The development of cardiovascular disease in relation to anthropometric indices and hypertension in British adults

To examine the predictive ability of simple anthropometric indices for the development of cardiovascular disease (CVD) over seven years in British adults, and the influence of hypertension on these associations. Longitudinal study of the development of CVD (morbidity or mortality) over a seven year period in a random stratified sample of British adults who were respondents in the 1984–1985 Health and Lifestyle Survey (HALS1) and who were seen again in 1991–1992 (HALS2) or who had died by then. Face-to-face interviews at HALS1 and HALS2 recorded socio-demographic, health and lifestyle details followed by measurements of height, weight, waist circumference and blood pressure (BP). The quintiles of body mass index (BMI), waist circumference, waist : height ratio (WHTR) and height were calculated for those aged between 35 and 75 y, at HALS1. Dates and causes of death were recorded. Logistic regression was used to estimate the odds ratios (OR) of developing CVD in 1284 men and 1570 women, aged 35–75 y who were free of known CVD, cancer and diabetes at HALS1.RESULTS: By HALS2, 316 respondents in the qualifying population had developed CVD, 114 of whom were dead. There were linear trends in the development of CVD (adjusted for age and smoking) for all the men from the lowest to the highest quintile of WHTR (P=0.034), but not for waist circumference (P=0.095), or BMI (P>0.2). Excluding the hypertensive men increased the significance of the trend for WHTR (P=0.005) and waist circumference (P=0.027). The significant interactions with hypertension for WHTR (P<0.001), waist circumference (P=0.006) and BMI (P=0.044) showed that there was an increasing incidence of CVD with increasing adiposity in non-hypertensive men but, in men with treated hypertension, although the overall incidence of CVD was higher, the relationship with adiposity was inverse.In the women, there were no significant linear trends for waist circumference, WHTR or BMI. Quintile estimates were more consistent with J-shaped curves with the lowest risk in the second quintile. Excluding the hypertensive women, increased the significance of these trends. In normotensive women, there was a significant quadratic trend (P=0.039) for the association between the incidence of CVD and the quintiles of waist circumference, but no associations for WHTR or BMI. For waist circumference there was weak evidence of an interaction with hypertension (P=0.053).CONCLUSIONS: For the men, indices involving waist circunference, particularly WHTR, had stronger linear associations with the log odds of CVD development than BMI. The interactions with hypertension were significant for WHTR, waist circunferenceand also BMI. In women, none of the indices was linearly associated with the log odds of CVD development, but there was a significant J-shaped curve for waist circumference and evidence of an interaction with hypertension. These results suggest that studies in which hypertensives are included, but in which possible hypertension interactions are overlooked, important hypertensive-specific associations between anthropometric indices and CVD development may be masked. Men on anti-hypertensive medication with the lowest central adiposity, experienced higher short-term CVD risk than those with greater central adiposity.

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title: Regional obesity and risk of cardiovascular disease; the Framingham Study.
abstract: Risk of cardiovascular events was determined over 24 years of surveillance in relation to general adiposity reflected by relative weight and by regional obesity estimated by skinfolds and waist girth per inch of height. Upper quintile values of relative weight, subscapular skinfolds and waist girth were each associated with increased risks of cardiovascular disease in both sexes. Risk of total cardiovascular events increased with the degree of regional, central or abdominal obesity. Mortality from cardiovascular disease was also increased. Increased relative weight and central obesity were both associated with increased risk factors including cholesterol, blood pressure, glucose and uric acid. Changes in weight were mirrored by changes in risk factors with linear trends over a 15 lb range of weight fluctuations. Subscapular skinfold and the ratio of subscapular-to-triceps skinfold, measures of central obesity, were in either sex also associated with an increased probability of coronary attacks in particular. The subscapular skinfold contributed to CHD risk independent of body mass index (BMI). Multivariate analyses taking all the risk factors into account indicate an independent effect of abdominal obesity on stroke, cardiac failure and cardiovascular and all-cause mortality in men. In women, only the subscapular-to-triceps skinfold ratio independently contributes to CHD, cardiovascular and all cause mortality. Regional obesity appears to be an independent contributor to cardiovascular disease at a given level of general adiposity, its effect only partially mediated through promotion of other known risk factors. These data suggest that cardiovascular disease is as closely linked to abdominal as to general adiposity.

title: Body mass index and cardiovascular mortality at different levels of blood pressure: a prospective study of Norwegian men and women.
abstract: The study investigated the joint effect of body mass index and systolic blood pressure on cardiovascular and total mortality. This was a prospective cohort study. The main outcome measures were age adjusted mortality and relative risks estimated from survival models. The population of the city of Bergen, Norway. Subjects were 21,145 men and 30,330 women aged 30-79 years at the time of examination in 1963. Both cause specific and all cause mortality increased with systolic blood pressure within each category of body mass index. Stroke mortality was not significantly associated with body mass index when adjusted for systolic blood pressure in either age group of men or women. Coronary heart disease mortality increased on average 30% per 5 kg/m2 increase in body mass index in men and women aged 30-59 years at baseline. Adjusted for systolic blood pressure, the relative risks were reduced to 1.20 (95% confidence interval (CI) 1.12, 1.29) in men and 1.10 (95% CI 1.03, 1.18) in women. They were similar at each level of systolic blood pressure. For coronary heart disease mortality in men and women aged 60-79 years at measurement a negative interaction between body mass index and systolic blood pressure was suggested in the first five years. Excluding the first five years, adjusted relative risks per 5 kg/m2, were 1.05 (95% CI 0.96, 1.15) in men and 1.11 (95% CI 1.04, 1.17) in women in the older age group. There was an upturn in cardiovascular mortality at low levels of body mass index in both age groups of women, but not in men. Hypertension is an important risk factor for cardiovascular and all cause mortality even in the obese. Body mass index is generally a weak predictor of cardiovascular mortality in this population. It is a stronger risk factor of coronary death in men when measured at a younger age. Thin people with hypertension are not at particularly high risk of death from coronary heart disease compared with their obese counterparts, except possibly in the first few years after measurement in the elderly. Being underweight is associated with increased risk of death from all cardiovascular causes in women, but not in men.

title: Skinfold thickness, body mass index and ischaemic heart disease.
abstract: To determine the relationship between obesity and subsequent incidence of ischaemic heart disease (IHD).  Prospective cohort survey.  Study of three occupational groups, with follow up examinations.  3500 people recruited between 1972 and 1978 (80% response rate), and followed up between 1978 and 1984. This report is based on subgroup of 1511 white men aged 40-64 at entry.  Information was obtained on smoking and family history of IHD. Blood pressure, weight, height, skinfold thickness at four sites, fibrinogen, factor VII activity and cholesterol were measured during follow up. Body mass index (BMI) was used as an index of obesity. BMI was found to be more strongly correlated with IHD than any of the skinfold measurements, none of which was significantly associated with IHD when BMI was allowed for. Increase in BMI by 1 SD (approximately 8 kg) was associated with a 44% increase in the risk of IHD. Of the four skinfolds, subscapular was the most closely associated with risk, confirming the relevance of central obesity. The association between obesity and IHD remained when possible mechanisms for its effects were taken into account, and its strength may increase with time: for 1 SD increase in BMI, risk of events within 5 years was increased by 28%, while risk of events after longer than 5 years was increased by 65%.  Preventive strategies for IHD should include avoidance of obesity.

title: Body size and fat distribution as predictors of coronary heart disease among middle-aged and older US men.
abstract: Obesity, android fat distribution, and other anthropometric measures have been associated with coronary heart disease in long-term prospective studies. However, fluctuations in weight due to age-related hormonal changes and changes in lifestyle practices may bias relative risk estimates over a long follow-up period. The authors prospectively studied the association between body mass index (BMI) (kg/m2), waist-to-hip ratio, and height as independent predictors of incident coronary heart disease in a 3-year prospective study among 29,122 US men aged 40-75 years in 1986. The authors documented 420 incident coronary events during the follow-up period. Body mass index, waist-to-hip ratio, short stature, and weight gain since age 21 were associated with an increased risk of coronary heart disease. Among men younger than 65, after adjusting for other coronary risk factors, the relative risk was 1.72 (95% confidence interval (CI) 1.10-2.69) for men with BMI of 25-28.9, 2.61 (95% CI 1.54-4.42) for BMI of 29.0-32.9, and 3.44 (95% CI 1.67-7.09) for obese men with BMI > or = 33 compared with lean men with BMI < 23.0. Among men > or = 65 years of age, the association between BMI and risk of coronary heart disease was much weaker. However, in this age group, the waist-to-hip ratio was a much stronger predictor of risk (relative risk = 2.76, 95% CI 1.22-6.23 between extreme quintiles). These results suggest that for younger men, obesity, independent of fat distribution, is a strong risk factor for coronary heart disease. For older men, measures of fat distribution may be better than body mass index at predicting risk of coronary disease.

title: Mortality by relative weight and exercise
abstract: Mortality in relation to relative weight and exercise was analyzed from data collected in the first 2 years of the American Cancer Society's Cancer Prevention Study II. It included data on 868,620 persons who had no history of cancer, heart disease, or stroke and who were not sick at the start of the study. Standardized mortality ratios (SMR) were 187 for men who were 20% or more underweight and 187 for men who were 40% or more overweight. Comparable SMR in women were 186 and 178. Current smokers had considerably higher SMR than nonsmokers for all causes of death and cancer deaths at each relative weight category. Degree of exercise reported by subjects was inversely related to mortality, independent of smoking habits. Subjects who exercised heavily and died of cancer of the lung, colonrectum, and pancreas had 20% to 37% higher SMR than men and women who reported moderate exercise.

title: Abdominal adipose tissue distribution, obesity, and risk of cardiovascular disease and death: 13 year follow up of participants in the study of men born in 1913.
abstract: In a prospective study of risk factors for ischaemic heart disease 792 54 year old men selected by year of birth (1913) and residence in Gothenburg agreed to attend for questioning and a battery of anthropometric and other measurements in 1967. Thirteen years later these baseline findings were reviewed in relation to the numbers of men who had subsequently suffered a stroke, ischaemic heart disease, or death from all causes. Neither quintiles nor deciles of initial indices of obesity (body mass index, sum of three skinfold thickness measurements, waist or hip circumference) showed a significant correlation with any of the three end points studied. Statistically significant associations were, however, found between the waist to hip circumference ratio and the occurrence of stroke (p = 0.002) and ischaemic heart disease (p = 0.04). When the confounding effect of body mass index or the sum of three skinfold thicknesses was accounted for the waist to hip circumference ratio was significantly associated with all three end points. This ratio, however, was not an independent long term predictor of these end points when smoking, systolic blood pressure, and serum cholesterol concentration were taken into account. These results indicate that in middle aged men the distribution of fat deposits may be a better predictor of cardiovascular disease and death than the degree of adiposity.

title: Overweight and stroke in the Whitehall study.
abstract: The aim was to examine the risk of increasing overweight for death from stroke. This was a prospective cohort study, in which the main outcome measure was the mortality ratio for stroke with increasing body mass index. Civil service departments, Whitehall, London. Participants were 17,753 men aged 40 to 64 years.  Men aged 40 to 54 in the most overweight quintile of body mass index had a mortality ratio of 2.01 (95% confidence interval 0.9 to 4.7) compared to the thinnest quintile. The mortality ratio was 1.19 (95% CI 0.7 to 2.0) in men aged 55 to 64. The increase in risk was more apparent in non-smokers: age adjusted mortality ratio 2.58 (95% CI 1.2 to 5.7). When smoking status and overweight were considered in combination a gradient of the age adjusted mortality ratio was observed, from 1.0 in thinner/non-smokers up to 3.15 in fatter/current smokers. On the assumption that smoking and obesity cause strokes, an estimated 60% of strokes could be prevented if these two easily identifiable risk factors could be avoided. The risks of overweight for death from stroke were more apparent in younger subjects and non-smokers. A substantial proportion of stroke deaths occurring under the age of 80 years would probably be prevented if cigarette smoking and overweight could be avoided.

title: Body size and fat distribution as predictors of stroke among US men.
abstract: Evidence for an association between general obesity and risk of stroke is weak. However, abdominal obesity may be more closely related to stroke risk. The association of body mass index and abdominal obesity (waist/hip ratio) with stroke incidence was examined in 28,643 US male health professionals, aged 40-75 years in 1986, who had no history of cardiovascular disease or stroke. In 5 years of follow-up, there were 118 cases of stroke, of which 80 were ischemic. Compared with men in the lowest quintile of body mass index, men in the highest quintile had an age-adjusted relative risk of stroke of 1.29 (95% confidence interval 0.73-2.27). In contrast, the age-adjusted relative risk for extreme quintiles of waist/hip ratio was 2.33 (95% confidence interval 1.25-4.37). This relative risk was not substantially altered in a multivariate model including body mass index, height, and other potential risk factors. There was a weaker relation with waist circumference alone, with men in the highest quintile (> 40.2 inches) having a relative risk of 1.52 (95% confidence interval 0.82-2.82) compared with men in the lowest quintile (< or = 34.5 inches) (1 inch = 2.54 cm). The results suggest that abdominal obesity, but not elevated body mass index, predicts risk of stroke in men.

title: Distribution of adipose tissue and risk of cardiovascular disease and death: a 12 year follow up of participants in the population study of women in Gothenburg, Sweden.
abstract: A longitudinal population study of 1462 women aged 38-60 was carried out in Gothenburg, Sweden, in 1968-9. In univariate analysis the ratio of waist to hip circumference showed a significant positive association with the 12 year incidence of myocardial infarction, angina pectoris, stroke, and death. The association with incidence of myocardial infarction remained in multivariate analysis and was independent of age, body mass index, smoking habit, serum cholesterol concentration, serum triglyceride concentration, and systolic blood pressure. The relation between the ratio of waist to hip circumference and the end points of myocardial infarction, angina pectoris, stroke, and death was stronger than for any other anthropometric variable studied.

title: Body size and mortality in women: a 29 year follow up of 12,000 pregnant women in northern Finland.
abstract: To examine the association between body height, body mass index (BMI), and mortality in fertile women of childbearing age.  A prospective cohort study with a 29 year mortality follow up.  A cohort of women (n = 11,997) expected to deliver during 1966 in two northern provinces of Finland. Data on height and pre-pregnancy weight, collected with those on sociodemographic characteristics and smoking by questionnaire at the third trimester, were provided by 91% of the participants. Follow up for mortality using national registries was from delivery until the end of 1994.  Height had a 'U' shaped association with total mortality over the whole follow up time. In women who were shorter than average, the death rate from cardiovascular diseases was increased and in taller women this was true for tumours. Compared with the women of 'normal weight' (BMI 21 to < 25 kg/m2), the obese subjects (BMI at least 29) did not have increased mortality during the first 20 years, but had a relative risk of 1.7 during the final nine years of follow up, primarily as a result of cardiovascular diseases. The lean women (BMI < 21) experienced a similar rate overall, but moderately overweight women (BMI 25 to < 29) had a consistently lower mortality than women of normal weight.  Among fertile women of childbearing age, both the short and tall seem to have an increased total mortality compared with those of average body height, resulting from opposite trends in major causes of death. Obesity is associated with raised long term total mortality.

title: Hazards of obesity--the Framingham experience.
abstract: Measurements of height, weight, skinfolds and waist girth were used as indicators of general and regional obesity in the Framingham study population of 5,209 men and women. Mean values of cholesterol, blood pressure, blood glucose and uric acid increased with increasing body mass index (BMI). Weight gain was associated with increases and weight loss with decreases in these risk factors. Cigarette smoking was more prevalent in men and women with low quintile BMI. Upper quintile values of BMI, subscapular skinfolds, and waist girth were associated with increased relative risks of death from all causes, coronary heart disease (CHD) and cerebrovascular disease but relative risks for intermittent claudication were not increased. General and central obesity each made independent contributions to risk of CHD but central obesity was a better predictor in males. BMI, cholesterol, systolic blood pressure and blood glucose were significantly independent predictors of CHD. These data show that increased relative weight and central obesity are associated with elevated levels of risk factors, with increased incidence of cardiovascular disease and with increased death rates for all causes combined. Mortality rates are also increased among the leanest members of the population, especially among older men.

title: Body fat distribution and self-reported prevalence of hypertension, heart attack, and other heart disease in older women.
abstract: The associations of self-reported body mass and fat distribution with self-reported prevalence rates of hypertension, heart attack, and other heart disease were examined in a sample of 40,000 women, aged 55-69 years. Fat distribution was measured by the waist-to-hip circumference ratio (WHR), which had a mean +/- SD of 0.838 +/- 0.085. Prevalence of hypertension was significantly and positively associated with both body mass index (BMI) and waist-to-hip ratio. The prevalence rate ratio for hypertension in the highest versus the lowest tertile of body mass index and waist-to-hip ratio (considered jointly) was 2.7. Prevalence rates of heart attack and other heart disease were significantly and positively associated with waist-to-hip ratio but not with body mass index. The prevalence rate ratios were 2.2 for heart attack and 1.4 for other heart disease in the highest versus the lowest tertile of body mass index and waist-to-hip ratio. Findings were substantiated using multiple logistic regression. These results support the hypothesis that a significant relationship exists between body fat distribution and the occurrence of cardiovascular disease in older women.

title: Association of anthropometric indices with elevated blood pressure in British adults
abstract: To investigate which of six anthropometric indices was most strongly associated with elevated blood pressure and frank hypertension in a representative population sample of young and middle-aged British adults.  A representative random sample of British adults (2712 men and 3279 women) aged between 18 and 64 y, who were resident in England, Scotland and Wales, were studied in the 1984–85 Health and Lifestyle Survey.  Following an interview where demographic, health and lifestyle details were recorded, measurements of height, weight and waist and hip circumference were made by a nurse at a home visit, where blood pressure and medication to control blood pressure were also recorded. BMI and the ratios of waist circumference to height (WHTR) and waist circumference to hip (WHR) were calculated. Respondents with a blood pressure above 140 mm Hg (systolic) and/or 90 mm Hg (diastolic) or who were being treated for hypertension were classified as having elevated blood pressure.  For men and women aged 18–39 and 40–64 y the prevalence of elevated blood pressure increased across the quintiles of BMI, weight, waist, WHTR and WHR was P<0.001 for each, with waist and WHTR having the highest odds ratios. Waist and height adjusted for each other were independently related to the prevalence of elevated blood pressure in 40–64 y old men and women. Height, on its own, was inversely related (P<0.05) only in the 40–64 y old men.  The age adjusted partial correlations between systolic and diastolic blood pressure measurements and the measurements of BMI, weight, waist, WHTR and WHR were close and significant, P<0.001 for each. The ranking and significance of the correlations were hardly affected by excluding the treated hypertensives.  The prevalence of elevated blood pressure was associated with quintiles of BMI, waist, WHTR, WHR and weight, with WHTR and WHR having the highest odds ratios. Waist and height were independently related to the prevalence of elevated blood pressure.

title: A prospective study of obesity and risk of coronary heart disease in women.
abstract: We examined the incidence of nonfatal and fatal coronary heart disease in relation to obesity in a prospective cohort study of 115,886 U.S. women who were 30 to 55 years of age in 1976 and free of diagnosed coronary disease, stroke, and cancer. During eight years of follow-up (775,430 person-years), we identified 605 first coronary events, including 306 nonfatal myocardial infarctions, 83 deaths due to coronary heart disease, and 216 cases of confirmed angina pectoris. A higher Quetelet index (weight in kilograms divided by the square of the height in meters) was positively associated with the occurrence of each category of coronary heart disease. For increasing levels of current Quetelet index (less than 21, 21 to less than 23, 23 to less than 25, 25 to less than 29, and greater than or equal to 29), the relative risks of nonfatal myocardial infarction and fatal coronary heart disease combined, as adjusted for age and cigarette smoking, were 1.0, 1.3, 1.3, 1.8, and 3.3 (Mantel-extension chi for trend = 7.29; P less than 0.00001). As expected, control for a history of hypertension, diabetes mellitus, and hypercholesterolemia--conditions known to be biologic effects of obesity--attenuated the strength of the association. The current Quetelet index was a more important determinant of coronary risk than that at the age of 18; an intervening weight gain increased risk substantially. These prospective data emphasize the importance of obesity as a determinant of coronary heart disease in women. After control for cigarette smoking, which is essential to assess the true effects of obesity, even mild-to-moderate overweight increased the risk of coronary disease in middle-aged women.

title: Is the relationship between blood pressure and cardiovascular risk dependent on body mass index?
abstract: The relationship between blood pressure and cardiovascular mortality according to body mass index has been analyzed in two French prospective studies: the Paris Prospective Study, composed of 7,704 men aged 40-53 years examined in 1967-1972, and the Investigations Pré-Cliniques Study, made up of 19,618 men aged 40-69 years who underwent a checkup in 1970-1980. In the Paris Prospective Study, during a mean follow-up of 11.2 years, 241 cardiovascular deaths occurred, while in the Investigations Pré-Cliniques Study, with a mean follow-up of 7.6 years, 262 cardiovascular deaths occurred. A Cox survival analysis was performed on the data of each study to test the interaction of blood pressure and body mass index in the prediction of cardiovascular risk. Both analyses demonstrate a significant negative interaction, suggesting that a decreasing trend of the relative risk of cardiovascular death with increasing body mass index is better supported by the data than a constant relative risk. These results might have some bearing on the problem of the management of hypertension in overweight subjects.

title: Short stature, lung function and risk of a heart attack.
abstract: In a large prospective study of cardiovascular disease in 7735 middle-aged men--the British Regional Heart Study--the 443 subjects who experienced a major ischaemic heart disease event within 7.5 years of follow-up were on average 1.6 cm shorter than the other men (p less than 0.001). The risk of heart attack was approximately twice as great in the shortest quintile of men compared with the tallest quintile. When a number of recognized risk factors for ischaemic heart disease were taken into account--age, social class, serum total cholesterol, HDL-cholesterol, systolic blood pressure, cigarette smoking--there was a marked reduction in the risk of heart attack associated with height. When a measure of lung function (FEV1 not standardized for height) was adjusted for in addition to these risk factors, the height-related risk of heart attack disappeared. Indeed, FEV1 alone was sufficient to account for most of the association between height and the risk of heart attack.

title: Short stature and risk for mortality and cardiovascular disease events. The Framingham Heart Study.
abstract: Several studies have observed an inverse association between height and risk for coronary disease, but it is unclear whether other traditional coronary disease risk factors may have confounded this association. We examined the original Framingham Heart Study cohort to determine whether short stature is associated with all-cause mortality, cardiovascular disease mortality, and myocardial infarction after adjusting for age and other traditional coronary heart disease risk factors.



A total of 2019 men and 2585 women were followed up to 35.6 years. Subjects were stratified by sex and divided into quartiles according to height. Risk ratios were calculated from proportional hazards analyses comparing the first, second, and third quartiles of height to the tallest quartile before and after adjusting for age, hypertension, smoking, serum cholesterol, diabetes, relative weight, and alcohol intake. In both sexes, there were significant differences in the unadjusted event rates between the shortest and the tallest quartile for all-cause mortality, cardiovascular mortality, and myocardial infarction. Once the analyses were age adjusted, differences among height quartiles persisted only for risk of myocardial infarction in women. Further adjustment for other clinical variables had little additional impact on the results.



After considering age and other coronary disease risk factors, short stature was not associated with increased risk for all-cause or cardiovascular mortality in either sex. It was associated with increased risk for myocardial infarction in women but not in men.

title: The health and lifestyle survey : seven years on
abstract: This work describes changes in self-reported and measured health, attitude to and knowledge about health, cognitive functioning and lifestyle habits - diet, smoking, alcohol consumption, exercise and leisure activities - between the first survey in 1984-5 and the second in 1991-2.

title: Obesity and essential hypertension. Hemodynamics, intravascular volume, sodium excretion, and plasma renin activity.
abstract: Systemic hemodynamics, intravascular volume, and plasma renin activity were determined in 135 lean, midly obese, or distinctly overweight subjects who were normotensive or had borderline or established essential hypertension. Cardiac output (but not index) was higher and peripheral resistance lower in obese than in lean subjects, except in borderline hypertension. Intravascular volume was increased in obese patients, and more so when corrected for body height; correction for body weight led to relative volume contraction. Intravascular volume correlated directly with cardiac output in the entire population, as well as in the subgroups. Intravascular volume correlated inversely with total peripheral resistance in all subjects and in each subgroup. Both correlations remained significant when an approximation was used to correct influences of obesity on total blood volume. Sodium excretion was higher in obese than in lean subjects. Thus, despite the expanded intravascular volume in obesity, the pathophysiologic relationship between systemic hemodynamics and intravascular volumes remains unchanged. Relatively low peripheral resistance in obesity may decrease the risk of systemic vascular disease. Nevertheless, since circulating volume is increased, the greater venous return adds an additional load to a left ventricle that is already burdened by a high afterload caused by arterial hypertension.

title: Waist circumference as a measure for indicating need for weight management
abstract: To test the hypothesis that a single measurement, waist circumference, might be used to identify people at health risk both from being overweight and from having a central fat distribution.  A community derived random sample of men and women and a second, validation sample.  North Glasgow.  904 men and 1014 women (first sample); 86 men and 202 women (validation sample).  Waist circumference, body mass index, waist:hip ratio.  Waist circumference >/=94 cm for men and >/=80 cm for women identified subjects with high body mass index (>/=25 kg/m2) and those with lower body mass index but high waist:hip ratio (>/=0.95 for men, >/=0.80 women) with a sensitivity of >96% and specificity >97.5%. Waist circumference >/=102 cm for men or >/=88 cm for women identified subjects with body mass index >/=30 and those with lower body mass index but high waist:hip ratio with a sensitivity of >96% and specificity >98%, with only about 2% of the sample being misclassified.  Waist circumference could be used in health promotion programmes to identify individuals who should seek and be offered weight management. Men with waist circumference >/=94 cm and women with waist circumference >/=80 cm should gain no further weight; men with waist circumference >/=102 cm and women with waist circumference >/=88 cm should reduce their weight.

title: Waist circumference action levels in the identification of cardiovascular risk factors: prevalence study in a random sample
abstract: To determine the frequency of cardiovascular risk factors in people categorised by previously defined “action g126 levels” of waist circumference.  Prevalence study in a random population sample.  Netherlands.  2183 men and 2698 women aged 20-59 years selected at random from the civil registry of Amsterdam and Maastricht.  Waist circumference, waist to hip ratio, body mass index (weight (kg)/height (m2)), total plasma cholesterol concentration, high density lipoprotein cholesterol concentration, blood pressure, age, and lifestyle.  A waist circumference exceeding 94 cm in men and 80 cm in women correctly identified subjects with body mass index of >/=25 and waist to hip ratios >/=0.95 in men and >/=0.80 in women with a sensitivity and specificity of >/=96%. Men and women with at least one cardiovascular risk factor (total cholesterol >/=6.5 mmol/l, high density lipoprotein cholesterol </=0.9 mmol/l, systolic blood pressure >/=160 mm Hg, diastolic blood pressure >/=95 mm Hg) were identified with sensitivities of 57% and 67% and specificities of 72% and 62% respectively. Compared with those with waist measurements below action levels, age and lifestyle adjusted odds ratios for having at least one risk factor were 2.2 (95% confidence interval 1.8 to 2.8) in men with a waist measurement of 94-102 cm and 1.6 (1.3 to 2.1) in women with a waist measurement of 80-88 cm. In men and women with larger waist measurements these age and lifestyle adjusted odds ratios were 4.6 (3.5 to 6.0) and 2.6 (2.0 to 3.2) respectively.  Larger waist circumference identifies people at increased cardiovascular risks.

title: Effectiveness of an abdominal obesity reduction programme in men: the GutBuster "waist loss' programme.
abstract: To examine the long term (1-2 year), as well as immediate effectiveness of a "waist loss' programme for men.



Two preliminary studies are reported; one following a small group of 42 men over two years after a 6 week "GutBuster' course, the second following men for 1 year after having completed the initial 6 week programme (n = 83), or the initial course plus an additional six fortnightly "advanced' course (n = 37).



Waist, hip and weight measures were reported for the 2 year group; waist and hip only in study 2. Dietary fat, exercise and alcohol intake were also recorded in study 2 through the use of questionnaires. The goal for the initial course was a 1% waist loss per week.



All groups achieved an average waist loss > 1%/week during the initial programme. Waist sizes reported in study 1 were significantly less after 2 years (t = 8.28, p < 0.001) averaging a 6% loss in the group. This equated with an average weight loss of 5.5 kg. A repeated measures ANOVA also showed a significant main effect (F = 85.35; p < 0.0001) for waist losses and an interaction effect (F = 16.53; p < 0.0001) between initial and advanced groups after 1 year in study 2. Average waist losses were 4% and 10% respectively. There were also significant changes in dietary fat intake, exercise and alcohol consumption.



Reductions in waist size in men appear to be more feasible than weight losses in women. "Waist loss' may also be a more valid measure of fat loss in men that body mass measures.

title: Waist circumference reduction and cardiovascular benefits during weight loss in women
abstract: To examine the relationship between waist circumference and cardiovascular risk factors during weight loss, and to consider possible waist reduction targets for weight management.  Single strand six month weight loss study on food based diets in 110 women aged 18–68 y, and body mass index≥25 kg/m2 set at an outpatient clinic.  Waist circumference, weight, body mass index (BMI), total plasma cholesterol, low (LDL) and high density lipoprotein (HDL) cholesterol, triglyceride, and blood pressure.  Anthropometric and metabolic measurements improved with mean weight loss of 4.9 (s.e.m.±0.4) kg at three months and 6.2 (s.e.m.±0.4) kg at six months. Weight loss closely related to waist reduction (% Weight loss=0.85×Waist reduction (cm) – 2.09; r=0.79). The proportion of subjects with waist circumference below Action Level 1 (<80 cm) or above Action Level 2 (≥88 cm) were 9 and 60% at baseline, 29 and 38% at three months and 36 and 33% at six months. Waist reduction (adjusted for age, smoking, alcohol consumption, diet treatment and baseline dependent and independent variables) correlated significantly with falls in total cholesterol (r=0.31; P<0.01), LDL cholesterol (r=0.35; P<0.01) and diastolic blood pressure (r=0.32; P<0.01), but not significantly with HDL cholesterol, triglyceride or systolic blood pressure. BMI showed similar correlations, whereas waist to hip ratio changes were not associated with changes in any cardiovascular risk factors. Amongst those whose waist fell by ≥5 cm, 45 at three months and 43 at six months, there were ≥10% improvements in at least one risk factor for 71 and 84% respectively. Amongst those whose waist fell by 5–10 cm, 40 women at three months and 30 at six months, at least one risk factor improved by ≥10% in 70% and in 83% respectively.  Waist reduction of 5–10 cm in Caucasian women, across a range of baseline BMI 25–50 kg/m2 or waist circumference 72–133 cm, may be used as guideline to encourage overweight women to achieve a realistic target with a high probability of health benefits.