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Invited Review
397
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398
Anthropometric Measurements
Body Mass Index
Body mass index (BMI), as weight in kg divided by the
square of the height in meters (or weight in pounds multiplied by 703, then divided by height in inches), is an
easy way to calculate body fatness and is widely used in
clinical practice. Both the World Health Organization
(WHO) task force and the National Institutes of Health
(NIH) guidelines stipulate normal, overweight, and obesity cutoffs according to BMI. A BMI between 18.5 and
24.9 kg/m2 is considered normal, between 25 and 29.9
kg/m2 is overweight, and >30 kg/m2 is obese (Table 1).16,17
Because these cutoffs are arbitrary, there is some dispute whether normal weight should be defined as a BMI
of < 25 kg/m2. There has been an increase in the prevalence of DM and mortality with increasing BMI in
patients within normal range.18,19 This trend may be
explained by the pattern of fat distribution, with a more
central and particularly visceral fat accumulation being
associated with increased risk for DM and cardiovascular
disease; when added to BMI in patients with a BMI
between 25 and 35 kg/m2, this improves health risk assessment.20 Recent data failed to show an increase in mortality in overweight individuals compared with individuals of
normal weight, possibly due to improved cardiovascular
risk management, whereas obese and underweight individuals had higher mortality rates.21 The association
between increased gluteofemoral adipose tissue and cardiovascular risk is a much weaker one.22,23 Another pitfall
of relying on BMI alone is that muscular patients may
Table 1.
Underweight
Normal weight
Overweight
Obesity (class 1)
Obesity (class 2)
Extreme obesity (class 3)
<18.5 kg/m2
18.5-24.9 kg/m2
25-29.9 kg/m2
30-34.9 kg/m2
35-39.9 kg/m2
>40 kg/m2
have relatively high BMIs but low fat mass, and in the elderly, BMI may underestimate fat mass due to a decrease in
lean body mass.24-26
Waist Circumference
As mentioned earlier, body fat distribution is an important risk factor for obesity-related disease. Increased
visceral adipose tissue (also called central or abdominal
fat) is associated with increased risk for cardiometabolic
disease.11,20
Precise measurement of the visceral fat component is
expensive and not feasible in clinical practice. Therefore,
WC is used as a surrogate marker of abdominal fat mass.
WC correlates with subcutaneous and visceral fat mass
and is related to increased cardiometabolic risk.20,27 A
WC >40 inches (102 cm) in men and >35 inches (88 cm)
in women is considered to confer an increased cardiometabolic risk. These WC cutoffs were derived from
Caucasian men and women living in the Netherlands to
correlate with WC values associated with a BMI 30
kg/m2, therefore identifying subjects who should be
advised to lose weight.28,29 The National Heart, Lung, and
Blood Institute (NHLBI) recommended measuring WC
along with BMI to assess patient risk stratification in subjects with a BMI between 25 and 35 kg/m2. Although not
incorporated in the guidelines, a comment recommends
measuring WC even in patients with normal BMI to
improve risk stratification.16 The cutoffs for normal WC
chosen by the NHLBI are as mentioned earlier: WC >40
inches (102 cm) in men and >35 inches (88 cm) in
women, independent of BMI or ethnicity. According to
the NHANES III, 1% of men and 14% of women with a
normal BMI had a high WC, and in the overweight range
(BMI between 25 and 29.9 kg/m2), 25% of men and
almost 70% of women had a high WC.11 Shen et al30 evaluated BMI, WC, and percent fat measured by DXA in
1010 healthy white and African American men and
women. WC had the strongest association with health
risk, followed by BMI and percent fat.
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399
Waist-to-Hip Ratio
Waist-to-hip ratio (WHR) is a common anthropometric index
used to assess abdominal obesity. The WHO included a high
WHR defined as a ratio >0.9 in men and >0.85 in women
as a criterion for diagnosing the metabolic syndrome.31 A
high WHR has been associated in epidemiological studies
with increased cardiovascular and DM risk.32,33 Because
both WHR and WC are measures of abdominal adiposity,
they both correlate with increased risk of cardiovascular
events. Some studies have found that WHR is a more accurate tool to diagnose patients with a higher cardiovascular
risk compared with WC and BMI,34 whereas other studies
have found a better correlation of cardiometabolic risk with
WC compared with WHR, particularly in women.35 The
Interheart Study, an epidemiological, retrospective case
control study in different populations, included more than
27, 000 people from 52 countries, with the study variable
being a history of myocardial infarction (MI). In this study,
BMI, WC, and WHR were all highly significantly associated with the risk for MI, but WHR was the strongest
anthropometric predictor of MI in men and women, independent of other risk factors or BMI category.36
Figure 1. Measuring tape position for waist circumference measurement. Reproduced with permission from the National Heart,
Lung, and Blood Institute as a part of the National Institutes of
Health and the U.S. Department of Health and Human Services.
Available at www.nhlbi.nih.gov/guidelines/obesity.
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400
Waist Circumference
and Type 2 Diabetes
The diabetes epidemic is closely linked to the obesity epidemic.53 In the Nurses Health Study, increases in BMI
within normal range were associated with a 4-fold risk of
developing type 2 DM (women with BMI <22 kg/m2 vs
women with BMI 23-25 kg/m2).18 The relationship
between WC and DM is very strong. WC is a stronger
predictor of DM than is BMI, and it is independent of traditional risk factors such as hypertension, lipoproteins,
and glucose levels.11 In the International Day for the
Evaluation of Abdominal Obesity (IDEA) study, which
included 69,409 subjects from 63 countries who consulted a primary care physician, BMI and particularly WC
were strongly linked to DM.54
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Table 2.
Study Group
Diagnostic criteria
WHO26
Glucose intolerance, IGT,
or DM and/or insulin
resistance together with
2 of the following:
Microalbuminuria
401
150 mg/dL
Men: <35 mg/dL
Women: <39 mg/dL
140/90 mm Hg
Men: waist-hip ratio >0.9
Women: waist-hip ratio >0.85
and/or BMI 30 kg/m2
IDF7,46
3 of the following
risk factors:
>100 mg/dL
(or diagnosed DM)
150 mg/dL
Men: <40 mg/dL
Women: <50 mg/dL
130/85 mm Hg
Men: waist circumference
>40 in (102 cm)
Women: waist circumference
>35 in (88 cm)
Central obesity
(waist circumference)
94 cm for Europid men
80 cm for Europid women
Ethnicity-specific values for
other groupsa
Plus presence of 2
of the following:
100 mg/dL
(or diagnosed DM)
150 mg/dL
Men: <40 mg/dL
Women: <50 mg/dL
130/85 mm Hg
DM, diabetes mellitus; HDL, high-density lipoprotein; IDF, International Diabetes Federation; IGT, impaired glucose tolerance;
NCEP ATP III, National Cholesterol Education Program, Adult Treatment Panel III; WHO, World Health Organization.
Ethnic specific cutoffs: South Asians men 90 cm, women 80 cm; Chinese men 90 cm, women 80 cm; Japanese men 85 cm,
women 90 cm (there is no agreement concerning the appropriate cutoff for the Japanese population).
Waist Circumference
in the Pediatric Population
Ethnicity
Ethnicity is known to have on impact on CVD and DM
risk, and because abdominal obesity is a better predictor
of cardiovascular disease than is BMI, the use of ethnicspecific WC seems appropriate. For example, it is known
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402
Weight Loss
Weight loss is known to improve insulin resistance, DM
control, hypertension, and lipid profile.69 Lifestyle
changes, including weight loss and physical activity, have
been shown to prevent or delay type 2 DM in high-risk
patients.70,71 In the Diabetes Prevention Program study,
lifestyle intervention was associated with a marked reduction in visceral fat (measured by CT during the first year
of the study) and a smaller decrease in subcutaneous fat,
body weight, BMI, and WC in both men and women.72
Pare et al73 evaluated the change in visceral fat, subcutaneous fat, and waist girth followed by weight loss in obese
men. Their results showed a greater relative reduction in
visceral fat than subcutaneous fat, suggesting greater
mobilization of visceral fat following weight loss in viscerally obese men.
Weight loss achieved through diet and pharmacotherapy with sibutramine, orlistat, and rimonabant
has shown a decrease in WC and improvement in cardiometabolic risk.73-76 Rimonabant therapy has shown a
higher decrease in WC than expected for weight loss, possibly due to its effect on the cannabinoid receptor 1
(CB1) in the VAT.
Summary
WC reflects the magnitude of the abdominal fat tissue,
including subcutaneous and visceral adipose tissue.
Although it is a simple and crude measurement, it correlates with VAT and, when increased, has been shown to
confer an increased risk for DM, CVD, and mortality,
independent of BMI. It is now clear that different ethnic
groups should be assessed according to their race-specific
cutoffs to improve risk evaluation. Further study is
needed to specify ethnic-specific WC values. WC measurement should be implemented as a vital sign to improve
cardiometabolic risk assessment.
References
1. Field AE, Coakley EH, Must A, et al. Impact of overweight on the
risk of developing common chronic diseases during a 10-year
period. Arch Intern Med. 2001;161:1581-1586.
2. Must A, Spadano J, Coakley EH, Field AE, Colditz G, Dietz WH.
The disease burden associated with overweight and obesity. JAMA.
1999;282:1523-1529.
3. Baskin ML, Ard J, Franklin F, Allison DB. Prevalence of obesity in
the United States. Obes Rev. 2005;6:5-7.
4. Pi-Sunyer FX. The obesity epidemic: pathophysiology and consequences of obesity. Obes Res. 2002;10(Suppl 2):97S-104S.
5. de Koning L, Merchant AT, Pogue J, Anand SS. Waist circumference and waist-to-hip ratio as predictors of cardiovascular events:
meta-regression analysis of prospective studies. Eur Heart J.
2007;28:850-856.
6. Third report of the National Cholesterol Education Program
(NCEP) Expert Panel on Detection, Evaluation, and Treatment of
High Blood Cholesterol in Adults (Adult Treatment Panel III) final
report. Circulation. 2002;106:3143.
7. The IDF consensus worldwide definition of the metabolic syndrome.
Available at: http://www.idf.org/webdata/docs/MetS_def_update2006.pdf.
8. Li C, Ford ES, McGuire LC, Mokdad AH. Increasing trends in
waist circumference and abdominal obesity among U.S. adults.
Obesity. 2007;15:216-224.
9. Ronti T, Lupattelli G, Mannarino E. The endocrine function of
adipose tissue: an update. Clin Endocrinol. 2006;64:355-365.
10. Despres J-P, Lemieux I. Abdominal obesity and metabolic syndrome. Nature. 2006;444:881-887.
11. Klein S, Allison DB, Heymsfield SB, et al. Waist circumference
and cardiometabolic risk: a consensus statement from Shaping
Americas Health: Association for Weight Management and
Obesity Prevention; NAASO, The Obesity Society; the American
Society for Nutrition; and the American Diabetes Association.
Diabetes Care. 2007;30:1647-1652.
12. Sinha R, Dufour S, Petersen KF, et al. Assessment of skeletal muscle triglyceride content by 1H nuclear magnetic resonance spectroscopy in lean and obese adolescents: relationships to insulin
sensitivity, total body fat, and central adiposity. Diabetes.
2002;51:1022-1027.
13. Schreuder TC, van Nieuwkerk CM, Mulder CJ. Nonalcoholic fatty
liver disease: an overview of current insights in pathogenesis, diagnosis and treatment. World J Gastroenterol. 2008;14:2474-2486.
14. Thomas EL, Hamilton G, Patel N, et al. Hepatic triglyceride content and its relation to body adiposity: a magnetic resonance imaging and proton magnetic resonance spectroscopy study. Gut.
2005;54:122-127.
15. Lewis GF, Carpentier A, Adeli K, Giacca A. Disordered fat storage
and mobilization in the pathogenesis of insulin resistance and type
2 diabetes. Endocr Rev. 2002;23:201-229.
16. National Institutes of Health. The Practical Guide: Identification,
Evaluation and Treatment of Overweight and Obesity in Adults.
Bethesda, MD: National Institutes of Health; 2000.
17. World Health Organization. Obesity: Preventing and Managing the
Global Epidemic: Report of a WHO Consultation on Obesity.
Geneva, Switzerland: World Health Organization; 1997.
18. Colditz GA, Willett WC, Rotnitzky A, Manson JE. Weight gain as
a risk factor for clinical diabetes mellitus in women. Ann Intern
Med. 1995;122:481-486.
19. Manson JE, Willett WC, Stampfer MJ, et al. Body weight and mortality among women. N Engl J Med. 1995;333:677-685.
20. Despres JP, Moorjani S, Lupien PJ, Tremblay A, Nadeau A,
Bouchard C. Regional distribution of body fat, plasma lipoproteins,
and cardiovascular disease. Arterioscler Thromb Vasc Biol.
1990;10:497-511.
Downloaded from ncp.sagepub.com at NATIONAL SUN YAT-SEN UNIV on August 22, 2014
21. Flegal KM, Graubard BI, Williamson DF, Gail MH. Excess deaths
associated with underweight, overweight, and obesity. JAMA.
2005;293:1861-1867.
22. Tanko LB, Bagger YZ, Alexandersen P, Larsen PJ, Christiansen C.
Peripheral adiposity exhibits an independent dominant antiatherogenic effect in elderly women. Circulation. 2003;107:1626-1631.
23. Bjorntorp P. Obesity. Lancet. 1997;350:423-426.
24. Wannamethee SG, Shaper AG, Morris RW, Whincup PH.
Measures of adiposity in the identification of metabolic abnormalities in elderly men. Am J Clin Nutr. 2005;81:1313-1321.
25. Wannamethee SG, Shaper AG, Lennon L, Whincup PH.
Decreased muscle mass and increased central adiposity are independently related to mortality in older men. Am J Clin Nutr.
2007;86:1339-1346.
26. Woo J, Ho SC, Yu ALM, Sham L. Is waist circumference a useful
measure in predicting health outcomes in the elderly? Int J Obes.
2002;26:1349-1355.
27. Despres JP. The insulin resistance-dyslipidemic syndrome of visceral
obesity: effect on patients risk. Obesity Res. 1998;6(Suppl 1):8S-17S.
28. Han TS, van Leer EM, Seidell JC, Lean MEJ. Waist circumference
action levels in the identification of cardiovascular risk factors:
prevalence study in a random sample. BMJ. 1995;311:1401-1405.
29. Lean MEJ, Han TS, Morrison CE. Waist circumference as a measure
for indicating need for weight management. BMJ. 1995;311:158-161.
30. Shen W, Punyanitya M, Chen J, et al. Waist circumference correlates with metabolic syndrome indicators better than percentage
fat. Obesity. 2006;14:727-736.
31. Definition, Diagnosis and Classification of Diabetes Mellitus and Its
Complications: Report of a WHO Consultation. Geneva, Switzerland:
Department of Noncommunicable Disease Surveillance, World
Health Organization; 1999.
32. Larsson B, Svrdsudd K, Welin L, Wilhelmsen L, Bjrntorp P,
Tibblin G. Abdominal adipose tissue distribution, obesity, and risk
of cardiovascular disease and death: 13 year follow up of participants in the study of men born in 1913. BMJ (Clin Res Ed).
1984;288:1401-1404.
33. Ohlson LO, Larsson B, Svrdsudd K, et al. The influence of body
fat distribution on the incidence of diabetes mellitus: 13.5 years of
follow-up of the participants in the study of men born in 1913.
Diabetes. 1985;34:1055-1058.
34. Dalton M, Cameron AJ, Zimmet PZ, et al. Waist circumference,
waist-hip ratio and body mass index and their correlation with cardiovascular disease risk factors in Australian adults. J Intern Med.
2003;254:555-563.
35. Pouliot MC, Despres JP, Lemieux S, et al. Waist circumference
and abdominal sagittal diameter: best simple anthropometric
indexes of abdominal visceral adipose tissue accumulation and
related cardiovascular risk in men and women. Am J Cardiol.
1994;73:460-468.
36. Yusuf S, Hawken S, Ounpuu S; INTERHEART Study Investigators.
Obesity and the risk of myocardial infarction in 27,000 participants
from 52 countries: a case-control study. Lancet. 2005;366:1640-1649.
37. Ross R, Berentzen T, Bradshaw AJ, et al. Does the relationship
between waist circumference, morbidity and mortality depend on
measurement protocol for waist circumference? Obes Rev.
2008;9:312-325.
38. Ahima RS. Adipose tissue as an endocrine organ. Obesity. 2006;
14(Suppl 4):242S-249S.
39. Shen W, Wang Z, Punyanita M, et al. Adipose tissue quantification
by imaging methods: a proposed classification. Obes Res.
2003;11:5-16.
40. Jensen MD. Is visceral fat involved in the pathogenesis of the metabolic syndrome? Human Model Obes. 2006;14(Suppl 1):20S-24S.
41. Lemieux I, Pascot A, Prudhomme D, et al. Elevated C-reactive
protein: another component of the atherothrombotic profile of
abdominal obesity. Arterioscler Thromb Vasc Biol. 2001;21:961-967.
403
42. Cook NR, Buring JE, Ridker PM. The effect of including C-reactive
protein in cardiovascular risk prediction models for women. Ann
Intern Med. 2006;145:21-29.
43. Neels JG, Olefsky JM. Inflamed fat: what starts the fire? J Clin
Invest. 2006;116:33-35.
44. Fontana L, Eagon JC, Trujillo ME, Scherer PE, Klein S. Visceral
fat adipokine secretion is associated with systemic inflammation in
obese humans. Diabetes. 2007;56:1010-1013.
45. Scherer PE. Adipose tissue: from lipid storage compartment to
endocrine organ. Diabetes. 2006;55:1537-1545.
46. Cote M, Mauriege P, Bergeron J, et al. Adiponectinemia in visceral
obesity: impact on glucose tolerance and plasma lipoprotein and
lipid levels in men. J Clin Endocrinol Metab. 2005;90:1434-1439.
47. Menzaghi C, Trischitta V, Doria A. Genetic influences of
adiponectin on insulin resistance, type 2 diabetes, and cardiovascular disease. Diabetes. 2007;56:1198-1209.
48. Rask E, Walker BR, Soderberg S, et al. Tissue-specific changes in
peripheral cortisol metabolism in obese women: increased adipose 11
-hydroxysteroid dehydrogenase type 1 activity. J Clin Endocrinol
Metab. 2002;87:3330-3336.
49. Grundy SM, Cleeman JI, Daniels SR, et al. Diagnosis and management of the metabolic syndrome: an American Heart
Association/National Heart, Lung, and Blood Institute scientific
statement. Circulation. 2005;112:2735-2752.
50. Alberti KG, Zimmet P, Shaw J. International Diabetes Federation:
a consensus on type 2 diabetes prevention. Diabetic Med. 2007;24:
451-463.
51. Kahn R, Buse J, Ferrannini E, Stern M. The metabolic syndrome:
time for a critical appraisal Joint statement from the American
Diabetes Association and the European Association for the Study
of Diabetes. Diabetes Care. 2005;28:2289-2304.
52. Grundy SM. Does the metabolic syndrome exist? Diabetes Care.
2006;29:1689-1692.
53. Harris MI, Flegal KM, Cowie CC, et al. Prevalence of diabetes,
impaired fasting glucose, and impaired glucose tolerance in U.S.
adults. The Third National Health and Nutrition Examination
Survey, 1988-1994. Diabetes Care. 1998;21:518-524.
54. Balkau B, Deanfield JE, Desprs JP, et al. International Day for the
Evaluation of Abdominal Obesity (IDEA): a study of waist circumference, cardiovascular disease, and diabetes mellitus in 168,000
primary care patients in 63 countries. Circulation. 2007;116:1942-1951.
55. Rexrode KM, Buring JE, Manson JE. Abdominal and total adiposity and risk of coronary heart disease in men. Int J Obes Relat
Metab Disord. 2001;25:1047-1056.
56. Freiberg MS, Pencina MJ, DAgostino RB, Lanier K, Wilson PWF,
Vasan RS. BMI vs. waist circumference for identifying vascular
risk. Obesity. 2008;16:463-469.
57. Rexrode KM, Carey VJ, Hennekens CH, et al. Abdominal adiposity
and coronary heart disease in women. JAMA. 1998;280:1843-1848.
58. Bigaard J, Tjonneland A, Thomsen BL, Overvad K, Heitmann BL,
Sorensen TIA. Waist circumference, BMI, smoking, and mortality
in middle-aged men and women. Obes Res. 2003;11:895-903.
59. Katzmarzyk PT, Janssen I, Ross R, Church TS, Blair SN. The
importance of waist circumference in the definition of metabolic
syndrome: prospective analyses of mortality in men. Diabetes Care.
2006;29:404-409.
60. Koster A, Leitzmann MF, Schatzkin A, et al. Waist circumference
and mortality. Am J Epidemiol. 2008;167:1465-1475.
61. Dietz WH, Robinson TN. Overweight children and adolescents. N
Engl J Med. 2005;352:2100-2109.
62. Claudio M, Claudia B, Giorgio T. Waist-to-height ratio, a useful
index to identify high metabolic risk in overweight children. J
Pediatr. 2008;152:207-213.
63. WHO Expert Consultation. Appropriate body-mass index for Asian
populations and its implications for policy and intervention strategies. Lancet. 2004;363:157-163.
Downloaded from ncp.sagepub.com at NATIONAL SUN YAT-SEN UNIV on August 22, 2014
404
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