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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.
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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
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
2 Methodsformeasuringwaistandhipcircumference............................................. 5
2.3 Measurementerror..........................................................................................7
2.5 Summaryandconclusions................................................................................7
3 Impactofvariationsinbodyfatdistributionbysex,ageandethnicity ................... 8
3.4 Ethnicity..........................................................................................................10
3.4.1 Ethnicgroupsforwhichwaistcircumferenceorwaisthip
ratiomayreflectmorebodyfatatagivenbodymassindex
level ...................................................................................................10
3.4.2 Populationsforwhichwaistcircumferenceorwaisthip
ratiomayreflectlessbodyfatatagivenbodymassindex
level ...................................................................................................10
3.5 Summaryandconclusions..............................................................................10
4 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
5 Summaryandconclusions.................................................................................... 19
5.1 Usefulnessofwaistcircumferenceandwaisthipratiofor
predictionofdiseaserisk ...............................................................................19
5.4 Universalorpopulationspecificcutoffpoints..............................................22
6 Recommendations............................................................................................... 24
AnnexA:Currentusesofwaistcircumferencesandwaisthipratios,and
recommendedcutoffpoints ............................................................................... 27
AnnexB:Listofparticipants............................................................................................. 32
References ....................................................................................................................... 34
vi
1 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.
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.
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.
TheNIHalsoprovidedaprotocolforthemeasurementofwaistcircumferenceforthe
MultiEthnicStudyofAtherosclerosis(MESA)study.Thisprotocolindicatesthatthewaist
measurementshouldbemadeattheleveloftheumbilicusornavel.However,published
reportsindicatethatmeasurementsofwaistcircumferencemadeatthelevelofthe
umbilicusmayunderestimatethetruewaistcircumference(Croftetal.,1995).
Somestudieshaveassessedthewaistcircumferenceatthepointoftheminimalwaist(Ross
etal.,2008).
Hip circumference
AlloftheprotocolsmentionedinSection2.1.1indicatethatthehipcircumference
measurementshouldbetakenaroundthewidestportionofthebuttocks.
BoththeprotocoldescribedinNIHPracticalguidetoobesity(NHLBIObesityEducation
Initiative,2000)andtheNHANESIIIprotocol(WestatInc,1998)recommendthatthe
measurementsbemadewiththetapeheldsnugly,butnotconstricting,andatalevel
paralleltothefloor.
Evenwhenthesameprotocolisused,theremaybevariabilitywithinandbetween
measurerswhenmorethanonemeasurementismade.Theexpertswereuncertain
whethertheseandotherissuesrelatedtomeasurementarerelevantateitherthe
populationortheclinicallevel,andfeltthatthismaybeanimportantareaforinclusionin
thefutureresearchagenda.
Forbothmeasurements,thesubjectshouldstandwithfeetclosetogether,armsattheside
andbodyweightevenlydistributed,andshouldwearlittleclothing.Thesubjectshouldbe
relaxed,andthemeasurementsshouldbetakenattheendofanormalexpiration.Each
measurementshouldberepeatedtwice;ifthemeasurementsarewithin1cmofone
another,theaverageshouldbecalculated.Ifthedifferencebetweenthetwo
measurementsexceeds1cm,thetwomeasurementsshouldberepeated.
3 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).
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).
10
havelessvisceraladiposetissueorpercentageofbodyfatatanygivenwaistcircumference.
Ifhigherlevelsofabdominalfatforawaistcircumferenceorwaisthipratiolevelare
reflectedinassociationswithhealthoutcomes,thenlowerthresholdsfortheseindicators
mightbeneededfortheaffectedpopulationsthanforEuropeanorotherreference
populations.ThereisrelativelyconsistentevidencethatthissituationmayapplytoAsian
populations. DataforAfricansandPacificIslandersareexamplesofpossibleindicationsfor
aneedforhighercutoffsthanthoseusedforEuropeanreferencepopulations.However,
giventhattheobjectiveistopredictdiseaserisk,drawingconclusionsaboutcutoffssolely
onthebasisofobservedrisksdoesnotseemappropriate.
11
4 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.
12
particularanthropometricmeasure;however,theremaybegeneralconsistencyinthe
cutoffpointsofwaisthipratioforpredictingCVDrisk.
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
Seidell(2010)concludedthat:
waistcircumferenceandwaisthipratioarebothrelatedtoincreasedriskofallcause
mortality,throughouttherangeofadultBMIs;
waistcircumferenceandwaisthipratioarestronglypredictiveinyoungandmiddle
agedadultscomparedtoolderpeopleandthosewithlowBMI;
waistcircumferencealonecouldreplacewaisthipratioandBMIasasingleriskfactor
forallcausemortality.
However,dataarelackingonappropriatecutoffsformeasuresofabdominalobesityfor
predictingriskofallcausemortalityinethnicandpopulationgroupsotherthanEuropean,
NorthAmericanandAustralianwhitepopulations.Evidenceforuseofwaistcircumference
orwaisthipratiotoreplaceBMIforpredictingmorbidityrelatedtocancerriskisless
strongthanforallcausemortality.
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).
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.
4.5.4 Mortality
Theevidencewithregardtoanthropometricmeasuresinparticularwaistcircumference
orwaisthipratiomeasuresandallcausemortalityispredominantlyfromwhite
EuropeanandAmericanadults,bothinyoungandmiddleagedadultsandolderpeople.
FewstudieshaveexaminedAfricanandAsianpopulations.Whenwaistcircumferencewas
adjustedforBMI,therelationshipappearsJshapedtoalmostlinear.
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 Waisthip ratio Waistheight Remarks and major
Relationship circumference ratio references
evidencea
Strength of
Relationship
evidencea
Strength of
Relationship
evidencea
Strength of
Relationship
evidencea
Strength of
CVD risk ++ Convincing ++++ Convincing ++++ Convincing +++ Convincing de Koning et al. (2007)
APCSC (2006)
Yusuf et al. (2005)
Gelber et al. (2008)
Zhu et al. (2005)
Overall CVD risk ++ Convincing +++ Convincing +++ Convincing +++ Convincing Lee et al. (2008)b
factors
(mainly cross-
sectional data)
CVD risk factors / / +++ Probable +++ Probable / / WHO (2008b)
(from STEPS
analysis presented
in the WHO
meeting)
Type 2 diabetes +++ Convincing +++ Convincing +++ Convincing / / Vazquez et al. (2007)
mellitus
(prospective
studies)
Type 2 diabetes +++ Convincing ++++ Convincing ++++ Convincing ++++ Convincing Huxley et al. (2007)
mellitus Huxley et al. (2008)
(cross-sectional Nyamdorj et al. (2008)b
studies) Qiao & Nyamdorj (2010b)
Hypertension +++ Convincing +++ Convincing +++ Convincing +++ Convincing Wolf & Colditz (1998)
(mainly cross- James et al. (2004)
sectional data) Huxley et al. (2007)
Huxley et al. (2008)
Nyamdorj et al. (2008)b
Overall mortality +++ Convincing +++ Convincing +++ Convincing +++ Convincing Koster et al. (2008)
(without mutual Zhang et al. (2008)
adjustment of the Welborn & Dhaliwal (2007)b
anthropometric Remarks:
parameters) Some studies showed J-
shape 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)
Overall mortality 0/ Probable ++++ Convincing ++++ Convincing / / Kalmijn et al. (1999)
(with mutual Pischon et al. (2008)
adjustment of the
17
Body mass index Waist Waisthip ratio Waistheight Remarks and major
circumference ratio references
Relationship
evidencea
Strength of
Relationship
evidencea
Strength of
Relationship
evidencea
Strength of
Relationship
evidencea
Strength of
anthropometric Bigaard et al. (2003)
parameters)
18
TheaimoftheexpertconsultationwastoprovideguidancethatWHOcouldusetodevelop
recommendationsandultimatelyprovideguidelinesfortheeffectiveuseofspecificcutoff
pointsforwaistcircumferenceandwaisthipratio.Makingdefinitivedecisionsonactual
cutoffpointswasoutsidethescopeoftheconsultation.However,theexpertconsultation
wasaskedtoadviseWHOonhowtheprocessofdevelopingactualcutoffpointscouldbe
movedforward,andtoidentifyanygapsinthedata.
Thischaptersummarizesthepotentialusefulnessandrelativeadvantagesof:
waistcircumferenceversuswaisthipratio,withorwithoutaccompanyingBMI
measurements;
measurementprotocolsforwaistcircumferenceandwaisthipratio;
methodsforselectingcutoffpoints;
considerationsfordeterminingtheneedforpopulationspecificcutoffpoints.
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 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 Disease risk (relative to normal weight and waist
circumference)
Men < 102 cm Men >102 cm
Women < 88 cm Women >88 cm
Underweight <18.5
Normal 18.524.9
Overweight 25.029.9 Increased High
Obesity 30.034.9 I High Very high
35.039.9 II Very high Very high
Extreme obesity >40.0 III Extremely 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 Waist circumference
(cm)
Europid Men >94
Women >80
South Asian Men >90
Women >80
Chinese Men >90
Women >80
Japanese Men >90
Women >80
Source: Adapted from Zimmet & Alberti (2006)
Thisprotocolcanbesummarizedasoutlinedbelow.
Measurethewaistcircumferenceattheendofseveralconsecutivenaturalbreaths,at
alevelparalleltothefloor,midpointbetweenthetopoftheiliaccrestandthelower
marginofthelastpalpableribinthemidaxillaryline.
Measurethehipcircumferenceatalevelparalleltothefloor,atthelargest
circumferenceofthebuttocks.
Makebothmeasurementswithastretchresistanttapethatiswrappedsnuglyaround
thesubject,butnottothepointthatthetapeisconstricting.Keepthetapeleveland
paralleltotheflooratthepointofmeasurement.
20
Ensurethatthesubjectisstandinguprightduringthemeasurement,witharmsrelaxed
attheside,feetevenlyspreadapartandbodyweightevenlydistributed.
21
cutoffpointsbasedondifferencesinpopulationcharacteristics(e.g.averagebodysize
ordiseaseprevalence).
Allthesequestionsneedtobecarefullyconsideredwhendeterminingthemethodand
processusedtoderivecutoffpointsforwaistcircumferenceandwaisthipratiofor
recommendationbyWHO. Thechoiceofmethodandtheprocesstobeoutlinedwillalso
dependonthepotentialusesofthederivedcutoffpointsandhealthrelevantpolicy
considerations.Forexample,specificproblemsofthepopulationgroupforwhichthecut
offpointsaretobeused shouldbetakenintoaccount.
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
6 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
1
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
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 Cut-off points Risk of metabolic complications
Waist circumference >94 cm (M); >80 cm (W) Increased
Waist circumference >102 cm (M); >88 cm (W) Substantially increased
Waisthip ratio 0.90 cm (M); 0.85 cm (W) Substantially increased
M, men; W, women
27
Table A2 International Diabetes Federation cut-off points for different ethnic groups
Men Women
Europids >94 cm >80 cm
South Asians, Chinese and >90 cm >80 cm
Japanese
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.
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.
Belowareexamplesofhowtheseconceptshavebeenusedastherationaleforwaist
circumferenceandwaisthipratiocutoffpointsindifferentcountries.
29
Maximum sensitivity
AstudyfromFranceprovidedcutoffpointsforthemostcorpulent30%ofthepopulation
(Balkauetal.,2006):
waistcircumferenceforobesity,diabetes,andCVD:96cmformenand83cmfor
women;
waisthipratioforgeneralriskandobesity:0.96formenand0.83forwomen.
Sensitivitywasofparamountimportance,withwaistcircumferencesensitivitiesof74%for
menand82%forwomen,andforwaisthipratioof66%formenand77%forwomen.
30
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.
However,thestudyalsoprovidedindividualcutoffpointsforeachdiseaserisk,andwould
clearlybeapplicableforclinicaluse(whereasthesinglevaluegivenabovewouldbeuseful
forpublichealthpurposes):
formen:82cm(hypertension);83cm(glycaemia);87cm(diabetes);85cm(total
cholesterolandtriglycerides);
forwomen:81cm(hypertension);82cm(glycaemia);87cm(diabetes);83cm(total
cholesterolandtriglycerides).
A3 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
2
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
DiseasesandHealthPromotion,WHO,Geneva,Switzerland
DrGojkaRoglic,MedicalOfficer,ChronicDiseasesPreventionandManagement,Chronic
DiseasesandHealthPromotion,WHO,Geneva,Switzerland
33
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