Appropriateness of waist circumference and waist-to-hip ratio cutoffs for different ethnic groups

European Journal of Clinical Nutrition, Aug 2009

Current waist circumference (WC) and waist-to-hip ratio (WHR) cutoffs have been identified from studies of predominantly European-derived populations. However, these cutoffs may not be appropriate for other ethnic groups. This paper reviews the literature regarding ethnic differences in body composition and the appropriateness of ethnic-specific WC and WHR cutoffs in various ethnic groups. Studies investigating ethnic-specific cutoffs were identified among Aboriginal, Asian, African (Sub-Saharan), African-American, Hispanic, Middle Eastern, Pacific Islander and South American populations. Abstracts that recommended WC and/or WHR cutoffs (or rejected the use of cutoffs) were included with their supporting literature. The evidence for ethnic-specific WC and/or WHR cutoffs was then rated as either convincing, probable, possible or insufficient. The majority of studies recommending ethnic-specific cutoffs was for Asian populations. Few studies recommended cutoffs in Aboriginal, African (Sub-Saharan), Pacific Islanders and South American populations. All studies were cross-sectional, and the overwhelming majority of studies used receiver operating characteristic curves. The studies used a number of methods for assessing WC and WHR, and a variety of outcome measures, making cross-study comparison difficult. There is possible evidence that Asians should have a lower WC cutoff than Europeans. The evidence is insufficient for specific cutoffs for African-American, Hispanic and Middle Eastern populations but some studies indicate current cutoffs for Europeans may be appropriate, whereas there is insufficient evidence for the other ethnic groups. Future studies are needed to address the methodological limitations of the current literature.

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Appropriateness of waist circumference and waist-to-hip ratio cutoffs for different ethnic groups

Abstract Current waist circumference (WC) and waist-to-hip ratio (WHR) cutoffs have been identified from studies of predominantly European-derived populations. However, these cutoffs may not be appropriate for other ethnic groups. This paper reviews the literature regarding ethnic differences in body composition and the appropriateness of ethnic-specific WC and WHR cutoffs in various ethnic groups. Studies investigating ethnic-specific cutoffs were identified among Aboriginal, Asian, African (Sub-Saharan), African-American, Hispanic, Middle Eastern, Pacific Islander and South American populations. Abstracts that recommended WC and/or WHR cutoffs (or rejected the use of cutoffs) were included with their supporting literature. The evidence for ethnic-specific WC and/or WHR cutoffs was then rated as either convincing, probable, possible or insufficient. The majority of studies recommending ethnic-specific cutoffs was for Asian populations. Few studies recommended cutoffs in Aboriginal, African (Sub-Saharan), Pacific Islanders and South American populations. All studies were cross-sectional, and the overwhelming majority of studies used receiver operating characteristic curves. The studies used a number of methods for assessing WC and WHR, and a variety of outcome measures, making cross-study comparison difficult. There is possible evidence that Asians should have a lower WC cutoff than Europeans. The evidence is insufficient for specific cutoffs for African-American, Hispanic and Middle Eastern populations but some studies indicate current cutoffs for Europeans may be appropriate, whereas there is insufficient evidence for the other ethnic groups. Future studies are needed to address the methodological limitations of the current literature. Introduction Abdominal obesity is generally assessed by either the waist circumference (WC) or waist-to-hip ratio (WHR) measures. Prospective and case–control studies indicate that even with a ‘normal’ body mass index (BMI), those with an elevated WC or WHR can have a two- to threefold increase in cardiovascular disease (CVD) risk and premature death (Rexrode et al., 1998; Yusuf et al., 2005; Pischon et al., 2008). It is believed that abdominal obesity reflects an increased amount of intra-abdominal fat including visceral adipose tissue (VAT). Measures of VAT are strongly correlated with numerous CVD risk factors (Pouliot et al., 1994; Lemieux et al., 2001; Johnson et al., 2002), CVD (Fujimoto et al., 1999; Nicklas et al., 2004) and all-cause mortality (Kuk et al., 2006). More recently, the importance of hepatic fat has been identified with respect to increased metabolic risk (McKimmie et al., 2008). Thus, an increase in WC and WHR likely reflects increased VAT and hepatic fat, and in turn, increased risk. The most commonly used cutoffs among Caucasians for WC are 102 cm for men and 88 cm for women (Lean et al., 1995, 1998; National Cholesterol Education Program, 2001). The WHR cutoff is 0.95 for men and 0.80 for women (U.S. Department of Agriculture, U.S. Department of Health and Human Services, 1990). However, these cutoffs have been based on studies in populations of European origin. A number of commentaries have raised the issue that these anthropometric cutoffs may not be appropriate for non-Europeans (World Health Organization, 2000; Misra, 2003; Stevens, 2003; Shiwaku et al., 2004; Wildman et al., 2004; Reaven, 2005). Indeed, a number of national and international organizations have put forward their own ethnic-specific guidelines in recent years (Table 1). This background paper aims to report, where literature is available, on the variations in disease risk that may occur at the same WC and/or WHR level among adults in different ethnic groups and the appropriateness of ethnicity-specific WC and/or WHR cutoffs in adults. Table 1: Existing thresholds for abdominal obesity Full size table Methodological considerations for literature review This review is focused on ethnic populations not represented in the earlier studies which identified WC/WHR cutoffs in Europeans. It must be recognized, that the term ethnicity is often very poorly defined, and individuals may also be associated with multiple ethnic groups depending on their heritage and where they currently reside. For this review, the following population groups were identified: Asians (Chinese, East Asian and South Asian), African (Sub-Saharan), Middle Eastern, and South American. These ethnic groups are consistent with those identified by the International Diabetes Federation in their worldwide definition of the metabolic syndrome (International Diabetes Federation, 2006). We have also included the following additional groups: Aboriginal, African-American, Hispanic and Pacific Islanders. The allocation of studies to these ethnic groups was based on how the study authors self-described their participants. Although it may be argued that African-American and African populations be grouped together, there are substantially more data available for African-American populations than those in Africa, and substantial differences in environments and culture also exist. This was also considered with respect to the Hispanic and South American populations, the former tending to refer to a population living in the United States of Puerto Rican, Mexican, Central American, South American or Spanish origin. Lastly, Pacific Islanders present with high BMI and low body fat, but have a high prevalence of diabetes, presenting a phenotype not found in other ethnic groups (Sundborn et al., 2008). Studies investigating ethnic-specific cutoffs were identified using the following parameters: the authors’ knowledge of existing literature, the use of the PubMed database using the above-mentioned ethnic groups cross-referenced with the term ‘waist’ and identification of appropriate references from those papers selected from the first two methods. Additional search terms of bone, skeletal muscle, osteoporosis and cancer were used in the PubMed search to focus on these areas, which may not be as predominant in the literature. On review of the selected abstracts (conducted by SAL), those articles that provided a recommendation regarding WC and/or WHR cutoffs (or recommendation of absence of support for cutoffs) were included. Further studies relevant to ethnic associations between WC and/or WHR with disease risk and outcomes, and different indices of body composition were reviewed. Searches for a number of health outcomes associated with WC and/or WHR, such as osteoporosis and cancer, showed that most studies related to metabolic risk factors for diabetes and CVD. The focus here on only CVD in certain ethnic groups simply reflects the absence of other data and should not be interpreted to indicate a lack of relationship, as the evidence is not currently available. Unless otherwise specified, receiver operating characteristic (ROC) curves were used to identify the recommended WC and/or WHR cutoffs. The evidence regarding ethnic-specific WC and/or WHR cutoffs was rated as either convincing, probable, possible or insufficient as defined in the Diet, nutrition and the prevention of chronic diseases: report of the joint WHO/FAO expert consultation (Table 2) (World Health Organization, 2003). Table 2: Criteria used to describe the strength of evidence (World Health Organization, 2003) Full size table Aboriginal populations Although Aboriginal populations worldwide have diverse cultures, and most likely diverse genetic backgrounds, these populations when ‘Westernized’ usually have higher obesity rates than other populations in their vicinity (Vanasse et al., 2006; Steele et al., 2008; Kondalsamy-Chennakesavan et al., 2008b). In the cited Aboriginal populations, WC and/or WHR are positively associated with adverse lipids, blood pressure, C-reactive protein, measures of insulin resistance, diabetes risk, carotid intima-media thickness and CVD risk (Delisle and Ekoe, 1993; O’Dea et al., 1993; Daniel et al., 1999; Hu et al., 2000; Connelly et al., 2003; Tavares et al., 2003; McDonald et al., 2004; Bradshaw et al., 2007; Gracey et al., 2007; Shemesh et al., 2007; Wang et al., 2007; Wang and Hoy, 2004b; Kondalsamy-Chennakesavan et al., 2008b). In North America, comparisons of Aboriginals and Europeans have reported no difference in the relationships between VAT and BMI (Gautier et al., 1999), total body fat (Lear et al., 2007c) or WC (Lear et al., 2007a). Some studies show differences in metabolic risk factors, whereas others show either no difference or clear increases in risk factors across a range of BMI and WC values (Young, 1996; Razak et al., 2005; Lear et al., 2007c; Razak et al., 2007). Australian Aboriginals living in a remote area were reported to have higher WHRs with lower BMIs than urban European Australians (Piers et al., 2003). In addition, Australian Aboriginals have higher rates of diabetes than Europeans of a similar body size (Kondalsamy-Chennakesavan et al., 2008b). To our knowledge, no studies have recommended specific WC and/or WHR cutoffs in Aboriginal populations. Therefore, there is insufficient evidence to suggest specific cutoffs for Aboriginal populations. Asian populations A number of studies have analyzed Asians as a homogeneous population. These studies found a higher percentage of body fat, increased prevalence of risk factors at lower BMIs (Deurenberg-Yap et al., 2000, 2001) and increased prevalence of abdominal obesity in Asians compared with those in Caucasians (Wu et al., 2007). Koster et al. (2008) found increased mortality to be associated with lower WCs in Asians compared with those in African-Americans and Europeans. Two meta-analyses conducted by the Obesity in Asia Collaboration recommended WC cutoffs of 85 and 80 cm for men and women, respectively, for the detection of both diabetes and hypertension risk (Table 3) (Huxley et al., 2007; Obesity in Asia Collaboration, 2008). However, they noted that the recommended WHR cutoffs of 0.90 for men and 0.80 for women were similar to those determined for Caucasians. Table 3: Studies suggesting new abdominal anthropometric targets for Asian men and women Full size table Chinese populations (mainland China, Hong Kong, Taiwan) Substantial evidence indicates that increased WC and/or WHR is associated with health risks, for example, hypertension, dyslipidemia, impaired fasting glucose, diabetes (Folsom et al., 1994; Huang et al., 2002; Hu et al., 2007), lower testosterone (Chinese men) (Chu et al., 2008), CVD (Zhang et al., 2004) and mortality in Chinese populations (Zhang et al., 2007; Koster et al., 2008). However, evidence for WC and/or WHR linked to bone mineral density (Chu et al., 2008) or low back pain (Yip et al., 2001) is inconclusive. Early evidence suggested that Chinese men and women have higher percentage body fat at the same BMIs as Europeans (Wang et al., 1994; Deurenberg et al., 1998, 1999). However, studies are inconsistent (Deurenberg et al., 1997; Lear et al., 2007b) and may reflect differences among Chinese populations such as the larger body build and lower percent body fat in Northern compared to Southern Chinese individuals (Deurenberg et al., 1999). Chinese men and women also display a greater amount of VAT for a given WC (Lear et al., 2007c) and body fat mass (Lear et al., 2007b) than Europeans. Consistent with these studies, Chinese men and women also have higher levels of metabolic risk factors at a given WC and/or WHR (Unwin et al., 1997; Lear et al., 2002; Razak et al., 2005). Seven studies investigated Chinese-specific WC and/or WHR targets (Table 3) (Ko et al., 1999; Deurenberg-Yap et al., 2001; Bei-Fan, 2002; Lin et al., 2002; Diaz et al., 2007; Ko and Tang, 2007; Bao et al., 2008; Li et al., 2008b). Recommendations for WC ranged from 80.5 to 95.1 cm for men and 71.5 to 83.7 cm for women. Two of these studies recommended WHRs ranging from 0.85 to 0.90 for men and 0.76 to 0.80 for women (Ko et al., 1999; Deurenberg-Yap et al., 2001; Lin et al., 2002). East Asian populations (Korea, Japan) Among Korean and Japanese men and women, there is a clear association between either the WC or WHR and metabolic risk factors (Iso et al., 1991; Masuda et al., 1993; Sung et al., 2007), carotid intima-media thickness (Takami et al., 2001), CVD (Huang et al., 1997) and all-cause mortality in Japanese men living in the United States (Kalmijn et al., 1999). Those from Eastern Asia have a higher percentage of body fat than Caucasians, across a range of WC values (Kagawa et al., 2007). In addition, Japanese men have been reported to have more VAT at a given WC than Caucasian men (Kadowaki et al., 2006). A total of 10 studies, ranging in size from 349 to 12 725 participants, have investigated specific WC cutoffs in these populations (Table 3) (Hara et al., 2006; Kim et al., 2006; Hayashi et al., 2007; Lee et al., 2007; Han et al., 2008; Hyun et al., 2008; Matoba et al., 2008; Narisawa et al., 2008; Oka et al., 2008; Sato et al., 2008). Recommended WC cutoffs ranged from 85 to 90 cm for men and 78 to 86 cm for women, but no studies reported cutoffs for WHR. South Asian populations (Bangladesh, India, Nepal, Pakistan, Sri Lanka) Abdominal obesity is associated with a variety of risk factors among South Asians including insulin action and insulin resistance (McKeigue et al., 1992; Banerji et al., 1999; Rush et al., 2007b), lipids, markers of inflammation, the metabolic syndrome, carotid intima-media thickness, angiographically determined atherosclerosis and risk for myocardial infarction (Pais et al., 1996; Chambers et al., 2001; Venkatramana and Reddy, 2002; Valsamakis et al., 2004; Chow et al., 2008; Wierzbicki et al., 2008). South Asians have increased abdominal adiposity at a given BMI (Lean et al., 2001; Orr-Walker et al., 2005) and a higher percentage of body fat (Banerji et al., 1999; Deurenberg-Yap et al., 2000; Lear et al., 2007b; Rush et al., 2007a) than Europeans. Various studies indicated that South Asians seem to have a greater VAT, increased lipid or insulin levels than Caucasians at the same BMI or WC/WHR (Chowdhury et al., 1996; Raji et al., 2001; Lear et al., 2007b, 2007c). This is consistent with South Asians having increased lipid and insulin levels compared with Europeans at the same WC and/or WHR (Chandalia et al., 1999; Patel et al., 1999; Lear et al., 2003; Vikram et al., 2003). Two studies reported appropriate WC and WHR cutoffs for South Asians. In a population representative study of men and women in Chennai, recommended WC values for detecting two or more of the following: diabetes, pre-diabetes, hypertension and dyslipidemia, were 87 cm for men and 82 cm for women (Mohan et al., 2007). A second study recommended WC values for identifying diabetes in men 40 years of age of Bangladeshi, Indian and Pakistani origin as 95.8, 97.2 and 95.8 cm, respectively, and 87.5, 88.7 and 101.3 cm for women, respectively (Diaz et al., 2007). Taken together, this evidence suggests that Asians have an increased metabolic risk at lower WC and WHR than Europeans, probably because of higher body fat and VAT. Those studies with European or Caucasian comparisons indicated a lower WC and/or WHR for Asians (Diaz et al., 2007; Huxley et al., 2007; Obesity in Asia Collaboration, 2008) We conclude that there is possible evidence for Asians to have lower WC and WHR cutoffs, and WC values of 85 and 80 cm, and WHR values of 0.90 and 0.80 for men and women, respectively, may be the most appropriate (Huxley et al., 2007; Obesity in Asia Collaboration, 2008). African populations (Sub-Sahara Africa) In Sub-Saharan African populations, WC is associated with blood pressure and hypertension, increased glucose, triglycerides and osteoporosis (Blaauw et al., 1994; Luke et al., 1997; Okosun et al., 1998; Okosun et al., 1999b; Mufunda et al., 2000; Olatunbosun et al., 2000; Snijder et al., 2004), whereas WHR has been reported to be associated with an increased risk of breast cancer in Nigerian women (Adebamowo et al., 2003; Okobia et al., 2006), and Nigerians with CVD have an increased WHR (Ebesunun et al., 2008). In addition, the WC cutoffs of 94 and 80 cm and the WHR cutoffs of 0.90 and 0.80, in men and women, respectively, were associated with an increased risk for dyslipidemia in the Seychelles (Paccaud et al., 2000). Black women in South Africa not only have a slightly lower BMI at a given percentage body fat, but also less abdominal adipose tissue (determined by dual X-ray absorptiometry) at the same WC than European women (Rush et al., 2007a). A few small studies report African women having less VAT, better free fatty acid metabolism and TC:HDL-C ratio but increased insulin resistance compared with white women (van der Merwe et al., 2000; Punyadeera et al., 2001a, 2001b). Only one study reported on WC cutoffs in Africans (none investigating WHR cutoffs), and recommended 75.6 and 80.5 cm for men and 71.5 and 81.5 cm for women of Nigerian and Cameroon origin, respectively, for the identification of hypertension (Okosun et al., 2000b). This evidence is insufficient for recommending specific cutoffs for Sub-Saharan Africans. African-American populations In African-American men and women, WC and/or WHR have been associated with increased metabolic risk factors, increased bone mineral content, diabetes, cancer, ischemic stroke and all-cause mortality (Haffner et al., 1987; Okosun et al., 1998; Okosun et al., 1999a; Sidney et al., 1999; Suk et al., 2003; Shen et al., 2006; Kristal et al., 2007; Koster et al., 2008; Perry et al., 2008; Travison et al., 2008). The 94 and 80 cm WC cutoffs for European men and women, respectively, have been associated with a 1.5- and 2.0-fold increased risk in hypertension and a 3.9- and 1.6-fold increase in diabetes in men and women, respectively (Okosun et al., 1998). African-Americans have been reported to have less body fat at a given BMI, and less VAT at a given total body fat mass, WC and/or WHR than Caucasians (Deurenberg et al., 1998). African-American women were reported to have higher WHR, appendicular muscle mass, total bone density and total body bone mineral content compared with white women matched for age, weight and height (Gasperino et al., 1995). Abdominal adiposity, as determined by dual X-ray absorptiometry, was also lower in African-American men, but not women, compared with Asian men and women, at a given total body fat, adjusted for age (Wu et al., 2007). In addition, African-American women may have higher subcutaneous abdominal adipose tissue than white women at a given fat mass (Lovejoy et al., 2001). These studies suggest that African-Americans may be at a decreased risk for CVD compared with Europeans at a similar WC and/or WHR. However, Haffner et al. (1996) reported lower insulin sensitivity in African-Americans compared with that in whites even after accounting for differences in body fat distribution. African-American men and women also have an increased risk for hypertension at a given WC (Harris et al., 2000; Okosun et al., 2001, 2006), and have higher ApoB/ApoA1 values associated with the WC cutoffs of 94 and 80 cm (Okosun et al., 1999c) than white men and women. Two studies provided WC cutoffs in African-Americans (Table 4) (Zhu et al., 2005; Diaz et al., 2007). The recommendations for WC cutoffs ranged from 89 to 108.9 cm for men and 83 and 104.6 cm for women. One additional study recommended that further investigation is needed (Okosun et al., 2000a), whereas another reported that African-Americans did not require WC cutoffs separate from whites (Okosun et al., 2000c). Unlike data in other ethnic groups, the finding that African-Americans may have less VAT than Europeans is inconsistent with findings of increased risks for CVD due to higher blood pressure and lipids at a given WC. These studies either suggest similar cutoffs to that of Europeans (possible evidence) or indicate insufficient evidence for specific cutoffs for African-Americans. Table 4: Studies suggesting new abdominal anthropometric targets for African-American, Hispanic, Middle Eastern and South American men and women Full size table Although not specifically searched, we identified two studies investigating populations living in the Caribbean (Sargeant et al., 2002; Okosun et al., 2000b). These studies suggested WC cutoffs ranging from 80 to 88 cm for men and 84 to 88 cm for women. One of these studies reported WHR cutoffs of 0.87 and 0.80 for men and women, respectively (Sargeant et al., 2002). Hispanic populations For people of Hispanic American background, WC and/or WHR are associated with increased rates of metabolic risk factors, increased bone mineral content, diabetes, cancer, ischemic stroke and all-cause mortality (Haffner et al., 1987; Edelstein et al., 1997; Wei et al., 1997; Han et al., 2002; Suk et al., 2003; Afghani et al., 2004; Kristal et al., 2007; Koster et al., 2008; Perry et al., 2008). One study reported that VAT at a given WC was not appreciably different from that of whites (Carroll et al., 2008) and that insulin sensitivity was similar in Hispanics after adjusting for body composition (Haffner et al., 1996; Nelson et al., 2008). In contrast, it has been reported that Hispanics have a higher risk for hypertension than non-Hispanic whites at a similar WC (Okosun et al., 2006). A total of five studies investigated Hispanic-specific WC cutoffs (Table 4) (Berber et al., 2001; Sanchez-Castillo et al., 2003; Zhu et al., 2005; Okosun et al., 2000a, 2000c). One study recommended a WC of 90 cm for men and 85 cm for women, and a WHR of 0.90–0.91 for men and 0.84–0.86 for men and women, respectively (Berber et al., 2001). Another study identified a range of WC cutoffs for detecting diabetes and hypertension using ROC curves, but then suggested that the ideal WC be at a point of identifying 80% of those with diabetes and/or hypertension, resulting in a recommendation of 90 cm for both men and women (Sanchez-Castillo et al., 2003). Two other studies recommended WC cutoffs based on BMI values (Okosun et al., 2000c; Zhu et al., 2005). The fourth study suggested that the current WC cutoffs based on Europeans provided low sensitivity with respect to metabolic risk factors (Okosun et al., 2000a). This evidence is insufficient to support specific WC or WHR cutoffs in Hispanic populations. Middle Eastern populations (including Northeast Africa) Studies investigating Middle Eastern populations have found that WC and/or WHR are associated with metabolic risk factors such as hypertension, diabetes, elevated glucose and insulin, insulin resistance, and TG (Emara et al., 1989; Onat et al., 1999; Al-Shayji and Akanji, 2004; Chehrei et al., 2007; Abolfotouh et al., 2008; Shahraki et al., 2008). In Turkish women, WHR has been reported to be associated with CVD (Onat et al., 1999). Five studies investigated WC cutoffs in populations residing in the Middle East (Mirmiran et al., 2004; Bouguerra et al., 2007; Mansour et al., 2007; Mansour and Al-Jazairi, 2007; Esteghamati et al., 2008; Al-Lawati and Jousilahti, 2008), whereas three reported on WHR cutoffs (Table 4) (Azizi et al., 2005; Mansour et al., 2007; Al-Lawati and Jousilahti, 2008). The recommended WC ranged from 80 to 97 cm in men and from 79 to 99 cm in women with those assessing WHR ranged from 0.86 to 0.97 for men and 0.78–0.92 for women. On the basis of these studies, there is insufficient evidence to suggest that those of Middle Eastern background have different WC or WHR cutoffs. Pacific Islander populations The Pacific Islander populations originate from the islands in the Pacific Ocean and may have similar genetic and cultural origins to one another. In these populations, WC/WHR is associated with adverse lipid and insulin levels, more glucose intolerance and some cancers (Goodman et al., 1997; Hodge et al., 1997; Grandinetti et al., 1998; Lindeberg et al., 1999; Bell et al., 2001; Novotny et al., 2007). Some studies have reported that Pacific Islanders have larger muscle masses and lower percentage body fat than Europeans at similar BMIs (Rush et al., 2004, 2009), and in women this has also been reported for similar WCs and WHRs (Rush et al., 2007a). Despite having less body fat and higher muscle mass, Pacific Islanders have a higher burden of CVD risk factors and prevalence of diabetes than New Zealand Europeans (Sundborn et al., 2008). Although no studies have investigated specific WC and/or WHR cutoffs, the commonly used cutoff of 88 cm was able to predict lipid and glucose levels associated with disease in Samoan women (Novotny et al., 2007). Given these findings, there is insufficient evidence to recommend specific WC and/or WHR cutoffs in Pacific Islanders. South American populations In populations within South America, WC and/or WHR have been reported to be associated with lipids, blood pressure, fasting glucose, insulin resistance and diabetes (Lemos-Santos et al., 2004; Olinto et al., 2004; Feldstein et al., 2005; Florencio et al., 2007; Perry et al., 2008). In addition, those with CVD have a higher prevalence of abdominal obesity (Oviedo et al., 2006). Six studies investigated WC and/or WHR cutoffs (Table 4) and recommended WC cutoffs between 88 and 90 cm for men and 83 and 84 cm for women (Pereira et al., 1999; Velasquez-Melendez et al., 2002; Perez et al., 2003; Pitanga and Lessa, 2005; Barbosa et al., 2006). The three studies reporting on WHR provided recommendations ranging from 0.85 to 0.95 in men and 0.80 to 1.18 for women (Pereira et al., 1999; Perez et al., 2003; Pitanga and Lessa, 2005). These studies suggest that WC cutoffs should be lower than, but WHR cutoffs similar to, those for Europeans. Nevertheless, the limited number of studies provides insufficient evidence to direct any recommendations. Discussion Across the ethnic groups, there are varying levels of evidence linking WC and/or WHR to metabolic risk, body composition and various recommended ethnic-specific cutoffs for these measures. Most investigations relate to Asians, with much less information available for Middle Eastern, South American and Sub-Saharan African populations. Evidence indicates that WC and/or WHR are associated with increased metabolic risk related to diabetes and CVD among all ethnic groups but little information relates to other morbidities such as osteoporosis and cancer in any ethnic group. In addition, detailed investigations on body composition also vary among these ethnic groups. In general, there is possible evidence to support Asians having lower cutoffs than Europeans, and for African-American and Hispanics to have similar cutoffs to Europeans, and insufficient evidence for the other ethnic groups to guide recommendations for ethnic-specific cutoffs. On the basis of these levels of evidence, Table 5 outlines WC and WHR cutoffs, and/or ranges suggested from the literature cited in this review. For Asians, the suggested WC and WHR cutoffs are predominantly based on the two meta-analyses of over 100 000 men and women (Huxley et al., 2007; Obesity in Asia Collaboration, 2008), which are consistent with the other investigations (of which some are included in the meta-analyses). For the African-American, Hispanic and Middle Eastern ethnic groups, although evidence supporting ethnic-specific cutoffs is insufficient, some studies indicated that WC and/or WHR cutoffs for Europeans may be appropriate to use pending further comprehensive research. For the other ethnic groups, we conclude that there is insufficient evidence to suggest any cutoffs whether similar to or different from those for Europeans. Table 5: Summary of suggested WC and WHR cutoffs from the studies reviewed and the strength of evidence for specific cutoffs in those ethnic groups Full size table The relationship between WC and/or WHR with disease risk is continuous (Yusuf et al., 2005; Zhang et al., 2007). However, for practical clinical management and population health promotion strategies, established cutoffs for these measures are needed and it is important to develop cutoffs based on the identification of similar risk levels across populations. The most commonly used cutoffs throughout the world are those defined by Lean et al. (1995), derived from a cross-sectional population from the Netherlands of predominantly European origin. These cutoffs were based on the WC values corresponding with average BMIs of 25 and 30 kg/m2, and were later shown to relate to increases in risk factors (Lean et al., 1998). Since then, a number of organizations have adopted their use in guiding clinical management (The Scottish Intercollegiate Guidelines Network, 1996; National Cholesterol Education Program, 2001; Balkau et al., 2007). However, given the strength of evidence suggesting that WC and/or WHR is associated with increased risk for a number of diseases, independent of BMI (Kabat et al., 2008; Koster et al., 2008; Masala et al., 2008; Wang et al., 2008), cutoffs should be identified through direct analyses of their prediction of risk markers and/or preferably for disease outcomes (Molarius et al., 1999). In the reviewed studies, most have identified cutoffs related to metabolic risk. This is important, as it cannot be assumed that the relationship between disease risk and BMI is the same for WC and/or WHR. The benefits of establishing ethnic-specific WC and WHR cutoffs need to be weighed against the practicality of their implementation. Defining ‘ethnicity’ among and within populations may prove to be challenging. In areas with significant representation of several ethnic groups and even sub-ethnic groups with different body composition and health characteristics such as Asian and South Asian sub-groups, this could mean the use of multiple cutoffs related to each individuals’ purported ethnicity. This may be a time-consuming task as well as a potentially sensitive issue for some. With individuals of mixed ethnic background, there are no analyses allowing the definition of specific cutoffs. However, in areas of ethnic homogeneity, the use of ethnic-specific cutoffs is likely to be more feasible. None of the cited analyses of ethnic-specific WC and/or WHR cutoffs address the issue of why these ethnic variations occur. Genetic differences may affect body composition, metabolic risk factors and/or protection or predisposition to disease differences but genetic diversity between supposedly ‘distinct’ ethnic groups may not be as great as once thought (Li et al., 2008a). Therefore, a strong environmental influence may prove to be equally if not more important. It is recognized that the stature of two populations who share a similar genetic background can differ because of environmental exposure and particularly nutritional differences. One component of these modifiers is different fetal and early childhood nutrition exposures, which can influence offspring growth and the predisposition to obesity (Hales and Barker, 1992; Kaati et al., 2002). This is proposed as a possible contributor to the Asian Indian obesity phenotype of small body size but high body fat (Yajnik, 2004) and may be implicated in other observed inter-ethnic differences. Limitations Limitations common to most of the reviewed studies include their cross-sectional nature, unrepresentative populations and the use of ROC curves, which depend on such basic characteristics as the prevalence of the exposure and its association to the outcome. Therefore, changes in either factor can result in different cutoffs. In addition, ROC curves provide a so-called ‘optimal’ cutoff for a given outcome by maximizing sensitivity and specificity, but this may not be the ideal management or public health policy approach to maximizing treatment or preventive strategies (James, 2005). In addition, the overwhelming majority of studies failed to provide a definition of ethnicity. Those studies that defined their measurement technique revealed six different methods for WC and five for hip circumference. The predominant method for assessing WC involved measuring midway between the bottom of the lower rib and top of the iliac crest. For hip circumference, measurements were mostly taken at the point of largest gluteal protuberance. In addition, these studies used varying outcomes of metabolic measures and definitions at which ‘risk factors’ are defined. Most studies targeted metabolic risk factors associated with diabetes and CVD but some studies did indicate that WC and/or WHR were related to other diseases such as osteoporosis and cancer, as well as to all-cause mortality (Orozco and Nolla, 1997; Friedenreich, 2001; Koster et al., 2008). Given these limitations, a consensus is needed on the appropriate approach to defining ethnic-specific WC and/or WHR cutoffs. Conclusions The value of WC and WHR measurements is that they require only a tape measure, and can provide information regarding an individual's or population's risk for future health problems. Thus cutoffs should be developed consistently to identify populations and individuals at a pre-defined level of risk. Studies over the past two decades indicate that risks are greater for a given WC and/or WHR in different ethnic groups; therefore, different cutoffs may be needed. However, currently the evidence is too limited except in those populations of Asian origin who possibly do have evidence of lower WC and WHR cutoffs than in Europeans at equivalent risk. The evidence is less robust for other ethnic groups; current cutoffs may be appropriate for African-American, Hispanic and Middle Eastern populations, but there is insufficient evidence for populations of Aboriginal, Sub-Saharan Africa, Pacific Islander and South America origin. The many methodological differences between studies limit direct comparisons, and the variety of chosen health outcome and measurement techniques adds a further difficulty. Future studies should be prospective in nature, use representative populations, use common health outcomes, use standardized methods for assessing WC and WHR, and use analytical approaches that are not dependent on the prevalence of excess weight gain and are defined clearly in pre-specified different ethnic groups. 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CASPubMedGoogle Scholar Download references Acknowledgements Dr Lear is a Canadian Institutes of Health Research New Investigator. Author information AffiliationsSchool of Kinesiology, Simon Fraser University and Division of Cardiology, University of British Columbia, Vancouver, British Columbia, CanadaS A LearInternational Obesity Task Force, London, UKP T JamesHong Kong Institute of Diabetes and Obesity, the Chinese University of Hong Kong, Hong Kong SAR, ChinaG T KoCenter for Clinical Epidemiology & Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, PA, USAS Kumanyika AuthorsSearch for S A Lear in:Nature Research journals • PubMed • Google ScholarSearch for P T James in:Nature Research journals • PubMed • Google ScholarSearch for G T Ko in:Nature Research journals • PubMed • Google ScholarSearch for S Kumanyika in:Nature Research journals • PubMed • Google Scholar Corresponding author Correspondence to S A Lear. Rights and permissions To obtain permission to re-use content from this article visit RightsLink. About this article Publication history Received 07 April 2009 Accepted 29 May 2009 Published 12 August 2009 DOI https://doi.org/10.1038/ejcn.2009.70


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S A Lear, P T James, G T Ko, S Kumanyika. Appropriateness of waist circumference and waist-to-hip ratio cutoffs for different ethnic groups, European Journal of Clinical Nutrition, 2009, 42-61, DOI: 10.1038/ejcn.2009.70