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Nutrition in Clinical Practice

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Waist Circumference Measurement in Clinical Practice


Rosane Ness-Abramof and Caroline M. Apovian
Nutr Clin Pract 2008 23: 397
DOI: 10.1177/0884533608321700
The online version of this article can be found at:
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Invited Review

Waist Circumference Measurement


in Clinical Practice

Nutrition in Clinical Practice


Volume 23 Number 4
August 2008 397-404
2008 American Society for
Parenteral and Enteral Nutrition
10.1177/0884533608321700
http://ncp.sagepub.com
hosted at
http://online.sagepub.com

Rosane Ness-Abramof, MD1; and Caroline M. Apovian, MD2


Financial disclosure: none declared.
The obesity epidemic is a major public health problem worldwide. Adult obesity is associated with increased morbidity and
mortality. Measurement of abdominal obesity is strongly associated with increased cardiometabolic risk, cardiovascular events,
and mortality. Although waist circumference is a crude measurement, it correlates with obesity and visceral fat amount, and
is a surrogate marker for insulin resistance. A normal waist circumference differs for specific ethnic groups due to different
cardiometabolic risk. For example, Asians have increased cardiometabolic risk at lower body mass indexes and with lower
waist circumferences than other populations. One criterion for

the diagnosis of the metabolic syndrome, according to different


study groups, includes measurement of abdominal obesity
(waist circumference or waist-to-hip ratio) because visceral adipose tissue is a key component of the syndrome. The waist circumference measurement is a simple tool that should be widely
implemented in clinical practice to improve cardiometabolic
risk stratification. (Nutr Clin Pract. 2008;23:397-404)

International Diabetes Federation (IDF).7 According to


the 2003-2004 National Health and Nutrition
Examination Survey (NHANES), more than 50% of U.S.
adults can be described as having abdominal obesity.8
This review summarizes the scientific data linking an
increased WC to increased cardiovascular, DM, and mortality risk and the importance of its assessment in clinical
practice.

Keywords: waist-hip ratio; body weight; body weight changes;


obesity; metabolic syndrome X; cardiovascular diseases; diabetes
mellitus

he current obesity epidemic poses a global concern


because of its related health problems. Obesity
increases the risk for diabetes mellitus (DM), hypertension, coronary heart disease, dyslipidemia, certain
cancers, and obstructive sleep apnea, among other
comorbidities.1-3 Although overweight and obesity are
associated with an increased risk for DM and cardiovascular disease, the pattern of fat distribution is also important in risk stratification.4 Intra-abdominal (visceral) fat
deposition is linked to an increased risk for developing
DM and cardiovascular disease compared with a more
peripheral (subcutaneous) fat distribution. The accurate
measurement of visceral fat requires the use of advanced
methods not available in clinical practice such as computed
tomography (CT) or magnetic resonance imaging (MRI).
On the other hand, a simple measurement of waist circumference (WC) is strongly correlated with risk for DM
and cardiovascular disease.5 Increased WC is one of the
diagnostic criteria for the metabolic syndrome, according
to the National Cholesterol Education Program (NCEP)
Adult Treatment Panel III (ATP III),6 and is essential for
the diagnosis of the metabolic syndrome, according to the

Measurement of Body Adiposity


Body fat is composed of cells that contain triglyceride
stores. Body fat can be divided into 2 main compartments: subcutaneous and intra-abdominal. Fat may also
accumulate at ectopic sites such as muscle, including the
heart, pancreas, and liver.9,10
There are many ways to measure total body fat; traditionally, the gold standard for body fat estimation has
been hydrodensitometry (underwater weighing), based on
the fact that fat tissue is less dense than muscle and bone.
Dual-energy X-ray absortiometry (DXA) is another
method for evaluating body composition. These 2 methods are used mainly in research and are not readily available for clinical practice or epidemiological studies.
Imaging studies such as CT, MRI, and DXA may evaluate fat partitioning, normally with most of the fat
located in the subcutaneous space and less in the visceral
space and most of the visceral fat located in the intraabdominal space (intraperitoneal and retroperitoneal).
The amount of visceral fat is influenced by gender, age,

From the 1Endocrine Unit, Meir Hospital, Kfar Saba, Sackler


School of Medicine, Tel Aviv University, Tel Aviv, Israel, and
2
Division of Endocrinology, Diabetes, Nutrition and
Metabolism, Boston Medical Center, Boston University School
of Medicine, Boston, Massachusetts.
Address correspondence to: Caroline M. Apovian, MD, Center
for Nutrition and Weight Management, Boston Medical Center,
88 East Newton Street Robinson Bldg, Suite 4400, Boston, MA
02118; e-mail: Caroline.Apovian@bmc.org.

397

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Nutrition in Clinical Practice / Vol. 23, No. 4, August 2008

race/ethnicity, physical activity, and total adiposity.11


Computed tomography and MRI are now the gold standards for the evaluation of the abdominal subcutaneous
and visceral adipose tissue. A single slice at the L4-L5
intervertebral level is used to measure the amount of fat,
expressed in cubic cm.11 It is possible that the intramuscular fat is correlated more to the visceral fat than the
subcutaneous fat.12 The deleterious effect of fat deposition in the liver is well known. Nonalcoholic steatohepatitis (NASH) is a common disorder known to correlate
with insulin resistance, increased triglyceride production
leading to an atherogenic dyslipidemia, type 2 DM, and
cirrhosis. Intrahepatic fat deposition can be evaluated
easily by ultrasound (US) of the liver, but US is not very
sensitive in the earlier stages of steatosis, and it does not
quantify lipid content. Computed tomography is used to
measure hepatic steatosis, whereas the most accurate tool
for quantifying lipid storage in the hepatocytes is
achieved by nuclear magnetic resonance (NMR).13,14
Pancreatic fat infiltration is also associated with
decreased insulin secretion and -cell apoptosis.15

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.

Classifications for Body Mass Index (BMI)

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

Adapted from the National Institutes of Health. The Practical


Guide: Identification, Evaluation and Treatment of Overweight
and Obesity in Adults. Bethesda, MD: National Institutes of
Health; 2000.

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

How Should Waist


Circumference Be Measured?
Different anatomic landmarks used to measure WC
include the midpoint between the lowest rib and the iliac
crest, the umbilicus, the narrowest or widest WC, just
below the lowest rib, and just above the iliac crest. The
NHLBI practical guide recommends measuring just
above the iliac crest.16 WC measurement should be done
with the patient standing, bare midriff, after the patient
exhales, with both feet touching and arms hanging freely.
The measuring tape should be made of a material that is
not easily stretched; it should be placed perpendicular to
the long axis of the body and horizontal to the floor and
applied with tension, but it should not put pressure on
the abdominal wall (Figure 1).
A recent systematic review by Ross et al37 evaluated
whether the site of WC measurement influenced its relationship to morbidity and mortality. The most commonly
used landmarks were the minimal waist (33%), the midpoint between the lowest rib and the iliac crest (26%),
and the umbilicus (27%). According to their review, WC
protocol did not influence outcome concerning all-cause
and cardiovascular disease (CVD) mortality, CVD, and
DM. Therefore, it seems that the site of measurement
does not influence clinical outcome.

Visceral Adipose Tissue


Adipose tissue is now viewed as an active endocrine organ
and not merely as an energy depot.38 The visceral adipose

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.

tissue (VAT) accounts for approximately 15% of total body


fat in the lean subject and includes the intraperitoneal
(mesenteric and omental) fat, which drains into the portal
circulation, and retroperitoneal fat, which drains into the
systemic circulation.39 There is a correlation between BMI
and WC with total adipose tissue mass, but WC has a
higher correlation with VAT than BMI alone.
Because the WC measures the subcutaneous abdominal tissue (SAT) and the VAT, it is not possible to discern
between the 2 compartments when measuring WC
(Figure 2).
The etiology of increased cardiometabolic risk in
patients with increased VAT is not known, but there are
many theories on the subject. Increased levels of free fatty
acids (FFAs) due to obesity and to increased VAT worsen
insulin resistance. The VAT is more insulin resistant, fueling
the hyperlipolytic state and worsening insulin resistance.
Although the VAT drains into the portal vein, most of the
FFA drained to the liver is derived from upper body non-VAT
fat.40 The increase in VAT mass possibly reflects the lack of
capacity of the subcutaneous tissue to store the energy
excess that accumulates in the liver, muscle, and pancreas,
worsening insulin resistance.10 Numerous cytokines are
secreted from the adipose tissue, including proinflammatory
molecules such as interleukin-6 (IL-6) and tumor necrosis
factor (TNF-). Plasma levels of C-reactive protein

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Nutrition in Clinical Practice / Vol. 23, No. 4, August 2008

Figure 2. Computed tomography scans from 2 subjects with


comparable body mass index. Subcutaneous fat is shown in
black under the skin and visceral fat area (VFA) in white. Scans
were made at the L4-L5 level. Reproduced with permission
from Tchernof A, Desprs JP. Obesity and lipoprotein metabolism. In: Kopelman PG, ed. Clinical Obesity. London: Blackwell
Science Ltd; 1998:176204.

(CRP), an inflammatory factor produced by the liver and


known to correlate with atherosclerosis, are increased in
patients with visceral obesity.41,42 It has been recently
shown that the adipose tissue is infiltrated by
macrophages, contributing to the inflammatory
process.43,44 Adiponectin, a protein derived from the adipose tissue, is known to improve insulin sensitivity and may
protect against atherosclerosis.45,46 Adiponectin levels are
decreased in obesity and in viscerally obese patients.46,47
Another contributing factor may be local generation of cortisol from cortisone due to increased activity of 11 hydroxysteroid dehydrogenase in the VAT, which may
further increase fat deposition, worsen insulin resistance,
and increase cardiometabolic risk.48

The Metabolic Syndrome


The metabolic syndrome consists of a cluster of risk factors strongly associated with an increased risk for atherosclerotic cardiovascular disease (ASCVD) and type 2 DM.
The metabolic risk factors consist of a specific pattern of
hyperlipidemia (elevated serum levels of triglycerides and
apolipoprotein B, small low-density lipoprotein [LDL]
particles, and low serum high-density lipoprotein [HDL]
cholesterol levels), elevated blood pressure, elevated
plasma glucose concentration, a proinflammatory state,
and a prothrombotic state.6,49 Possibly the most important
risk factors for the development of the syndrome are
abdominal obesity and insulin resistance.
The NCEP ATP III held in 2001 provided diagnostic
criteria for the metabolic syndrome that could be easily
implemented in clinical practice. These criteria include
WC, blood pressure measurements, and serum levels of

triglycerides, HDL-C, and fasting glucose. The criteria


were further updated in 2005 by an executive summary by
the American Heart Association and NHLBI. One change
in the diagnostic criteria is a decrease in normal serum
glucose values to < 100 mg/dL instead of < 110 mg/dL,
and although WC cutoffs were not changed, there is a
recommendation that some white, black, and Hispanic
adults with marginally increased WC (e.g., 94-101 cm
[37-39 in] in men and 80-87 cm [31-34 in] in women)
may benefit from changes in lifestyle, similar to subjects
with higher WC and that a lower cutoff for WC (90 cm
[35 in] in men and 80 cm [31 in] in women) appears to
be appropriate for Asian Americans because this population is more prone to insulin resistance.
The IDF has adopted the same diagnostic criteria for
the metabolic syndrome but proposed an adaptation to
WC according to ethnic group, due to different risk in different populations. According to the IDF criteria, an
increased WC is essential for the diagnosis of the metabolic syndrome because it incorporates both insulin
resistance and abdominal obesity. The presence of 2 other
criteria is required for the diagnosis of the metabolic syndrome.7,50 The WHO criteria require a diagnosis of
insulin resistance (glucose intolerance, impaired glucose
tolerance [IGT], or DM and/or insulin resistance measured under hyperinsulinemic euglycemic conditions).
Table 2 compared the different criteria required for the
diagnosis according to the 3 different groups.
There has been some dispute whether the metabolic
syndrome can be called a syndrome or if it adds to risk
stratification of patients beyond the regular risk factors
(eg, hyperlipidemia, hypertension, DM).51 Because obesity is the main culprit for the epidemic proportion of the
metabolic syndrome, those in favor of the definition point
out that it is more important to focus on lifestyle changes
that may improve all components of the syndrome instead
of on each individual risk factor.52

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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Waist Circumference Measurement / Ness-Abramof, Apovian

Table 2.
Study Group
Diagnostic criteria

Metabolic Syndrome Definitions

WHO26
Glucose intolerance, IGT,
or DM and/or insulin
resistance together with
2 of the following:

Fasting plasma glucose


Serum triglycerides
Serum HDL-cholesterol
Hypertension
Obesity

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

NCEP ATP III6

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

Albumin/creatinine >30 mg/g


or urinary albumin
excretion rate 20 g/min

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, Cardiovascular


Disease, and Mortality

Waist Circumference
in the Pediatric Population

The correlation between CVD risk and an increased WC


is well known, although it seems to be less than the correlation between WC and DM. Values for WC are related
to the risk for developing CVD and remain statistically
significant after adjusting for BMI and other cardiovascular risk factors, consistent in men and women.11,36,55-57
All-cause mortality is also related to WC, even when
adjusted for BMI. For any given BMI, an increased
WC confers a higher mortality risk.32,58,59 A recent study
evaluated the association between WC and mortality
among 154,776 men and 90,757 women aged 51 to
72 years at baseline and followed for 9 years. All-cause
mortality was higher in patients with increasing WC,
even when adjusted for BMI and other covariates. Men
with increased WC had a 22% increased mortality risk
and women a 28% increased mortality risk. This finding
was consistent in all races and among smokers and nonsmokers.60

Pediatric obesity is a serious medical problem worldwide.


In the U.S., 19% of children between 6 and 11 years old
are overweight, with BMI greater than the 95th percentile
for their age and sex.61 Cardiometabolic risk factors are
already present in this population (hypertension, dyslipidemia, and impaired glucose tolerance). The use of ageand gender-specific cutoffs (90th percentile) for WC
seems to be a reliable marker for the detection of high-risk
overweight pediatric patients.62 In this population, the use
of WHR (normal 0.5) may be easier in clinical practice
because it does not require age-specific tables.

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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Nutrition in Clinical Practice / Vol. 23, No. 4, August 2008

that Asians have a higher risk for DM and CVD with


lower BMIs and WC, corresponding to higher VAT for a
given BMI.63-66 African Americans, on the other hand,
have lower VAT compared with Caucasians of the same
BMI and WC.67,68
The IDF has adopted a lower cutoff WC for
Caucasians compared with the NCEP ATP III, corresponding to a BMI of 25 kg/m2, and includes ethnicand gender-specific cutoffs (Table 2). There are still
populations (sub-Saharan Africans, ethnic South and
Central Americans, Eastern Mediterranean, and
Middle East populations) for which ethnic-specific
cutoffs for WC have not been specified; these should
adopt the Caucasian cutoffs for the time being.7

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.

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