To test the validity of internationally accepted waist circumference (WC) action levels for adult Asian Indians.
Analysis of data from multisite cross-sectional epidemiological studies in north India.
In all, 2050 adult subjects >18 years of age (883 male and 1167 female subjects).
Body mass index (BMI), WC, waist-to-hip circumference ratio, blood pressure, and fasting samples for blood glucose, total cholesterol, serum triglycerides, and high-density lipoprotein cholesterol.
In male subjects, a WC cutoff point of 78 cm (sensitivity 74.3%, specificity 68.0%), and in female subjects, a cutoff point of 72 cm (sensitivity 68.7%, specificity 71.8%) were appropriate in identifying those with at least one cardiovascular risk factor and for identifying those with a BMI >21 kg/m2. WC levels of ⩾90 and ⩾80 cm for men and women, respectively, identified high odds ratio for cardiovascular risk factor(s) and BMI level of ⩾25 kg/m2. The current internationally accepted WC cutoff points (102 cm in men and 88 cm in women) showed lower sensitivity and lower correct classification as compared to the WC cutoff points generated in the present study.
We propose the following WC action levels for adult Asian Indians: action level 1: men, ⩾78 cm, women, ⩾72 cm; and action level 2: men, ⩾90 cm, women, ⩾80 cm.
The criteria for selection of cutoff points of waist circumference (action level 1: men, ⩾94 cm, women, ⩾80 cm; and action level 2: men, ⩾102 cm, women, ⩾88 cm)1 for diagnosis of abdominal obesity are based on data derived from white Caucasians. These waist circumference cutoff points were based on high sensitivity and specificity profiles against cutoff values of body mass index (BMI) (25 kg/m2 for action level 1 and 30 kg/m2 for action level 2) and waist-to-hip circumference ratio (W-HR) (0.95 for men and 0.80 for women) for both action levels in adult European Caucasians.1 However, sensitivity and specificity of these cutoff points were low in the same Caucasian population when correlated with individual cardiovascular risk factors.2 The cutoff points of waist circumference have also been identified in white Caucasians in Canada, based on absolute amount of visceral fat area.3
Importantly, these cutoff points of waist circumference have been analyzed based on arbitrary limits of W-HR and visceral fat area as references. Furthermore, the reference BMI limits against which the waist circumference sensitivity and specificity profile were calculated do not apply to Asians4 in whom a limit of 23 kg/m2 has been considered to be appropriate for diagnosis of overweight.5
A major hindrance in setting uniformly applicable criteria for waist circumference or identification of abdominal obesity is heterogeneity in total mass and composition of skeletal muscles, subcutaneous and intra-abdominal adipose tissue, and bone in different ethnic groups. Less skeletal muscle mass and pelvic skeleton dimensions are seen in Asians, particularly those who have suffered childhood malnutrition, and may affect waist and hip circumferences.6, 7 More importantly, Asian Indians have excess body fat and abdominal adiposity.8 All these and racial factors affect the relationships between abdominal obesity and waist or hip circumference.
Considering these data, experts have opined that due to heterogeneity in the average levels of measures of obesity in different populations, cutoff points of BMI and waist circumference should be set differently for Asian populations and persons of Asian ancestry living in Western countries.9 The WHO Expert Committee on Obesity in Asian and Pacific populations suggested revised cutoff points for waist circumference: 90 cm for men and 80 cm for women for identifying persons with abdominal obesity.5 However, these preliminary proposals were derived from limited data. In a previous study on limited number of subjects, we had concluded that definition of ‘normal’ ranges of waist circumference need to be revised for Asian Indians.10 Studies in Asian Indians are few10, 11 and suffer from limitations in methodology, sample size, or design.
We hypothesized that waist circumference action levels for Asian Indians are lower than those currently accepted internationally. To investigate this hypothesis, we evaluated several waist circumference cutoff points in relation to BMI cutoff points and cardiovascular risk factors in Asian Indians residing in north India.
Materials and methods
Study design and sampling method
For the current analysis, data from three studies approved by institutional review boards were analyzed. These epidemiological, population-based studies were conducted between 1998 and 2003 in two metropolitan cities in north India by two investigators. Two studies were conducted in New Delhi by our group (AM, NKV): the first on urban adult population12 and the second on subjects aged 14–25 years.13 The first study from New Delhi included subjects residing in an urban resettlement colony. Out of the total population of about 30 000, 650 subjects were screened using systematic random sampling method. Out of these, complete data were available for 534 subjects, which were used for analysis in this study. The second study from New Delhi included subjects aged 18–25 years drawn from an approximate total population of 15 000 subjects from schools and colleges of southwest Delhi using multistage cluster sampling based on modified World Health Organization (WHO) Expanded Program of Immunization Sampling Plan as described elsewhere.13 Complete data were available for 512 subjects in this age group, which were used for analysis in this study. The third study, Jaipur Heart Watch-2 (JHW-2), was conducted by another investigator (RG) in the city of Jaipur located in the northwest of Rajasthan, nearly 250 km from New Delhi, according to the previously published methods.14 The city of Jaipur has a total population of about 2 324 319 distributed in 70 municipal wards with population in each ward varying from 18 000 to 20 000 people. For the study, 1123 subjects were selected randomly from each locality using the random number technique on the voters' list from six wards, with a total population of about 130 000. An informed consent was obtained from all subjects. For the present study, data from the subjects older than 18 years of age have been analyzed.
Clinical profile and measurements
The data of blood pressure measurement and anthropometric parameters (height, weight, and waist and hip circumferences) were available for all subjects. Blood pressure was measured in the right arm with the subject seated and rested for 5 min using a standard mercury sphygmomanometer in all the studies. At least two readings at 5 min intervals were taken and if an abnormal value was obtained, then another reading was taken after 30 min of rest. Waist circumference was measured midway between the iliac crest and the lower most margin of the ribs with bare belly and at the end of normal expiration, and the hip girth was measured at the intertrochantric level according to the WHO guidelines.15 All the measurements were made by a single observer in each of the respective studies.
For all the three studies, fasting blood glucose (FBG) levels and lipid profile were estimated according to previously described methods.13, 16, 17 Total cholesterol (TC), triglycerides (TG), and high-density lipoprotein cholesterol (HDL-c) were measured according to the methods described earlier13, 16, 17 Low-density lipoprotein cholesterol (LDL-c) levels were calculated using the Friedewald's formula.18
Value of BMI ⩾23 kg/m2 was used to define overweight and ⩾25 kg/m2 was used to define obese.5 High waist circumference was defined using two cutoff points. According to the first definition, value of waist circumference >90 cm in men and >80 cm in women was defined as abnormal.5 The second cutoff points were as defined by National Cholesterol Education Program, Adult Treatment Panel III (NCEP, ATP III): men, >102 cm, women, >88 cm.19 Hypertension was defined as a blood pressure of ⩾140/90 mmHg or if the person was on treatment with antihypertensive medication(s).20 Dyslipidemia was defined according to NCEP, ATP III guidelines.19 Type 2 diabetes was diagnosed according to the American Diabetes Association criteria of fasting plasma glucose value ⩾126 mg/dl alone and history of diabetes.21 For effective primary prevention, it is necessary to initiate preventive measures at the earliest, that is, at the time of detection of any single risk factor (action level 1). If the individuals with one risk factor were not identified early, the development of additional factors would increase the risk further. Therefore, in the present study, the presence of one risk factor was defined as a positive case. The cardiovascular risk factors were defined as type 2 diabetes mellitus, hypertension, hypertriglyceridemia, hypercholesterolemia, and low levels of HDL-c.
The data were pooled together and managed on an excel spreadsheet. Data from a total of 2050 subjects (1046 subjects from two studies conducted in New Delhi and 1004 subjects from JHW-2 study) have been included in this analysis. Mean and standard deviations summarized the continuous variables. The differences in the anthropometric and biochemical parameters were compared using Z-test. Subjects were categorized into those in whom no cardiovascular risk factors was present and in those in whom at least one of the cardiovascular risk factor was present. Receiver Operating Characteristics Curve (ROC) analysis was performed to determine the appropriate cutoff points of BMI and waist circumference in identifying those with presence of at least one cardiovascular risk factor. Subsequently, the sensitivity and specificity of the new cutoff points of BMI and waist circumference were compared with the standard respective cutoff points (international cutoffs and those suggested for Asian Indians) in identifying those with at least one risk factor. In addition, the sensitivity and specificity of various waist circumference cutoff points in identifying subjects with various BMI cutoff points (⩾23, ⩾25 kg/m2, and the new cutoff points generated) was determined. Logistic regression analysis was used to determine the odds ratio (95% CI) of the presence of at least one cardiovascular risk factor in subjects categorized by the waist circumference levels with adjustments made for age. STATA 8.0 Intercooled version (Stata Corporation, College Station, TX, USA) was used for the statistical analysis. For this analysis, P-value <0.05 was considered as statistically significant.
Anthropometric and biochemical profile (Table 1)
A total of 2050 subjects (883 men and 1167 women) were included in the study. Women (mean age 40.5±14.7 years) were older than men (mean age 38.8±14.8 years, P=0.01). Mean value of BMI was comparable in both the sexes but men had significantly higher waist circumference and W-HR than women. Among the biochemical parameters, mean values of TC, LDL-c, and HDL-c were higher in women, mean value of serum TG was higher in men, and mean FBG was comparable in both the sexes. Prevalence of type 2 diabetes mellitus and hypertriglyceridemia was comparable in both men and women, whereas prevalence of hypertension, hypercholesterolemia, and low levels of HDL-c was higher in women.
BMI cutoff point 21 kg/m2 was observed to identify those with at least one risk factor with a sensitivity and specificity of 63.6 and 65.1%, respectively (Table 2). The other BMI cutoff points, ⩾23 and ⩾25 kg/m2, had higher specificity but much lower sensitivity than the cutoff point of ⩾21 kg/m2 in identifying those with at least one cardiovascular risk factor.
In men, a cutoff point of 78 cm (sensitivity 74.3%, specificity 68.0%), and in women, a cutoff point of 72 cm (sensitivity 68.7%, specificity 71.8%) were optimal in identifying those with at least one cardiovascular risk factor (Table 2). The previously suggested cutoff points of waist circumference given by NCEP, ATP III (102 cm in men and 88 cm in women) and that proposed for Asians (90 cm in men and 80 cm in women) were observed to have lower sensitivity and less correct classification as compared to the cutoff points generated in the present study (Table 2). In men, the risk of at least one cardiovascular risk factor was 2, 4.2, and 4.3 times with a waist circumference value of 78–90, 90–102, and >102 cm, respectively. In women, the risk was 1.3, 2.2, and 3.4 times with a waist circumference value of 72–80, 80–88, and >88 cm, respectively, for the presence of at least one cardiovascular risk factor (Table 3).
The ability of various cutoff points of waist circumference in identifying subjects with a BMI ⩾21, ⩾23, and ⩾25 kg/m2 is shown in Table 4. The waist circumference cutoff points of 78 and 72 cm for men and women, respectively, were observed to be optimum (high sensitivity and high specificity) in identifying those with a BMI ⩾21 kg/m2. The waist circumference cutoff points of 90 cm in men and 80 cm in women were observed to be optimum in identifying those with a BMI ⩾25 kg/m2. In identifying those with a BMI ⩾23 kg/m2, in men, the waist circumference cutoff point of 90 cm had lower sensitivity but higher specificity and correct classification than the cutoff point of 78 cm. In women, the waist circumference cutoff point of 80 cm was observed to be optimum in identifying those with a BMI ⩾23 kg/m2. The NCEP, ATP III-defined waist circumference cutoff points of 102 cm in men and 88 cm in women had high specificities, but had much lower sensitivities than the other waist circumference cutoff points in identifying those with any cutoff point of BMI. The prevalence of at least one risk factor was observed to be higher with the waist circumference cutoff points of 78 and 72 cm than other waist circumference cutoffs at any BMI cutoff point.
This is the first study in Asian Indians showing detailed analysis of waist circumference cutoff points using multiple cardiovascular risk factors and BMI as reference points. Waist circumference level 1 cutoff points, which identified those with at least one cardiovascular risk factor and BMI levels of 21–23 kg/m2, were 78 and 72 cm for men and women, respectively. Waist circumference level 2 cutoff points, which identified high odds ratio for cardiovascular risk factor(s) and BMI level of 25 kg/m2, were 90 and 80 cm for men and women, respectively.
Validity of internationally accepted waist circumference action levels has been questioned. In a study of 32 978 subjects from 19 populations with widely different prevalences of overweight (WHO MONICA Project), Molarius et al.22 showed varying sensitivity of waist action levels to identify subjects with overweight or obesity. At waist circumference action level 1, sensitivity varied between 40 and 86% between populations when compared with the cutoff points based on BMI and W-HR, while the specificity was ⩾90%. Further, at waist circumference action level 2, the sensitivity was even lower. The investigators stressed that a substantial proportion of those who would need health advice would be missed according to the presently accepted waist circumference cutoff points, and emphasized a need for population-specific waist circumference cutoff points.22 Lower waist circumference cutoff points than presently accepted have been reported for several non-Asian populations in the following countries: Nigeria, Cameroon, Jamaica, St Lucia, and Barbados,23 Brazil,24 Mexico,25 and Iran.26
A need for setting lower cutoff points of waist circumference for Asian populations has been pointed out by several investigators. McNeely et al.27 reported that only 15 of 240 Japanese Americans studied prospectively met the criteria of abdominal obesity, concluding that the established guidelines for waist circumference were insensitive predictors of risk for development of type 2 diabetes mellitus in Japanese Americans.27 Waist circumference cutoff point were defined to be 80.5 and 71.5 cm for Taiwanese28 and ⩾85 and ⩾80 cm for Chinese men and women, respectively.29 Lower waist circumference cutoff points as compared to the presently accepted values have been shown for other Asian populations as well: Japanese30 and Malays.31
Asian Indians have relatively higher truncal and abdominal fat mass as compared to Caucasians and black population despite similar or less average value of waist circumference.8 Banerji et al.32 showed that visceral adipose tissue mass of Asian Indians was identical to African-American men, despite lower waist circumference (waist circumference: 86.2±8.4 vs 90.9±7.1 cm (P<0.001); visceral fat mass (L): 3.48±0.15 vs 3.49±1.65 (P=NS) in Asian Indians and African-Americans, respectively). Similarly, at a similar value of BMI, Asian Indians have significantly greater total abdominal fat and visceral fat area.33 Finally, truncal subcutaneous fat was significantly higher in Asian Indians having lower waist circumference than white Caucasians.34 High body fat and truncal and abdominal adiposity may result in insulin resistance and other cardiovascular risk factors to manifest in Asian Indians at a lower value of waist circumference than white Caucasians.10, 33, 34
Cardiovascular risk seems to manifest at lower waist circumference level as compared to Caucasians. Asian Indians have significantly lower glucose disposal rates during the insulin clamp, higher procoagulant tendency, and dyslipidemia at lower BMI and waist circumference as compared to Caucasians.33, 34 We have previously shown that in persons with BMI <25 kg/m2 and within ‘normal’ limits of waist circumference, odds ratios for cardiovascular risk factors were high. Specifically, for waist circumference between 71.1 and 80.0 cm, odds ratios for hypertension (2.4 (1.1–5.8)) and hypertriglyceridemia (2.4 (1.2–5.2)) were significantly high for women, and for waist circumference between 70.1 and 80.0 cm, odds ratio for hypertriglyceridemia (3.2 (1.0–10.3)) was significantly high for men.10 Finally, in the present study, remarkably high cardiovascular risk at waist circumference values of >90 cm in men and >80 cm in women would need medically supervised therapy.
Occurrence of cardiovascular morbidities at a lower level of waist circumference in Asian Indians according to the data of present investigation, and those of other investigators, underlines our proposal that the cutoff points of waist circumference for the diagnosis of abdominal obesity should be lowered for Asian Indians. We propose the following action levels for adult Asian Indians (⩾19 years of age): action level 1: men, ⩾78 cm, women, ⩾72 cm; and action level 2: men, ⩾90 cm, women, ⩾80 cm. If the presence of ⩾3 risk factors was defined as a positive case, the waist circumference cutoff values of 89 cm for men (sensitivity 72.4%, specificity 64.2%, correct classification 65.9%) and 81 cm for women (sensitivity 62.5%, specificity 60.3%, correct classification 61.0%) were observed to be optimum (data not shown). These cutoffs are similar to the proposed action level 2 cutoffs. Any Asian Indian with waist circumference above action level 1 should be advised to avoid weight gain or lose weight and to maintain increased physical activity. Subjects with a waist circumference above action level 2 should seek advice from physicians for medically supervised weight management. Finally, studies are required to define waist circumference action levels for Asian Indian children and adolescents.
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This study was partially supported by a grant from the Science and Society Division, Department of Science and Technology, Ministry of Science and Technology, Government of India and by a perpetual grant from Monilek Hospital and Research Centre, Jaipur, India. Mr Ramesh Giri assisted in anthropometry and body fat measurement, and Mr Inder Taneja, Mr Gian Chand, and Mrs Alice Jacob performed biochemical investigations and insulin assay. Ms Seema and Mrs Jyoti helped in the preparation of manuscript. The cooperation of the subjects who took part in the study is greatly appreciated.
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Cite this article
Misra, A., Vikram, N., Gupta, R. et al. Waist circumference cutoff points and action levels for Asian Indians for identification of abdominal obesity. Int J Obes 30, 106–111 (2006) doi:10.1038/sj.ijo.0803111
- waist circumference
- abdominal obesity
- action levels
- Asian Indians
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