1
Introduction........................................................................................................... 1
Methodsformeasuringwaistandhipcircumference............................................. 5
2.1
Placement,tightnessandtypeofmeasuringtape ..........................................5
2.1.1 Placementoftape ...............................................................................5
2.1.2 Tightnessandtypeoftape..................................................................6
2.2
Subjectpostureandotherfactors ...................................................................6
2.2.1 Postureofthesubjectsduringthemeasurement ..............................6
2.2.2 Phaseofrespirationattheexactpointofmeasurement ...................6
2.2.3 Abdominaltensionatthepointofmeasurement ..............................6
2.2.4 Influenceofstomachcontentsattimeofmeasurement ...................6
2.3
Measurementerror..........................................................................................7
2.4
Implicationsofdifferencesinmethodology ....................................................7
2.5
Summaryandconclusions................................................................................7
Impactofvariationsinbodyfatdistributionbysex,ageandethnicity ................... 8
3.1
Sex ....................................................................................................................8
3.2
Reproductivestatus .........................................................................................8
3.3
Age ...................................................................................................................9
3.4
Ethnicity..........................................................................................................10
3.4.1 Ethnicgroupsforwhichwaistcircumferenceorwaisthip
ratiomayreflectmorebodyfatatagivenbodymassindex
level ...................................................................................................10
3.4.2 Populationsforwhichwaistcircumferenceorwaisthip
ratiomayreflectlessbodyfatatagivenbodymassindex
level ...................................................................................................10
3.5
Summaryandconclusions..............................................................................10
Relationshipsofwaistcircumferenceandwaisthipratiotodiseaserisk
andmortality....................................................................................................... 12
4.1
Measuresofobesityandabdominalobesityandcardiovascular
diseaserisk .....................................................................................................12
4.2
Measuresofobesity,abdominalobesityandtype2diabetesrisk................13
4.3
Measuresofobesityandabdominalobesityandallcausemortality
andmortalityfromspecificcauses ................................................................14
4.4
Ethnicdifferences...........................................................................................14
4.5
Summaryandconclusions..............................................................................15
4.5.1 Cardiovasculardisease......................................................................15
4.5.2 Diabetes ............................................................................................16
4.5.3 Riskfactors ........................................................................................16
4.5.4 Mortality ...........................................................................................16
4.5.5 Ethnicdifferences..............................................................................16
Summaryandconclusions.................................................................................... 19
5.1
Usefulnessofwaistcircumferenceandwaisthipratiofor
predictionofdiseaserisk ...............................................................................19
5.2
Measurementprotocol ..................................................................................20
5.3
Selectingcutoffpoints ..................................................................................21
5.4
Universalorpopulationspecificcutoffpoints..............................................22
Recommendations............................................................................................... 24
AnnexA:Currentusesofwaistcircumferencesandwaisthipratios,and
recommendedcutoffpoints ............................................................................... 27
AnnexB:Listofparticipants............................................................................................. 32
References ....................................................................................................................... 34
vi
Introduction
TheWorldHealthOrganization(WHO)ExpertConsultationonWaistCircumferenceand
WaistHipRatiowasheldinGeneva,Switzerlandon811December2008.Theconsultation
wasorganizedbyWHOsDepartmentofNutritionforHealthandDevelopment,in
collaborationwiththeDepartmentofChronicDiseasesandHealthPromotion.Itwas
openedbyDrAlaAlwan,WHOAssistantDirectorGeneralforNoncommunicableDiseases
andMentalHealth.TheconsultationwasconvenedaspartofWHO's:
effortsinimplementingtherecommendationsmadeattheWHOConsultationon
AppropriateBodyMassIndexforAsianPopulations(WHO,2004);
responsetotheemergingproblemofobesityandrelatedchronicdiseases,inparticular
inlowandmiddleincomecountries.
The1997WHOExpertConsultationonObesityrecognizedtheimportanceofabdominalfat
mass(referredtoasabdominal,centralorvisceralobesity),whichcanvaryconsiderably
withinanarrowrangeoftotalbodyfatandbodymassindex(BMI).Italsohighlightedthe
needforotherindicatorstocomplementthemeasurementofBMI,toidentifyindividualsat
increasedriskofobesityrelatedmorbidityduetoaccumulationofabdominalfat(WHO,
2000a).Waisthipratio(i.e.thewaistcircumferencedividedbythehipcircumference)was
suggestedasanadditionalmeasureofbodyfatdistribution.Theratiocanbemeasured
morepreciselythanskinfolds,anditprovidesanindexofbothsubcutaneousandintra
abdominaladiposetissue(Bjorntorp,1987).Thesuggestionfortheuseofproxy
anthropometricindicatorsarosefroma12yearfollowupofmiddleagedmen,which
showedthatabdominalobesity(measuredaswaisthipratio)wasassociatedwithan
increasedriskofmyocardialinfarction,strokeandprematuredeath,whereasthese
diseaseswerenotassociatedwithmeasuresofgeneralizedobesitysuchasBMI(Larssonet
al.,1984).Inwomen,BMIwasassociatedwithincreasedriskofthesediseases;however,
waisthipratioappearedtobeastrongerindependentriskfactorthanBMI(Lapidusetal.,
1984).
The2002WHOExpertConsultationonAppropriateBodyMassIndexforAsianPopulations
andItsImplicationsforPolicyandInterventionStrategies(WHO,2004)reviewedtheissue
ofethnicdifferencesinthemeaningofBMIcutoffvalues.Inpopulationswitha
predispositiontocentral(i.e.abdominalorvisceral)obesityandtherelatedincreasedrisk
ofdevelopingmetabolicsyndrome,theconsultationrecommendedthat,wherepossible,
waistcircumferenceshouldbeusedtorefineactionlevelsbasedonBMI. Forexample,
levelsbasedonBMImightbeincreasedbyonelevelifthewaistcircumferencewere
elevatedaboveaspecifiedlevel.Thechoiceoftheactionlevelforwaistcircumference
shouldbebasedonpopulationspecificdataandhealthconsiderations.Anexpertworking
groupwasformedbythe2002consultation,tostartexaminingdataontherelation
betweenwaistcircumferenceandmorbidity,andonanyassociationbetweenBMI,waist
circumferenceandhealthrisk.Theaimwastodeveloprecommendationsforusingwaist
measurementstofurtherdefinerisks.
WHOsGlobalStrategyforthePreventionandControlofNoncommunicableDiseases
(WHO,2000b),andthemorerecent20082013ActionPlanfortheGlobalStrategyforthe
PreventionandControlofNoncommunicableDiseases(WHO,2008a),providetheplatform
forWHOsworkonnoncommunicablediseases(NCDs).Thesepublicationsidentifiedthe
monitoringofNCDsandtheirdeterminantsasakeycomponentfor:
developingpolicies;
evaluatingtheeffectivenessandimpactofinterventions;
assessingtheprogressmade.
TheExpertConsultationonWaistCircumferenceandWaistHipRatiocontributedtothe
implementationoftheglobalstrategyandNCDactionplan.Itachievedthisbyreviewing
andupdatingthewaistcircumferenceandwaisthipratioissuesrelatedtodiagnostic
criteria,classificationsand(possibly)managementguidelinesformajorNCDs.
Theoverallaimoftheexpertconsultationwastoreviewthescientificevidenceandmake
recommendationsontheissuesrelatedtowaistcircumferenceandwaisthipratio.It
focusedparticularlyonissuesrelatedto:
methodsofmeasurement;
variationsbysex,ageandethnicity;
predictingrisksofcardiovasculardisease(CVD)anddiabetes,andofoverallmortality;
relationshipwithBMIinpredictingdiseaserisks.
Thespecificobjectivesoftheconsultationwereto:
reviewtheusefulnessofwaistcircumferenceandwaisthipratiomeasuresas
predictorsofNCDrisk;
assessoperationalconsiderationsrelatedtomeasurementprotocolsandcutoffpoints
forpublichealthaction;
definepotentialcutoffpointsforpublichealthaction;
identifyfutureresearchneeds.
Toachievetheseobjectives,sixpeerreviewedbackgroundpaperswerepreparedby
selectedexpertsintherelatedfields. Theselectionofexperts,bothforthepreparationof
thebackgrounddocumentsandfortheactualconsultation,followedWHOprocessand
guidelines;aspartoftheprocess,allexpertparticipants,peerreviewersandtemporary
advisorssignedadeclarationofinterests.
Wherepossible,thebackgroundpaperspreparedfortheconsultationevaluatedthe
strengthoftheevidence,usingmodifiedcriteriafromtheWorldCancerResearchFund,as
adaptedbyanearlierjointWHOandFoodandAgricultureOrganizationoftheUnited
Nations(FAO)ExpertConsultationonDiet,NutritionandthePreventionofChronicDisease
(WHO/FAO,2003)(seeTable1.1,below).Muchofthedataandmanyofthestudydesigns
didnoteasilylendthemselvestorigorousevaluationbasedonthesecriteria.Nevertheless,
thecriteriawereusefultothediscussionsattheexpertconsultation,inrelationto
understandingconclusionsonthedifferencesamongdiversepopulationsderivedfrom
examinationofassociationsbetweenBMIandproxyanthropometricindicatorsof
abdominalfat,anddifferenthealthoutcomes.
Table 1.1
Criteria for assessing strength of the evidence of association
Convincing evidence
Based on epidemiological studies
showing consistent associations
between exposure and disease,
with little or no evidence to the
contrary
Based on a substantial number of
studies including prospective
observational studies and, where
relevant, randomized controlled
trials of sufficient size, duration and
quality showing consistent effects
Association should be biologically
plausible
Probable evidence
Based on epidemiological studies
showing fairly consistent
associations, but with perceived
shortcomings in available evidence
or some evidence to the contrary,
precluding a more definite
judgement
Shortcomings in the evidence may
include insufficient duration of
trials/studies, insufficient availability
of trials/studies, inadequate sample
sizes, and incomplete follow-up
Laboratory evidence is usually
supportive
plausible
Possible evidence
Based mainly from casecontrol
and cross-sectional studies, and
data from insufficient randomized
control trials, observational studies,
non-randomized control trials and
evidence from non-epidemiological
studies (i.e. clinical and laboratory
based)
More trials are required to support
tentative associations
plausible
Adapted from WHO/FAO (2003)
Thisreportprovidesasummaryofthediscussionsoftheexpertconsultation.Itincludes:
discussionofthemethodsformeasuringwaistcircumferenceandwaisthipratio
(Chapter2);
age,sexandethnicvariationsinfatdistribution(Chapter3);
associationsofwaistcircumferenceandwaisthipratiowithBMI,andwithhealth
outcomes(Chapter4).
Chapter5presentsasummaryandconclusionsonthesedifferentaspects,anddiscusses
approachesandresearchneedsforusingmeasurementsofwaistcircumferenceandwaist
hipratio.Chapter6outlinesstepsthatcouldbetakentoarriveatappropriateWHO
recommendations.AnnexAcontainsbackgroundinformation(compiledbytheWHO
Secretariat)onexistingcutoffpointsforwaistcircumferenceandwaisthipratio.These
cutoffpointsareusedtovariableextents,someforclinicalanddiagnosticpurposes,others
forscreeningandsurveillanceforpublichealthpurposes.AnnexBliststheparticipantsin
theconsultation.
Thedetailedbackgroundpapers,togetherwithanoverviewoftheexpertconsultation,
havebeenpublishedelsewhere(Huxleyetal.,2010;Learetal.,2010;Nishidaetal.,2010;
Qiao&Nyamdorj,2010a;Qiao&Nyamdorj,2010b;Seidell,2010;Stevensetal.,2010).The
mainfindingsandkeyissuesidentifiedfromthesebackgroundpapersareincludedinthis
report.
Someofthepotentialusesofthecutoffpointsforwaistcircumferenceandwaisthipratio
include:
surveillance
screening
diagnosisanddecisiontotreatinaclinicalsituation
assessingthevalueoftreatmentofanindividual
assessingthevalueofinterventioninthecommunity.
Touseeitherorbothofthesemeasures,themethodforselectingcutoffpointstoindicate
thresholdsforriskneedstobespecified(WHO,1995).Thebasisforidentifyingthesecutoff
pointsmaybeidenticalforthedifferentmeasurementsormaydiffer,dependingonthe
purposeforwhichthecutoffpointsareused.Therelevancetopublichealthisrelatedto
preventionandthepredictionofdiseaseburden,ratherthanthepredictionofmortality. As
partofanevidencebasetoinformpolicy,thesemeasuresmaybeusedtoassesstheneed
forinterventions,andtoassesseffectivenessofinterventionsinreducinghealthrisksor
associatedcostsandburdens.
Methods for measuring waist and hip

circumference
Animportantissueinusingandinterpretingwaistcircumferenceorwaisthipratioisthe
protocolusedtoobtainthemeasurements.Alsoimportantistheextenttowhichthe
measurementprotocolvariesacrossstudies,andthepotentialforstandardizingthese
measurementswithinastudyorsurvey,whentakenbydifferentpeople.
Theoretically,differencesinmeasurementsprotocolsacrossstudiescouldberesponsible
forvariationintheassociationofthesemeasureswithriskfactors,ordiseaseormortality
outcomes.Therefore,theexpertconsultationconsideredbackgroundinformationon
protocolscurrentlyinuse,andtheimpactofdifferencesinmeasurementapproacheson
measurementerrorandassociationswithhealthoutcomes.Theaimwastorecommendan
appropriateprotocolforinternationaluse.
Elementsoftheprotocoldiscussedbelowinclude:
theanatomicalplacementofthemeasuringtape,itstightnessandthetypeoftape
used;
thesubjectsposture,phaseofrespiration,abdominaltension,stomachcontentsand
clothing.
2.1
Placement, tightness and type of measuring tape
2.1.1
Placement of tape
Waist circumference
TheWHOSTEPwiseApproachtoSurveillance(STEPS)providesasimplestandardized
methodforcollecting,analysinganddisseminatingdatainWHOMembercountries.The
WHOSTEPSprotocolformeasuringwaistcircumferenceinstructsthatthemeasurementbe
madeattheapproximatemidpointbetweenthelowermarginofthelastpalpableriband
thetopoftheiliaccrest(WHO,2008b).TheUnitedStates(US)NationalInstitutesofHealth
(NIH)protocolprovidedintheNIHPracticalguidetoobesity(NHLBIObesityEducation
Initiative,2000)andtheprotocolusedintheUSNationalHealthandNutritionExamination
Survey(NHANES)III(WestatInc,1998)indicatethatthewaistcircumferencemeasurement
shouldbemadeatthetopoftheiliaccrest.
TheNIHalsoprovidedaprotocolforthemeasurementofwaistcircumferenceforthe
MultiEthnicStudyofAtherosclerosis(MESA)study.Thisprotocolindicatesthatthewaist
measurementshouldbemadeattheleveloftheumbilicusornavel.However,published
reportsindicatethatmeasurementsofwaistcircumferencemadeatthelevelofthe
umbilicusmayunderestimatethetruewaistcircumference(Croftetal.,1995).
Somestudieshaveassessedthewaistcircumferenceatthepointoftheminimalwaist(Ross
etal.,2008).
Hip circumference
AlloftheprotocolsmentionedinSection2.1.1indicatethatthehipcircumference
measurementshouldbetakenaroundthewidestportionofthebuttocks.
2.1.2
Tightness and type of tape

Theaccuracyofwaistandhipcircumferencemeasurementsdependsonthetightnessof
themeasuringtape,andonitscorrectpositioning(i.e.paralleltotheflooratthelevelat
whichthemeasurementismade).TheWHOSTEPSprotocolstatesthat,forbothwaistand
hip,thetapeshouldbesnugaroundthebody,butnotpulledsotightthatitisconstricting
(WHO,2008b).Theprotocolalsorecommendstheuseofastretchresistanttapethat
providesaconstant100goftensionthroughtheuseofaspecialindicatorbuckle;useof
thistypeoftapereducesdifferencesintightness.
BoththeprotocoldescribedinNIHPracticalguidetoobesity(NHLBIObesityEducation
Initiative,2000)andtheNHANESIIIprotocol(WestatInc,1998)recommendthatthe
measurementsbemadewiththetapeheldsnugly,butnotconstricting,andatalevel
paralleltothefloor.
2.2
Subject posture and other factors
2.2.1
Posture of the subjects during the measurement

Thepostureofthesubjectatthetimethemeasurementistakeninfluencestheaccuracyof
themeasurement.Thus,theWHOSTEPSprotocolrecommendsthatthesubjectstandswith
armsatthesides,feetpositionedclosetogether,andweightevenlydistributedacrossthe
feet(WHO,2008b).TheNHANESIIIprotocolrecommendsthatthesubjectbestanding
erect,withthebodyweightevenlydistributed(WestatInc,1998).
2.2.2
Phase of respiration at the exact point of measurement

Thephaseofrespirationdeterminestheextentoffullnessofthelungsandthepositionof
thediaphragmatthetimeofmeasurement;italsoinfluencestheaccuracyofthewaist
circumference.TheWHOSTEPSprotocolsuggeststhatthewaistcircumferenceshouldbe
measuredattheendofanormalexpiration,whenthelungsareattheirfunctionalresidual
capacity (WHO,2008b).TheNHANESIIIprotocolstatesthatthewaistcircumferenceshould
bemeasuredatminimalexpiration(WestatInc,1998).
2.2.3
Abdominal tension at the point of measurement

Thetensionoftheabdominalwallinfluencestheaccuracyofthewaistcircumference
measurement.Loweringthetensionoftheabdominalwallincreaseswaistcircumference,
whereasincreasingthetension(bysuckingin)reduceswaistcircumference.Many
individualsunconsciouslyreacttowaistmeasurementsbysuckingintheabdominalwall;
hence,arelaxedpostureisbestfortakingwaistmeasurements.TheWHOSTEPSprotocol
recommendsadvisingthesubjecttorelaxandtakeafewdeep,naturalbreathsbeforethe
actualmeasurementismade,tominimizetheinwardpulloftheabdominalcontentsduring
thewaistmeasurement(WHO,2008b).
2.2.4
Influence of stomach contents at time of measurement

Theamountofwater,foodorgasinthegastrointestinaltractwillaffecttheaccuracyofthe
waistmeasurement.Gibson(1990)suggeststhatawaistmeasurementbemadeafterthe
subjecthasfastedovernightorisinafastedstate,toreducethiseffect.Noneofthe
protocolsevaluatedaddressthisissue,perhapsbecauseitwouldentailthesubjectbeing
notifiedinadvanceofthemeasurement,andbeingpresentthemorningafteranovernight
fast.
2.3
Measurement error
Informationonthemeasurementerrorofthewaistcircumferenceandhipcircumference
hascomefromstudiesinadolescents.Lohmanetal.(1988)calculatedthetechnicalerrorof
waistcircumferencemeasurementinadolescentstobe1.31cmfromintrameasurererror
and1.56cmfromintermeasurererror.Forhipmeasurements,theauthorscalculatedthe
technicalerrortobe1.23cmfromintrameasurererrorand1.38fromintermeasurererror.
2.4
Implications of differences in methodology

Therehasbeennoevaluationoftheeffectsofdifferencesinthemethodsofmeasurements
ofwaistandhipcircumferencesonmeasurementerrorandonthepredictionorestimation
ofspecificadiposetissuedepots(e.g.abdominalfat).However,asystematicreviewof
120 studiesexaminedwhethermeasurementprotocolsinfluencedtherelationshipofwaist
circumferencewithmorbidityfromCVDanddiabetes,andmortalityfromCVDandall
causes(Ross,etal.,2008).Thereviewonlyfocusedontheanatomicalsiteofplacementof
thetapeforwaistcircumferencemeasurement.Mostprotocolsmeasuredatthemidpoint
(36%),umbilicallevel(28%)andminimalwaistlevel(25%).Similarpatternsofassociation
wereobservedbetweenhealthoutcomesandallwaistcircumferenceprotocolsacross
samplesize,sex,age,raceandethnicity.Thereviewconcludedthatwaistcircumference
measurementprotocolhadnosubstantialinfluenceontheassociationbetweenwaist
circumference,allcauseandCVDspecificmortality,andriskofCVDanddiabetes(Ross,et
al.,2008).
Evenwhenthesameprotocolisused,theremaybevariabilitywithinandbetween
measurerswhenmorethanonemeasurementismade.Theexpertswereuncertain
whethertheseandotherissuesrelatedtomeasurementarerelevantateitherthe
populationortheclinicallevel,andfeltthatthismaybeanimportantareaforinclusionin
thefutureresearchagenda.
2.5
Summary and conclusions

Waistcircumferenceshouldbemeasuredatthemidpointbetweenthelowermarginofthe
leastpalpableribandthetopoftheiliaccrest,usingastretchresistanttapethatprovidesa
constant100gtension.Hipcircumferenceshouldbemeasuredaroundthewidestportion
ofthebuttocks,withthetapeparalleltothefloor.
Forbothmeasurements,thesubjectshouldstandwithfeetclosetogether,armsattheside
andbodyweightevenlydistributed,andshouldwearlittleclothing.Thesubjectshouldbe
relaxed,andthemeasurementsshouldbetakenattheendofanormalexpiration.Each
measurementshouldberepeatedtwice;ifthemeasurementsarewithin1cmofone
another,theaverageshouldbecalculated.Ifthedifferencebetweenthetwo
measurementsexceeds1cm,thetwomeasurementsshouldberepeated.
I m pa c t o f v a r i a t i o n s i n b o d y f a t
distribution by sex, age and ethnicity
Commonlyusedcutoffpointsforwaistcircumferenceandwaisthipratioarebasedon
studiesundertakenpredominantlyinpopulationsofEuropeanorigin. Theimportanceof
takingintoaccountethnicdifferencesintheamountofbodyfatassociatedwithwaist
circumferenceorwaisthipratioatdifferentBMIlevelswasaprimarymotivationforthis
expertconsultation,basedonthefindingsofthe2002WHOExpertConsultationon
AppropriateBodyMassIndexforAsianPopulationsandItsImplicationsforPolicyand
InterventionStrategies(WHO,2004).
Thekeyissueiswhethertherearesystematicdifferencesintheextenttowhichagiven
waistcircumferenceorwaisthipratiolevelpredictsdiseaseoutcomesindifferentethnic
groups,particularlyifsuchdifferencescouldleadtounderestimationofriskincertain
populations.Systematicdifferencescouldrelatetooneorbothofthefollowing:
differencesinbodycompositionthatis,therelativeamountsortypesoffatreflected
inthewaistcircumferenceorwaisthipratiomeasurement;
differencesindiseaseriskforaparticularbodyfatprofile.
Alsoofinterestwerevariationsinbodyfatdistributionthatmayaffectallpopulations;for
example,variationsbetweenmenandwomen,andwithageing.Thischaptersummarizes
theissuesrelatedtosex,ageandethnicvariations.Moredetaileddiscussionswere
providedinthebackgroundpaperthatexaminedassociationsbetweensex,reproductive
statusandage,andwaistcircumference(Stevens,etal.,2010);andthepaperthat
examinedassociationsbetweenethnicityandwaistcircumference(Lear,etal.,2010).
3.1
Sex
Sexdifferencesindepositionofbodyfatareevidentevenatthefoetalstage,butthey
becomemuchmorepronouncedduringpuberty(Wells,2007).Afteradjustingfor
differencesinheight,menhavegreatertotalleanmassandbonemineralmass,andalower
fatmassthanwomen;thesedifferencescontinuethroughoutadultlife. Womenhave
substantiallymoretotaladiposetissuethanmen,andthesewholebodysexdifferencesare
complementedbymajordifferencesintissuedistribution. Menhavegreaterarmmuscle
mass,largerandstrongerbones,lesslimbfatandarelativelygreatercentraldistributionof
fat.Womenhaveamoreperipheraldistributionoffatinearlyadulthood.Sexdifferencesin
bodycompositionareprimarilyattributabletotheactionofsexsteroidhormones,which
drivethedimorphismsduringpubertaldevelopment.Inmen,areductioninfree
testosteronelevelsisassociatedwithanincreaseinfatmassandreductioninmusclemass,
andbothtotalandfreetestosteronelevelsareinverselyassociatedwithobesity(Derbyet
al.,2006).
3.2
Reproductive status
Parityisanimportantcontributortochangesinbodycompositionandbodyshapein
women.Pregnancyisassociatedwithgainsinvisceralandcentraladipositypostpartum.
CrosssectionalanalysisofdatafromNHANESIIIillustratedhowparityisassociatedwith
changesinbodyshape(Lassek&Gaulin,2006).Datafrom16325womenshowedthat
womenwhohadgivenbirthhadlesslowerbodyfatandgreaterwaistcircumference.After
controllingforageandBMI,increasingparitywasassociatedwithlowerhipandthigh
circumferences,andhigher waistcircumference.Thesefindingsaresupportedbydataover
10yearsoffollowupfromtheCoronaryArteryRiskDevelopmentinYoungAdults(CARDIA)
studyofwomenaged1830years(Gundersonetal.,2004).Bothfirstandhigherorder
birthswereassociatedwithincreasesinwaistcircumference.
Menopauseisalsoassociatedwithanincreaseinfatmass,andaredistributionoffattothe
abdominalarea(Tothetal.,2000).Itisnotclearwhethersuchchangesaredueto
hormonalchangesortotheageingprocess.TheStudyofWomensHealthAcrossthe
Nation(SWAN)includedanethnicallydiversecohortof3064women,withanaverageage
of45.9years.SWANshowednoindependenteffectofmenopauseonfatdistribution
(Sternfeldetal.,2004).Overa3yearfollowup,thestudyshowedameanweightgainof
2.1 kg(3%increase)andameanincreaseinwaistcircumferenceof2.2 cm(2.8%increase);
gainsthatcouldbeattributedtoageandphysicalactivitylevel.Otherstudiesconcurred
withSWAN,suggestingthat,onaverage,womenexperiencea0.68 kgperyearincreasein
weightduringtheir40sand50s,regardlessofmenopausalstatus(Macdonaldetal.,2003;
Wingetal.,1991).
3.3
Age
Toappreciatetheeffectofageingonfatdistribution,changesinBMIthatoccurwith
increasingageneedtobeconsidered.ChangesinbodyweightandBMIarestronglyrelated
tochangesinfatfreemass,andexplain54%ofthevarianceinthosechanges(Forbes,
1999).WhiletheassociationsbetweenBMIandbodyfatarelinear,theassociationwithper
centbodyfatiscurvilinear,withtheslopesteeperatlowerBMIsthanathigherBMIs
(Welch&Sowers,2000).Percentbodyfatmayremainconstantorincreasewithage,but
ageingisassociatedwithsubstantialredistributionoffattissueamongdepots(Cartwright
etal.,2007).Fromlatemiddleageuntilthe80sorlater,thereisadeclineinthevolumeof
subcutaneousfat,andaredistributionoffatfromsubcutaneoustovisceraldepots.This
ageassociateddeclineinthesizeofadiposedepotsisaccompaniedbytheaccumulationof
fatoutsideadiposetissue(inmuscle,liverandbonemarrow),andlossofleanbodymass.
DatafromNHANESshowthatwaistcircumferenceincreaseswithage,andislargerinolder
thaninyoungeradultsofbothsexesuptotheageof70years(Fordetal.,2003).Similarly,
intheBaltimoreLongitudinalStudyofAging,agerelateddifferencesinwaisthipratiowere
alsoreportedinallBMIcategoriesexaminedinbothmenandwomen(Shimokataetal.,
1989).ChangesinwaistcircumferencewerefollowedupinFinnishadults(9025menand
9950womenaged2564years),andmeanwaistcircumferencewasseentoincreaseby
2.7 cminmenand4.3 cminwomenovera15yearperiod(LahtiKoskietal.,2007).BMI
alsoincreasedoverthestudyperiod,butthechangeswererelativelysmall(1.2%orlessper
5yearperiod)inallbuttheyoungestagecategory(2534years),whileincreasesinwaist
circumferencewereseenineveryagegroup.
TheBaltimoreLongitudinalStudyofAgingalsoexaminedtheeffectsofweightchangeon
changesinfatdistribution(Shimokata,etal.,1989).Thestudyfoundthatchangesinwaist
andhipcircumferencescorrelateddirectlywithchangesinweight,buttherewere
differencesinthepatternofchangebysex. Inmen,waistchangeswerelargerthanhip
changes,whereasinwomentheyweresimilar.Thisresultedinweightchangesinmen
havingalargereffectonwaisthipratio.Onaverage,witha4.5kgweightgain,menhada
4 cmincreaseinwaistcircumferenceanda2.5 cmincreaseinhipcircumference.
Comparablevaluesforwomenwere3.3cmand3.6cm,respectively.
3.4
Ethnicity
Interpretationofevidenceonethnicdifferencesiscomplicatedbyissuesrelatedtodefining
ethnicity,andothermethodologicalissuesthatareoutlinedinthebackgroundpaper
preparedbyLearetal.(2010).Thebackgroundreviewonlyconsideredstudieson
populationsthatwerenotrepresentedinearlieranalysesandthatledtorecommendations
aboutwaistcircumferenceorwaisthipratiocutoffsinEuropeans.Thepotential
significanceofthesedifferencesforidentifyingcutoffpointstopredicthealthoutcomesis
consideredinChapter4.
3.4.1
Ethnic groups for which waist circumference or waisthip ratio may reflect
more body fat at a given body mass index level
StudiesinvestigatingbodycompositionandtheassociationwithhealthoutcomesinAsian
populationshavefocusedonstudypopulationsdefinedasChinese,JapaneseandKoreanor
SouthAsian(orIndian).However,anumberofstudieshaveanalysedtheseethnicgroupsas
ahomogeneouspopulationlabelledasAsians.Thesestudiesfoundahigherpercentageof
bodyfatinAsiansatlowerBMI(DeurenbergYapetal.,2001;DeurenbergYapetal.,2000),
aswellasanincreasedprevalenceoftruncalfat,comparedtoCaucasians(Wuetal.,2007).
3.4.2
Populations for which waist circumference or waisthip ratio may reflect less
body fat at a given body mass index level
ChineseandSouthAsianmenandwomendisplayagreateramountofvisceraladipose
tissueforagivenwaistcircumferencethanEuropeans(Learetal.,2007b).Similarly,a
higherpercentageofbodyfatacrossarangeofwaistcircumferencevalueshasbeen
documentedinEastAsia(Kagawaetal.,2007).
InNorthAmerica,comparisonsofIndigenouspeopleandCaucasianshavereportedno
differenceintherelationshipsbetweenvisceraladiposetissueandBMI(Gautieretal.,
1999),totalbodyfat(Lear,etal.,2007b)orwaistcircumference(Learetal.,2007a).
AustralianAboriginalslivinginaremoteareawerereportedtohavehigherwaisthipratios
withlowerBMIsthanurbanAustraliansofEuropeanorigin(Piersetal.,2003).
ComparedtoEuropeanwomen,blackwomeninSouthAfricahaveaslightlylowerBMIata
givenpercentagebodyfat,butalsohavelessabdominaladiposetissueasdeterminedby
dualXrayabsorptiometry(DEXA)atthesamewaistcircumference(Rushetal.,2007).A
fewsmallstudiesreportAfricanwomenashavinglessvisceraladiposetissuethanwhite
women(Punyadeeraetal.,2001a;Punyadeeraetal.,2001b;vanderMerweetal.,2000).
InHispanics,onestudyreportedthatvisceraladiposetissueatagivenwaistcircumference
wasnotappreciablydifferentfromthatofwhites(Carrolletal.,2008;Haffneretal.,1996;
Nelsonetal.,2008).
SomestudieshavereportedthatPacificIslandershavelargermusclemassesandlower
percentagebodyfatthanEuropeansatsimilarBMIs(Rushetal.,2004;Rushetal.,2009).In
women,thishasalsobeenreportedforsimilarwaistcircumferencesandwaisthipratios
(Rush,etal.,2007).
3.5

Thereissubstantialevidenceofsexandagevariationsinwaistcircumferenceandwaisthip
ratio,andsomeevidenceforethnicdifferences.ComparedtoEuropeans,Asianpopulations
havegreatervisceraladiposetissue,andAfricanpopulationsand,possibly,PacificIslanders
10
havelessvisceraladiposetissueorpercentageofbodyfatatanygivenwaistcircumference.
Ifhigherlevelsofabdominalfatforawaistcircumferenceorwaisthipratiolevelare
reflectedinassociationswithhealthoutcomes,thenlowerthresholdsfortheseindicators
mightbeneededfortheaffectedpopulationsthanforEuropeanorotherreference
populations.ThereisrelativelyconsistentevidencethatthissituationmayapplytoAsian
populations. DataforAfricansandPacificIslandersareexamplesofpossibleindicationsfor
aneedforhighercutoffsthanthoseusedforEuropeanreferencepopulations.However,
giventhattheobjectiveistopredictdiseaserisk,drawingconclusionsaboutcutoffssolely
onthebasisofobservedrisksdoesnotseemappropriate.
11
R e l a t i o n s h i ps o f w a i s t c i r c u m f e r e n c e
and waisthip ratio to disease risk and
m o r ta l i t y
Bothgeneralizedandabdominalobesityareassociatedwithincreasedriskofmorbidityand
mortality.ThemaincauseofobesityrelateddeathsisCVD,forwhichabdominalobesityisa
predisposingfactor.Itisunclearwhichanthropometricmeasureisthemostimportant
predictorofriskofCVDinadultsBMI,waistcircumference,waisthipratioorevenhip
circumference.
BMIhastraditionallybeenthechosenindicatorbywhichtomeasurebodysizeand
composition,andtodiagnoseunderweightandoverweight.However,alternativemeasures
thatreflectabdominaladiposity,suchaswaistcircumference,waisthipratioandwaist
heightratio,havebeensuggestedasbeingsuperiortoBMIinpredictingCVDrisk.Thisis
basedlargelyontherationalethatincreasedvisceraladiposetissueisassociatedwitha
rangeofmetabolicabnormalities,includingdecreasedglucosetolerance,reducedinsulin
sensitivityandadverselipidprofiles,whichareriskfactorsfortype2diabetesandCVD.
Thischaptersummarizestheexpertsdiscussionsonthestrengthofassociationsbetween
anthropometricmeasuresandhealthoutcomes.Moredetailedreviewsareprovidedin
severalofthebackgroundpapers(Huxley,etal.,2010;Qiao&Nyamdorj,2010a;Qiao&
Nyamdorj,2010b;Seidell,2010).
Onepaperexaminedhowwaistcircumference,waisthipratioandBMIperformin
predictinganddifferentiatingrisksofhypertension,dyslipidaemiaanddiabetes(asmajor
riskfactorsforCVD),andrisksofCVDevents(Huxley,etal.,2010).Theauthorsreviewed
datacomparingAsianandPacificwithCaucasianpopulations,anddataonotherethnically
diversestudypopulations.Otherstudiesexaminedtherelativeassociationsofwaist
circumference,waisthipratioandBMIwithdiabetesrisk(Qiao&Nyamdorj,2010a;Qiao&
Nyamdorj,2010b).Seidell(2010)revieweddataonallcausemortality,cancerandsleep
apnoeainassociationwithwaistcircumference,waisthipratioandBMI,highlighting
variationsinfindingsaccordingtochoiceofindicator,ageandBMIstatusofthepopulation.
4.1
Measures of obesity and abdominal obesity and cardiovascular

disease risk
Basedonanextensivereview,Huxleyetal.(2010)concludedthattherewasconvincing
evidencethatmeasuresofgeneralobesity(e.g.BMI)andmeasuresofabdominaladiposity
(e.g.waistcircumference,waisthipratioandwaistheightratio)areassociatedwithCVD
riskfactorsandincidentCVDevents.Theauthorsalsoconcludedthattherewasprobable
evidencethat:
measuresofabdominalobesityarebetterthanBMIaspredictorsofCVDrisk,although
combiningBMIwiththesemeasuresmayimprovetheirdiscriminatorycapability;
foranygivenlevelofBMI,waistcircumferenceorwaisthipratio,theabsoluteriskof
diabetesorhypertension(riskfactorsforCVDincidence)ishigherinsomepopulation
groupsthaninCaucasianadults;
universalcutoffpointsforBMIandwaistcircumferencearenotappropriateforuse
worldwide,givenethnicorpopulationspecificdifferencesindiseaseriskforany
12
particularanthropometricmeasure;however,theremaybegeneralconsistencyinthe
cutoffpointsofwaisthipratioforpredictingCVDrisk.
4.2
Measures of obesity, abdominal obesity and type 2 diabetes risk

Thepositiveassociationbetweenobesityandtheriskofdevelopingtype2diabeteshas
beenrepeatedlyobserved,bothincrosssectionalstudies(Hartzetal.,1983;Shatenetal.,
1993;Skarforsetal.,1991)andinprospectivestudies(Cassanoetal.,1992;Colditzetal.,
1990;Ohlsonetal.,1985).Theconsistencyoftheassociationacrosspopulationsdespite
differencesinmeasuresoffatnessanddiagnosticcriteriafordiabetesinadultsreflects
thestrengthofthisrelationship.Theriskoftype2diabetesinadultsincreasescontinuously
withincreasingobesity,anddecreaseswithweightloss. Acarefulanalysisofthe
relationshipbetweenobesityandadultonsetdiabetesconfirmsthatabdominalobesityis
animportantriskfactor,evenaftercontrollingforage,smokingandfamilyhistory. Since
waistcircumferencecorrelatesmorecloselywithabdominaladiposetissuethanBMI,the
associationbetweenindicatorsofsuchobesity(e.g.waistcircumferenceandwaisthip
ratio)hasbeenstudiedextensivelyinthelasttwodecades.
Qiao&Nyamdorj(2010b)concludedthat,withrespecttotype2diabetes,all
anthropometricmeasures(BMI,waistcircumference,waisthipratioandwaistheight
ratio)performedsimilarlyinpredictingrisk.However,datafrommostofthecrosssectional
studiessuggestedthatwaistcircumferenceorwaisthipratioarebetterindicatorsthan
BMIoftheriskofdiabetes.Thenumberofprospectivestudieswaslimited,andthestudies
coveredonlyafewethnicorpopulationgroups;thus,theevidencethatwaist
circumferenceorwaisthipratioispreferableisneitherconvincingnorgeneralizable.The
crosssectionalstudiesprovideonlypossibleassociation,andthestrengthofevidencemay
beconsideredaspossible(seeTable1.1).Allthesestudieshaveprovidedevidencethat
eitherBMIorwaistcircumferencepredictedanassociationwithdiabetes,andanincreased
riskofthedisease,independentofotherfactors.
Keymethodologicalissuesthataffectedtheabilitytodrawclearconclusionswere
emphasizedbyQiao&Nyamdorj(2010b).Inthereviewsundertaken,moststudiesusedthe
sensitivityandspecificityapproachtodeterminetheoptimalcutoffpointsfor
anthropometricmeasurespredictingtype2diabetesrisk.Selectionofcutoffpointsusing
suchanapproachisarbitrary,becausevaluesarebasedonanalysisofthetradeoffs
betweensensitivityandspecificity.Althoughahighsensitivityforthewaistcircumference
measurementmaybepreferredinhealthpromotion(toincreasepublicawarenessof
obesityanddiabetes),ahighspecificityindiagnosticcriteriaisexpectedinclinicalpractice.
Thus,theusefulnessofwaistcircumferencemeasurementasafirststepdiagnostictool
whenassessinganindividualsriskofdiabetesisunclear.Furtherinvestigationbasedon
welldesignedprospectivestudieswithincidenttype2diabetesastheoutcomewouldbe
neededtomakerecommendationsontheuseofthewaistcircumference.Mostpublished
studiesarecrosssectional,sotheinterpretationofresultsislikelytobeconfoundedby
otherconcurrentconditionssuchashypertensionanddyslipidaemia.However,the
literaturereviewandanalysisdidconfirmthattheoptimalcutoffpointsforindicatorsof
overweightandobesity,andmeasuresofabdominalobesity,varyacrossdifferent
ethnicitiesandpopulationgroups.Thefindingsalsosupportedtheviewthatthereisno
optimalcutoffpointthatcanbeappliedworldwide.ThereviewundertakenbyQiao&
Nyamdorj(2010b)suggestedthatcountryorregionspecificcutoffpointsmayneedtobe
used,takingintoconsiderationthepurposeforwhichthevalueisrequiredandthe
availabilityofresources.
13
4.3
Measures of obesity and abdominal obesity and all-cause

mortality and mortality from specific causes
Duetoinconsistenciesintheliterature,controversycontinuesabouttherelationship
betweenobesityandoverallmortality(WHO,2000a).SomestudieshavefoundaUorJ
shapedassociation,withhighermortalityratesatboththeupperandlowerweightranges.
Othershaveshownagradualandcontinuousincreaseinmortalitywithincreasingbody
weight,ornoassociationatallbetweenbodyweightandmortality.Manyofthestudieson
obesityandmortalityhavesystemicallyunderestimatedtheimpactofobesityon
prematuremortality,duetobiasinthestudydesign.Thisbiasmaybetheresultoffailure
tocontrolforsmoking,inappropriatecontrolforassociatedconditions(e.g.hypertension,
dyslipidaemiaandhyperglycaemia,whichareessentiallycomorbiditiesofobesity),failure
tocontrolforweightlosswithillnessandfailuretostandardizeforage(Mansonetal.,
1987;Seidelletal.,1996).
Seidell(2010)concludedthat:
waistcircumferenceandwaisthipratioarebothrelatedtoincreasedriskofallcause
mortality,throughouttherangeofadultBMIs;
waistcircumferenceandwaisthipratioarestronglypredictiveinyoungandmiddle
agedadultscomparedtoolderpeopleandthosewithlowBMI;
waistcircumferencealonecouldreplacewaisthipratioandBMIasasingleriskfactor
forallcausemortality.
However,dataarelackingonappropriatecutoffsformeasuresofabdominalobesityfor
predictingriskofallcausemortalityinethnicandpopulationgroupsotherthanEuropean,
NorthAmericanandAustralianwhitepopulations.Evidenceforuseofwaistcircumference
orwaisthipratiotoreplaceBMIforpredictingmorbidityrelatedtocancerriskisless
strongthanforallcausemortality.
4.4
Ethnic differences
Numerousstudiesofpopulationsthroughouttheworldhavesuggestedusingcutoffpoints
specific toethnicgroups.Thissectionhighlightsstudiesthathaveevaluated(directlyor
indirectly)thepotentialbasisforwaistcircumferenceorwaisthipratiocutoffpointsthat
differfromthoseproposedforgeneraluseandarebasedonEuropeanorCaucasian
referencepopulations.
WhenstudiesinAsianpopulationsaretakentogether,Asiansappeartohaveanincreased
metabolicriskatlowerwaistcircumferenceandwaisthipratiothanEuropeans.Thisis
probablyduetohigherlevelsofbodyfatandabdominaladiposetissue. Inparticular,those
studiesthatincludedaEuropeanorCaucasiancomparisongroupindicatedalowerwaist
circumferenceforAsians,andsomealsosuggestedalowerwaisthipratio(Diazetal.,
2007;Huxleyetal.,2007;2008).Thesedataindicatealowerwaistcircumferenceand
waisthipratiocutoffpointforAsians;forexample,waistcircumferencevaluesof85cm
and80cm,andwaisthipratiovaluesof0.90and0.80formenandwomen,respectively.
StudiesinpopulationsresidingintheMiddleEasthaveprovidedwaistcircumferenceand
waisthipratiocutoffpointssimilartothosesuggestedforEuropeans.Onlyoneanalysis
reportedonwaistcircumferencecutoffpointsinAfricans(noneinvestigatedwaisthip
ratiocutoffpoints).Thatanalysisrecommended75.6cmand80.5cmformen,and71.5cm
and81.5cmforwomenofNigerianandCameroonorigin,respectively,fortheidentification
ofhypertension(Okosunetal.,2000a;Okosunetal.,2000b).Giventhatnootherstudies
14
haveinvestigatedcutoffsinthispopulationgroup,thereisinsufficientevidencefor
recommendingspecificcutoffsforsubSaharanAfricans.
Cutoffpointsforwaistcircumferenceof94cmand80cm(determinedforEuropeanmen
andwomen,respectively)havebeenassociatedwitha1.52.0foldincreasedriskin
hypertension,anda3.9and1.6foldincreaseindiabetes,inmenandwomenofAfrican
origin,respectively(Okosunetal.,1998).FindingsthatAfricanAmericanstendtobeleaner
thanEuropeansareinconsistentwiththedataindicatingthatAfricanAmericansareat
increasedriskforCVDatagivenwaistcircumference(duetohigherbloodpressureand
lipids).StudiesinvestigatingspecificcutoffpointsforAfricanAmericanseithersuggested
similarcutoffpointstothoseusedforEuropeans,basedonthelimitedevidenceavailable,
orindicatedthattherewasnotenoughevidencetosetspecificcutoffpointsforAfrican
Americans.
StudiesinvestigatingSouthAmericansrecommendedwaistcircumferencecutoffpointsof
8890cmformen,and8384cmforwomen(Lear,etal.,2010).Threestudiesreportingon
waisthipratioindicatedavaluerangingfrom0.85to0.95inmen,andfrom0.80to1.18in
women.Thesestudiessuggestedthatwaistcircumferencecutoffpointsshouldbelower
thanthoseforEuropeans,butthatwaisthipratiocutoffpointsshouldbesimilartothose
forEuropeans. OnlyonestudyinHispanicsprovidedarecommendationforcutoffpoints;it
suggestedawaistcircumferenceof90cmformenand85cmforwomen,andawaisthip
ratioof0.900.91formenand0.840.86forwomen(Berberetal.,2001).Anotherstudy
suggestedthatthecurrentwaistcircumferencecutoffpointsbasedonEuropeansprovided
lowsensitivitywithrespecttometabolicriskfactorsfortheHispanicpopulation(Okosun,et
al.,2000a).
4.5

Theoverallresultsoftheevaluationoftheassociationsbetweenwaistcircumferenceand
waisthipratiowithmeasuresofmetabolicdiseasesandriskfactorsaresummarizedin
Table4.1,andpresentedbelow.
4.5.1
Cardiovascular disease
ThebiologicalrationaleforrelatingmeasuresofcentraladipositytoCVDriskisthat
abdominaladiposetissue(whichispositivelyassociatedwithwaistcircumferenceand
waisthipratio)isrelatedtoarangeofmetabolicabnormalities.Theseabnormalities
includedecreasedglucosetolerance,reducedinsulinsensitivityandadverselipidprofiles,
whichareriskfactorsfortype2diabetesandCVD.Mostanthropometricindicatorsof
abdominalobesityhavebeenderivedfrompredominantlyEuropeanpopulations.Thishas
raisedissuesabouttheapplicabilityoftherecommendedcutoffpointstononEuropean
populations,amongwhomtheproblemiscurrentlyofmuchgreaterconcern.Neitheris
thereconsensusoverwhichofthesemeasuresofcentraladiposityismoststrongly
associatedwithCVDrisk,eitherwithinorbetweendifferentethnicgroups.
Ithasbeensuggestedthatwaistcircumference,waisthipratioandwaistheightratio,
whichreflectabdominaladiposity,aresuperiortoBMIinpredictingCVDrisk.Forexample,
intheINTERHEARTcasecontrolstudyofmyocardialinfarctionindiversepopulationsin52
countries(Yusufetal.,2005),BMI,waistcircumferenceandwaisthipratiowereall
stronglyandlinearlyassociatedwithriskofmyocardialinfarction.RelationshipswithBMI
wereattenuatedbyadjustmentforwaisthipratio,butrelationshipswithwaistmeasures
wererelativelyunaffectedbyadjustmentforBMI,indicatingtheindependenceofmeasures
15
ofabdominalobesityinpredictingrisk.However,a combinedanalysisofthePhysicians
HealthStudyandtheWomensHealthStudyfoundthat(Gelberetal.,2008):
themagnitudeofassociationsofBMI,waistcircumference,waisthipratioandwaist
heightratiowithCVDriskweresimilar;
thesemeasureswerenotentirelyindependentaspredictorsofrisk;
differencesaccordingtothemeasureusedwerenotlikelytobeclinicallysignificant.
IntheAsiaPacificCohortStudy,noneoftheanthropometricindiceswereclearlyassociated
withstrokeoutcomes(APCSC,2006).Overall,thesemeasuresseemtobecomparablein
theirdiscriminatorycapabilityasassessedbytheareaunderthereceiveroperating
characteristiccurve(AUC)atidentifyingthoseindividualswiththehighestriskofCVD
(Huxley,etal.,2010).
4.5.2
Diabetes
Datafromprospectivestudiesshowawiderangeofrelationshipsbetweenanthropometric
measuresandriskoftype2diabetes;hence,itwouldbedifficulttoconcludethatmeasures
ofabdominalobesityarealwayssuperiortoBMIinpredictingrisk.However,mostofthe
crosssectionalstudiesshowedthattheAUCwasslightlylargerforwaistcircumferenceor
waisthipratiothanforBMI.
4.5.3
Risk factors
Thisreviewsuggeststhat,atanygivenlevelofbodysize,theprevalenceofhypertension,
diabetesanddyslipidaemiaishigherinAsianthaninnonAsianpopulations.Italsosuggests
thatnoanthropometricmeasureismorestronglyassociatedwithbloodpressure,plasma
glucose,diabetesandlipidlevelsthananyothermeasure.However,BMIappearstobeless
informativethanothermeasures.
4.5.4
Mortality
Theevidencewithregardtoanthropometricmeasuresinparticularwaistcircumference
orwaisthipratiomeasuresandallcausemortalityispredominantlyfromwhite
EuropeanandAmericanadults,bothinyoungandmiddleagedadultsandolderpeople.
FewstudieshaveexaminedAfricanandAsianpopulations.Whenwaistcircumferencewas
adjustedforBMI,therelationshipappearsJshapedtoalmostlinear.
4.5.5
Ethnic differences
Overall,thedatasuggestedthat,foragivencombinationofBMIandwaistcircumferenceor
waisthipratiomeasures,theriskishigherforAsiansforalldiseaseoutcomes;however,it
wasnotpossibletodrawdefinitiveconclusions,duetolimitationsofthedata.Onlyin
populationsofAsiandescentweredifferencesinrisksufficienttowarrantconsiderationof
alternativecutoffpoints.Themultiplecausalityandimpactofthenutritiontransitionmay
alsocontributetotheinterpretationofapparentethnicdifferences.Specifically,theimpact
ofexposuretoundernutrition(includinggestationalexposuretomaternalundernutrition)
onsubsequentweightgainandfatdepositionwasnotedasapossiblefactorcontributingto
differencesamongpopulations.Arisingrelativeriskofdiseasealongthecontinuumof
waistcircumferenceorwaisthipratiowasalsoevident.However,theabsoluterisk
currentlydeterminedbythemultipleriskfactorsassociatedwithbodyfatandits
distributionmaywellreflectthephaseofdiseasetransitioninapopulation.Hence,the
thresholdsforriskassociatedwithwaistcircumferenceorwaisthipratiomayvarywith
16
time.Theseconsiderationsmakeitdifficulttospecifycutoffpointsonthebasisof
ethnicity.
Table 4.1
Summary of the associations of body mass index, waist circumference, waisthip

ratio and waistheight ratio with disease risk
Body mass index
Waist
circumference
Waisthip ratio
Waistheight
ratio
Remarks and major

references
Strength of
evidencea
Relationship
Strength of
evidencea
Relationship
Strength of
evidencea
Relationship
Strength of
evidencea
Relationship
CVD risk
++
Convincing ++++ Convincing ++++ Convincing +++
Overall CVD risk

factors
(mainly crosssectional data)
CVD risk factors
(from STEPS
analysis presented
in the WHO
meeting)
Type 2 diabetes
mellitus
(prospective
studies)
Type 2 diabetes
mellitus
(cross-sectional
studies)
++
Convincing +++
Convincing +++
Convincing +++
Convincing de Koning et al. (2007)

APCSC (2006)
Yusuf et al. (2005)
Gelber et al. (2008)
Zhu et al. (2005)
Convincing Lee et al. (2008)b
+++
Probable +++
Probable
WHO (2008b)
+++
Convincing +++
Convincing +++
Convincing /
Vazquez et al. (2007)
+++
Hypertension
(mainly crosssectional data)
+++
Convincing ++++ Convincing ++++ Convincing ++++ Convincing Huxley et al. (2007)
Huxley et al. (2008)
Nyamdorj et al. (2008)b
Qiao & Nyamdorj (2010b)
Convincing +++ Convincing +++ Convincing +++ Convincing Wolf & Colditz (1998)
James et al. (2004)
Nyamdorj et al. (2008)b
Convincing +++ Convincing +++ Convincing +++ Convincing Koster et al. (2008)
Zhang et al. (2008)
Welborn & Dhaliwal (2007)b
Remarks:
Some studies showed Jshape relationship with BMI,
especially elderly people
(Dolan et al., 2007;
Katzmarzyk et al., 2002)
Evidence is less consistent
in elderly people (Baik et al.,
2000; Price et al., 2006)
Probable
++++ Convincing ++++ Convincing /
/
Kalmijn et al. (1999)
Pischon et al. (2008)
Overall mortality +++

(without mutual
adjustment of the
anthropometric
parameters)
Overall mortality 0/
(with mutual
adjustment of the
17
Body mass index
Waist
circumference
Waisthip ratio
Waistheight
ratio
Strength of
evidencea
Relationship
Strength of
evidencea
Relationship
Strength of
evidencea
Relationship
Strength of
evidencea
Relationship
Bigaard et al. (2003)
anthropometric
parameters)
Cancer
+++
colorectum, breast
(post-menopause)
+
Cancer
pancreas,
endometrium,
cervix, kidney,
gallbladder
Remarks and major

references
Convincing ++
Convincing ++
Convincing NR
NR
Moghaddam et al. (2007)

Harvie et al. (2003)
Possible
Possible
Possible
NR
AICR (2007)
NR
APCSC, Asia Pacific Cohort Studies Collaboration; BMI, body mass index; CVD, cardiovascular disease; FAO, Food and
Agriculture Organization of the United Nations; NR, not reported; STEPS, STEPwise Approach to Surveillance; WHO, World
Health Organization
Levels of evidence are based on the report of the joint WHO/FAO expert consultation (WHO/FAO, 2003) (see Table 3.1 of
that report)
Relationship: + to ++++ = positive association, mild to strong; 0/ = negative association, nil to mild
a Definitions of the strength of evidence are based on those that were used by the 2002 joint WHO/FAO Expert Consultation
on diet, nutrition and the prevention of chronic diseases (WHO/FAO, 2003)
b References with evidence on waistheight ratio
18

TheaimoftheexpertconsultationwastoprovideguidancethatWHOcouldusetodevelop
recommendationsandultimatelyprovideguidelinesfortheeffectiveuseofspecificcutoff
pointsforwaistcircumferenceandwaisthipratio.Makingdefinitivedecisionsonactual
cutoffpointswasoutsidethescopeoftheconsultation.However,theexpertconsultation
wasaskedtoadviseWHOonhowtheprocessofdevelopingactualcutoffpointscouldbe
movedforward,andtoidentifyanygapsinthedata.
Thischaptersummarizesthepotentialusefulnessandrelativeadvantagesof:
5.1
waistcircumferenceversuswaisthipratio,withorwithoutaccompanyingBMI
measurements;
measurementprotocolsforwaistcircumferenceandwaisthipratio;
methodsforselectingcutoffpoints;
considerationsfordeterminingtheneedforpopulationspecificcutoffpoints.
Usefulness of waist circumference and waisthip ratio for

prediction of disease risk
Thefundamentalquestionofwhetherwaistcircumferenceandwaisthipratioareuseful
measuresforpredictingdiseaseriskwasansweredwithconvincingevidence.Anincreasein
bothoftheseindicesisassociatedwithincreaseddiseaserisk,andthisassociationis
evidentindiversepopulations,althoughmostofthedatawerederivedfrompopulationsof
Europeandescent.Waistcircumferenceandwaisthipratio (asmeasuresofabdominal
obesity)werecorrelatedwithBMI,butthelevelofassociationvaried,suggestingthatthese
measuresmayprovidedifferentinformationandthusmaynotbeinterchangeable.Practical
considerationsappearedtofavourtheuseofwaistcircumferenceasanalternativetoBMI.
Forexample,waistcircumferencemaybejustifiedwhenmeasuringthewaistiseasierand
moreaccuratethanmeasuringweightandheight.Measuringhipcircumferencemaybe
moredifficultthanmeasuringwaistcircumferencealone;thiscouldlimitthepotentialuse
ofwaisthipratioasanalternativetoeitherwaistcircumferencealoneorBMI.
InassessingthecomplementarityofBMIandwaistmeasures,themainissuewaswhether
therewasasubstantialgainininformationwhenusingbothmeasures,assuggestedinthe
NIHPracticalguidetoobesity(Table5.1)andtheInternationalDiabetesFederation(IDF)
guidelines(Table5.2).Thisalsoraisedsomemoregeneralissues:
theextenttowhichtherangeofwaistcircumferencedependsonbodysize;
whetherdifferencesinthewaistcircumferencedistributioninpopulationswith
differentbodysizesmaycreateproblemsinarrivingatappropriatecutoffpointsthat
wouldbesimilarlysensitivetohealthriskinallpopulations(e.g.theNIHPracticalguide
toobesitysuggeststhatwaistcircumferencecutoffsareonlyusefuluptoaBMIof35,
afterwhichmostindividualswillexceedthecutoffpoints).
Duetotherelativeeaseofobtainingwaistcircumference,itsuseisfavouredoverwaisthip
ratio.Therewasinsufficientdataonotherproxymeasures(e.g.waistheightratio),to
suggestgivingothermeasuresanypriorityatpresent. AlthoughBMIandabdominal
adipositymeasuresmaybehighlycorrelated,itisdesirabletoobtainaBMI,wherepossible,
andconsidertheutilityofjointuseofthetwoindicators.
19
Table 5.1
Underweight
Normal
Overweight
Obesity
Extreme obesity
Combined recommendations of body mass index and waist circumference cut-off

points made for overweight or obesity, and association with disease risk
Body mass index
Obesity class
<18.5
18.524.9
25.029.9
30.034.9
35.039.9
>40.0
I
II
III
Disease risk (relative to normal weight and waist

circumference)
Men < 102 cm
Men >102 cm
Women < 88 cm
Women >88 cm
Increased
High
Very high
Extremely high
High
Very high
Very high
Extremely high
Source: NHLBI Obesity Education Initiative (2000)
Table 5.2
International Diabetes Federation criteria for ethnic or country-specific values for

waist circumference
Country or ethnic group
Sex
Europid
Men
Women
Men
Women
Men
Women
Men
Women
South Asian
Chinese
Japanese
Waist circumference
(cm)
>94
>80
>90
>80
>90
>80
>90
>80
Source: Adapted from Zimmet & Alberti (2006)
5.2
Measurement protocol
Itwasrelativelystraightforwardtodeterminetherecommendedprotocolforthe
standardizedmeasurementofwaistcircumferenceandhipcircumference,andforthe
assessmentofabdominalobesity.Therearemanypotentialpointsofvariationinhowthese
measurementscanbetaken,andmanypotentialsourcesofmeasurementerroramongand
withinmeasurers.Nevertheless,theconsultationagreedthatthemeasurementprotocol
previouslyapprovedbyWHOshouldberecommended.Thisprotocolisinextensiveuseby
STEPS,andhasbeenfeaturedinseveralpreviousWHOexpertmeetingreports(WHO,1995;
WHO,2000a;WHO/FAO,2003).
Thisprotocolcanbesummarizedasoutlinedbelow.
Measurethewaistcircumferenceattheendofseveralconsecutivenaturalbreaths,at
alevelparalleltothefloor,midpointbetweenthetopoftheiliaccrestandthelower
marginofthelastpalpableribinthemidaxillaryline.
Measurethehipcircumferenceatalevelparalleltothefloor,atthelargest
circumferenceofthebuttocks.
Makebothmeasurementswithastretchresistanttapethatiswrappedsnuglyaround
thesubject,butnottothepointthatthetapeisconstricting.Keepthetapeleveland
paralleltotheflooratthepointofmeasurement.
20
5.3
Ensurethatthesubjectisstandinguprightduringthemeasurement,witharmsrelaxed
attheside,feetevenlyspreadapartandbodyweightevenlydistributed.
Selecting cut-off points

Theexpertsgenerallyagreedthatthebasisforeffectiveuseofwaistcircumferenceand
waisthipratiocutoffpointsinclinicalandpublichealthshouldrelatetohealthoutcomes
ratherthantoassociationswithintraabdominalfat,becauseriskpredictionismore
straightforwardifbasedonhealthoutcomes.Otherissuesthatneedtobeconsideredare
outlinedbelow:
Whichhealthoutcomeoroutcomesshouldbeused?
Shouldoutcomemeasuresfromcrosssectionaldatabeused?Althoughuseofcross
sectionaldataispractical,thedatamaybeconfoundedbyeffectsofexistingdisease
anditsdiagnosisandtreatmentonriskstatusorassociations. Aclearpreferencewas
statedforoutcomesfromlongitudinaldata,whichavoidthebiasassociatedwith
relyingonprevalentcases.
Arerelativerisksorabsoluteriskspreferablewhencomparingriskfactorordisease
levelsatdifferentlevelsofwaistcircumferenceorwaisthipratio?Relativerisks(the
outcomeinthosewithwaistcircumferenceorwaisthipratioaboveagivencutoff
pointcomparedtotheoutcomeinthosebelowthecutoffpoint)vary,dependingon
thereferencecategoryusedtocalculatetheratio;thus,theydonotnecessarilyreflect
thediseaseburdenonanabsolutescale.Absoluterisks(thedifference,bysubtraction,
indiseaseburdenamongthosewithwaistcircumferenceorwaisthipratioaboveor
belowaspecifiedcutoffpoint)maybemorerelevantfromapolicyperspective.This
situationmaybeparticularlyrelevanttotheissueofethnicdifferences.Ahighbaseline
diseaseratewilldecreaseratiosrelativetopopulationswithlowerbaselinerates,but
willnotinfluencethecalculationofriskdifferences.
Wouldlinkingwaistcircumferenceorwaisthipratiomeasurestooverallbodysizeor
generalizedobesitygrades (e.g.byusingBMIcategories)addvaluableinformation
withinpopulations,withinagivenrangeofbodysize,oracrosspopulationsubgroups
withsubstantiallydifferentBMIdistributions?Thisquestioncouldbeansweredby
analysingpotentialdifferencesintherangeanddistributionofwaistcircumferenceor
waisthipratioinpopulationswithdifferentBMIrangeanddistribution.Forexample,
suchanalysesmightcomparewaistcircumferenceandwaisthipratiodistributionsand
healthoutcomesinAsianpopulations(inwhommeanBMIlevelsarerelativelylow)
withEuropeanorotherpopulations(inwhommeanBMIlevelsarerelativelyhigh),to
determinewhetheronesetofwaistcircumferenceorwaisthipratiocutoffpoints
wouldbesufficientlysensitiveinbothpopulations.Theperformanceofmeasuressuch
aswaistcircumferenceandwaisthipratio,usedinconjunctionwithBMI,might
contributetothedevelopmentofcompositeindicesforusewithindividualsandthe
community.
Shouldcutoffpointsbedeterminedusingstatisticalapproachessuchasreceiver
operatingcharacteristic(ROC)curves;ifso,howshouldsuchapproachesbeused?
WithrespecttotheuseofROCcurves,questionsincludedwhethertochoosecutoff
pointsonthebasisofthemaximumlevelofsensitivityidentified,likelihoodratiosor
equivalenceofsensitivitytospecificity,andwhethertoresorttoanarbitrarily
designatedlevelofsensitivity(e.g.85%)ascriteriaforcutoff values.Asindicatedin
AnnexA,allofthesemeasuresarecurrentlyinusebyvariouscountries.The
consultationdidnotidentifyabasisforgivingprioritytoaparticularapproach.In
addition,potentiallimitationsoftheROCmethodwerenoted,includingdifferencesin
21
cutoffpointsbasedondifferencesinpopulationcharacteristics(e.g.averagebodysize
ordiseaseprevalence).
Allthesequestionsneedtobecarefullyconsideredwhendeterminingthemethodand
processusedtoderivecutoffpointsforwaistcircumferenceandwaisthipratiofor
recommendationbyWHO. Thechoiceofmethodandtheprocesstobeoutlinedwillalso
dependonthepotentialusesofthederivedcutoffpointsandhealthrelevantpolicy
considerations.Forexample,specificproblemsofthepopulationgroupforwhichthecut
offpointsaretobeused shouldbetakenintoaccount.
5.4
Universal or population-specific cut-off points

Theissueofsexspecificcutoffpointswasnotdeliberatedassuch,buttheconsultation
notedthatmanycountriesorsettingscurrentlyspecifydifferentcutoffpointsformenand
women(seeAnnexA).Theexpertsdidnotidentifyevidencefordiscontinuingtheuseof
sexspecificcutoffpoints.
Withrespecttoethnicityspecificcutoffpoints,therewassubstantialevidenceof
populationdependentvariationsinassociationofdiseaseriskwithmeasuresofabdominal
obesity.However,otherevidencediscouragedthedevelopmentanduseofethnicallybased
cutoffpoints.ThepopulationsofgreatestinterestinthisrespectareofAsiandescent,
becauserisksofcertaindiseases(e.g.diabetes)arenotablyhigherinthesepopulationsthan
wouldbeexpectedfromtheirmeanBMIlevels.Understandingthebasisforthisincreased
riskofdiabetesamongAsianpopulations,forinstance,wouldbeimportanttoidentifythe
potentialenvironmentalvariationsandtheheterogeneityamongpopulationsdesignatedas
Asian.
Theconsultationidentifiedtheneedforatransparentandmethodologicallysound
empiricalapproachtodevelopingpopulationorgeographyspecificcutoffpointsfor
abdominalobesity.Atthesametime,theexpertsrecognizedtheutilityofthecurrent
recommendedcutoffpoints,whicharesimpleanduniversallyapplicable.Thebackground
paperbyLearandcolleagues(2010)providedexamplesofhowitmightbepossibletoset
cutoffpointsthataregenerallyapplicable,butalsorecognizethedifferencesinriskamong
populations.However,thereweretoomanyunresolvedissuesfortheconsultationto
determinewhetherthisprocesswouldbeuseful.
Theconsultationidentifiedmanychallengesrelatedtotheuseofsurrogatemeasuresof
abdominalobesityforthederivationofuniversallyapplicablecutoffpointsforhealth
outcomes.Forexample,thereareinherentchallengesrelatedtodeterminationofhealth
outcomes,includingsexdifferences;agerelatedchangesinbodycompositionand
conformation;andgroup,populationandgeographicaldifferences.Someofthese
confoundersneedtobeevaluatedmorecarefully,asoutlinedbelow:
Inindividualsofthesamesexandageanywhereintheworld,isthesamelevel,
proportionorquantityof:
totalfatoradiposetissuepresentforagivenBMI?
intraabdominalorvisceraladiposetissuepresentforagivenwaistcircumference
orwaisthipratio?
Inindividualsofthesamesexandageanywhereintheworld,istheriskofdiseaseand
mortalitythesameforagivenBMI(i.e.levelofobesity),orwaistcircumferenceor
waisthipratio(i.e.levelofabdominalobesity)?
22
Istherelationshipbetweenadiposityandtheproxymeasure,andtheassociationwitha
givenhealthrisk,thesameforbothsexes?
Istherelationshipbetweenadiposityandtheproxymeasure,andtheassociationwitha
givenhealthrisk,affectedbyincreasingageforbothsexes?
Addressingtheseissueswillbeamajorchallenge.Itisclearfromthedatareviewedatthis
expertconsultationandfrompreviousWHOpublicationsthatthecurrentevidencebase
cannotanswerthesequestions.Furtherstudiesareneededtodeterminewhether
recommendedcutoffpointsshouldbespecifictosex,ageandpopulation.
23
Recommendations
Theexpertconsultationagreedthattheanthropometricindicatorsandmeasuresused
previously(i.e.BMI,waistcircumferenceandwaisthipratio)arepredictiveoftheriskof
chronicdisease.Hence,anywaistcircumferenceandwaisthipratiocutoffpoints
developedfollowingtheprocessrecommendedbytheconsultationcouldbeusedaloneor
inconjunctionwithBMI.
Ideally,thecharacteristicsassociatedwiththemostusefulanalysesforoneormoreusesof
waistcircumferenceorwaisthipratiowouldbethat:
thedataarerepresentativeofallpopulationgroups(withrespecttoage,sex,social
classandconcurrentdiseases)incountriesfromallregions;
datacollectedincludeanthropometricmeasures(ofbothcentraladiposityandBMI)
andatleastthreeriskfactors(e.g.bloodpressure,bloodglucoseandcholesterol);
standardizedmethodswereusedformeasurementofwaistcircumferenceandother
anthropometricindicators;
measuredweightandheightwereavailableandwerenotselfreporteddata;
thedatasetincludeinformationoncharacteristicssuchasage,sexanddemographics;
sufficientlongitudinaldatafromappropriatepopulationsbeavailable,withhighquality
followupofdiseasestatusalongthetimecourse,topermitconfirmationofkey
conclusionsaboutcutoffpointsderivedusingcrosssectionaldata.
Giventhedataavailable,theconsultationfeltthatthestepspresentedbelow(whichare
notinanyspecificorder)couldbetakentoarriveatappropriateWHOrecommendationsin
thiscriticalarea:
Determinewhethermultiplesetsofcutoffpointswillbeneeded(e.g.bysex,bodysize
orhealthstatuscharacteristicsofthepopulation).
Thiscouldbeaccomplishedbyevaluatingsimilaritiesordifferencesintheassociations
ofwaistcircumferenceorwaisthipratiowithvarioushealthoutcomes,across
populationsorpopulationsubgroups.Theapproachwouldcomparepopulationsthat
differindistributionsofwaistcircumferenceandwaisthipratio,orindiseaseprofiles.
Type2diabetesshouldbeconsideredasamajorhealthriskfactororoutcomein
evaluatingassociationswithwaistcircumferenceandwaisthipratio.Inpopulations
throughouttheworld,diabetesapparentlyincreaseswithoverallandabdominalfat
gainandobesitydevelopment.Comparisonsbasedondiabeteswouldallow
identificationofthepotentialvariationsinthepredictivepotentialofvariouscutoff
points.
Foranysetofcutoffpointstobedeveloped,choosethemostsoundandpolicy
relevantstatisticalapproachtodeterminecutoffpointsforwaistcircumferenceand
waisthipratio,andspecifytheresultingdecisionrules.
Developaschemawithdifferentlevelsofriskandthreesetsofcutoffpoints.Thiscould
beachievedbylinkingdatasetstodiabetesprevalenceforcountries,andexamining
whethertherecommendedcutoffpointsareappropriateforthereliableidentification
ofdiseaserisk.Inaddition,itwouldbehelpfultoanalysepopulationswithhighrisk,to
ensurethatthecutoffpointsdevelopedareasensitivemeasureofrisk.
24
Alternatively,chooseasetofthreeindicativeriskfactors(e.g.highbloodpressure,
elevatedcholesterolandelevatedbloodglucose),wherebyapopulationorgroupcould
beidentifiedbywaistcircumferencecutoffpointsashavingoneofthreelevelsofrisk:
LevelI:MinimalriskAtthiscutoffpoint,lessthan10%ofpeoplewouldhaveany
oneofthethreeindicativeriskfactors;hence,thiswouldbethelowestlevelofrisk.
Theobjectiveistoidentifyavaluethatnationalgovernmentscouldusefor
surveillanceandtodeterminetheneedforpublichealthinterventions.
LevelII:ModerateriskAtthiscutoffpoint,therewouldbeahighprobabilitythat
80%ofpeoplehaveatleastoneofthethreeindicativeriskfactors,inwhichcase,
givinghealthadviceorotherappropriateactionwouldbedeemedessential.The
suggestionwastoexaminecombineddatasets(bearinginmindglobalvariation),to
judgewhetheritwaspossibletoarriveatauniversalcutoffpointtoindicatethis
levelofpopulationrisk.Issuestoconsiderwouldbetheeffectsofusing80%asthe
basisforLevelIIclassification,andwhetherthisvaluewouldhavethesameutility
acrosspopulationgroups.Criticalanalysisofthedatashouldultimatelyenable
WHOtocreateaschemetoderivecutoffpointstailoredfordifferentpurposes.
LevelIII:SubstantialorhighriskAtthiscutoffpoint,everyoneinthepopulation
groupwouldbealmostcertaintohaveatleastoneofthethreeindicativerisk
factors.Thisdeterminationwouldbebasedonnationalorregionaldatasetsthat
suggestthattheindividualsinthisgroupwillhaveadoublingofriskcomparedto
lowriskgroups.Highriskgroupsmayincludesubgroupsorpopulationsdefinedby
obesityordiabetesprevalence.
Thequestionofhowtocopewithtransitionsindiseaseriskalsoneedstobeaddressed.
Associationsofwaistcircumferenceorwaisthipratiowithriskfactorsanddiseases
maychangeovertimeinpopulationsinwhichincidenceofobesityrelateddiseasesis
increasinginassociationwithsocialandeconomictransitions.
Tofacilitatetheimplementationoftheproposednextstepandcarrythisprocessforward,
theconsultationformedaworkinggroupofexpertsinthisareatoworkcloselywithWHO.1
Theworkinggroupcomprisesacademicresearchers,clinicianswhohaveexpertiseinthis
field,statisticiansanddataanalysts.Theworkinggroupwillalsoconsidergapsinthe
availableglobaldataanditemsappropriateforfutureresearch.
Theconsultationrecommendedthattheworkinggroupbeaskedtodevelopandsuggest
theappropriatemethodsandcriteriaforaprocessforopenandtransparentanalysisand
clarificationoftherelationshipsbetweenabdominalfatdistributionanditsmeasures,and
diseaseriskandhealthoutcomes.
Itwasagreedthattheworkinggroupneedsaccesstoawiderangeofdatabasesworldwide,
includingtheSTEPSdatawithinWHO.Theconsultationrecommendedthattheworking
groupbeassistedtogainaccesstotheavailabledatasets.
TheconsultationurgedWHOtoviewthismatterasbeingofutmosturgency,andtoenable
completionofthetaskwithina2yearperiod.TheultimaterecommendationsfromWHO
willdependonwhetherWHOcanobtainrepresentativedatasetstopermitsystematic
The recommended follow-up work to be carried out by the working group that was formed by the consultation has been
overtaken by the new guideline development process implemented by WHO as of 1 January 2009. During 20112012, the
WHO Nutrition Guidance Expert Advisory Group (NUGAG) will take forward the follow-up action recommended by the expert
consultation, through its subgroup on Diet and Health.
25
analysisofalltheissuesraisedintheconsultation.UltimaterecommendationsfromWHO
needtotakeintoconsideration:
thevariouswaistcircumferenceandwaisthipratiocriteriathatarealreadyinuseby
nationalgovernments,andbynationalandinternationalmedicalorganizations;
thepotentialpolicyandpracticalimplicationsassociatedwithanyattemptstoalign
diversecutoffs.
Ontheotherhand,timelyandauthoritativeguidanceisneededtoensurethatmeasures
thatcanguideappropriatepublichealthandclinicalactionsontheproblemsrelatedto
NCDsarebroughtintofulluseasquicklyaspossible.NCDsarerapidlyincreasingworldwide,
particularlyinlowandmiddleincomecountries.
26
Annex A: Current uses of waist

circumferences and waisthip ratios,
a n d r e c o m m e n d e d c u t - o f f p o i n ts
A1
Recommendations from different organizations

World Health Organization
AnumberofWHOpublicationsmakerecommendationsforwaistcircumferenceandwaist
hipratio.
Recommendationsaboutabdominalobesityandwaistcircumferencehavebeenmadeas
oneofthecomponentsofmetabolicsyndromeinareportondiabetesmellitus(WHO,
1999),underthedefinitionofmetabolicsyndrome.Accordingtothisreport,theworking
definitionofmetabolicsyndromeisaconditioncharacterizedbyglucoseintolerance,IGT
[impairedglucosetolerance]ordiabetesmellitus,and/orinsulinresistancetogetherwith
twoormorecomponentslistedbelow,whichincludesabdominalobesityinadditionto
raisedarterialpressure,raisedplasmatriglyceridesandmicroalbuminuria.Abdominal
obesityisfurtherdefinedaswaisthipratioabove0.90formalesandabove0.85for
females,oraBMIabove30.0.
ThemorerecentreportoftheWHOExpertConsultationonObesity(2000a)statedthe
needtodevelopsexspecificwaistcircumferencecutoffpointsappropriatefordifferent
populations.Thatreportprovidesatableasanexampleofsexspecificwaist
circumferenceandriskofmetaboliccomplicationsassociatedwithobesityinCaucasians.
ThetableisbasedontheincreasedrelativeriskobservedintheNetherlandsfromarandom
sampleof2183menand2698womenaged2059years(Hanetal.,1995).The
recommendedsexspecificcutoffpointsare94cm(men)and80cm(women)forincreased
risk,and102cm(men)and88cm(women)forsubstantiallyincreasedrisk.
BasedonthesetwoWHOreports,therecommendationsoftenattributedtoWHOare
showninTableA1althoughthosesexspecificcutoffpointscitedinthereportoftheWHO
ExpertConsultationonObesity(2000b)wereanexampleonlyandnotWHO
recommendations.
Table A1
World Health Organization cut-off points and risk of metabolic complications
Indicator
Waist circumference
Waist circumference
Waisthip ratio
Cut-off points
>94 cm (M); >80 cm (W)
>102 cm (M); >88 cm (W)
0.90 cm (M); 0.85 cm (W)
Risk of metabolic complications

Increased
Substantially increased
Substantially increased
M, men; W, women
International Diabetes Federation

TheInternationalDiabetesFederation(IDF)hasalsoprovidedrecommendationsforcutoffs
forwaistcircumferenceandwaisthipratio(IDF,2006;Zimmet&Alberti,2006).The
recommendationsofIDFforwaistcircumferencearenotonlysexspecific,butarealso
population andgeographyspecific.ValuesareshowninTableA2.
27
Table A2
International Diabetes Federation cut-off points for different ethnic groups
Europids
South Asians, Chinese and
Japanese
Men
>94 cm
>90 cm
Women
>80 cm
>80 cm
United States National Cholesterol Education Program

Anothersetofrecommendationswidelyusedaretheonesrecommendedbytheexpertsof
theAdultTreatmentPanel(ATP)(APTIII,2001)undertheaegisoftheNationalCholesterol
EducationProgram(NCEP)oftheNIHsNationalHeart,Lung,andBloodInstitute.TheNCEP
recommendsasinglesetofsexspecificcutoffs,ofabove102cmformenandabove88cm
forwomen.
Other countries
AnanalysisconductedbyWHOaspartofthepreparationsfortheexpertconsultation
showedthatsomecountriesadheredtooneortheotherofthethreerecommendations
mentionedabove,whereasothershadtheirownspecificrecommendations.Forexample,
manycountriesusetheWHOcutoffpoints;SouthAfricausestheIDFrecommendations;
andtheRepublicofKorea,SaudiArabia,Singapore,SlovakiaandTurkeyusetheIDF
recommendationsplusotherspecifiedsources.TheNCEPrecommendationsareusedby
Ecuador,Greece,Italy,Jordan,Thailand,TurkeyandtheUS,withseveralofthesecountries
alsousingothersourcesofrecommendations.SaudiArabia,SingaporeandSlovakia,use
boththeIDFandtheNCEPrecommendations.
Thereislittleinformationontheendorsementofwaistcircumferenceandwaisthipratio
cutoffpointsatnationallevelbynationalministriesofhealth.However,themostpopular
cutoffpointsusedworldwideweretheonesattributedtotworeportsfromWHO(WHO,
1999;WHO,2000a).TheIDFrecommendationsandtheNCEPcutoffpointswerefrequently
usedinresearchornationalsurveysinmanycountries. However,therationaleforthe
choiceanduseofaspecificrecommendationwasoftenunknownandunclear.
Severalothercountrieshavedevelopedtheirownrecommendationsandcutoffpoints.
However,someofthesearesimplysuggestedorusedinspecificpopulationsinpublished
studies,ratherthanbeingnationalrecommendations.Someexamplesareprovidedinthe
followingsection.
A2
Rationale for selection of cut-off points

Themostcommonapproachtodeterminingcutoffpointsisbasedontheuseofsensitivity
andspecificityasinterpretedfromreceiveroperatingcharacteristic(ROC)curves.
Sensitivitymeasurestheproportionofactualpositivescorrectlyidentifiedassuch,and
specificitymeasurestheproportionofactualnegativescorrectlyidentifiedassuch.
Inanytest,thereisusuallyatradeoffbetweenoptimizingsensitivityandoptimizing
specificity.ThiscanberepresentedgraphicallyusingaROCcurve(seeFigureA1)(WHO,
2003),whichisaplotofthetruepositiverate(TPR,orsensitivity)againstthefalsepositive
rate(FPR,or1specificity). Usefulcutoffpointsarethosethatprovideforahigh
proportionoftruepositiveswhilegivingalowproportionoffalsepositives.AROCcurveis
alsoknownasarelativeoperatingcharacteristiccurve,becauseitcomparestwo
28
operatingcharacteristics(TPRandFPR)asthecriterionchanges.Thus,ROCisdirectly
relatedtodiagnosticdecisionmaking.
TherearelimitationstousingaROCapproachforchoosingasinglecutoffpoint (e.g.to
designateahighwaistcircumference),particularlyiftheintentistochooseasinglecut
offpointthatisapplicableacrossdifferencepopulationsandsurveyconditions.TheROC
approachshouldtakeintoaccountthevalidity,reliabilityandreproducibilityofthetestor
criterionmeasure(e.g.thewaistmeasurement),andtheprevalenceoftheconditionof
interest(e.g.highbloodpressureordiabetes)inthepopulationtobescreened. Population
prevalenceisimportantbecausethepredictivevalue(e.g.theprobabilityofhavinga
diseasegivenapositivetestresult)ishigherinpopulationswithahighprevalenceofthe
diseasecomparedtopopulationswithalowprevalence.Thiswouldapplytodifferencesin
diseaseprevalencebothacrossandwithinpopulations(e.g.ifonlyhighriskindividualsare
selectedforscreening,asopposedtothepopulationatlarge).Measurementerrorsalso
reducetheutilityofROCcurves.
Figure A1
Example of a ROC curve
1specificity (false-positive probability)
Source: WHO (2003: p 40)
Belowareexamplesofhowtheseconceptshavebeenusedastherationaleforwaist
circumferenceandwaisthipratiocutoffpointsindifferentcountries.
Sensitivity is equal to specificity
TableA3showsexamplesofstudiesfromdifferentcountriesthathavesetcutoffpoints
basedonsensitivitybeingequaltospecificity.
29
Table A3
Country
Barbados
China
Islamic Republic of
Iran
Islamic Republic of
Iran
Mexico
Mexico
Mexico
Mexico
Cut-off points based on sensitivity being equal to specificity

Cut-off point
Waist
circumference
for general risk
Waist
circumference
for obesity,
diabetes, and
CVD risk
Waist
circumference
for CVD for
those at risk of
CVD but
requiring only life
style change
Waist
circumference
for CVD for
those at high risk
for CVD events,
requiring
immediate
intervention for
CVD prevention
Diabetes and
CVD
Waisthip ratio
Men
87.3 cm
Women
87.5 cm
Reference
(Okosun, et al.,
2000b)
Notes
8085 cm
7580 cm
(Wildman et al., 2004)
In this range, the

sensitivity equaled the
specificity
90 cm
90 cm
(Delavari et al., 2009;

Esteghamati et al.,
2009; Mirmiran et al.,
2004)
95 cm
95 cm
90
85
(Berber, et al., 2001)
0.90
0.85
(Berber, et al., 2001)
Waist
circumference
for diabetes
Waist
circumference
for hypertension
9398 cm
9499 cm
(Sanchez-Castillo et
al., 2003)
9296 cm
9396 cm
Sensitivity equals
specificity (based on
the ROC technique),
from a study in a
hospital population in
Mexico City
These national
recommendations are
based on the
intersection of lines of
specificity and
sensitivity
CVD, cardiovascular disease; ROC, receiver operating characteristic
Maximum sensitivity
AstudyfromFranceprovidedcutoffpointsforthemostcorpulent30%ofthepopulation
(Balkauetal.,2006):
waistcircumferenceforobesity,diabetes,andCVD:96cmformenand83cmfor
women;
waisthipratioforgeneralriskandobesity:0.96formenand0.83forwomen.
Sensitivitywasofparamountimportance,withwaistcircumferencesensitivitiesof74%for
menand82%forwomen,andforwaisthipratioof66%formenand77%forwomen.
30
Optimal sensitivity and specificity

AstudyfromChile,forexample,providedcutoffpointsforCVDandmetabolicriskfor
women:awaistcircumferenceofatleast87.7cmandawaisthipratioofatleast0.84
(Kochetal.,2008).Specificcutoffpointswerebasedonoptimalsensitivityandspecificity
fordetectingoneormorecardiovascularandmetabolicriskfactorsinthepopulationunder
study.
Shortest distance between any point on the ROC curve and top-left corner on
the y-axis
AstudyfromOmanprovidedcutoffpointsforCVDasfollows(AlLawati&Jousilahti,2008):
waistcircumference:80cmformenand84.5cmforwomen;
waisthipratio:0.91forbothmenandwomen.
SeparateROCcurveswereplottedforwaistcircumferenceandwaisthipratio.
Range of values and best cut-off points for multiple indicators
AstudyfromTunisiaprovidedacutoffpointforwaistcircumference(forobesity,diabetes,
andCVD)of85cmforbothmenandwomen,basedonsensitivitybeingequaltospecificity
(Bouguerraetal.,2007).
However,thestudyalsoprovidedindividualcutoffpointsforeachdiseaserisk,andwould
clearlybeapplicableforclinicaluse(whereasthesinglevaluegivenabovewouldbeuseful
forpublichealthpurposes):
A3
formen:82cm(hypertension);83cm(glycaemia);87cm(diabetes);85cm(total
cholesterolandtriglycerides);
forwomen:81cm(hypertension);82cm(glycaemia);87cm(diabetes);83cm(total
cholesterolandtriglycerides).
Summary
Cutoffpointschosenvaryconsiderablybetweencountries;also,thevariationisgreaterfor
waistcircumferencethanforwaisthipratio.Thecutoffpointsappeartobechosenbased
ondiseaserisk(e.g.CVD,type2diabetesandriskfactorsofCVD)andonhardoutcomes
suchasmortality.Rationalesvary,butaregenerallybasedonindicesofsensitivityand
specificity.Insomecases,therearemultiplespecificcutoffpointsfordifferentdiseasesor
riskfactors.Inadditiontotheaboveexamples,somecountries(e.g.Japan)havebasedtheir
cutoffpointsonassessmentofvisceraladiposetissuefromcomputerizedtomography
thatis,theextenttowhichmeasurementspredictintraabdominalfatratherthandisease
risk(JSSO,2002)andDEXA(Itoetal.,2003).
31
A n n e x B : L i s t o f pa r t i c i pa n ts
ThisannexliststheparticipantsattheWHOExpertConsultationonWaistCircumference
andWaistHipRatio,Geneva,Switzerland,811December2008.
B1
Members2
ProfessorSirGeorgeAlberti,SCMS(DiabetesResearchGroup),TheMedicalSchool,
UniversityofNewcastleuponTyne,NewcastleuponTyne,UnitedKingdom
ProfessorFereidounAzizi,Director,ResearchInstituteforEndocrinologyandMetabolism,
ShaheedBeheshtiUniversityofMedicalSciences,Tehran,IslamicRepublicofIran
ProfessorJulianaCNChan,Director,HongKongInstituteofDiabetesandObesity,The
ChineseUniversityofHongKong,DepartmentofMedicineandTherapeutics,ThePrinceof
WalesHospital,Shatin,HongKongSAR,People'sRepublicofChina
ProfessorRachelHuxley,Director,Nutrition&LifestyleDivision,TheGeorgeInstitutefor
GlobalHealth,Camperdown,Sydney,NewSouthWales,Australia
ProfessorPhilipJames,InternationalObesityTaskForce,London,UnitedKingdom
ProfessorTakashiKadowaki,DepartmentofMetabolicDiseases,GraduateSchoolof
Medicine,UniversityofTokyo,Tokyo,Japan
ProfessorKayTeeKhaw,DepartmentofClinicalGerontology,UniversityofCambridge,
Addenbrooke'sHospital,Cambridge,UnitedKingdom
DrGaryTinChoiKo,HongKongInstituteofDiabetesandObesity,TheChineseUniversityof
HongKong,ThePrinceofWalesHospital,Shatin,HongKongSAR,People'sRepublicof
China(Rapporteur)
ProfessorShirikiKumanyika,CenterforClinicalEpidemiology&Biostatistics,Universityof
PennsylvaniaSchoolofMedicine,Philadelphia,Pennsylvania,US(Chairperson)
ProfessorScottLear,SchoolofKinesiology,SimonFraserUniversity,Vancouver,British
Columbia,Canada
ProfessorJeanClaudeMbanya,ViceDean/ProfessorofMedicineandEndocrinology,
FacultyofMedicineandBiomedicalSciences,UniversityofYaound,Yaound,Cameroon
DrQingQiao,AcademyResearchFellow,DepartmentofPublicHealth,Universityof
Helsinki,Helsinki,Finland
ProfessorK.SrinathReddy,President,PublicHealthFoundationofIndia,NewDelhi,India
ProfessorJaapSeidell,Head,DepartmentofNutrition&Health,FacultyofEarthandLife
Sciences,FreeUniversityofAmsterdam,Amsterdam,TheNetherlands
Unable to attend: Dr Viswanathan Mohan, President & Chief of Diabetes Research, Madras Diabetes Research
Foundation, Indian Council of Medical Research (ICMR) Advanced Centre for Genomics of Diabetes, Chennai, India
32
ProfessorThorkildIASrensen,InstituteDirectorandProfessorofClinicalEpidemiology,
InstituteofPreventiveMedicine,CentreforHealthandSociety,Copenhagen,Denmark
ProfessorJuneStevens,Chair,DepartmentofNutrition,SchoolsofPublicHealthand
Medicine,UniversityofNorthCarolinaatChapelHill,ChapelHill,NorthCarolina,US
ProfessorPaulZimmet,EmeritusDirectorandDirectorofInternationalResearch,BakerIDI
HeartandDiabetesInstitute,Caulfield,Victoria,Australia
B2
Secretariat
DrAlaAlwan,AssistantDirectorGeneral,NoncommunicableDiseasesandMentalHealth,
WHO,Geneva,Switzerland
DrFrancescoBranca,Director,NutritionforHealthandDevelopment,WHO,Geneva,
Switzerland
DrChizuruNishida,Scientist,Countryfocusednutritionpoliciesandprogrammes,Nutrition
forHealthandDevelopment,WHO,Geneva,Switzerland
DrJonathanSiekmann,TechnicalOfficer,Countryfocusednutritionpoliciesand
programmes,NutritionforHealthandDevelopment,WHO,Geneva,Switzerland
DrPrakashShetty,TemporaryAdvisor,Countryfocusednutritionpoliciesandprogrammes,
NutritionforHealthandDevelopment,WHO,Geneva,Switzerland
DrElaineRush,Consultant,Countryfocusednutritionpoliciesandprogrammes,Nutrition
forHealthandDevelopment,WHO,Geneva,Switzerland
MsYingLiu,TechnicalAssistant,Countryfocusednutritionpoliciesandprogrammes,
NutritionforHealthandDevelopment,WHO,Geneva,Switzerland
DrFionaAdshead,Director,ChronicDiseasesandHealthPromotion,WHO,Geneva,
Switzerland
DrTimothyArmstrong,Coordinator,SurveillanceandPopulationbasedPrevention,Chronic
DiseasesandHealthPromotion,WHO,Geneva,Switzerland
MrGodreyXuereb,TechnicalOfficer,SurveillanceandPopulationbasedPrevention,
ChronicDiseasesandHealthPromotion,WHO,Geneva,Switzerland
MrsLeanneRiley,Scientist,SurveillanceandPopulationbasedPrevention,ChronicDiseases
andHealthPromotion,WHO,Geneva,Switzerland
DrShanthiMendis,Coordinator,ChronicDiseasesPreventionandManagement,Chronic
DrGojkaRoglic,MedicalOfficer,ChronicDiseasesPreventionandManagement,Chronic
33
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Waist Circumference

and Waist-Hip Ratio

Waist Circumference and WaistHip Ratio:

WHO Library Cataloguing-in-Publication Data

(NLM classification: QU 100)

World Health Organization 2011

Abbreviations and acronyms

Criteria for assessing strength of the evidence of association

Adapted from WHO/FAO (2003)

Methods for measuring waist and hip

Placement, tightness and type of measuring tape

Tightness and type of tape

Subject posture and other factors

Posture of the subjects during the measurement

Phase of respiration at the exact point of measurement

Abdominal tension at the point of measurement

Influence of stomach contents at time of measurement

Implications of differences in methodology

Summary and conclusions

Summary and conclusions

Measures of obesity and abdominal obesity and cardiovascular

Measures of obesity, abdominal obesity and type 2 diabetes risk

Measures of obesity and abdominal obesity and all-cause

Summary and conclusions

Summary of the associations of body mass index, waist circumference, waisthip

Body mass index

Remarks and major

Convincing ++++ Convincing ++++ Convincing +++

Overall CVD risk

Convincing de Koning et al. (2007)

Vazquez et al. (2007)

Overall mortality +++

Body mass index

Bigaard et al. (2003)

Remarks and major

Moghaddam et al. (2007)

Summary and conclusions

Usefulness of waist circumference and waisthip ratio for

Combined recommendations of body mass index and waist circumference cut-off

Disease risk (relative to normal weight and waist

Source: NHLBI Obesity Education Initiative (2000)

International Diabetes Federation criteria for ethnic or country-specific values for

Country or ethnic group

Source: Adapted from Zimmet & Alberti (2006)

Selecting cut-off points

Universal or population-specific cut-off points

Annex A: Current uses of waist

Recommendations from different organizations

World Health Organization cut-off points and risk of metabolic complications

Risk of metabolic complications

International Diabetes Federation

International Diabetes Federation cut-off points for different ethnic groups

United States National Cholesterol Education Program

Rationale for selection of cut-off points

Example of a ROC curve

1specificity (false-positive probability)

Source: WHO (2003: p 40)

Cut-off points based on sensitivity being equal to specificity

(Wildman et al., 2004)

In this range, the

(Delavari et al., 2009;

(Berber, et al., 2001)

(Berber, et al., 2001)

CVD, cardiovascular disease; ROC, receiver operating characteristic