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1.  Association between obesity indices and cardiovascular risk factors in late adolescence in the Seychelles 
BMC Pediatrics  2012;12:176.
The ability of different obesity indices to predict cardiovascular risk is still debated in youth and few data are available in sub Saharan Africa. We compared the associations between several indices of obesity and cardiovascular risk factors (CVRFs) in late adolescence in the Seychelles.
We measured body mass index (BMI), waist circumference, waist/hip ratio (WHiR), waist/height ratio (WHtR) and percent fat mass (by bioimpedance) and 6 CVRFs (blood pressure, LDL-cholesterol, HDL-cholesterol, triglycerides, fasting blood glucose and uric acid) in 423 youths aged 19–20 years from the general population.
The prevalence of overweight/obesity and several CVRFs was high, with substantial sex differences. Except for glucose in males and LDL-cholesterol in females, all obesity indices were associated with CVRFs. BMI consistently predicted CVRFs at least as well as the other indices. Linear regression on BMI had standardized regression coefficients of 0.25-0.36 for most CVRFs (p<0.01) and ROC analysis had an AUC between 60%-75% for most CVRFs. BMI also predicted well various combinations of CVRFs: 36% of male and 16% of female lean subjects (BMI P90).
There was an elevated prevalence of obesity and of several CVRFs in youths in Seychelles. BMI predicted single or combined CVRFs at least as well as other simple obesity indices.
PMCID: PMC3507891  PMID: 23134594
Obesity; Body mass index (BMI); Cardiovascular risk factors; Screening; Youth; Adolescents; Young adults; Africa
2.  Does Waist Indicate Dyslipidemia better than BMI in Korean Adult Population? 
Obesity is an independent and modifiable risk factor for cardiovascular disease, and known as a core of the metabolic syndrome. Obesity has been largely diagnosed based upon anthrompometric measurements like waist circumference (WC) and body mass index (BMI). We sought to determine associations between anthropometric measurements and dyslipidemia in a community adult sample composed of 1,032 community residents (356 men, 676 women) aged 50 yr and over in Namwon, Korea. Blood tests for lipid profiles, including total cholesterol (TC) and HDL cholesterol (HDL) were performed, and dyslipidemia was defined as TC/HDL greater than 4. Anthropometric measurements included WC, waist-to-height ratio (WHtR), waist-to-hip ratio, and BMI. All anthropometric measures were categorized into quartiles and evaluated for associations with dyslipidemia. TC/HDL showed the significant associations with the anthropometric measures, independently of potential confounders. In women, increases of obesity indexes by quartile analyses showed linear increases of odds ratios for dyslipidemia (p values <0.01 by trend test). In men, except BMI, same patterns of association were noted. WC and WHtR were significantly associated with dyslipidemia in Korean adult population. As a simple and non-invasive method for a detection of obesity and dyslipidemia, anthropometric measurements could be efficiently used in clinical and epidemiologic fields.
PMCID: PMC2808579  PMID: 15716594
Anthropometry; Waist Circumference; Body Mass Index; Hyperlipidemia; Population
3.  Association between adiposity indices and cardiometabolic risk factors among adults living in Puerto Rico 
Public health nutrition  2011;14(10):1714-1723.
To compare the general adiposity index (BMI) with abdominal obesity indices (waist circumference (WC), waist-to-hip ratio (WHR) and waist-to-height ratio (WHtR)) in order to examine the best predictor of cardiometabolic risk factors among Hispanics living in Puerto Rico.
Secondary analysis of measurements taken from a representative sample of adults. Logistic regression models (prevalence odds ratios (POR)), partial Pearson’s correlations (controlling for age and sex) and receiver-operating characteristic (ROC) curves were calculated between indices of obesity (BMI, WC, WHR and WHtR) and blood pressure, HDL cholesterol (HDL-C), LDL cholesterol (LDL-C), total cholesterol (TC):HDL-C, TAG, fasting blood glucose, glycosylated Hb, high-sensitivity C-reactive protein (hs-CRP), fibrinogen, plasminogen activator inhibitor-1 (PAI-1) and an aggregated measure of cardiometabolic risk.
Household study conducted between 2005 and 2007 in the San Juan Metropolitan Area in Puerto Rico.
A representative sample of 858 non-institutionalized adults.
All four obesity indices significantly correlated with the cardiometabolic risk factors. WHtR had the highest POR for high TC:HDL-C, blood pressure, hs-CRP, fibrinogen and PAI-1; WC had the highest POR for low HDL-C and high LDL-C and fasting blood glucose; WHR had the highest POR for overall cardiometabolic risk, TAG and glycosylated Hb. BMI had the lowest POR for most risk factors and smallest ROC curve for overall cardiometabolic risk.
The findings of the study suggest that general adiposity and abdominal adiposity are both associated with cardiometabolic risk in this population, although WC, WHR and WHtR appear to be slightly better predictors than BMI.
PMCID: PMC3438511  PMID: 21729484
Waist circumference; Waist-to-hip ratio; BMI; Waist-to-height ratio; Cardiometabolic risk
4.  Association of lipid profile and waist circumference as cardiovascular risk factors for overweight and obesity among school children in Qatar 
Childhood obesity is a national as well as worldwide problem. The aim of this study was to evaluate the association of overweight and obesity among Qatari children with lipid profile and waist circumference as adverse cardiovascular risk factors in children aged 6–11 years. International Obesity Task Force reference values were used to screen for overweight and obesity.
A cross-sectional study in a randomly selected sample was conducted in 315 Qatari primary school students aged 6–11 years. Anthropometric measurements, including body weight, height, waist circumference, and body mass index were calculated for 151 girls and 164 boys. Weight categories were based on International Obesity Task Force reference values. Fasting blood glucose, total cholesterol, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), and triglycerides were measured, and atherogenic index was calculated.
In total, 31.71% of boys and 32.78% of girls were overweight or obese. Overweight and obese children screened against International Obesity Task Force reference values had a significantly increased risk of high waist circumference (P < 0.0001), hypertriglyceridemia (P = 0.002), low HDL-C (P = 0.017), and atherogenic index (P = 0.021) compared with children who were not overweight or obese. The partial correlation coefficient for the cardiovascular risk marker of waist circumference indicated a positive significant association with total cholesterol (r = 0.465, P = 0.003), triglycerides (r = 0.563, P < 0.001), and LDL-C (r = 0.267, P = 0.003), and a significant negative association with HDL-C (r = −0.361, P = 0.004). Overweight and obesity significantly increase the odds ratios (ORs) and 95% confidence interval (CIs) of cardiovascular risk factors as follows: hypertriglyceridemia (OR 6.34, CI 2.49–13.44, P < 0.0001); LDL-C (OR 3.18, CI 1.04–9.75, P = 0.043); hypercholesterolemia (OR 1.88, CI 1.10–3.19, P = 0.020); and increased waist circumference (OR 1.40, CI 1.29–1.55, P = 0.022). Overweight and obesity significantly increased the risk of atherosclerosis (assessed by atherogenic index) by about two-fold (OR 1.83, 95% CI 1.06–3.15, P = 0.025).
Overweight and obese children screened by International Obesity Task Force reference values are at increased risk of cardiovascular disease in adulthood.
PMCID: PMC3532017  PMID: 23277742
cardiovascular risks; children; lipid profile; obesity; and waist circumference
5.  The Use of Obesity Indicators for the Prediction of Hypertension Risk among Youth in the United Arab Emirates 
Obesity is a significant risk factor for metabolic disorders including increase in blood pressure. Body mass index (BMI), waist circumference (WC) and Waist/Hip ratio (WHR) are simple and effective indicators of obesity. The objectives of this study were to examine the relationships between obesity anthropometric indicators and hypertension and to identify the best anthropometric indicator/s that can predict hypertension risk among youth in the UAE.
A 110 first year students in a Medical University in Ajman, UAE, during the year 2009–2010 were included in a cross-sectional study. The height, weight, WC, hip circumference and blood pressure were measured and the BMI and WHR were calculated for each student and used in the analyses.
The mean values for BMI, WC, hip circumference and WHR, were significantly higher in the Pre/Hypertensive group compared to normal blood pressure group. The risk of Pre/ hypertension was significantly increased by 4.3 times for participants who had general obesity (BMI≥ 30) or abdominal obesity (identified from high WC). Highly significant correlations were noticed between systolic and diastolic blood pressure and all anthropometric indicators except that for Hip circumference and systolic blood pressure. Step-wise linear regression model showed that when all obesity indicators were studied together, the waist circumference was the only indicator which showed significant relationship with both systolic and diastolic blood pressure.
Waist circumference is the best anthropometric indicator that can predict hypertension risk among youth in the UAE.
PMCID: PMC3481645  PMID: 23113084
Hypertension; Youth; Obesity indicators
6.  Association of waist circumference, body mass index and conicity index with cardiovascular risk factors in postmenopausal women 
Cardiovascular Journal of Africa  2012;23(8):442-445.
In menopause, changes in body fat distribution lead to increasing risk of cardiovascular disease and metabolic disorders. The aim of this study was to assess the association of adiposity using the conicity index (CI), body mass index (BMI) and waist circumference (WC) with cardiovascular risk factors (hypertension, diabetes and dyslipidaemia). The sample of this cross-sectional study was collected from June to October 2010 and 165 consecutive menopausal women who had attended the Health and Treatment Centre and Endocrine Research Centre of Firoozgar Hospital in Tehran, Iran were assessed. Age, weight, height, WC, waist–hip ratio (WHR), CI and fat mass were measured. Systolic and diastolic blood pressure (SBP and DBP), fasting blood glucose, insulin, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C) and total cholesterol (TC) levels were also determined. All statistical analyses were performed by SPSS version 17 (SPSS Inc, Chicago, IL, USA).
Results showed that BMI was positively and significantly associated with SBP (r = 0.21; p = 0.009). WC was positively and significantly correlated with SBP (r = 0.26; p = 0.02) and DBP (r = 0.16; p = 0.05). WHR was also significantly and positively associated with SBP (r = 0.29; p = 0.001). Age and WC were associated with CI quartiles at the 0.05 significance level. The correlation of CI quartiles with SBP and weight were at the 0.01 significance level.
We showed a significant association of WC with SBP and DBP, and that BMI could be an important determining factor of SBP. For assessing the association between CI and cardiovascular risk factors, future studies with larger sample sizes are recommended.
PMCID: PMC3721927  PMID: 23044499
body mass index; cardiovascular risk factors; conicity index; waist circumference
7.  Different anthropometric adiposity measures and their association with cardiovascular disease risk factors: a meta-analysis 
Netherlands Heart Journal  2012;20(5):208-218.
To investigate which anthropometric adiposity measure has the strongest association with cardiovascular disease (CVD) risk factors in Caucasian men and women without a history of CVD.
Systematic review and meta-analysis.
We searched databases for studies reporting correlations between anthropometric adiposity measures and CVD risk factors in Caucasian subjects without a history of CVD. Body mass index (BMI), waist circumference, waist-to-hip ratio, waist-to-height ratio and body fat percentage were considered the anthropometric adiposity measures. Primary CVD risk factors were: systolic blood pressure, diastolic blood pressure, high density lipoprotein (HDL) cholesterol, triglycerides and fasting glucose. Two independent reviewers performed abstract, full text and data selection.
Twenty articles were included describing 21,618 males and 24,139 females. Waist circumference had the strongest correlation with all CVD risk factors for both men and women, except for HDL and LDL in men. When comparing BMI with waist circumference, the latter showed significantly better correlations to CVD risk factors, except for diastolic blood pressure in women and HDL and total cholesterol in men.
We recommend the use of waist circumference in clinical and research studies above other anthropometric adiposity measures, especially compared with BMI, when evaluating CVD risk factors.
PMCID: PMC3346869  PMID: 22231153
Meta-analysis; Cardiovascular disease risk factors; Anthropometric; Adiposity; Waist circumference; Medicine & Public Health; Medicine/Public Health, general
8.  Prevalence of Elevated Blood Pressure and Association with Obesity in Egyptian School Adolescents 
Aim. To investigate the relationship between high blood pressure (HBP) and obesity in Egyptian adolescents. Methods. A cross-sectional study of 1500 adolescents (11–19 years) in Alexandria, Egypt, was conducted. Resting BP was measured and measurements were categorized using the 2004 fourth report on blood pressure screening recommendations. Additional measures included height, weight, and waist and hip circumferences. Obesity was determined based on BMI, waist circumference (WC) and waist-to-hip ratio (WHR), and waist-to-height ratio (WHtR) indicators. Crude and adjusted odds ratios were used as measures of association between BP and obesity. Results. Prevalence rates of prehypertension and hypertension were 5.7% and 4.0%, respectively. Obesity was seen in 34.6%, 16.1%, 4.5%, and 16.7% according to BMI, WHR, WC, and WHtR, respectively. Adjusting for confounders, HBP was significantly associated with overall obesity based on BMI (OR = 2.18, 95%, CI = 1.38-3.44) and central obesity based on WC (OR = 3.14, 95%, CI = 1.67-5.94). Conclusion. Both overall obesity and central obesity were significant predictors of HBP in Egyptian adolescents.
PMCID: PMC3057063  PMID: 21423685
9.  Overweight and obesity in relation to cardiovascular disease risk factors among medical students in Crete, Greece 
BMC Public Health  2003;3:3.
Recent data indicate increasing rates of adult obesity and mortality from cardiovascular disease (CVD) in Greece. No data, however, are available on prevalence of overweight and obesity in relation to CVD risk factors among young adults in Greece.
A total of 989 third-year medical students (527 men, 462 women), aged 22 ± 2 years, were recruited from the University of Crete during the period 1989–2001. Anthropometric measures and blood chemistries were obtained. The relationships between obesity indices (body mass index [BMI], waist circumference [WC], waist-to-hip ratio [WHpR], waist-to-height ratio [WHtR]) and CVD risk factor variables (blood pressure, glucose, serum lipoproteins) were investigated.
Approximately 40% of men and 23% of women had BMI ≥ 25.0 kg/m2. Central obesity was found in 33.4% (average percentage corresponding to WC ≥ 90 cm, WHpR ≥ 0.9 and WHtR ≥ 50.0) of male and 21.7% (using WC ≥ 80 cm, WHpR ≥ 0.8, WHtR ≥ 50.0) of female students. Subjects above the obesity indices cut-offs had significantly higher values of CVD risk factor variables. BMI was the strongest predictor of hypertension. WHtR in men and WC in women were the most important indicators of dyslipidaemia.
A substantial proportion of Greek medical students were overweight or obese, obesity status being related to the presence of hypertension and dyslipidaemia. Simple anthropometric indices can be used to identify these CVD risk factors. Our results underscore the need to implement health promotion programmes and perform large-scale epidemiological studies within the general Greek young adult population.
PMCID: PMC140012  PMID: 12517305
10.  Informativeness of indices of blood pressure, obesity and serum lipids in relation to ischaemic heart disease mortality: the HUNT-II study 
European Journal of Epidemiology  2011;26(6):457-461.
The informativeness of blood pressure, obesity and serum lipids associated with cardiovascular events may depend on how the indices are expressed, and mid blood pressure, waist-to-hip ratio adjusted for body-mass index (BMI) and the ratio of total to HDL cholesterol may be more informative than other expressions. Our aim was to study the informativeness of indices of blood pressure, obesity and serum lipids associated with ischaemic heart disease mortality in a large, homogeneous population. Blood pressure, weight, height, waist and hip circumference, total and HDL cholesterol, and triglycerides were measured at baseline (1995–1997) in 28,158 men and 32,573 women. Information on deaths from ischaemic heart disease (IHD) was obtained from the Causes of Death Registry in Norway from baseline until the end of 2007. Informativeness was analysed using the difference in twice the log-likelihood of a Cox model with and without each index. During 11 years of follow-up, 597 men and 418 women had died from IHD. Systolic blood pressure in men and pulse pressure in women were the most informative predictors of blood pressure, and waist-to-hip ratio adjusted for BMI was the most informative expression of obesity in both men and women. Among serum lipids, the most informative predictor was the ratio of total cholesterol to HDL cholesterol. Using more informative expressions of conventional risk factors for ischemic heart disease may improve both the validity and precision of estimates of risk, and may be useful both clinically and for preventive purposes.
Electronic supplementary material
The online version of this article (doi:10.1007/s10654-011-9572-7) contains supplementary material, which is available to authorized users.
PMCID: PMC3115050  PMID: 21461943
Ischaemic heart disease; Blood pressure; Obesity; Lipids; Risk; Informativeness
11.  Waist circumference, waist-hip ratio and waist-height ratio percentiles and central obesity among Pakistani children aged five to twelve years 
BMC Pediatrics  2011;11:105.
Central obesity has been associated with the risk of cardiovascular and metabolic disease in children and anthropometric indices predictive of central obesity include waist circumference (WC), waist-hip ratio (WHR) and waist-height ratio (WHtR). South Asian children have higher body fat distribution in the trunk region but the literature regarding WC and related indices is scarce in this region. The study was aimed to provide age- and gender-specific WC, WHR and WHtR smoothed percentiles, and to explore prevalence and correlates of central obesity, among Pakistani children aged five to twelve years.
A population-based cross-sectional study was conducted with a representative multistage random cluster sample of 1860 primary school children aged five to twelve years in Lahore, Pakistan. Smoothed percentile curves were constructed for WC, WHR and WHtR by the LMS method. Central obesity was defined as having both age- and gender-specific WC percentile ≥90th and WHtR ≥0.5. Chi-square test was used as the test of trend. Multivariate logistic regression was used to quantify the independent predictors of central obesity and adjusted odds ratios (aOR) with 95% CI were obtained. Linear regression was used to explore the independent determinants of WC and WHtR. Statistical significance was considered at P < 0.05.
First ever age- and gender-specific smoothed WC, WHR and WHtR reference curves for Pakistani children aged five to twelve years are presented. WC increased with age among both boys and girls. Fiftieth WC percentile curves for Pakistani children were higher as compared to those for Hong Kong and British children, and were lower as compared to those for Iranian, German and Swiss children. WHR showed a plateau pattern among boys while plateau among girls until nine years of age and decreased afterwards. WHtR was age-independent among both boys and girls, and WHtR cut-off of ≥0.5 for defining central obesity corresponded to 85th WHtR percentile irrespective of age and gender. Twelve percent children (95% CI 10.1-13.0) had a WC ≥90th percentile and 16.5% children (95% CI 14.7-18.1) had a WHtR ≥0.5 while 11% children (95% CI 8.9-11.6) had both WC ≥90th percentile and WHtR ≥0.5. Significant predictors of central obesity included higher grade, urban area with high socioeconomic status (SES), high-income neighborhood and higher parental education. Children studying in higher grade (aOR 5.11, 95% CI 1.76-14.85) and those living in urban area with high SES (aOR 82.34, 95% CI 15.76-430.31) showed a significant independent association. Urban area with high SES and higher parental education showed a significant independent association with higher WC and higher WHtR while higher grade showed a significant independent association with higher WC.
Comprehensive worldwide reference values are needed to define central obesity and the present study is the first one to report anthropometric indices predictive of central obesity for Pakistani school-aged children. Eleven percent children were centrally obese and strong predictors included higher grade, urban area with high SES and higher parental education. These findings support the need for developing a National strategy for childhood obesity and implementing targeted interventions, prioritizing the higher social class and involving communities.
PMCID: PMC3239239  PMID: 22104025
12.  Impact of education on obesity and blood pressure in developing countries: A study on the Ibos of Nigeria 
Increase in the prevalence of hypertension, obesity and obesity related diseases has become significant cause of disability and premature death in both developing and newly developed countries, with over bearing demand on national health budgets.
To evaluate the impact of various levels of education on obesity and blood pressure.
Materials and Method:
325 male and 254 female Nigerians of ages 20-80 years of the Ibo ethnicity through random sampling, were selected for this study. The participants were broken into three major groups based on their educational levels; primary, secondary and tertiary levels. systolic and diastolic blood pressure (SBP & DBP) levels, body mass index (BMI), waist hip ratio (WHR), waist height ratio (WHtR), waist circumference (WC),various skin fold thicknesses, and other anthropometric parameters were measured.
For all the indicators of subcutaneous fat, general obesity, and central obesity, largest mean deposition was noted to be highest in the lowest education group and least in the highest education group. Mean blood pressure parameters were also highest in the least education group. While fat deposition was noted to be highest in all the females of all the groups, the males showed larger mean BP values. Education was noted to have a significant inverse relationship with most of the fat indicators and blood pressure parameters and cardiovascular disease risk highest in the least education groups.
Education showed a significant impact on obesity and blood pressure and could be one of the major tools to reduce the high prevalence of obesity, hypertension and other obesity associated diseases.
PMCID: PMC3341639  PMID: 22558581
Anthropometry; obesity; adiposity; blood pressure; BMI; obesity prevalence; obesity related disorder; hypertension; cardiovascular disease risk; waist hip ratio
13.  Can body mass index, waist circumference, waist-hip ratio and waist-height ratio predict the presence of multiple metabolic risk factors in Chinese subjects? 
BMC Public Health  2011;11:35.
Obesity is associated with metabolic risk factors. Body mass index (BMI), waist circumference, waist-hip ratio (WHR) and waist-height ratio (WHtR) are used to predict the risk of obesity related diseases. However, it has not been examined whether these four indicators can detect the clustering of metabolic risk factors in Chinese subjects.
There are 772 Chinese subjects in the present study. Metabolic risk factors including high blood pressure, dyslipidemia, and glucose intolerance were identified according to the criteria from WHO. All statistical analyses were performed separately according to sex by using the SPSS 12.0.
BMI, waist circumference and WHtR values were all significantly associated with blood pressure, glucose, triglyceride and also with the number of metabolic risk factors in both male and female subjects (all of P < 0.05). According to receiver operating characteristic (ROC) analysis, the area under curve values of BMI, waist circumference and WHtR did not differ in male (0.682 vs. 0.661 vs. 0.651) and female (0.702 vs. 0.671 vs. 0.674) subjects, indicating that the three values could be useful in detecting the occurrence of multiple metabolic risk factors. The appropriate cut-off values of BMI, waist circumference and WHtR to predict the presence of multiple metabolic risk factors were 22.85 and 23.30 kg/m2 in males and females, respectively. Those of waist circumference and WHtR were 91.3cm and 87.1cm, 0.51 and 0.53 in males and females, respectively.
The BMI, waist circumference and WHtR values can similarly predict the presence of multiple metabolic risk factors in Chinese subjects.
PMCID: PMC3032682  PMID: 21226967
14.  Lipid Profile In Relation To Anthropometric Indices and Insulin Resistance in Overweight Women with Polycystic Ovary Syndrome 
Health Promotion Perspectives  2013;3(2):206-216.
Background: The present study was aimed to investigate lipid profile in relation to anthropometric indices and insulin resistance in overweight or obese women with polycystic ovary syndrome (PCOS).
Methods: In this cross-sectional study, lipid profile and anthropometric indices including body mass index (BMI), waist and hip circumference, waist to hip ratio (WHR), and waist to height ratio (WHtR) were evaluated in 63 overweight or obese PCOS patients subdivided into insulin-resistant (IR) and non insulin-resistant (NIR) groups. IR was defined as homeostasis model of insulin resistance (HOMA-IR) ≥3.8.
Results: Fasting insulin concentration and HOMA-IR were higher (P<0.001) and high-density lipoprotein cholesterol (P=0.012) was lower in IR group. All of the anthropometric measures other than WHR and BMI showed significant correlations with several lipid parameters. Amongst, WHtR showed the strongest correlation with total cholesterol (TC) (r=0.37; P=0.004) and low density lipoprotein cholesterol (LDL-C) (r=0.33; P=0.011) in the whole PCOS patients.
Conclusion: Anthropometric characteristics (especially BMI and hip circum­ference) are more important parameters correlated to lipid profile than IR in overweight or obesePCOS patients, confirming the importance of early treat­ment of obesity to prevent dyslipidemia in the future.
PMCID: PMC3963667
Lipid profile; Dyslipidemia; Insulin resistance; Obesity; Polycystic ovary syndrome
15.  Sex-specific association of anthropometric measures of body composition with arterial stiffness in a healthy population 
Anthropometric measures of body composition and arterial stiffness are commonly used as indicators of cardiovascular risk. Little is known, however, about the association of the anthropometric measures with arterial stiffness, especially in a healthy, generally non-obese population.
In a sample of 352 healthy subjects (200 premenopausal women), 3 arterial stiffness indices were analyzed (pulse wave velocity, augmentation index and central systolic blood pressure) in relation to 5 anthropometric measures of body composition (body mass index – BMI, body fat percentage by skinfold measurements –%BF, waist circumference – WC, waist-hip ratio – WHpR, and waist-height ratio – WHtR). Data were analyzed using correlation and regression analyses, with adjustment for the following confounders: age, blood pressures, height, heart rate, blood lipids and smoking.
Most correlations between anthropometric measures and arterial stiffness indices were significant and positive in both sex groups (r=0.14–0.40, P<0.05). After adjustment for confounding effects, BMI, WC and WHtR remained significant (but inverse) predictors of arterial stiffness (β from −0.06 to −0.16; P<0.05) in the females, while in the males BMI was the only measure inversely predicting arterial stiffness (β from −0.09 to −0.13; P<0.05).
Measures of body composition are weak and inverse predictors of arterial stiffness and their influence is sex-dependent. BMI, WC and WHtR were key predictors of arterial stiffness in the females, while BMI was the principal predictor in the males. The associations of anthropometric measures with arterial stiffness are strongly and differently confounded by various factors that have to be taken into account when explaining results of similar studies.
PMCID: PMC3560590  PMID: 22293879
anthropometric measurements; BMI; arterial stiffness; pulse wave velocity; augmentation index
16.  Body Configuration as a Predictor of Mortality: Comparison of Five Anthropometric Measures in a 12 Year Follow-Up of the Norwegian HUNT 2 Study 
PLoS ONE  2011;6(10):e26621.
Distribution of body fat is more important than the amount of fat as a prognostic factor for life expectancy. Despite that, body mass index (BMI) still holds its status as the most used indicator of obesity in clinical work.
We assessed the association of five different anthropometric measures with mortality in general and cardiovascular disease (CVD) mortality in particular using Cox proportional hazards models. Predictive properties were compared by computing integrated discrimination improvement and net reclassification improvement for two different prediction models. The measures studied were BMI, waist circumference, hip circumference, waist-to-hip ratio (WHR), and waist-to-height ratio (WHtR). The study population was a prospective cohort of 62,223 Norwegians, age 20–79, followed up for mortality from 1995–1997 to the end of 2008 (mean follow-up 12.0 years) in the Nord-Trøndelag Health Study (HUNT 2).
After adjusting for age, smoking and physical activity WHR and WHtR were found to be the strongest predictors of death. Hazard ratios (HRs) for CVD mortality per increase in WHR of one standard deviation were 1.23 for men and 1.27 for women. For WHtR, these HRs were 1.24 for men and 1.23 for women. WHR offered the greatest integrated discrimination improvement to the prediction models studied, followed by WHtR and waist circumference. Hip circumference was in strong inverse association with mortality when adjusting for waist circumference. In all analyses, BMI had weaker association with mortality than three of the other four measures studied.
Our study adds further knowledge to the evidence that BMI is not the most appropriate measure of obesity in everyday clinical practice. WHR can reliably be measured and is as easy to calculate as BMI and is currently better documented than WHtR. It appears reasonable to recommend WHR as the primary measure of body composition and obesity.
PMCID: PMC3197688  PMID: 22028926
17.  Common Variant of FTO Gene, rs9939609, and Obesity in Pakistani Females 
BioMed Research International  2013;2013:324093.
Numerous studies confirmed the association of FTO (fat mass and obesity associated gene) common variant, rs9939609, with obesity in European populations. However, studies in Asian populations revealed conflicting results. We examined the association of rs9939609 variant of FTO gene with obesity and obesity-related anthropometric and metabolic parameters in Pakistani population. Body weight, height, waist circumference, hip circumference, and blood pressure (BP) were measured. BMI and waist-to-hip ratio (WHR) were calculated. Levels of fasting blood glucose (FBG), insulin, leptin, and leptin receptors were measured by enzyme linked immunosorbent assay (ELISA), and homeostasis model assessment of insulin resistance (HOMA-IR) was calculated. The results showed association of FTO gene, rs9939609, with obesity in females (>18 years of age). FTO minor allele increased the risk of obesity by 2.8 times (95% CI = 1.3–6.0) in females. This allele showed association with body weight, BMI, waist circumference, hip circumference, WHR, BP, plasma FBG levels, HOMA-IR, plasma insulin levels, and plasma leptin levels. In conclusion, FTO gene, rs9939609, is associated with BMI and risk of obesity in adult Pakistani females. Association of rs9939609 variant with higher FBG, plasma insulin, and leptin levels indicates that this polymorphism may disturb the metabolism in adult females and predispose them to obesity and type 2 diabetes. However, the above-mentioned findings were not seen in children or males.
PMCID: PMC3775403  PMID: 24102053
18.  Obesity and its Measurement in a Community-Based Sample of Women with Systemic Lupus Erythematosus 
Arthritis care & research  2011;63(2):261-268.
To determine the prevalence of obesity and evaluate how accurately standard anthropometric measures identify obesity among women with SLE.
Dual-energy x-ray absorptiometry (DEXA), height, weight, and waist and hip circumference were collected from 145 women with SLE. Three anthropometric proxies of obesity (body mass index (BMI) ≥30 kg/m2, waist circumference (WC) ≥88 cm, and waist-hip ratio (WHR) ≥0.85) were compared to a DEXA-based obesity criterion. Correspondence between measures was assessed with Cohen’s kappa. Receiver operating characteristic (ROC) curves determined optimal cut-points for each anthropometric measure, relative to DEXA. Framingham cardiovascular risk scores were compared among women who were classified as not obese by both traditional and revised anthropometric definitions, obese by both definitions, and obese only by the revised definition.
28%, 29%, 41%, and 50% were classified as obese by WC, BMI, WHR, and DEXA, respectively. Correspondence between anthropometric and DEXA-based measures was moderate. Women misclassified by anthropometric measures had less truncal fat and more appendicular lean and fat mass. Cut-points were identified for anthropometric measures to better approximate DEXA estimates of percent body fat: BMI ≥26.8 kg/m2, waist circumference ≥84.75 cm., and waist-hip ratio ≥0.80. Framingham risk scores were significantly higher in women classified as obese by either traditional or revised criteria.
A large percentage of this group of women with SLE was obese. Substantial portions of women were misclassified by anthropometric measures. Utility of revised cut-points compared to traditional cut-points in identifying risk of cardiovascular disease or disability remains to be examined in prospective studies, but results from the Framingham risk score analysis suggest that traditional cut-points exclude a significant number of at-risk women with SLE.
PMCID: PMC3010264  PMID: 20824801
19.  Limited Weight Loss or Simply No Weight Gain following Lifestyle-Only Intervention Tends to Redistribute Body Fat, to Decrease Lipid Concentrations, and to Improve Parameters of Insulin Sensitivity in Obese Children 
Objectives. To investigate whether lifestyle-only intervention in obese children who maintain or lose a modest amount of weight redistributes parameters of body composition and reverses metabolic abnormalities. Study Design. Clinical, anthropometric, and metabolic parameters were assessed in 111 overweight or obese children (CA of 11.3 ± 2.8 years; 63 females and 48 males), during 8 months of lifestyle intervention. Patients maintained or lost weight (1–5%) (group A; n: 72) or gained weight (group B). Results. Group A patients presented with a decrease in systolic blood pressure (SBP) and diastolic blood pressure (DBP) ( and , resp.), BMI (), z-score BMI (), waist circumference (), fat mass (), LDL-C (), Tg/HDL-C ratio (), fasting and postprandial insulin (), and HOMA (), while HDL-C () and QUICKI increased (). Conversely, group B patients had an increase in BMI (), waist circumference (), SBP (), and in QUICKI (), while fat mass (), fasting insulin (), and HOMA () decreased. Lean mass, DBP, lipid concentrations, fasting and postprandial glucose, postprandial insulin, and ultrasensitive C-reactive protein (CRP) remained stable. Conclusions. Obese children who maintain or lose a modest amount of weight following lifestyle-only intervention tend to redistribute their body fat, decrease blood pressure and lipid levels, and to improve parameters of insulin sensitivity.
PMCID: PMC3198742  PMID: 21603203
20.  Differential Association of Adiposity Measures with Heart Rate Variability Measures in Koreans 
Yonsei Medical Journal  2012;54(1):55-61.
Although obesity has been associated with imbalances in cardiac autonomic nervous system, it is unclear whether there are differential relationships between adiposity measures and heart rate variability (HRV) measures. We aimed to examine differences in the relationship between adiposity measures and HRV indices in a healthy Korean population.
Materials and Methods
In all, 1409 non-smokers (811 males, 598 females) without known histories of cardiovascular (CV), endocrine, or neurological diseases underwent adiposity measurements [(body mass index (BMI), percentage of body fat mass (PBF), and waist-to-hip ratio (WHR)], the HRV assessment (SDNN, RMSSD, LF, HF, LF/HF, and pNN50), and examination for CV risk factors (fasting glucose, LDL-cholesterol, HDL-cholesterol, triglycerides, hs-CRP, and blood pressure).
Compared with BMI and PBF, WHR was more strongly correlated with each HRV index and more likely to predict decreased HRV (<15 percentile vs. ≥15 percentile of each HRV index) in ROC curves analysis. In linear regression analysis, all adiposity measures were inversely associated with each HRV measure before adjusting for age, gender, and CV risk factors (p<0.05). After adjusting for the covariates, WHR was inversely related to RMSSD, LF, and pNN50; PBF with RMSSD, HF, and pNN50; BMI with RMSSD (p<0.05). The inversed association between HRV indices and the gender-specific WHR tertile was significant for subjects with BMI ≥25 kg/m2, but not for those with BMI <25 kg/m2.
WHR and PBF appear to be better indicators for low HRV than BMI, and the association between abdominal adiposity and HRV may be stronger in overweight subjects.
PMCID: PMC3521274  PMID: 23225799
Heart rate variability; adiposity; abdominal fat; cardiac autonomic function; obesity
21.  Comparison of Waist Circumference, Body Mass Index, Percent Body Fat and Other Measure of Adiposity in Identifying Cardiovascular Disease Risks among Thai Adults 
To compare the abilities of body mass index (BMI), percent body fat (%BF), waist circumference (WC), waist-hip ratio (WHR) and waist-height ratio (WHtR) to identify cardiovascular disease risk factors.
This cross-sectional study is comprised of 1,391 Thai participants (451 men and 940 women) receiving annual health check-ups. Spearman’s rank correlation was used to determine the association of the five anthropometric indices with metabolic parameters including fasting plasma glucose, triglyceride, high density lipoprotein and blood pressure. The prevalence of cardiovascular disease risk factors was determined according to tertile of each anthropometric measure. Receiver operating characteristic (ROC) curves were plotted to compare anthropometric measure as predictors of the prevalence of cardiovascular risk factors.
Metabolic parameters were more strongly associated with %BF and WHR and least correlated with BMI in men. Among women, BMI was most strongly correlated with metabolic parameters. In both genders, the prevalence of cardiovascular disease risk factors increased across successive tertiles for each anthropometric measure. Review of ROC curves indicated that %BF and WHR performed slightly better than other measures in identifying differences in CVD risk factors among men. BMI performed at least as well or better than other measures of adiposity among women.
These findings confirm high correlations between anthropometric measures and metabolic parameters. BMI, WC and other measures were not materially different in identifying cardiovascular disease risk factors. Although small differences were observed, the magnitudes of those differences are not likely to be of public health or clinical significance.
PMCID: PMC3627423  PMID: 23599834
Epidemiology; Body Mass Index; Body Fat; Waist Circumference; Waist-Hip Ratio; Waist-Height Ratio; Cardiovascular Risk Factors
22.  The Effects of an Exercise Program on Anthropometric, Metabolic, and Cardiovascular Parameters in Obese Children 
Korean Circulation Journal  2010;40(4):179-184.
Background and Objectives
Obesity is a chronic disease that requires good eating habits and an active life style. Obesity may start in childhood and continue until adulthood. Severely obese children have complications such as diabetes, hypercholesterolemia, hypertension and atherosclerosis. The goal of this study was to determine the effects of exercise programs on anthropometric, metabolic, and cardiovascular parameters in obese children.
Subjects and Methods
Fifty four obese children were included. Anthropometric data such as blood pressures, body mass index (BMI) and obesity index (OI) were measured. Blood glucose, total cholesterol, triglycerides, low density lipoprotein-cholesterol (LDL-C), high density lipoprotein-cholesterol (HDL-C), aspartate aminotransferase (AST), alanine aminotransferase (ALT), high sensitive-CRP (hs-CRP), brachial-ankle pulse wave velocity (BaPWV) and ankle brachial index (ABI) were measured. Physical fitness measurements were done. Obese children were divided into three groups: an aerobic exercise group (n=16), a combined exercise group (n=20), and a control group (n=18). Obese children exercised in each program for 10 weeks while those in the control group maintained their former lifestyle. After 10 weeks, anthropometric data and cardiovascular parameters were compared with the data obtained before the exercise program.
LDL-C, waist circumference, and systolic blood pressure decreased significantly in the aerobic exercise group compared to the control group (p<0.05). Waist circumference and systolic blood pressure decreased significantly in the combined exercise group compared to controls (p<0.05). Physical fitness level increased significantly after the exercise programs (p<0.05 vs. control). PWV did not show a significant change after exercise.
A short-term exercise program can play an important role in decreasing BMI, blood pressure, waist circumference, LDL-C and in improving physical fitness. Future investigations are now necessary to clarify the effectiveness of exercise on various parameters.
PMCID: PMC2859335  PMID: 20421958
Obesity; Exercise; Cardiovascular disease
23.  Prevalence of prehypertension in young military adults & its association with overweight & dyslipidaemia 
Background & objectives:
Estimation of prevalence of prehypertension in a population and its association with risk factors of cardiovascular disease is important to design preventive programmes. This cross-sectional study was carried out in a healthy military population to assess the prevalence of prehypertension and its association with risk factors such as overweight, abdominal adiposity and dyslipidaemia.
The study included 767 participants (130 officers and 637 from other ranks). The blood pressure, serum triglycerides and serum cholesterol (total, HDL and LDL) were assessed along with anthropometric measurements such as height, weight, waist-hip ratio in apparently healthy military personnel. Information on smoking, alcohol intake, dietary habits and physical activity was collected using pretested questionnaire. Prehypertension was defined as systolic blood pressure (SBP) 120-139 mm Hg and diastolic blood pressure (DBP) 80-89 mm Hg.
The overall prevalence of prehypertension was high (about 80%). The prevalence of other risk factors such as overweight (BMI>23 kg/m2), serum total cholesterol > 200 mg/dl, serum LDL cholesterol > 130 mg/dl, serum HDL cholesterol <40 mg/dl, serum triglyceride > 150 mg/dl in the total group was 30, 22, 22, 67, and 14 per cent, respectively. Most of the personnel undertook moderate or heavy exercise. A significantly higher proportion of individuals with prehypertension had clinical and behavioural risk factors such as overweight, dyslipidaemia and adverse dietary practices like saturated fat and added salt intake. On multivariate logistic regression analysis, prehypertension had significant positive association with BMI>23 kg/m2 (OR 1.75), age (OR 1.89), serum triglyceride >150 mg/dl (OR 2.25)and serum HDL cholesterol <40 mg/dl (OR 1.51).
Interpretation & conclusions:
The high prevalence of prehypertension and its association with overweight and dyslipidaemia in this young, physically active military population indicates an urgent need for targeted interventions to reduce the cardiovascular risk.
PMCID: PMC3181015  PMID: 21911967
Cardiovascular risk; dyslipidaemia; overweight; prehypertension
24.  The relationship between indices of iron status and selected anthropometric cardiovascular disease risk markers in an African population: the THUSA study 
Cardiovascular Journal of Africa  2011;22(5):249-256.
There is evidence that certain indices of iron status are associated with anthropometric measures, which are used independently as markers of cardiovascular disease (CVD) risk. This study examined whether this association exists in an African population. The study was a cross-sectional comparative study that examined a total of 1 854 African participants. Ferritin was positively associated with body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR), percentage body fat and subscapular skinfold thickness. Serum ferritin concentration was higher in the high-WHR category than the normal-WHR category for both genders. Additionally, WC and WHR increased with increasing ferritin concentrations in both genders. Serum iron was lower in the obese than the normal-weight and pre-obese women only. In this population-based study, increased serum ferritin concentrations associated positively with increased WHR and WC, indicating that individuals or populations at risk of iron overload as defined by high serum ferritin concentrations may be at a greater risk of developing CVD.
PMCID: PMC3721951  PMID: 21556462
iron indices; anthropometry; cardiovascular diseases; African; THUSA study
25.  Cross sectional study of childhood obesity and prevalence of risk factors for cardiovascular disease and diabetes in children aged 11–13 
BMC Public Health  2009;9:86.
Childhood obesity levels are rising with estimates suggesting that around one in three children in Western countries are overweight. People from lower socioeconomic status and ethnic minority backgrounds are at higher risk of obesity and subsequent CVD and diabetes.
Within this study we examine the prevalence of risk factors for CVD and diabetes (obesity, hypercholesterolemia, hypertension) and examine factors associated with the presence of these risk factors in school children aged 11–13.
Methods and design
Participants will be recruited from schools across South Wales. Schools will be selected based on catchment area, recruiting those with high ethnic minority or deprived catchment areas. Data collection will take place during the PE lessons and on school premises. Data will include: anthropometrical variables (height, weight, waist, hip and neck circumferences, skinfold thickness at 4 sites), physiological variables (blood pressure and aerobic fitness (20 metre multi stage fitness test (20 MSFT)), diet (self-reported seven-day food diary), physical activity (Physical Activity Questionnire for Adolescents (PAQ-A), accelerometery) and blood tests (fasting glucose, insulin, lipids, fibrinogen (Fg), adiponectin (high molecular weight), C-reactive protein (CRP) and interleukin-6 (IL-6)). Deprivation at the school level will be measured via information on the number of children receiving free school meals. Townsend deprivation scores will be calculated based on the individual childs postcode and self assigned ethnicity for each participating child will be collected. It is anticipated 800 children will be recruited. Multilevel modeling will be used to examine shared and individual factors associated with obesity, stratified by ethnic background, deprivation level and school.
This study is part of a larger project which includes interviews with older children regarding health behaviours and analysis of existing cohort studies (Millennium cohort study) for factors associated with childhood obesity.
The project will contribute to the evidence base needed to develop multi-dimensional interventions for addressing childhood obesity.
PMCID: PMC2667418  PMID: 19317914

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