Waist Circumference and Waist-Hip Ratio

Report of a WHO Expert Consultation

GENEVA, 811 DECEMBER 2008

Waist Circumference and WaistHip Ratio:

Report of a WHO Expert Consultation
Geneva, 811 December 2008

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

World Health Organization 2011

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ii

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

iii

Abbreviations and acronyms

ATP AUC BMI CARDIA CVD DEXA FAO FPR IDF MESA NCD NCEP NHANES NHLBI NIH ROC STEPS SWAN TPR US WHO AdultTreatmentPanel areaunderthereceiveroperatingcharacteristiccurve bodymassindex CoronaryArteryRiskDevelopmentinYoungAdults cardiovasculardisease dualXrayabsorptiometry FoodandAgricultureOrganizationoftheUnitedNations falsepositiverate InternationalDiabetesFederation MultiEthnicStudyofAtherosclerosis noncommunicabledisease NationalCholesterolEducationProgram NationalHealthandNutritionExaminationSurvey NationalHeart,LungandBloodInstitute NationalInstitutesofHealth receiveroperatingcharacteristic STEPwiseApproachtoSurveillance(WHO) StudyofWomensHealthAcrosstheNation truepositiverate UnitedStates WorldHealthOrganization

iv

C o n t e n ts
Acknowledgements........................................................................................................... iii Abbreviationsandacronyms............................................................................................. iv 1 2 Introduction........................................................................................................... 1 Methodsformeasuringwaistandhipcircumference............................................. 5 2.1 Placement,tightnessandtypeofmeasuringtape ..........................................5 2.1.1 Placementoftape ...............................................................................5 2.1.2 Tightnessandtypeoftape..................................................................6 Subjectpostureandotherfactors ...................................................................6 2.2.1 Postureofthesubjectsduringthemeasurement ..............................6 2.2.2 Phaseofrespirationattheexactpointofmeasurement ...................6 2.2.3 Abdominaltensionatthepointofmeasurement ..............................6 2.2.4 Influenceofstomachcontentsattimeofmeasurement ...................6 Measurementerror..........................................................................................7 Implicationsofdifferencesinmethodology ....................................................7 Summaryandconclusions................................................................................7

2.2

2.3 2.4 2.5 3

Impactofvariationsinbodyfatdistributionbysex,ageandethnicity ................... 8 3.1 3.2 3.3 3.4 Sex ....................................................................................................................8 Reproductivestatus .........................................................................................8 Age ...................................................................................................................9 Ethnicity..........................................................................................................10 3.4.1 Ethnicgroupsforwhichwaistcircumferenceorwaisthip ratiomayreflectmorebodyfatatagivenbodymassindex level ...................................................................................................10 3.4.2 Populationsforwhichwaistcircumferenceorwaisthip ratiomayreflectlessbodyfatatagivenbodymassindex level ...................................................................................................10 Summaryandconclusions..............................................................................10

3.5 4

Relationshipsofwaistcircumferenceandwaisthipratiotodiseaserisk andmortality....................................................................................................... 12 4.1 4.2 Measuresofobesityandabdominalobesityandcardiovascular diseaserisk .....................................................................................................12 Measuresofobesity,abdominalobesityandtype2diabetesrisk................13

4.3 4.4 4.5

Measuresofobesityandabdominalobesityandallcausemortality andmortalityfromspecificcauses ................................................................14 Ethnicdifferences...........................................................................................14 Summaryandconclusions..............................................................................15 4.5.1 Cardiovasculardisease......................................................................15 4.5.2 Diabetes ............................................................................................16 4.5.3 Riskfactors ........................................................................................16 4.5.4 Mortality ...........................................................................................16 4.5.5 Ethnicdifferences..............................................................................16

Summaryandconclusions.................................................................................... 19 5.1 5.2 5.3 5.4 Usefulnessofwaistcircumferenceandwaisthipratiofor predictionofdiseaserisk ...............................................................................19 Measurementprotocol ..................................................................................20 Selectingcutoffpoints ..................................................................................21 Universalorpopulationspecificcutoffpoints..............................................22

Recommendations............................................................................................... 24

AnnexA:Currentusesofwaistcircumferencesandwaisthipratios,and recommendedcutoffpoints ............................................................................... 27 AnnexB:Listofparticipants............................................................................................. 32 References ....................................................................................................................... 34

vi

Introduction
TheWorldHealthOrganization(WHO)ExpertConsultationonWaistCircumferenceand WaistHipRatiowasheldinGeneva,Switzerlandon811December2008.Theconsultation wasorganizedbyWHOsDepartmentofNutritionforHealthandDevelopment,in collaborationwiththeDepartmentofChronicDiseasesandHealthPromotion.Itwas openedbyDrAlaAlwan,WHOAssistantDirectorGeneralforNoncommunicableDiseases andMentalHealth.TheconsultationwasconvenedaspartofWHO's: effortsinimplementingtherecommendationsmadeattheWHOConsultationon AppropriateBodyMassIndexforAsianPopulations(WHO,2004); responsetotheemergingproblemofobesityandrelatedchronicdiseases,inparticular inlowandmiddleincomecountries.

The1997WHOExpertConsultationonObesityrecognizedtheimportanceofabdominalfat mass(referredtoasabdominal,centralorvisceralobesity),whichcanvaryconsiderably withinanarrowrangeoftotalbodyfatandbodymassindex(BMI).Italsohighlightedthe needforotherindicatorstocomplementthemeasurementofBMI,toidentifyindividualsat increasedriskofobesityrelatedmorbidityduetoaccumulationofabdominalfat(WHO, 2000a).Waisthipratio(i.e.thewaistcircumferencedividedbythehipcircumference)was suggestedasanadditionalmeasureofbodyfatdistribution.Theratiocanbemeasured morepreciselythanskinfolds,anditprovidesanindexofbothsubcutaneousandintra abdominaladiposetissue(Bjorntorp,1987).Thesuggestionfortheuseofproxy anthropometricindicatorsarosefroma12yearfollowupofmiddleagedmen,which showedthatabdominalobesity(measuredaswaisthipratio)wasassociatedwithan increasedriskofmyocardialinfarction,strokeandprematuredeath,whereasthese diseaseswerenotassociatedwithmeasuresofgeneralizedobesitysuchasBMI(Larssonet al.,1984).Inwomen,BMIwasassociatedwithincreasedriskofthesediseases;however, waisthipratioappearedtobeastrongerindependentriskfactorthanBMI(Lapidusetal., 1984). The2002WHOExpertConsultationonAppropriateBodyMassIndexforAsianPopulations andItsImplicationsforPolicyandInterventionStrategies(WHO,2004)reviewedtheissue ofethnicdifferencesinthemeaningofBMIcutoffvalues.Inpopulationswitha predispositiontocentral(i.e.abdominalorvisceral)obesityandtherelatedincreasedrisk ofdevelopingmetabolicsyndrome,theconsultationrecommendedthat,wherepossible, waistcircumferenceshouldbeusedtorefineactionlevelsbasedonBMI. Forexample, levelsbasedonBMImightbeincreasedbyonelevelifthewaistcircumferencewere elevatedaboveaspecifiedlevel.Thechoiceoftheactionlevelforwaistcircumference shouldbebasedonpopulationspecificdataandhealthconsiderations.Anexpertworking groupwasformedbythe2002consultation,tostartexaminingdataontherelation betweenwaistcircumferenceandmorbidity,andonanyassociationbetweenBMI,waist circumferenceandhealthrisk.Theaimwastodeveloprecommendationsforusingwaist measurementstofurtherdefinerisks.

WHOsGlobalStrategyforthePreventionandControlofNoncommunicableDiseases (WHO,2000b),andthemorerecent20082013ActionPlanfortheGlobalStrategyforthe PreventionandControlofNoncommunicableDiseases(WHO,2008a),providetheplatform forWHOsworkonnoncommunicablediseases(NCDs).Thesepublicationsidentifiedthe monitoringofNCDsandtheirdeterminantsasakeycomponentfor: developingpolicies; evaluatingtheeffectivenessandimpactofinterventions; assessingtheprogressmade.

TheExpertConsultationonWaistCircumferenceandWaistHipRatiocontributedtothe implementationoftheglobalstrategyandNCDactionplan.Itachievedthisbyreviewing andupdatingthewaistcircumferenceandwaisthipratioissuesrelatedtodiagnostic criteria,classificationsand(possibly)managementguidelinesformajorNCDs. Theoverallaimoftheexpertconsultationwastoreviewthescientificevidenceandmake recommendationsontheissuesrelatedtowaistcircumferenceandwaisthipratio.It focusedparticularlyonissuesrelatedto: methodsofmeasurement; variationsbysex,ageandethnicity; predictingrisksofcardiovasculardisease(CVD)anddiabetes,andofoverallmortality; relationshipwithBMIinpredictingdiseaserisks.

Thespecificobjectivesoftheconsultationwereto: reviewtheusefulnessofwaistcircumferenceandwaisthipratiomeasuresas predictorsofNCDrisk; assessoperationalconsiderationsrelatedtomeasurementprotocolsandcutoffpoints forpublichealthaction; definepotentialcutoffpointsforpublichealthaction; identifyfutureresearchneeds.

Toachievetheseobjectives,sixpeerreviewedbackgroundpaperswerepreparedby selectedexpertsintherelatedfields. Theselectionofexperts,bothforthepreparationof thebackgrounddocumentsandfortheactualconsultation,followedWHOprocessand guidelines;aspartoftheprocess,allexpertparticipants,peerreviewersandtemporary advisorssignedadeclarationofinterests. Wherepossible,thebackgroundpaperspreparedfortheconsultationevaluatedthe strengthoftheevidence,usingmodifiedcriteriafromtheWorldCancerResearchFund,as adaptedbyanearlierjointWHOandFoodandAgricultureOrganizationoftheUnited Nations(FAO)ExpertConsultationonDiet,NutritionandthePreventionofChronicDisease (WHO/FAO,2003)(seeTable1.1,below).Muchofthedataandmanyofthestudydesigns didnoteasilylendthemselvestorigorousevaluationbasedonthesecriteria.Nevertheless, thecriteriawereusefultothediscussionsattheexpertconsultation,inrelationto understandingconclusionsonthedifferencesamongdiversepopulationsderivedfrom examinationofassociationsbetweenBMIandproxyanthropometricindicatorsof abdominalfat,anddifferenthealthoutcomes.

Table 1.1

Criteria for assessing strength of the evidence of association

Probable evidence Based on epidemiological studies showing fairly consistent associations, but with perceived shortcomings in available evidence or some evidence to the contrary, precluding a more definite judgement Shortcomings in the evidence may include insufficient duration of trials/studies, insufficient availability of trials/studies, inadequate sample sizes, and incomplete follow-up Laboratory evidence is usually supportive Association should be biologically plausible Possible evidence Based mainly from casecontrol and cross-sectional studies, and data from insufficient randomized control trials, observational studies, non-randomized control trials and evidence from non-epidemiological studies (i.e. clinical and laboratory based) More trials are required to support tentative associations Association should be biologically plausible

Convincing evidence Based on epidemiological studies showing consistent associations between exposure and disease, with little or no evidence to the contrary Based on a substantial number of studies including prospective observational studies and, where relevant, randomized controlled trials of sufficient size, duration and quality showing consistent effects Association should be biologically plausible

Adapted from WHO/FAO (2003)

Thisreportprovidesasummaryofthediscussionsoftheexpertconsultation.Itincludes: discussionofthemethodsformeasuringwaistcircumferenceandwaisthipratio (Chapter2); age,sexandethnicvariationsinfatdistribution(Chapter3); associationsofwaistcircumferenceandwaisthipratiowithBMI,andwithhealth outcomes(Chapter4).

Chapter5presentsasummaryandconclusionsonthesedifferentaspects,anddiscusses approachesandresearchneedsforusingmeasurementsofwaistcircumferenceandwaist hipratio.Chapter6outlinesstepsthatcouldbetakentoarriveatappropriateWHO recommendations.AnnexAcontainsbackgroundinformation(compiledbytheWHO Secretariat)onexistingcutoffpointsforwaistcircumferenceandwaisthipratio.These cutoffpointsareusedtovariableextents,someforclinicalanddiagnosticpurposes,others forscreeningandsurveillanceforpublichealthpurposes.AnnexBliststheparticipantsin theconsultation. Thedetailedbackgroundpapers,togetherwithanoverviewoftheexpertconsultation, havebeenpublishedelsewhere(Huxleyetal.,2010;Learetal.,2010;Nishidaetal.,2010; Qiao&Nyamdorj,2010a;Qiao&Nyamdorj,2010b;Seidell,2010;Stevensetal.,2010).The mainfindingsandkeyissuesidentifiedfromthesebackgroundpapersareincludedinthis report. Someofthepotentialusesofthecutoffpointsforwaistcircumferenceandwaisthipratio include: surveillance screening diagnosisanddecisiontotreatinaclinicalsituation assessingthevalueoftreatmentofanindividual assessingthevalueofinterventioninthecommunity.

Touseeitherorbothofthesemeasures,themethodforselectingcutoffpointstoindicate thresholdsforriskneedstobespecified(WHO,1995).Thebasisforidentifyingthesecutoff pointsmaybeidenticalforthedifferentmeasurementsormaydiffer,dependingonthe purposeforwhichthecutoffpointsareused.Therelevancetopublichealthisrelatedto preventionandthepredictionofdiseaseburden,ratherthanthepredictionofmortality. As partofanevidencebasetoinformpolicy,thesemeasuresmaybeusedtoassesstheneed forinterventions,andtoassesseffectivenessofinterventionsinreducinghealthrisksor associatedcostsandburdens.

Methods for measuring waist and hip circumference

Animportantissueinusingandinterpretingwaistcircumferenceorwaisthipratioisthe protocolusedtoobtainthemeasurements.Alsoimportantistheextenttowhichthe measurementprotocolvariesacrossstudies,andthepotentialforstandardizingthese measurementswithinastudyorsurvey,whentakenbydifferentpeople. Theoretically,differencesinmeasurementsprotocolsacrossstudiescouldberesponsible forvariationintheassociationofthesemeasureswithriskfactors,ordiseaseormortality outcomes.Therefore,theexpertconsultationconsideredbackgroundinformationon protocolscurrentlyinuse,andtheimpactofdifferencesinmeasurementapproacheson measurementerrorandassociationswithhealthoutcomes.Theaimwastorecommendan appropriateprotocolforinternationaluse. Elementsoftheprotocoldiscussedbelowinclude: theanatomicalplacementofthemeasuringtape,itstightnessandthetypeoftape used; thesubjectsposture,phaseofrespiration,abdominaltension,stomachcontentsand clothing.

2.1
2.1.1

Placement, tightness and type of measuring tape

Placement of tape TheWHOSTEPwiseApproachtoSurveillance(STEPS)providesasimplestandardized methodforcollecting,analysinganddisseminatingdatainWHOMembercountries.The WHOSTEPSprotocolformeasuringwaistcircumferenceinstructsthatthemeasurementbe madeattheapproximatemidpointbetweenthelowermarginofthelastpalpableriband thetopoftheiliaccrest(WHO,2008b).TheUnitedStates(US)NationalInstitutesofHealth (NIH)protocolprovidedintheNIHPracticalguidetoobesity(NHLBIObesityEducation Initiative,2000)andtheprotocolusedintheUSNationalHealthandNutritionExamination Survey(NHANES)III(WestatInc,1998)indicatethatthewaistcircumferencemeasurement shouldbemadeatthetopoftheiliaccrest. TheNIHalsoprovidedaprotocolforthemeasurementofwaistcircumferenceforthe MultiEthnicStudyofAtherosclerosis(MESA)study.Thisprotocolindicatesthatthewaist measurementshouldbemadeattheleveloftheumbilicusornavel.However,published reportsindicatethatmeasurementsofwaistcircumferencemadeatthelevelofthe umbilicusmayunderestimatethetruewaistcircumference(Croftetal.,1995). Somestudieshaveassessedthewaistcircumferenceatthepointoftheminimalwaist(Ross etal.,2008).

Waist circumference

Hip circumference

AlloftheprotocolsmentionedinSection2.1.1indicatethatthehipcircumference measurementshouldbetakenaroundthewidestportionofthebuttocks.

2.1.2

Tightness and type of tape Theaccuracyofwaistandhipcircumferencemeasurementsdependsonthetightnessof themeasuringtape,andonitscorrectpositioning(i.e.paralleltotheflooratthelevelat whichthemeasurementismade).TheWHOSTEPSprotocolstatesthat,forbothwaistand hip,thetapeshouldbesnugaroundthebody,butnotpulledsotightthatitisconstricting (WHO,2008b).Theprotocolalsorecommendstheuseofastretchresistanttapethat providesaconstant100goftensionthroughtheuseofaspecialindicatorbuckle;useof thistypeoftapereducesdifferencesintightness. BoththeprotocoldescribedinNIHPracticalguidetoobesity(NHLBIObesityEducation Initiative,2000)andtheNHANESIIIprotocol(WestatInc,1998)recommendthatthe measurementsbemadewiththetapeheldsnugly,butnotconstricting,andatalevel paralleltothefloor.

2.2
2.2.1

Subject posture and other factors

Posture of the subjects during the measurement Thepostureofthesubjectatthetimethemeasurementistakeninfluencestheaccuracyof themeasurement.Thus,theWHOSTEPSprotocolrecommendsthatthesubjectstandswith armsatthesides,feetpositionedclosetogether,andweightevenlydistributedacrossthe feet(WHO,2008b).TheNHANESIIIprotocolrecommendsthatthesubjectbestanding erect,withthebodyweightevenlydistributed(WestatInc,1998).

2.2.2

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

2.2.3

Abdominal tension at the point of measurement Thetensionoftheabdominalwallinfluencestheaccuracyofthewaistcircumference measurement.Loweringthetensionoftheabdominalwallincreaseswaistcircumference, whereasincreasingthetension(bysuckingin)reduceswaistcircumference.Many individualsunconsciouslyreacttowaistmeasurementsbysuckingintheabdominalwall; hence,arelaxedpostureisbestfortakingwaistmeasurements.TheWHOSTEPSprotocol recommendsadvisingthesubjecttorelaxandtakeafewdeep,naturalbreathsbeforethe actualmeasurementismade,tominimizetheinwardpulloftheabdominalcontentsduring thewaistmeasurement(WHO,2008b).

2.2.4

Influence of stomach contents at time of measurement Theamountofwater,foodorgasinthegastrointestinaltractwillaffecttheaccuracyofthe waistmeasurement.Gibson(1990)suggeststhatawaistmeasurementbemadeafterthe subjecthasfastedovernightorisinafastedstate,toreducethiseffect.Noneofthe protocolsevaluatedaddressthisissue,perhapsbecauseitwouldentailthesubjectbeing notifiedinadvanceofthemeasurement,andbeingpresentthemorningafteranovernight fast.

2.3

Measurement error
Informationonthemeasurementerrorofthewaistcircumferenceandhipcircumference hascomefromstudiesinadolescents.Lohmanetal.(1988)calculatedthetechnicalerrorof waistcircumferencemeasurementinadolescentstobe1.31cmfromintrameasurererror and1.56cmfromintermeasurererror.Forhipmeasurements,theauthorscalculatedthe technicalerrortobe1.23cmfromintrameasurererrorand1.38fromintermeasurererror.

2.4

Implications of differences in methodology

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

2.5

Summary and conclusions

Waistcircumferenceshouldbemeasuredatthemidpointbetweenthelowermarginofthe leastpalpableribandthetopoftheiliaccrest,usingastretchresistanttapethatprovidesa constant100gtension.Hipcircumferenceshouldbemeasuredaroundthewidestportion ofthebuttocks,withthetapeparalleltothefloor. Forbothmeasurements,thesubjectshouldstandwithfeetclosetogether,armsattheside andbodyweightevenlydistributed,andshouldwearlittleclothing.Thesubjectshouldbe relaxed,andthemeasurementsshouldbetakenattheendofanormalexpiration.Each measurementshouldberepeatedtwice;ifthemeasurementsarewithin1cmofone another,theaverageshouldbecalculated.Ifthedifferencebetweenthetwo measurementsexceeds1cm,thetwomeasurementsshouldberepeated.

I m pa c t o f v a r i a t i o n s i n b o d y f a t distribution by sex, age and ethnicity

Commonlyusedcutoffpointsforwaistcircumferenceandwaisthipratioarebasedon studiesundertakenpredominantlyinpopulationsofEuropeanorigin. Theimportanceof takingintoaccountethnicdifferencesintheamountofbodyfatassociatedwithwaist circumferenceorwaisthipratioatdifferentBMIlevelswasaprimarymotivationforthis expertconsultation,basedonthefindingsofthe2002WHOExpertConsultationon AppropriateBodyMassIndexforAsianPopulationsandItsImplicationsforPolicyand InterventionStrategies(WHO,2004). Thekeyissueiswhethertherearesystematicdifferencesintheextenttowhichagiven waistcircumferenceorwaisthipratiolevelpredictsdiseaseoutcomesindifferentethnic groups,particularlyifsuchdifferencescouldleadtounderestimationofriskincertain populations.Systematicdifferencescouldrelatetooneorbothofthefollowing: differencesinbodycompositionthatis,therelativeamountsortypesoffatreflected inthewaistcircumferenceorwaisthipratiomeasurement; differencesindiseaseriskforaparticularbodyfatprofile.

Alsoofinterestwerevariationsinbodyfatdistributionthatmayaffectallpopulations;for example,variationsbetweenmenandwomen,andwithageing.Thischaptersummarizes theissuesrelatedtosex,ageandethnicvariations.Moredetaileddiscussionswere providedinthebackgroundpaperthatexaminedassociationsbetweensex,reproductive statusandage,andwaistcircumference(Stevens,etal.,2010);andthepaperthat examinedassociationsbetweenethnicityandwaistcircumference(Lear,etal.,2010).

3.1

Sex
Sexdifferencesindepositionofbodyfatareevidentevenatthefoetalstage,butthey becomemuchmorepronouncedduringpuberty(Wells,2007).Afteradjustingfor differencesinheight,menhavegreatertotalleanmassandbonemineralmass,andalower fatmassthanwomen;thesedifferencescontinuethroughoutadultlife. Womenhave substantiallymoretotaladiposetissuethanmen,andthesewholebodysexdifferencesare complementedbymajordifferencesintissuedistribution. Menhavegreaterarmmuscle mass,largerandstrongerbones,lesslimbfatandarelativelygreatercentraldistributionof fat.Womenhaveamoreperipheraldistributionoffatinearlyadulthood.Sexdifferencesin bodycompositionareprimarilyattributabletotheactionofsexsteroidhormones,which drivethedimorphismsduringpubertaldevelopment.Inmen,areductioninfree testosteronelevelsisassociatedwithanincreaseinfatmassandreductioninmusclemass, andbothtotalandfreetestosteronelevelsareinverselyassociatedwithobesity(Derbyet al.,2006).

3.2

Reproductive status
Parityisanimportantcontributortochangesinbodycompositionandbodyshapein women.Pregnancyisassociatedwithgainsinvisceralandcentraladipositypostpartum. CrosssectionalanalysisofdatafromNHANESIIIillustratedhowparityisassociatedwith changesinbodyshape(Lassek&Gaulin,2006).Datafrom16325womenshowedthat womenwhohadgivenbirthhadlesslowerbodyfatandgreaterwaistcircumference.After

controllingforageandBMI,increasingparitywasassociatedwithlowerhipandthigh circumferences,andhigher waistcircumference.Thesefindingsaresupportedbydataover 10yearsoffollowupfromtheCoronaryArteryRiskDevelopmentinYoungAdults(CARDIA) studyofwomenaged1830years(Gundersonetal.,2004).Bothfirstandhigherorder birthswereassociatedwithincreasesinwaistcircumference. Menopauseisalsoassociatedwithanincreaseinfatmass,andaredistributionoffattothe abdominalarea(Tothetal.,2000).Itisnotclearwhethersuchchangesaredueto hormonalchangesortotheageingprocess.TheStudyofWomensHealthAcrossthe Nation(SWAN)includedanethnicallydiversecohortof3064women,withanaverageage of45.9years.SWANshowednoindependenteffectofmenopauseonfatdistribution (Sternfeldetal.,2004).Overa3yearfollowup,thestudyshowedameanweightgainof 2.1 kg(3%increase)andameanincreaseinwaistcircumferenceof2.2 cm(2.8%increase); gainsthatcouldbeattributedtoageandphysicalactivitylevel.Otherstudiesconcurred withSWAN,suggestingthat,onaverage,womenexperiencea0.68 kgperyearincreasein weightduringtheir40sand50s,regardlessofmenopausalstatus(Macdonaldetal.,2003; Wingetal.,1991).

3.3

Age
Toappreciatetheeffectofageingonfatdistribution,changesinBMIthatoccurwith increasingageneedtobeconsidered.ChangesinbodyweightandBMIarestronglyrelated tochangesinfatfreemass,andexplain54%ofthevarianceinthosechanges(Forbes, 1999).WhiletheassociationsbetweenBMIandbodyfatarelinear,theassociationwithper centbodyfatiscurvilinear,withtheslopesteeperatlowerBMIsthanathigherBMIs (Welch&Sowers,2000).Percentbodyfatmayremainconstantorincreasewithage,but ageingisassociatedwithsubstantialredistributionoffattissueamongdepots(Cartwright etal.,2007).Fromlatemiddleageuntilthe80sorlater,thereisadeclineinthevolumeof subcutaneousfat,andaredistributionoffatfromsubcutaneoustovisceraldepots.This ageassociateddeclineinthesizeofadiposedepotsisaccompaniedbytheaccumulationof fatoutsideadiposetissue(inmuscle,liverandbonemarrow),andlossofleanbodymass. DatafromNHANESshowthatwaistcircumferenceincreaseswithage,andislargerinolder thaninyoungeradultsofbothsexesuptotheageof70years(Fordetal.,2003).Similarly, intheBaltimoreLongitudinalStudyofAging,agerelateddifferencesinwaisthipratiowere alsoreportedinallBMIcategoriesexaminedinbothmenandwomen(Shimokataetal., 1989).ChangesinwaistcircumferencewerefollowedupinFinnishadults(9025menand 9950womenaged2564years),andmeanwaistcircumferencewasseentoincreaseby 2.7 cminmenand4.3 cminwomenovera15yearperiod(LahtiKoskietal.,2007).BMI alsoincreasedoverthestudyperiod,butthechangeswererelativelysmall(1.2%orlessper 5yearperiod)inallbuttheyoungestagecategory(2534years),whileincreasesinwaist circumferencewereseenineveryagegroup. TheBaltimoreLongitudinalStudyofAgingalsoexaminedtheeffectsofweightchangeon changesinfatdistribution(Shimokata,etal.,1989).Thestudyfoundthatchangesinwaist andhipcircumferencescorrelateddirectlywithchangesinweight,buttherewere differencesinthepatternofchangebysex. Inmen,waistchangeswerelargerthanhip changes,whereasinwomentheyweresimilar.Thisresultedinweightchangesinmen havingalargereffectonwaisthipratio.Onaverage,witha4.5kgweightgain,menhada 4 cmincreaseinwaistcircumferenceanda2.5 cmincreaseinhipcircumference. Comparablevaluesforwomenwere3.3cmand3.6cm,respectively.

3.4

Ethnicity
Interpretationofevidenceonethnicdifferencesiscomplicatedbyissuesrelatedtodefining ethnicity,andothermethodologicalissuesthatareoutlinedinthebackgroundpaper preparedbyLearetal.(2010).Thebackgroundreviewonlyconsideredstudieson populationsthatwerenotrepresentedinearlieranalysesandthatledtorecommendations aboutwaistcircumferenceorwaisthipratiocutoffsinEuropeans.Thepotential significanceofthesedifferencesforidentifyingcutoffpointstopredicthealthoutcomesis consideredinChapter4.

3.4.1

Ethnic groups for which waist circumference or waisthip ratio may reflect more body fat at a given body mass index level StudiesinvestigatingbodycompositionandtheassociationwithhealthoutcomesinAsian populationshavefocusedonstudypopulationsdefinedasChinese,JapaneseandKoreanor SouthAsian(orIndian).However,anumberofstudieshaveanalysedtheseethnicgroupsas ahomogeneouspopulationlabelledasAsians.Thesestudiesfoundahigherpercentageof bodyfatinAsiansatlowerBMI(DeurenbergYapetal.,2001;DeurenbergYapetal.,2000), aswellasanincreasedprevalenceoftruncalfat,comparedtoCaucasians(Wuetal.,2007).

3.4.2

Populations for which waist circumference or waisthip ratio may reflect less body fat at a given body mass index level ChineseandSouthAsianmenandwomendisplayagreateramountofvisceraladipose tissueforagivenwaistcircumferencethanEuropeans(Learetal.,2007b).Similarly,a higherpercentageofbodyfatacrossarangeofwaistcircumferencevalueshasbeen documentedinEastAsia(Kagawaetal.,2007). InNorthAmerica,comparisonsofIndigenouspeopleandCaucasianshavereportedno differenceintherelationshipsbetweenvisceraladiposetissueandBMI(Gautieretal., 1999),totalbodyfat(Lear,etal.,2007b)orwaistcircumference(Learetal.,2007a). AustralianAboriginalslivinginaremoteareawerereportedtohavehigherwaisthipratios withlowerBMIsthanurbanAustraliansofEuropeanorigin(Piersetal.,2003). ComparedtoEuropeanwomen,blackwomeninSouthAfricahaveaslightlylowerBMIata givenpercentagebodyfat,butalsohavelessabdominaladiposetissueasdeterminedby dualXrayabsorptiometry(DEXA)atthesamewaistcircumference(Rushetal.,2007).A fewsmallstudiesreportAfricanwomenashavinglessvisceraladiposetissuethanwhite women(Punyadeeraetal.,2001a;Punyadeeraetal.,2001b;vanderMerweetal.,2000). InHispanics,onestudyreportedthatvisceraladiposetissueatagivenwaistcircumference wasnotappreciablydifferentfromthatofwhites(Carrolletal.,2008;Haffneretal.,1996; Nelsonetal.,2008). SomestudieshavereportedthatPacificIslandershavelargermusclemassesandlower percentagebodyfatthanEuropeansatsimilarBMIs(Rushetal.,2004;Rushetal.,2009).In women,thishasalsobeenreportedforsimilarwaistcircumferencesandwaisthipratios (Rush,etal.,2007).

3.5

Summary and conclusions

Thereissubstantialevidenceofsexandagevariationsinwaistcircumferenceandwaisthip ratio,andsomeevidenceforethnicdifferences.ComparedtoEuropeans,Asianpopulations havegreatervisceraladiposetissue,andAfricanpopulationsand,possibly,PacificIslanders

10

havelessvisceraladiposetissueorpercentageofbodyfatatanygivenwaistcircumference. Ifhigherlevelsofabdominalfatforawaistcircumferenceorwaisthipratiolevelare reflectedinassociationswithhealthoutcomes,thenlowerthresholdsfortheseindicators mightbeneededfortheaffectedpopulationsthanforEuropeanorotherreference populations.ThereisrelativelyconsistentevidencethatthissituationmayapplytoAsian populations. DataforAfricansandPacificIslandersareexamplesofpossibleindicationsfor aneedforhighercutoffsthanthoseusedforEuropeanreferencepopulations.However, giventhattheobjectiveistopredictdiseaserisk,drawingconclusionsaboutcutoffssolely onthebasisofobservedrisksdoesnotseemappropriate.

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R e l a t i o n s h i ps o f w a i s t c i r c u m f e r e n c e and waisthip ratio to disease risk and m o r ta l i t y

Bothgeneralizedandabdominalobesityareassociatedwithincreasedriskofmorbidityand mortality.ThemaincauseofobesityrelateddeathsisCVD,forwhichabdominalobesityisa predisposingfactor.Itisunclearwhichanthropometricmeasureisthemostimportant predictorofriskofCVDinadultsBMI,waistcircumference,waisthipratioorevenhip circumference. BMIhastraditionallybeenthechosenindicatorbywhichtomeasurebodysizeand composition,andtodiagnoseunderweightandoverweight.However,alternativemeasures thatreflectabdominaladiposity,suchaswaistcircumference,waisthipratioandwaist heightratio,havebeensuggestedasbeingsuperiortoBMIinpredictingCVDrisk.Thisis basedlargelyontherationalethatincreasedvisceraladiposetissueisassociatedwitha rangeofmetabolicabnormalities,includingdecreasedglucosetolerance,reducedinsulin sensitivityandadverselipidprofiles,whichareriskfactorsfortype2diabetesandCVD. Thischaptersummarizestheexpertsdiscussionsonthestrengthofassociationsbetween anthropometricmeasuresandhealthoutcomes.Moredetailedreviewsareprovidedin severalofthebackgroundpapers(Huxley,etal.,2010;Qiao&Nyamdorj,2010a;Qiao& Nyamdorj,2010b;Seidell,2010). Onepaperexaminedhowwaistcircumference,waisthipratioandBMIperformin predictinganddifferentiatingrisksofhypertension,dyslipidaemiaanddiabetes(asmajor riskfactorsforCVD),andrisksofCVDevents(Huxley,etal.,2010).Theauthorsreviewed datacomparingAsianandPacificwithCaucasianpopulations,anddataonotherethnically diversestudypopulations.Otherstudiesexaminedtherelativeassociationsofwaist circumference,waisthipratioandBMIwithdiabetesrisk(Qiao&Nyamdorj,2010a;Qiao& Nyamdorj,2010b).Seidell(2010)revieweddataonallcausemortality,cancerandsleep apnoeainassociationwithwaistcircumference,waisthipratioandBMI,highlighting variationsinfindingsaccordingtochoiceofindicator,ageandBMIstatusofthepopulation.

4.1

Measures of obesity and abdominal obesity and cardiovascular disease risk

Basedonanextensivereview,Huxleyetal.(2010)concludedthattherewasconvincing evidencethatmeasuresofgeneralobesity(e.g.BMI)andmeasuresofabdominaladiposity (e.g.waistcircumference,waisthipratioandwaistheightratio)areassociatedwithCVD riskfactorsandincidentCVDevents.Theauthorsalsoconcludedthattherewasprobable evidencethat: measuresofabdominalobesityarebetterthanBMIaspredictorsofCVDrisk,although combiningBMIwiththesemeasuresmayimprovetheirdiscriminatorycapability; foranygivenlevelofBMI,waistcircumferenceorwaisthipratio,theabsoluteriskof diabetesorhypertension(riskfactorsforCVDincidence)ishigherinsomepopulation groupsthaninCaucasianadults; universalcutoffpointsforBMIandwaistcircumferencearenotappropriateforuse worldwide,givenethnicorpopulationspecificdifferencesindiseaseriskforany

12

particularanthropometricmeasure;however,theremaybegeneralconsistencyinthe cutoffpointsofwaisthipratioforpredictingCVDrisk.

4.2

Measures of obesity, abdominal obesity and type 2 diabetes risk

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

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4.3

Measures of obesity and abdominal obesity and all-cause mortality and mortality from specific causes
Duetoinconsistenciesintheliterature,controversycontinuesabouttherelationship betweenobesityandoverallmortality(WHO,2000a).SomestudieshavefoundaUorJ shapedassociation,withhighermortalityratesatboththeupperandlowerweightranges. Othershaveshownagradualandcontinuousincreaseinmortalitywithincreasingbody weight,ornoassociationatallbetweenbodyweightandmortality.Manyofthestudieson obesityandmortalityhavesystemicallyunderestimatedtheimpactofobesityon prematuremortality,duetobiasinthestudydesign.Thisbiasmaybetheresultoffailure tocontrolforsmoking,inappropriatecontrolforassociatedconditions(e.g.hypertension, dyslipidaemiaandhyperglycaemia,whichareessentiallycomorbiditiesofobesity),failure tocontrolforweightlosswithillnessandfailuretostandardizeforage(Mansonetal., 1987;Seidelletal.,1996). Seidell(2010)concludedthat: waistcircumferenceandwaisthipratioarebothrelatedtoincreasedriskofallcause mortality,throughouttherangeofadultBMIs; waistcircumferenceandwaisthipratioarestronglypredictiveinyoungandmiddle agedadultscomparedtoolderpeopleandthosewithlowBMI; waistcircumferencealonecouldreplacewaisthipratioandBMIasasingleriskfactor forallcausemortality.

However,dataarelackingonappropriatecutoffsformeasuresofabdominalobesityfor predictingriskofallcausemortalityinethnicandpopulationgroupsotherthanEuropean, NorthAmericanandAustralianwhitepopulations.Evidenceforuseofwaistcircumference orwaisthipratiotoreplaceBMIforpredictingmorbidityrelatedtocancerriskisless strongthanforallcausemortality.

4.4

Ethnic differences
Numerousstudiesofpopulationsthroughouttheworldhavesuggestedusingcutoffpoints specific toethnicgroups.Thissectionhighlightsstudiesthathaveevaluated(directlyor indirectly)thepotentialbasisforwaistcircumferenceorwaisthipratiocutoffpointsthat differfromthoseproposedforgeneraluseandarebasedonEuropeanorCaucasian referencepopulations. WhenstudiesinAsianpopulationsaretakentogether,Asiansappeartohaveanincreased metabolicriskatlowerwaistcircumferenceandwaisthipratiothanEuropeans.Thisis probablyduetohigherlevelsofbodyfatandabdominaladiposetissue. Inparticular,those studiesthatincludedaEuropeanorCaucasiancomparisongroupindicatedalowerwaist circumferenceforAsians,andsomealsosuggestedalowerwaisthipratio(Diazetal., 2007;Huxleyetal.,2007;2008).Thesedataindicatealowerwaistcircumferenceand waisthipratiocutoffpointforAsians;forexample,waistcircumferencevaluesof85cm and80cm,andwaisthipratiovaluesof0.90and0.80formenandwomen,respectively. StudiesinpopulationsresidingintheMiddleEasthaveprovidedwaistcircumferenceand waisthipratiocutoffpointssimilartothosesuggestedforEuropeans.Onlyoneanalysis reportedonwaistcircumferencecutoffpointsinAfricans(noneinvestigatedwaisthip ratiocutoffpoints).Thatanalysisrecommended75.6cmand80.5cmformen,and71.5cm and81.5cmforwomenofNigerianandCameroonorigin,respectively,fortheidentification ofhypertension(Okosunetal.,2000a;Okosunetal.,2000b).Giventhatnootherstudies

14

haveinvestigatedcutoffsinthispopulationgroup,thereisinsufficientevidencefor recommendingspecificcutoffsforsubSaharanAfricans. Cutoffpointsforwaistcircumferenceof94cmand80cm(determinedforEuropeanmen andwomen,respectively)havebeenassociatedwitha1.52.0foldincreasedriskin hypertension,anda3.9and1.6foldincreaseindiabetes,inmenandwomenofAfrican origin,respectively(Okosunetal.,1998).FindingsthatAfricanAmericanstendtobeleaner thanEuropeansareinconsistentwiththedataindicatingthatAfricanAmericansareat increasedriskforCVDatagivenwaistcircumference(duetohigherbloodpressureand lipids).StudiesinvestigatingspecificcutoffpointsforAfricanAmericanseithersuggested similarcutoffpointstothoseusedforEuropeans,basedonthelimitedevidenceavailable, orindicatedthattherewasnotenoughevidencetosetspecificcutoffpointsforAfrican Americans. StudiesinvestigatingSouthAmericansrecommendedwaistcircumferencecutoffpointsof 8890cmformen,and8384cmforwomen(Lear,etal.,2010).Threestudiesreportingon waisthipratioindicatedavaluerangingfrom0.85to0.95inmen,andfrom0.80to1.18in women.Thesestudiessuggestedthatwaistcircumferencecutoffpointsshouldbelower thanthoseforEuropeans,butthatwaisthipratiocutoffpointsshouldbesimilartothose forEuropeans. OnlyonestudyinHispanicsprovidedarecommendationforcutoffpoints;it suggestedawaistcircumferenceof90cmformenand85cmforwomen,andawaisthip ratioof0.900.91formenand0.840.86forwomen(Berberetal.,2001).Anotherstudy suggestedthatthecurrentwaistcircumferencecutoffpointsbasedonEuropeansprovided lowsensitivitywithrespecttometabolicriskfactorsfortheHispanicpopulation(Okosun,et al.,2000a).

4.5

Summary and conclusions

Theoverallresultsoftheevaluationoftheassociationsbetweenwaistcircumferenceand waisthipratiowithmeasuresofmetabolicdiseasesandriskfactorsaresummarizedin Table4.1,andpresentedbelow.

4.5.1

Cardiovascular disease ThebiologicalrationaleforrelatingmeasuresofcentraladipositytoCVDriskisthat abdominaladiposetissue(whichispositivelyassociatedwithwaistcircumferenceand waisthipratio)isrelatedtoarangeofmetabolicabnormalities.Theseabnormalities includedecreasedglucosetolerance,reducedinsulinsensitivityandadverselipidprofiles, whichareriskfactorsfortype2diabetesandCVD.Mostanthropometricindicatorsof abdominalobesityhavebeenderivedfrompredominantlyEuropeanpopulations.Thishas raisedissuesabouttheapplicabilityoftherecommendedcutoffpointstononEuropean populations,amongwhomtheproblemiscurrentlyofmuchgreaterconcern.Neitheris thereconsensusoverwhichofthesemeasuresofcentraladiposityismoststrongly associatedwithCVDrisk,eitherwithinorbetweendifferentethnicgroups. Ithasbeensuggestedthatwaistcircumference,waisthipratioandwaistheightratio, whichreflectabdominaladiposity,aresuperiortoBMIinpredictingCVDrisk.Forexample, intheINTERHEARTcasecontrolstudyofmyocardialinfarctionindiversepopulationsin52 countries(Yusufetal.,2005),BMI,waistcircumferenceandwaisthipratiowereall stronglyandlinearlyassociatedwithriskofmyocardialinfarction.RelationshipswithBMI wereattenuatedbyadjustmentforwaisthipratio,butrelationshipswithwaistmeasures wererelativelyunaffectedbyadjustmentforBMI,indicatingtheindependenceofmeasures

15

ofabdominalobesityinpredictingrisk.However,a combinedanalysisofthePhysicians HealthStudyandtheWomensHealthStudyfoundthat(Gelberetal.,2008): themagnitudeofassociationsofBMI,waistcircumference,waisthipratioandwaist heightratiowithCVDriskweresimilar; thesemeasureswerenotentirelyindependentaspredictorsofrisk; differencesaccordingtothemeasureusedwerenotlikelytobeclinicallysignificant.

IntheAsiaPacificCohortStudy,noneoftheanthropometricindiceswereclearlyassociated withstrokeoutcomes(APCSC,2006).Overall,thesemeasuresseemtobecomparablein theirdiscriminatorycapabilityasassessedbytheareaunderthereceiveroperating characteristiccurve(AUC)atidentifyingthoseindividualswiththehighestriskofCVD (Huxley,etal.,2010). 4.5.2 Diabetes Datafromprospectivestudiesshowawiderangeofrelationshipsbetweenanthropometric measuresandriskoftype2diabetes;hence,itwouldbedifficulttoconcludethatmeasures ofabdominalobesityarealwayssuperiortoBMIinpredictingrisk.However,mostofthe crosssectionalstudiesshowedthattheAUCwasslightlylargerforwaistcircumferenceor waisthipratiothanforBMI. 4.5.3 Risk factors Thisreviewsuggeststhat,atanygivenlevelofbodysize,theprevalenceofhypertension, diabetesanddyslipidaemiaishigherinAsianthaninnonAsianpopulations.Italsosuggests thatnoanthropometricmeasureismorestronglyassociatedwithbloodpressure,plasma glucose,diabetesandlipidlevelsthananyothermeasure.However,BMIappearstobeless informativethanothermeasures. 4.5.4 Mortality Theevidencewithregardtoanthropometricmeasuresinparticularwaistcircumference orwaisthipratiomeasuresandallcausemortalityispredominantlyfromwhite EuropeanandAmericanadults,bothinyoungandmiddleagedadultsandolderpeople. FewstudieshaveexaminedAfricanandAsianpopulations.Whenwaistcircumferencewas adjustedforBMI,therelationshipappearsJshapedtoalmostlinear. 4.5.5 Ethnic differences Overall,thedatasuggestedthat,foragivencombinationofBMIandwaistcircumferenceor waisthipratiomeasures,theriskishigherforAsiansforalldiseaseoutcomes;however,it wasnotpossibletodrawdefinitiveconclusions,duetolimitationsofthedata.Onlyin populationsofAsiandescentweredifferencesinrisksufficienttowarrantconsiderationof alternativecutoffpoints.Themultiplecausalityandimpactofthenutritiontransitionmay alsocontributetotheinterpretationofapparentethnicdifferences.Specifically,theimpact ofexposuretoundernutrition(includinggestationalexposuretomaternalundernutrition) onsubsequentweightgainandfatdepositionwasnotedasapossiblefactorcontributingto differencesamongpopulations.Arisingrelativeriskofdiseasealongthecontinuumof waistcircumferenceorwaisthipratiowasalsoevident.However,theabsoluterisk currentlydeterminedbythemultipleriskfactorsassociatedwithbodyfatandits distributionmaywellreflectthephaseofdiseasetransitioninapopulation.Hence,the thresholdsforriskassociatedwithwaistcircumferenceorwaisthipratiomayvarywith

16

time.Theseconsiderationsmakeitdifficulttospecifycutoffpointsonthebasisof ethnicity. Table 4.1 Summary of the associations of body mass index, waist circumference, waisthip ratio and waistheight ratio with disease risk
Waist circumference Relationship Strength of evidencea Waisthip ratio Relationship Strength of evidencea Waistheight ratio Relationship Strength of evidencea Remarks and major references

Body mass index Relationship Strength of evidencea

CVD risk

++

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

Overall CVD risk factors (mainly crosssectional data) CVD risk factors (from STEPS analysis presented in the WHO meeting) Type 2 diabetes mellitus (prospective studies) Type 2 diabetes mellitus (cross-sectional studies) Hypertension (mainly crosssectional data)

++

Convincing +++

Convincing +++

Convincing +++

Convincing de Koning et al. (2007) APCSC (2006) Yusuf et al. (2005) Gelber et al. (2008) Zhu et al. (2005) Convincing Lee et al. (2008)b

+++

Probable +++

Probable

WHO (2008b)

+++

Convincing +++

Convincing +++

Convincing /

Vazquez et al. (2007)

+++

+++

Overall mortality +++ (without mutual adjustment of the anthropometric parameters)

Overall mortality 0/ (with mutual adjustment of the

Convincing ++++ Convincing ++++ Convincing ++++ Convincing Huxley et al. (2007) Huxley et al. (2008) Nyamdorj et al. (2008)b Qiao & Nyamdorj (2010b) Convincing +++ Convincing +++ Convincing +++ Convincing Wolf & Colditz (1998) James et al. (2004) Huxley et al. (2007) Huxley et al. (2008) Nyamdorj et al. (2008)b Convincing +++ Convincing +++ Convincing +++ Convincing Koster et al. (2008) Zhang et al. (2008) Welborn & Dhaliwal (2007)b Remarks: Some studies showed Jshape relationship with BMI, especially elderly people (Dolan et al., 2007; Katzmarzyk et al., 2002) Evidence is less consistent in elderly people (Baik et al., 2000; Price et al., 2006) Probable ++++ Convincing ++++ Convincing / / Kalmijn et al. (1999) Pischon et al. (2008)

17

Body mass index Relationship Strength of evidencea

Waist circumference Relationship Strength of evidencea

Waisthip ratio Relationship Strength of evidencea

Waistheight ratio Relationship Strength of evidencea

Remarks and major references

anthropometric parameters) Cancer +++ colorectum, breast (post-menopause) + Cancer pancreas, endometrium, cervix, kidney, gallbladder Convincing ++ Convincing ++ Convincing NR NR

Bigaard et al. (2003) Moghaddam et al. (2007) Harvie et al. (2003) AICR (2007)

Possible

Possible

Possible

NR

NR

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

18

Summary and conclusions

TheaimoftheexpertconsultationwastoprovideguidancethatWHOcouldusetodevelop recommendationsandultimatelyprovideguidelinesfortheeffectiveuseofspecificcutoff pointsforwaistcircumferenceandwaisthipratio.Makingdefinitivedecisionsonactual cutoffpointswasoutsidethescopeoftheconsultation.However,theexpertconsultation wasaskedtoadviseWHOonhowtheprocessofdevelopingactualcutoffpointscouldbe movedforward,andtoidentifyanygapsinthedata. Thischaptersummarizesthepotentialusefulnessandrelativeadvantagesof: waistcircumferenceversuswaisthipratio,withorwithoutaccompanyingBMI measurements; measurementprotocolsforwaistcircumferenceandwaisthipratio; methodsforselectingcutoffpoints; considerationsfordeterminingtheneedforpopulationspecificcutoffpoints.

5.1

Usefulness of waist circumference and waisthip ratio for prediction of disease risk
Thefundamentalquestionofwhetherwaistcircumferenceandwaisthipratioareuseful measuresforpredictingdiseaseriskwasansweredwithconvincingevidence.Anincreasein bothoftheseindicesisassociatedwithincreaseddiseaserisk,andthisassociationis evidentindiversepopulations,althoughmostofthedatawerederivedfrompopulationsof Europeandescent.Waistcircumferenceandwaisthipratio (asmeasuresofabdominal obesity)werecorrelatedwithBMI,butthelevelofassociationvaried,suggestingthatthese measuresmayprovidedifferentinformationandthusmaynotbeinterchangeable.Practical considerationsappearedtofavourtheuseofwaistcircumferenceasanalternativetoBMI. Forexample,waistcircumferencemaybejustifiedwhenmeasuringthewaistiseasierand moreaccuratethanmeasuringweightandheight.Measuringhipcircumferencemaybe moredifficultthanmeasuringwaistcircumferencealone;thiscouldlimitthepotentialuse ofwaisthipratioasanalternativetoeitherwaistcircumferencealoneorBMI. InassessingthecomplementarityofBMIandwaistmeasures,themainissuewaswhether therewasasubstantialgainininformationwhenusingbothmeasures,assuggestedinthe NIHPracticalguidetoobesity(Table5.1)andtheInternationalDiabetesFederation(IDF) guidelines(Table5.2).Thisalsoraisedsomemoregeneralissues: theextenttowhichtherangeofwaistcircumferencedependsonbodysize; whetherdifferencesinthewaistcircumferencedistributioninpopulationswith differentbodysizesmaycreateproblemsinarrivingatappropriatecutoffpointsthat wouldbesimilarlysensitivetohealthriskinallpopulations(e.g.theNIHPracticalguide toobesitysuggeststhatwaistcircumferencecutoffsareonlyusefuluptoaBMIof35, afterwhichmostindividualswillexceedthecutoffpoints).

Duetotherelativeeaseofobtainingwaistcircumference,itsuseisfavouredoverwaisthip ratio.Therewasinsufficientdataonotherproxymeasures(e.g.waistheightratio),to suggestgivingothermeasuresanypriorityatpresent. AlthoughBMIandabdominal adipositymeasuresmaybehighlycorrelated,itisdesirabletoobtainaBMI,wherepossible, andconsidertheutilityofjointuseofthetwoindicators.

19

Table 5.1

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 Normal Overweight Obesity Extreme obesity

<18.5 18.524.9 25.029.9 30.034.9 35.039.9 >40.0

I II III

Increased High Very high Extremely high

High Very high Very high Extremely high

Source: NHLBI Obesity Education Initiative (2000)

Table 5.2

International Diabetes Federation criteria for ethnic or country-specific values for waist circumference
Sex Men Women Men Women Men Women Men Women Waist circumference (cm) >94 >80 >90 >80 >90 >80 >90 >80

Country or ethnic group Europid South Asian Chinese Japanese

Source: Adapted from Zimmet & Alberti (2006)

5.2

Measurement protocol
Itwasrelativelystraightforwardtodeterminetherecommendedprotocolforthe standardizedmeasurementofwaistcircumferenceandhipcircumference,andforthe assessmentofabdominalobesity.Therearemanypotentialpointsofvariationinhowthese measurementscanbetaken,andmanypotentialsourcesofmeasurementerroramongand withinmeasurers.Nevertheless,theconsultationagreedthatthemeasurementprotocol previouslyapprovedbyWHOshouldberecommended.Thisprotocolisinextensiveuseby STEPS,andhasbeenfeaturedinseveralpreviousWHOexpertmeetingreports(WHO,1995; WHO,2000a;WHO/FAO,2003). Thisprotocolcanbesummarizedasoutlinedbelow. Measurethewaistcircumferenceattheendofseveralconsecutivenaturalbreaths,at alevelparalleltothefloor,midpointbetweenthetopoftheiliaccrestandthelower marginofthelastpalpableribinthemidaxillaryline. Measurethehipcircumferenceatalevelparalleltothefloor,atthelargest circumferenceofthebuttocks. Makebothmeasurementswithastretchresistanttapethatiswrappedsnuglyaround thesubject,butnottothepointthatthetapeisconstricting.Keepthetapeleveland paralleltotheflooratthepointofmeasurement.

20

Ensurethatthesubjectisstandinguprightduringthemeasurement,witharmsrelaxed attheside,feetevenlyspreadapartandbodyweightevenlydistributed.

5.3

Selecting cut-off points

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

21

cutoffpointsbasedondifferencesinpopulationcharacteristics(e.g.averagebodysize ordiseaseprevalence). Allthesequestionsneedtobecarefullyconsideredwhendeterminingthemethodand processusedtoderivecutoffpointsforwaistcircumferenceandwaisthipratiofor recommendationbyWHO. Thechoiceofmethodandtheprocesstobeoutlinedwillalso dependonthepotentialusesofthederivedcutoffpointsandhealthrelevantpolicy considerations.Forexample,specificproblemsofthepopulationgroupforwhichthecut offpointsaretobeused shouldbetakenintoaccount.

5.4

Universal or population-specific cut-off points

Theissueofsexspecificcutoffpointswasnotdeliberatedassuch,buttheconsultation notedthatmanycountriesorsettingscurrentlyspecifydifferentcutoffpointsformenand women(seeAnnexA).Theexpertsdidnotidentifyevidencefordiscontinuingtheuseof sexspecificcutoffpoints. Withrespecttoethnicityspecificcutoffpoints,therewassubstantialevidenceof populationdependentvariationsinassociationofdiseaseriskwithmeasuresofabdominal obesity.However,otherevidencediscouragedthedevelopmentanduseofethnicallybased cutoffpoints.ThepopulationsofgreatestinterestinthisrespectareofAsiandescent, becauserisksofcertaindiseases(e.g.diabetes)arenotablyhigherinthesepopulationsthan wouldbeexpectedfromtheirmeanBMIlevels.Understandingthebasisforthisincreased riskofdiabetesamongAsianpopulations,forinstance,wouldbeimportanttoidentifythe potentialenvironmentalvariationsandtheheterogeneityamongpopulationsdesignatedas Asian. Theconsultationidentifiedtheneedforatransparentandmethodologicallysound empiricalapproachtodevelopingpopulationorgeographyspecificcutoffpointsfor abdominalobesity.Atthesametime,theexpertsrecognizedtheutilityofthecurrent recommendedcutoffpoints,whicharesimpleanduniversallyapplicable.Thebackground paperbyLearandcolleagues(2010)providedexamplesofhowitmightbepossibletoset cutoffpointsthataregenerallyapplicable,butalsorecognizethedifferencesinriskamong populations.However,thereweretoomanyunresolvedissuesfortheconsultationto determinewhetherthisprocesswouldbeuseful. Theconsultationidentifiedmanychallengesrelatedtotheuseofsurrogatemeasuresof abdominalobesityforthederivationofuniversallyapplicablecutoffpointsforhealth outcomes.Forexample,thereareinherentchallengesrelatedtodeterminationofhealth outcomes,includingsexdifferences;agerelatedchangesinbodycompositionand conformation;andgroup,populationandgeographicaldifferences.Someofthese confoundersneedtobeevaluatedmorecarefully,asoutlinedbelow: Inindividualsofthesamesexandageanywhereintheworld,isthesamelevel, proportionorquantityof:

totalfatoradiposetissuepresentforagivenBMI? intraabdominalorvisceraladiposetissuepresentforagivenwaistcircumference orwaisthipratio?

Inindividualsofthesamesexandageanywhereintheworld,istheriskofdiseaseand mortalitythesameforagivenBMI(i.e.levelofobesity),orwaistcircumferenceor waisthipratio(i.e.levelofabdominalobesity)?

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Istherelationshipbetweenadiposityandtheproxymeasure,andtheassociationwitha givenhealthrisk,thesameforbothsexes? Istherelationshipbetweenadiposityandtheproxymeasure,andtheassociationwitha givenhealthrisk,affectedbyincreasingageforbothsexes?

Addressingtheseissueswillbeamajorchallenge.Itisclearfromthedatareviewedatthis expertconsultationandfrompreviousWHOpublicationsthatthecurrentevidencebase cannotanswerthesequestions.Furtherstudiesareneededtodeterminewhether recommendedcutoffpointsshouldbespecifictosex,ageandpopulation.

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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.

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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.

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analysisofalltheissuesraisedintheconsultation.UltimaterecommendationsfromWHO needtotakeintoconsideration: thevariouswaistcircumferenceandwaisthipratiocriteriathatarealreadyinuseby nationalgovernments,andbynationalandinternationalmedicalorganizations; thepotentialpolicyandpracticalimplicationsassociatedwithanyattemptstoalign diversecutoffs.

Ontheotherhand,timelyandauthoritativeguidanceisneededtoensurethatmeasures thatcanguideappropriatepublichealthandclinicalactionsontheproblemsrelatedto NCDsarebroughtintofulluseasquicklyaspossible.NCDsarerapidlyincreasingworldwide, particularlyinlowandmiddleincomecountries.

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Annex A: Current uses of waist circumferences and waisthip ratios, a n d r e c o m m e n d e d c u t - o f f p o i n ts

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

Indicator Waist circumference Waist circumference Waisthip ratio

M, men; W, women

International Diabetes Federation TheInternationalDiabetesFederation(IDF)hasalsoprovidedrecommendationsforcutoffs forwaistcircumferenceandwaisthipratio(IDF,2006;Zimmet&Alberti,2006).The recommendationsofIDFforwaistcircumferencearenotonlysexspecific,butarealso population andgeographyspecific.ValuesareshowninTableA2.

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Table A2

International Diabetes Federation cut-off points for different ethnic groups

Men >94 cm >90 cm Women >80 cm >80 cm

Europids South Asians, Chinese and Japanese

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

A2

Rationale for selection of cut-off points

Themostcommonapproachtodeterminingcutoffpointsisbasedontheuseofsensitivity andspecificityasinterpretedfromreceiveroperatingcharacteristic(ROC)curves. Sensitivitymeasurestheproportionofactualpositivescorrectlyidentifiedassuch,and specificitymeasurestheproportionofactualnegativescorrectlyidentifiedassuch. Inanytest,thereisusuallyatradeoffbetweenoptimizingsensitivityandoptimizing specificity.ThiscanberepresentedgraphicallyusingaROCcurve(seeFigureA1)(WHO, 2003),whichisaplotofthetruepositiverate(TPR,orsensitivity)againstthefalsepositive rate(FPR,or1specificity). Usefulcutoffpointsarethosethatprovideforahigh proportionoftruepositiveswhilegivingalowproportionoffalsepositives.AROCcurveis alsoknownasarelativeoperatingcharacteristiccurve,becauseitcomparestwo

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operatingcharacteristics(TPRandFPR)asthecriterionchanges.Thus,ROCisdirectly relatedtodiagnosticdecisionmaking. TherearelimitationstousingaROCapproachforchoosingasinglecutoffpoint (e.g.to designateahighwaistcircumference),particularlyiftheintentistochooseasinglecut offpointthatisapplicableacrossdifferencepopulationsandsurveyconditions.TheROC approachshouldtakeintoaccountthevalidity,reliabilityandreproducibilityofthetestor criterionmeasure(e.g.thewaistmeasurement),andtheprevalenceoftheconditionof interest(e.g.highbloodpressureordiabetes)inthepopulationtobescreened. Population prevalenceisimportantbecausethepredictivevalue(e.g.theprobabilityofhavinga diseasegivenapositivetestresult)ishigherinpopulationswithahighprevalenceofthe diseasecomparedtopopulationswithalowprevalence.Thiswouldapplytodifferencesin diseaseprevalencebothacrossandwithinpopulations(e.g.ifonlyhighriskindividualsare selectedforscreening,asopposedtothepopulationatlarge).Measurementerrorsalso reducetheutilityofROCcurves. Figure A1 Example of a ROC curve

1specificity (false-positive probability)

Source: WHO (2003: p 40)

Belowareexamplesofhowtheseconceptshavebeenusedastherationaleforwaist circumferenceandwaisthipratiocutoffpointsindifferentcountries. Sensitivity is equal to specificity TableA3showsexamplesofstudiesfromdifferentcountriesthathavesetcutoffpoints basedonsensitivitybeingequaltospecificity.

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Table A3
Country Barbados

Cut-off points based on sensitivity being equal to specificity

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

China

8085 cm

7580 cm

In this range, the sensitivity equaled the specificity

Islamic Republic of Iran

90 cm

90 cm

(Delavari et al., 2009; Esteghamati et al., 2009; Mirmiran et al., 2004)

Islamic Republic of Iran

95 cm

95 cm

Mexico Mexico

90 0.90

85 0.85

(Berber, et al., 2001) (Berber, et al., 2001) Sensitivity equals specificity (based on the ROC technique), from a study in a hospital population in Mexico City These national recommendations are based on the intersection of lines of specificity and sensitivity

Mexico

Mexico

Waist circumference for diabetes Waist circumference for hypertension

9398 cm

9499 cm

(Sanchez-Castillo et al., 2003)

9296 cm

9396 cm

CVD, cardiovascular disease; ROC, receiver operating characteristic

Maximum sensitivity AstudyfromFranceprovidedcutoffpointsforthemostcorpulent30%ofthepopulation (Balkauetal.,2006): waistcircumferenceforobesity,diabetes,andCVD:96cmformenand83cmfor women; waisthipratioforgeneralriskandobesity:0.96formenand0.83forwomen.

Sensitivitywasofparamountimportance,withwaistcircumferencesensitivitiesof74%for menand82%forwomen,andforwaisthipratioof66%formenand77%forwomen.

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Optimal sensitivity and specificity AstudyfromChile,forexample,providedcutoffpointsforCVDandmetabolicriskfor women:awaistcircumferenceofatleast87.7cmandawaisthipratioofatleast0.84 (Kochetal.,2008).Specificcutoffpointswerebasedonoptimalsensitivityandspecificity fordetectingoneormorecardiovascularandmetabolicriskfactorsinthepopulationunder study. Shortest distance between any point on the ROC curve and top-left corner on the y-axis AstudyfromOmanprovidedcutoffpointsforCVDasfollows(AlLawati&Jousilahti,2008): waistcircumference:80cmformenand84.5cmforwomen; waisthipratio:0.91forbothmenandwomen.

SeparateROCcurveswereplottedforwaistcircumferenceandwaisthipratio. Range of values and best cut-off points for multiple indicators AstudyfromTunisiaprovidedacutoffpointforwaistcircumference(forobesity,diabetes, andCVD)of85cmforbothmenandwomen,basedonsensitivitybeingequaltospecificity (Bouguerraetal.,2007). However,thestudyalsoprovidedindividualcutoffpointsforeachdiseaserisk,andwould clearlybeapplicableforclinicaluse(whereasthesinglevaluegivenabovewouldbeuseful forpublichealthpurposes): 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).

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A n n e x B : L i s t o f pa r t i c i pa n ts
ThisannexliststheparticipantsattheWHOExpertConsultationonWaistCircumference andWaistHipRatio,Geneva,Switzerland,811December2008.

B1

Members2
ProfessorSirGeorgeAlberti,SCMS(DiabetesResearchGroup),TheMedicalSchool, UniversityofNewcastleuponTyne,NewcastleuponTyne,UnitedKingdom ProfessorFereidounAzizi,Director,ResearchInstituteforEndocrinologyandMetabolism, ShaheedBeheshtiUniversityofMedicalSciences,Tehran,IslamicRepublicofIran ProfessorJulianaCNChan,Director,HongKongInstituteofDiabetesandObesity,The ChineseUniversityofHongKong,DepartmentofMedicineandTherapeutics,ThePrinceof WalesHospital,Shatin,HongKongSAR,People'sRepublicofChina ProfessorRachelHuxley,Director,Nutrition&LifestyleDivision,TheGeorgeInstitutefor GlobalHealth,Camperdown,Sydney,NewSouthWales,Australia ProfessorPhilipJames,InternationalObesityTaskForce,London,UnitedKingdom ProfessorTakashiKadowaki,DepartmentofMetabolicDiseases,GraduateSchoolof Medicine,UniversityofTokyo,Tokyo,Japan ProfessorKayTeeKhaw,DepartmentofClinicalGerontology,UniversityofCambridge, Addenbrooke'sHospital,Cambridge,UnitedKingdom DrGaryTinChoiKo,HongKongInstituteofDiabetesandObesity,TheChineseUniversityof HongKong,ThePrinceofWalesHospital,Shatin,HongKongSAR,People'sRepublicof China(Rapporteur) ProfessorShirikiKumanyika,CenterforClinicalEpidemiology&Biostatistics,Universityof PennsylvaniaSchoolofMedicine,Philadelphia,Pennsylvania,US(Chairperson) ProfessorScottLear,SchoolofKinesiology,SimonFraserUniversity,Vancouver,British Columbia,Canada ProfessorJeanClaudeMbanya,ViceDean/ProfessorofMedicineandEndocrinology, FacultyofMedicineandBiomedicalSciences,UniversityofYaound,Yaound,Cameroon DrQingQiao,AcademyResearchFellow,DepartmentofPublicHealth,Universityof Helsinki,Helsinki,Finland ProfessorK.SrinathReddy,President,PublicHealthFoundationofIndia,NewDelhi,India ProfessorJaapSeidell,Head,DepartmentofNutrition&Health,FacultyofEarthandLife Sciences,FreeUniversityofAmsterdam,Amsterdam,TheNetherlands

Unable to attend: Dr Viswanathan Mohan, President & Chief of Diabetes Research, Madras Diabetes Research Foundation, Indian Council of Medical Research (ICMR) Advanced Centre for Genomics of Diabetes, Chennai, India

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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

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