Four anthropometric indices and cardiovascular risk factors in Taiwan

PAPER

Four anthropometric indices and cardiovascular risk

factors in Taiwan

K-C Huang

*, W-Y Lin

, L-T Lee

, C-Y Chen

, H Lo

, H-H Hsia

, I-L Liu

, W-Y Shau

and

R-S Lin

1

_{Obesity Research Group, Department of Family Medicine, National Taiwan University Hospital, Taipei, Taiwan;}

_{Department of}

Family Medicine, China Medical College Hospital, Taichung, Taiwan;

_{Health Care Administration, Chia-Nan University of}

Pharmacy and Science, Taipei, Taiwan;

_{MJ Health Screening Center, Taipei, Taiwan;}

_{Graduate Institute of Preventive Medicine,}

National Taiwan University, Taipei, Taiwan; and

_{Preventive Medicine, National Taiwan University, Taipei, Taiwan}

OBJECTIVE: To examine the relationships between four anthropometric measurements and cardiovascular risk factors in Taiwan.

DESIGN: The data was collected from four nationwide health screen centers in Taiwan from 1998 to 1999.

SUBJECTS: A total of 38 556 subjects: 18 280 men and 20 276 women, mean age ¼ 37.0  11.1 y. None had any known major

systemic diseases or were currently on medication.

MEASUREMENTS: Individual body weight, height, waist circumference (WC), and cardiovascular risk factors (blood pressure,

fasting plasma glucose, triglycerides, total cholesterol level, low-density and high-density-lipoprotein cholesterol level) were

assessed and their relationships were examined.

RESULTS: In both sexes, with increasing body mass index (BMI), WC, WHpR (waist-to-hip ratio) and WHtR (waist-to-height

ratio), there were significantly higher risks of hypertension, impaired fasting glucose, diabetes and dyslipidemia (P < 0.001) in

almost all age groups. In the age groups older than 65, however, the relationships were statistically inconsistent.

CONCLUSIONS: In Taiwan, the four anthropometric indexes (BMI, WC, WHpR, WHtR) are closely related to cardiovascular risk

factors.

International Journal of Obesity (2002) 26, 1060 – 1068. doi:10.1038/sj.ijo.0802047

Keywords: anthropometric indices; cardiovascular risk factors; prevalence; odds ratio; Taiwan

Introduction

The prevalence of obesity is high and increasing in

devel-oped regions like Europe, the United States, and Oceania.

Obesity has been known to be associated with hypertension,

diabetes, dyslipidemia and increased cardiovascular risk.

In addition, cardiovascular disease mortality is about 3-fold

higher among obese men and women, and about 21 and

28% of cardiovascular disease mortality in men and women,

respectively, could be attributed to being overweight.

Central distribution of body fat, which suggests excessive

deposition of intra-abdominal fat, is also found to be an

important predictor of cardiovascular risk.

Obesity is defined as a condition where there is an excess

of body fat. Although there are several instruments to

mea-sure total body fat and its distribution,

_{anthropometric}

measurements still play an important role in clinical

prac-tice. The body mass index (BMI) is often used to reflect total

body fat amounts while the waist circumference (WC),

waist-to-hip ratio (WHpR), and waist-to-height ratio (WHtR) are

used as surrogates for body fat centralization.

_These

measurements have been associated with cardiovascular

risk factors, such as blood pressure, plasma lipid levels, and

glucose concentrations across ethnic groups.

_However,

there are few reports and only small studies in the

Asia-Pacific region. In this study, we examine the relationship

between the four common anthropometric measurements

and cardiovascular risk factors in Taiwan.

Subjects and methods

The data was collected from four health screen centers in

Taiwan from 1998 to 1999. A total of 38 556 ‘healthy’

subjects (18 280 men and 20 276 women, mean age

37.0  11.1 y), without any previous systemic diseases or

*Correspondence: Kuo-Chin Huang, Department of Family Medicine, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei, 100 Taiwan.

E-mail: chin3@ha.mc.ntu.edu.tw

Received 29 August 2001; revised 26 February 2002; accepted 13 March 2002

medications related to body weight change or affecting

blood pressure, glucose and lipid levels (such as DM, HTN,

dyslipidemia or thyroid diseases and their related

medica-tions), out of a total 148 625 people were included in our

study. In addition, people whose body weight had changed

by more than 5% within 3 months were also excluded. The

population structure in our study was similar to national

data on adults published by our government.

_The

anthro-pometric and metabolic variables of the study population are

shown in Table 1. Height, waist and hip circumferences

(measured to the nearest 0.1 cm) and weight (measured to

the nearest 0.1 kg) were measured by trained staff during one

visit. Waist circumference was taken at the midway point

between the inferior margin of the last rib and the crest of

the ilium in a horizontal plane and measured to the nearest

0.1 cm. Hip circumference was taken around the pelvis at the

point of maximal protrusion of the buttocks and measured

to the nearest 0.1 cm. BMI was calculated as weight (kg)

divided by height squared (m

_{). In addition, WHpR and}

WHtR were also calculated. Blood pressure was measured in

the right arm with an adequate cuff by the same staff using a

standard mercury sphygmomanometer. The systolic BP was

determined by the onset of the ‘tapping’ Korotkoff sound

(K

). The fifth Korotkoff sound (K

), or the disappearance of

Korotkoff sounds, defined the diastolic BP. A venous blood

sample was taken after 12 h of fasting for measuring plasma

glucose, triglycerides, total cholesterol (TCHO), low-density

lipoprotein (LDL) cholesterol and high-density lipoprotein

(HDL) cholesterol using an HITACHI 7150. Hypertension

(HTN) was defined as a systolic BP  140 mmHg and=or

diastolic BP  90 mmHg. Type 2 diabetes mellitus (DM)

and impaired fasting glucose (IFG) were defined as fasting

plasma glucose

7.0 mmol=l and 7.0 > plasma glucose

6.1mmol=l. The criteria for

dyslipidemia-hypercholestero-lemia, hypertriglyceridemia, elevated LDL cholesterol and

abnormal HDL cholesterol were defined as total plasma

cholesterol



6.2 mmol=l,

triglycerides



2.3 mmol=l,

LDL-cholesterol

4.1 mmol=l

and

HDL-cholesterol

<0.9 mmol=l, respectively.

Statistical analysis

BMI was grouped according to the proposed criteria for the

Asia-Pacific region, where being overweight is defined as

BMI



23 kg=m

_and

_obesity

_is

_defined

_as

_BMI

25 kg=m

_.

_{Waist circumference was grouped in men}

from 90 cm and in women from 80 cm to smaller sizes by

5 cm increments. WHpR and WHtR were grouped according

to case numbers in quartiles. We analyzed the association

between different anthropometric indices and disease

pre-valences, or actual plasma concentrations and blood pressure

values by testing their trends. Odds ratios were calculated as

the ratios of each cardiovascular risk factor prevalence

rela-tive to the one in the lowest anthropometric variables within

the same sex and age groups. All the analyses were stratified

into three groups according to age (20 – 39, 40 – 64

and  65 y). Statistical analysis was performed using SPSS

for Windows (version 10.0) on an IBM PC compatible

computer.

Results

In Table 2, there were statistically significant trends of

increasing prevalence in cardiovascular risk factors, except

Table 1 Anthropometric indexes and metabolic factors in both sexes (mean  s.d.)

Men (n ¼ 18 280) Women (n ¼ 20 276)

Variables I (n ¼ 12 038) II (n ¼ 5106) III (n ¼ 528) I (n ¼ 13 880) II (n ¼ 5911) III (n ¼ 485)

Age (y) 31.11  4.85 48.09  6.89 69.79  4.36 36.61  4.95 48.99  6.99 69.37  4.21 Height (cm) 170.70  5.79 167.79  5.92 164.26  5.88 158.51  5.31 155.31  5.23 151.56  5.11 Weight (kg) 67.87  10.63 67.63  9.31 62.75  9.25 52.78  8.01 56.17  8.05 54.61  8.39 BMI (kg=m2_{) 23.27  3.25 24.0  2.84 23.23  2.98 21.00  2.98 23.29  3.15 23.74  3.21} WC (cm) 79.07  8.53 83.09  8.02 83.82  9.05 68.21  6.74 74.08  7.73 80.09  8.73 Hip (cm) 94.22  6.21 94.69  5.62 93.64  6.07 91.98  6.00 94.74  6.03 94.46  6.71 WHpR 0.84  0.05 0.88  0.06 0.89  0.06 0.74  0.05 0.78  0.06 0.85  0.07 WHtR 0.46  0.05 0.50  0.05 0.51  0.06 0.43  0.04 0.48  0.05 0.53  0.06 SBP (mmHg) 118.7  13.2 121.8  16.1 132.8  19.6 108.8  12.3 120.3  18.1 139.3  19.6 DBP (mmHg) 72.8  9.9 76.2  10.7 75.6  11.2 67.1  9.4 72.8  10.9 75.9  11.4 Glucose (mmol=l) 5.26  0.57 5.53  0.97 5.61  1.19 5.05  0.43 5.37  0.90 5.62  0.95 TCHO (mmol=l) 5.05  0.90 5.43  0.92 5.41  0.93 4.79  0.81 5.37  0.95 5.79  1.00 TG (mmol=l) 1.33  0.72 1.57  0.80 1.34  0.70 0.89  0.43 1.18  0.62 1.49  0.70 HDL (mmol=l) 1.16  0.30 1.17  0.32 1.24  0.36 1.43  0.33 1.42  0.36 1.40  0.37 LDL (mmol=l) 3.28  0.81 3.55  0.83 3.56  0.81 2.95  0.72 3.40  0.84 3.71  0.91 BMI  25 kg=m2 27.3% 34.8% 29.8% 9.3% 26.8% 30.1% BMI  30 kg=m2 _{3.2% 2.7% 0.7% 1.4% 3.3% 3.7%} WC  90 cm in men or  80 cm in women 11.4% 20.8% 26.9% 5.8% 22.1% 50.1%

Age groups: I, 20 – 39; II, 40 – 64; III,  65 y. BMI, body mass index; WC, waist circumference; WHpR, waist-to-hip ratio; WHtR, waist-to-height ratio; SBP, systolic blood pressure; DBP, diastolic blood pressure; glucose, fasting plasma glucose; TCHO, total cholesterol; TG, fasting triglycerides; HDL, high-density lipoprotein cholesterol; LDL, low density lipoprotein cholesterol.

for hypertension and hypercholesterolemia in women older

than 65 y, according to different BMI groups. In men, the

trends were similar in men except for those  65 y. There was

no statistically significant relationship between elevated LDL

cholesterol and BMI in men aged  40 y, which is shown in

Table 4. As shown in Tables 3 and 5, in terms of actual plasma

concentrations and blood pressure values, the increasing

trends of various CVD risk factors with BMIs were also

noted in both men and women aged less than 65 y. However,

the associations showed inconsistent in both men and

Table 2 BMI groups and cardiovascular (CVD) risk factors in three age groups of women. BMI groups were defined by: 1, < 18.5; 2, 18.5 – 22.9; 3, 23 – 24.9; 4, 25 – 29.9; 5,  30 kg=m2

BMI groups

Age groups CVD risk factors (%) 1 2 3 4 5 Pvalue

I HTN 1.3 1.9 2.7 5.4 15.2 <0.001 II HTN 5.6 10.9 18.6 26.0 34.0 <0.001 III HTN 53.3 44.4 51.8 48.4 72.2 0.156 I IFG 0.5 0.8 1.1 3.6 8.6 <0.001 I DM 0.0 0.1 0.2 0.9 0.0 II IFG 2.5 3.7 6.4 9.7 11.7 <0.001 II DM 0.0 1.0 2.3 4.2 7.6 III IFG 6.7 8.0 13.9 10.9 27.8 <0.001 III DM 0.0 1.1 5.8 10.2 22.2 I TG 0.2 1.0 3.5 8.6 13.1 <0.001 II TG 0.5 4.3 9.8 12.3 19.3 <0.001 III TG 0.0 9.1 21.9 16.4 22.2 0.008 I TCHO 4.2 4.9 5.7 7.1 10.1 <0.001 II TCHO 11.2 15.6 19.5 20.5 27.4 <0.001 III TCHO 26.7 32.6 35.0 35.2 38.9 0.420 I HDL 3.2 4.9 8.7 13.5 16.7 <0.001 II HDL 1.0 3.5 8.4 10.9 14.7 <0.001 III HDL 0.0 6.4 6.6 12.5 16.7 0.013 I LDL 3.5 5.6 6.6 9.3 13.1 <0.001 II LDL 8.1 15.0 18.8 20.8 25.4 <0.001 III LDL 13.3 25.1 29.2 35.9 44.4 0.005

Table 3 BMI groups vs various prevalences of CVD risk factors BMI groups vs blood pressure values and actual plasma concentrations

BMI groups

Age groups CVD risk factors (mean þ s.d.) 1 2 3 4 5 P-value

I SBP (mmHg) 106.98  11.47 108.09  11.92 110.16  12.58 114.87  13.41 121.67  13.88 < 0.0001 II 111.90  13.72 116.34  16.71 122.25  17.76 126.22  18.77 131.39  20.24 < 0.0001 III 136.13  24.28 137.23  18.40 138.41  18.38 142.32  21.35 148.39  19.55 0.055 I DBP (mmHg) 66.42  9.16 66.68  9.20 67.54  9.44 69.90  9.60 75.42  10.62 < 0.0001 II 69.38  10.15 70.66  10.34 73.54  10.68 75.93  11.21 78.71  11.69 < 0.0001 III 70.60  11.22 74.59  11.61 75.41  10.87 77.42  10.48 86.44  12.27 < 0.0001 I Glucose (mmol=l) 4.96  0.37 5.03  0.42 5.12  0.41 5.23  0.56 5.30  0.50 <0.0001 II 5.11  0.39 5.25  0.76 5.40  0.89 5.57  1.10 5.73  1.10 <0.0001 III 5.34  0.46 5.42  0.63 5.67  1.03 5.80  1.16 6.19  1.15 0.001 I TG (mmol=l) 0.76  0.27 0.85  0.37 1.03  0.51 1.28  0.65 1.41  0.64 <0.0001 II 0.81  0.32 1.04  0.52 1.26  0.64 1.41  0.69 1.58  0.57 <0.0001 III 1.04  0.39 1.30  0.61 1.64  0.73 1.65  0.74 1.67  0.61 0.032 I TCHO (mmol=l) 4.70  0.81 4.78  0.80 4.82  0.80 4.97  0.87 5.01  0.92 <0.0001 II 5.16  0.81 5.30  0.92 5.42  0.94 5.46  0.95 5.61  1.31 <0.0001 III 5.50  0.84 5.66  0.94 5.90  1.05 5.86  1.02 6.06  1.15 0.106 I HDL (mmol=l) 1.54  0.33 1.45  0.32 1.31  0.32 1.21  0.28 1.14  0.29 <0.0001 II 1.68  0.39 1.50  0.36 1.37  0.35 1.30  0.32 1.24  0.31 <0.0001 III 1.67  0.46 1.46  0.38 1.39  0.34 1.30  0.35 1.29  0.39 <0.0001 I LDL (mmol=l) 2.82  0.70 2.94  0.71 3.04  0.70 3.18  0.78 3.22  0.82 <0.0001 II 3.11  0.70 3.32  0.81 3.48  0.82 3.51  0.85 3.65  1.24 <0.0001 III 3.35  0.65 3.60  0.83 3.76  1.01 3.80  0.91 4.01  0.97 0.091

1062

women aged greater than 65 y. In Tables 6 and 8, similarly,

there were no statistically significant trends in

hypercholes-terolemia and elevated LDL cholesterol by different waist

groups in both sexes  65 y. The associations between

differ-ent waist circumference groups and actual values of various

CVD risk factors were also shown to be inconsistent in both

men and women aged greater than 65 y. In Figure 1, BMI and

waist circumference groups were found to be closely related

to the changes of odds ratios of DM and IFG across all age

groups in both sexes. The risks of DM or IFG became

significantly increased (2-fold greater) at lower BMI (23 –

24.9 kg=m

_{) and WC groups (90 cm for men and 80 cm for}

Table 4 BMI groups and cardiovascular (CVD) risk factors in three age groups of men. BMI groups were defined by: 1, < 18.5; 2, 18.5 – 22.9; 3, 23 – 24.9; 4, 25 – 29.9; 5,  30 kg=m2_{. BMI groupsvs various prevalences of CVD risk}

factors

BMI groups

Age groups CVD risk factors (%) 1 2 3 4 5 P-value

I HTN 5.9 5.5 9.6 13.1 24.7 <0.001 II HTN 5.7 12.8 17.0 24.1 35.5 <0.001 III HTN 21.9 28.0 43.9 40.1 75.0 0.001 I IFG 1.5 1.5 2.5 4.5 8.1 <0.001 I DM 0.0 0.2 0.5 1.4 2.8 II IFG 4.1 6.4 8.7 10.7 17.0 <0.001 II DM 0.8 1.3 2.0 5.1 9.2 III IFG 3.1 5.2 4.4 17.2 0.0 0.01 III DM 3.1 4.3 6.1 3.8 25.0 I TG 0.6 4.4 14.1 24.8 34.6 <0.001 II TG 3.3 10.9 19.8 29.4 38.3 <0.001 III TG 0.0 8.2 12.3 17.2 25.0 <0.001 I TCHO 4.2 7.4 12.5 15.8 21.0 <0.001 II TCHO 10.6 18.9 20.0 20.4 37.6 <0.001 III TCHO 21.9 14.2 19.3 21.0 25.0 0.186 I HDL 6.5 12.6 20.4 32.3 41.4 <0.001 II HDL 4.9 14.7 22.4 30.3 36.9 <0.001 III HDL 3.1 10.3 21.9 29.3 0.0 <0.001 I LDL 6.0 10.2 16.1 18.3 22.0 <0.001 II LDL 13.8 21.6 22.8 21.0 31.2 0.185 III LDL 21.9 15.5 22.8 22.3 50.0 0.097

Table 5 BMI groupsvs blood pressure values and actual plasma concentrations

BMI groups

Age groups CVD risk factors (mean  s.d.) 1 2 3 4 5 P-value

I SBP (mmHg) 114.50  12.38 116.62  12.49 119.15  12.96 121.71  13.28 127.52  14.72 < 0.0001 II 112.33  14.80 118.84  15.29 121.58  15.58 125.24  16.30 129.94  17.52 < 0.0001 III 128.39  21.15 129.40  19.72 136.01  21.18 136.22  17.18 136.50  8.43 0.002 I DBP (mmHg) 70.55  9.88 71.18  9.35 73.28  9.77 75.20  9.94 79.00  10.83 < 0.0001 II 70.45  8.87 74.06  10.04 75.98  10.28 78.71  11.10 81.97  11.76 < 0.0001 III 73.39  11.78 73.82  10.81 76.84  11.22 77.66  11.11 80.00  14.02 0.005 I Glucose (mmol=l) 5.10  0.37 5.19  0.50 5.28  0.43 5.38  0.71 5.52  1.00 <0.0001 II 5.25  0.50 5.40  0.72 5.52  0.90 5.69  1.24 5.80  0.98 <0.0001 III 5.38  0.86 5.52  0.89 5.72  1.84 5.68  1.04 6.09  0.70 0.264 I TG (mmol=l) 0.87  0.34 1.09  0.54 1.43  0.70 1.70  0.83 1.92  0.87 <0.0001 II 0.94  0.40 1.33  0.71 1.62  0.77 1.79  0.84 2.05  0.80 <0.0001 III 0.95  0.35 1.22  0.68 1.39  0.67 1.57  0.72 1.46  0.77 <0.0001 I TCHO (mmol=l) 4.61  0.82 4.88  0.86 5.18  0.88 5.29  0.91 5.40  0.93 <0.0001 II 5.07  0.83 5.39  0.93 5.45  0.91 5.45  0.91 5.77  0.89 <0.0001 III 5.38  1.21 5.33  0.86 5.55  0.90 5.43  0.99 6.28  0.80 0.067 I HDL (mmol=l) 1.35  0.30 1.23  0.30 1.13  0.28 1.04  0.26 0.97  0.23 <0.0001 II 1.45  0.38 1.27  0.34 1.13  0.29 1.07  0.27 1.04  0.24 <0.0001 III 1.49  0.36 1.32  0.36 1.21  0.35 1.09  0.29 1.22  0.23 <0.0001 I LDL (mmol=l) 2.86  0.72 3.15  0.78 3.40  0.80 3.47  0.82 3.55  0.89 <0.0001 II 3.19  0.77 3.51  0.85 3.57  0.83 3.56  0.81 3.79  0.81 <0.0001 III 3.47  1.02 3.45  0.74 3.71  0.81 3.61  0.84 4.38  0.71 0.009

1063

women). As shown in Figure 2, the trends in different

WHpR groups were not statistically significant for women

aged  65 y for CHD risk factors, except for DM or IFG, and

only for hypercholesterolemia and elevated LDL cholesterol

in men aged  65 y. In Figure 3, no significant trends

by different WHtR groups were noted in hypertension,

hypercholesterolemia and elevated LDL cholesterol in

women



65 y, nor hypercholesterolemia and elevated

LDL cholesterol in men aged  65 y. Among the above

cardiovascular risk factors, only DM or IFG showed

consis-Table 6 Waist circumference groups and cardiovascular (CVD) risk factors in three age groups of women. Waist circumference groups were defined by: 1, < 70; 2, 70 – 74.9; 3, 75 – 79.9; 4,  80 cm. Waist circumference groupsvs various prevalences of CVD risk factors

Waist circumference groups

Age groups CVD risk factors (%) 1 2 3 4 P-value

I HTN 1.6 2.7 3.7 7.6 <0.001 II HTN 8.4 13.4 21.4 29.2 <0.001 III HTN 40.0 45.2 40.9 55.1 0.017 I IFG 0.6 1.1 2.5 5.1 <0.001 I DM 0.0 0.2 0.4 1.0 II IFG 2.5 5.2 6.6 11.1 <0.001 II DM 0.6 0.8 2.8 6.1 III IFG 8.0 6.7 9.1 14.4 0.001 III DM 0.0 3.8 4.5 7.8 I TG 0.6 2.5 5.1 10.0 <0.001 II TG 2.2 6.5 10.2 15.2 <0.001 III TG 4.0 9.6 21.6 16.9 0.011 I TCHO 4.4 5.7 6.5 8.6 <0.001 II TCHO 12.8 17.5 20.4 23.1 <0.001 III TCHO 42.0 33.7 31.8 33.3 0.402 I HDL 4.5 6.1 10.6 15.0 <0.001 II HDL 2.6 5.6 8.4 12.0 <0.001 III HDL 2.0 4.8 9.1 10.7 0.014 I LDL 4.6 6.7 8.9 10.6 <0.001 II LDL 12.4 17.0 20.3 22.1 <0.001 III LDL 28.0 28.8 27.3 30.9 0.605

Table 7 Waist circumference groupsvs blood pressure values and actual plasma concentrations

Waist circumference groups

Age groups CVD risk factors (mean  s.d.) 1 2 3 4 P-value

I SBP (mmHg) 107.66  11.70 109.53  12.43 111.62  13.25 115.64  14.58 <0.0001 II 114.47  15.48 119.13  17.40 123.64  18.38 127.71  19.33 <0.0001 III 137.86  16.97 135.66  19.39 137.51  21.49 141.83  19.15 0.034 I DBP (mmHg) 66.49  9.17 67.41  9.44 68.31  9.55 70.70  10.10 <0.0001 II 70.00  10.11 72.01  10.60 74.19  10.91 76.49  11.35 <0.0001 III 72.36  5.35 75.38  5.50 75.37  5.63 77.20  5.76 0.038 I Glucose (mmol=l) 5.00  0.37 5.09  0.48 5.19  0.59 5.26  0.64 <0.0001 II 5.17  0.49 5.29  0.76 5.49  1.04 5.69  1.29 <0.0001 III 5.35  0.47 5.50  0.78 5.63  1.15 5.76  1.12 0.02 I TG (mmol=l) 0.81  0.37 0.98  0.51 1.15  0.70 1.38  0.87 <0.0001 II 0.94  0.45 1.18  0.75 1.34  0.79 1.59  1.07 <0.0001 III 1.23  1.18 1.40  0.81 1.70  1.09 1.80  1.94 0.034 I TCHO (mmol=l) 4.74  0.80 4.84  0.81 4.90  0.85 5.01  0.90 <0.0001 II 5.21  0.88 5.36  0.93 5.48  0.96 5.55  1.04 <0.0001 III 5.75  1.06 5.70  0.97 5.89  1.08 5.84  1.05 0.555 I HDL (mmol=l) 1.49  0.33 1.37  0.31 1.28  0.31 1.19  0.30 <0.0001 II 1.55  0.37 1.43  0.35 1.36  0.34 1.29  0.32 <0.0001 III 1.57  0.38 1.45  0.36 1.40  0.37 1.34  0.36 0.001 I LDL (mmol=l) 2.89  0.70 3.03  0.72 3.10  0.75 3.20  0.80 <0.0001 II 3.22  0.77 3.40  0.82 3.53  0.83 3.56  0.93 <0.0001 III 3.66  0.87 3.67  0.85 3.73  0.96 3.72  0.93 0.937

1064

tent trends in four anthropometric indices across different

age groups.

Discussion

Most studies examining the risk of adverse health associated

with obesity have been based on data from Europe or the

United States. The increased risks associated with obesity

have been shown to occur at lower BMIs in Asians, and these

populations are predisposed to visceral or abdominal

obe-sity.

_{Therefore, the WHO proposes a lower BMI value to}

define overweight and obesity in the Asia-Pacific region.

However, there are as yet a few reports, and small sample

sizes of studies in Asia-Pacific region. Our study provides a

Table 8 Waist circumference groups and cardiovascular (CVD) risk factors in three age groups of men. Waist circumference groups were defined by 1, < 80; 2, 80 – 84.9; 3, 85 – 89.9; 4,  90 cm. Waist circumference groupsvs various prevalences of CVD risk factors

Waist circumference groups

Age groups CVD risk factors (%) 1 2 3 4 P-value

I HTN 5.8 10.2 11.9 18.0 <0.001 II HTN 12.2 16.0 19.1 28.7 <0.001 III HTN 30.8 27.4 39.4 42.1 0.013 I IFG 1.4 2.8 3.7 7.0 <0.001 I DM 0.2 0.8 1.1 1.8 II IFG 6.9 7.5 9.6 11.8 <0.001 II DM 1.3 2.2 2.8 6.5 III IFG 4.7 7.1 7.3 14.5 0.002 III DM 2.3 5.3 5.5 6.2 I TG 4.5 14.4 24.5 31.5 <0.001 II TG 9.1 17.1 25.9 34.4 <0.001 III TG 2.9 11.5 11.9 20.7 0.011 I TCHO 7.0 13.3 15.6 19.4 <0.001 II TCHO 17.4 18.4 21.1 24.8 <0.001 III TCHO 15.1 17.7 15.6 22.8 0.118 I HDL 13.0 22.6 29.5 35.4 <0.001 II HDL 14.2 22.5 26.2 30.7 <0.001 III HDL 6.4 16.8 23.9 27.6 0.014 I LDL 10.0 16.4 18.0 21.1 <0.001 II LDL 20.0 21.7 22.8 23.7 0.015 III LDL 26.4 21.7 18.9 33.0 0.115

Table 9 Waist circumference groupsvs blood pressure values and actual plasma concentrations

Waist circumference groups

Age groups CVD risk factors (mean  s.d.) 1 2 3 4 P-value

I SBP (mmHg) 116.90  12.55 119.21  13.10 120.49  13.48 123.88  13.86 <0.0001 II 118.28  15.38 120.90  15.03 123.36  15.84 126.88  17.11 <0.0001 III 130.92  21.20 128.53  19.55 135.10  19.87 136.54  16.47 0.005 I DBP (mmol=l) 71.27  9.42 73.42  9.83 74.70  9.94 77.13  10.25 <0.0001 II 73.76  10.06 75.67  10.36 77.25  10.56 79.68  11.25 <0.0001 III 74.36  11.23 73.51  10.09 76.90  12.18 77.72  10.75 0.005 I Glucose (mmol=l) 5.18  0.42 5.29  0.59 5.35  0.64 5.46  0.88 <0.0001 II 5.40  0.70 5.48  0.85 5.58  1.08 5.76  1.28 <0.0001 III 5.44  0.62 5.47  0.89 5.74  1.40 5.82  1.63 0.009 I TG (mmol=l) 1.09  0.55 1.45  0.70 1.68  0.83 1.87  0.85 <0.0001 II 1.26  0.66 1.56  0.76 1.73  0.82 1.91  0.85 <0.0001 III 1.07  0.50 1.28  0.73 1.40  0.65 1.67  0.76 <0.0001 I TCHO (mmol=l) 4.87  0.86 5.17  0.87 5.30  0.92 5.40  0.94 <0.0001 II 5.34  0.94 5.40  0.89 5.48  0.90 5.56  0.93 <0.0001 III 5.35  0.96 5.36  0.90 5.41  0.82 5.53  1.01 0.313 I HDL (mmol=l) 1.23  0.30 1.11  0.27 1.06  0.25 1.02  0.25 <0.0001 II 1.28  0.35 1.14  0.29 1.11  0.28 1.07  0.28 <0.0001 III 1.39  0.38 1.24  0.32 1.15  0.31 1.13  0.32 <0.0001 I LDL (mmol=l) 3.14  0.78 3.40  0.79 3.47  0.84 3.52  0.86 <0.0001 II 3.48  0.86 3.54  0.81 3.58  0.83 3.61  0.83 <0.0001 III 3.47  0.82 3.53  0.81 3.62  0.76 3.64  0.82 0.238

1065

larger sample size of data. Furthermore, our study implicates

the relationships between the anthropomethric indices and

the cumulative incidences

_{among ‘healthy’ people of}

cardiovascular risk factors. More prospective epidemiological

studies, however, need to be performed to determine the

relative risk of developing these co-morbiditites with obesity.

Obesity is characterized by an increased amount of body

fat. BMI, WC, WHpR and WHtR have been accepted as

simple anthropometric indexes for assessing body fat

amount and distribution and are useful indices for

provid-ing important information to predict cardiovascular

dis-ease.

_{Ko et al}

_{also found that WHpR and WHtR}

were the main predictors for DM and hypertension in

work-ing aged men and women. These four indices have been

proven useful in predicting the probability of dyslipidemia.

In our study, the four anthropometric indices were found to

be closely related to cardiovascular disease, including

hyper-tension, DM and dyslipidemia in both men and women aged

20 – 64 y. In the age groups older than 65, however, the

Figure 1 Different BMI or waist circumference groupsvs IFG (impaired fasting glucose) and DM (type 2 diabetes mellitus) in three age groups of men and women. Age groups were defined by: 20 – 39, 40 – 64 and  65 y. BMI groups were defined by: 1, < 18.5; 2, 18.5 – 22.9; 3, 23 – 24.9; 4, 25 – 29.9; 5,  30 kg=m2. Waist circumference groups were defined by: 1, < 70; 2, 70 – 74.9; 3, 75 – 79.9; 4,  80 cm for women; and 1, < 80; 2, 80 – 84.9; 3, 85 – 89.9; 4,  90 cm for men. The results of statistics by testing for trends all showed consistentlyP  0.01.

Figure 2 Waist-to-hip ratio groups vs CVD risk factors in three age groups of women and men. Waist-to-hip ratio groups were defined by: 1, < 0.70; 2, 0.70 – 0.74; 3, 0.75 – 0.79; 4,  0.80 for women; and 1, <0.80; 2, 0.80 – 0.84; 3, 0.85 – 0.89; 4,  0.90 for men. The results of statistics by testing for trends showedP-value > 0.05: HTN, TG, TCHO, HDL, LDL in age group III for women and TCHO, LDL in age group III and LDL in age group II for men; othersP-value  0.05.

relationships were statistically inconsistent for lipid

abnorm-alities. This discrepancy may be due to the relatively smaller

sample size of senior subjects in our study. In addition, our

results showed that most cardiovascular risk factors, except

hypercholesterolemia and elevated LDL cholesterol, were

closely related to WC. Similarly, Turcato et al

_{found that}

waist and abdominal sagittal diameters the anthropometric

indicators of fat distribution most closely related to

cardio-vascular risk factors in old age. Taken together, the

relation-ship

between

cardiovascular

risk

factors

and

simple

anthropometric indices in older subjects should be clarified

in future research.

Central obesity, especially intra-abdominal fat

accumula-tion, is known to be closely related to insulin resistance and

its related disorders, including diabetes, hypertension and

dyslipidemia.

_{There is now much data to confirm the}

importance of central adiposity as a cardiovascular risk

factor.

_{Despite the close association between}

cen-tral adiposity and cardiovascular risks, there remains some

controversy regarding the best anthropometric index for

central adiposity. Some works have shown that WC is a

better

correlate

of

cardiovascular

risk

factors

than

WHpR.

_{Using computed tomographic scanning to}

mea-sure adipose tissue, WC is found to be a better estimate of

abdominal visceral adipose accumulation than WHtR and

may be a better predictor of multiple cardiovascular risk

factors than WHpR.

_{In our study, all four}

anthorpo-metric indices nevertheless provided useful information on

cardiovascular risk factors, although at various degrees of

importance.

In conclusion, the four anthropometric indices (BMI, WC,

WHpR, WHtR) are closely related to the cardiovascular risk

factors of Taiwanese people aged 20 – 64 y. The relationships,

however, are statistically inconsistent for the elderly. Further

studies must demonstrate for the importance of

anthropo-metric measurements in more senior subjects.

References

1 World Health Organization. Obesity: preventing and managing the global epidemic. WHO: Geneva; 1998.

2 Flegal KM, Carroll MD, Kuczmarski RJ, Johnson CL. Overweight and obesity in the United States: prevalence and trends, 1960 – 1994. Int J Obes Relat Metab Disord 1998; 22: 39 – 47.

3 Kuczmarski RJ, Flegal KM, Campbell SM, Johnson CL. Increasing prevalence of overweight among US adults. The National Health and Nutrition Examination Surveys, 1960 to 1991. JAMA 1994; 272: 205 – 211.

4 Kopelman. Obesity as a medical problem. Nature 2000; 404: 635 – 643.

5 Pi-Sunyer X. Health implications of obesity. Am J Clin Nutr 1991; 53: 1595s – 1603s.

6 Hubert HB, Feinleib M, McNamara PM, Castelli WP. Obesity as an independent risk factor for cardiovascular disease: a 26-year follow-up of participants in the Framingham Heart Study. Circu-lation 1983; 67: 968 – 977.

7 William BK, Ralph BD, Janet LC. Effect of weight on cardiovas-cular disease. Am J Clin Nutr 1996; 63: 419s – 422s.

8 Seidell JC, Verschu Ren WM, Van Leer EM, Kromhout D. Over-weight, underOver-weight, and mortality. A prospective study of 48,187 men and women. Arch Intern Med 1996; 156: 958 – 963. 9 Bjo¨rntorp P. Metabolic implications of body fat distribution.

Diabetes Care 1991; 14: 1132 – 1143.

10 Larsson B, Svardsud K, Welin L, Wilhelmsen L, Bjorntorp P, Tibblin G. Abdominal adipose tissue distribution, obesity, and the risk of cardiovascular disease and death: 13-year follow up of participants in the study of men born in 1913. Br Med J 1984; 288: 1401 – 1404.

11 Kissebah AH, Vydelingum N, Murray R, Evans DJ, Hartz AJ, Kalkhoff RK, Adams PW. Relation of body fat distribution to metabolic complications of obesity. J Clin Endocrinol Metab 1982; 54: 254 – 260.

12 Mazess RB, Barden HS, Bisek JP, Hanson J. Dual-energy X-ray absorptiometry for total body and regional bone mineral and soft tissue composition. Am J Clin Nutr 1990; 51: 1106 – 1112. Figure 3 Waist-to-height ratio groupsvs CVD risk factors in three age

groups of women and men. Waist-to-height ratio groups were defined by: 1, < 0.41; 2, 0.41 – 0.43; 3, 0.44 – 0.47; 4,  0.48 for women; and 1, < 0.44; 2, 0.44 – 0.46; 3, 0.47 – 0.50: 4,  0.51 for men. The results of statistics by testing for trends showedP-value > 0.05: HTN, TCHO, LDL in age group III and LDL in age group II for women and TCHO, LDL in age group III for men; othersP-value  0.05.

13 Lukaski HC. Methods for the assessment of human body compo-sition: Traditional and new. Am J Clin Nutr 1987; 46: 537 – 556. 14 Friedl KE, Deluca JP, Marchitelli LJ, Vogel JA. Reliability of

body-fat estimations from a four-compartment model by using density, body water, and bone mineral measurements. Am J Clin Nutr 1992; 55: 764 – 770.

15 Kushner RF, Schoeller DA, Fjeld CR, Danford L. Is the impedance index (H2_{=R) significant in predicting total body water. Am J Clin}

Nutr 1992; 56: 835 – 839.

16 Gallagher D, Visser M, Sepulveda D, Pierson RN, Harris T, Heyms-field SB. How useful is body mass index for comparison of body fatness across age, sex, and ethnic groups? Am J Epidemiol 1996; 143: 228 – 239.

17 Deurenberg P, Yap M, van Staveren WA. Body mass index and percent body fat: a meta-analysis among different ethnic groups. Int J Obes 1988; 22: 1164 – 1171.

18 Pouliot MC, Despres JP, Lemieux S, Moorjani S, Bouchard C, Tremblay A, Nadeau A, Lupien PJ. Waist circumference and abdominal sagittal diameter: the best simple anthropometric indices of abdominal visceral adipose tissue accumulation and related cardiovascular risk in men and women. Am J Cardiol 1994; 73: 460 – 468.

19 Dospres J-P, Denis P, Marie-C, Pouliot, Angelo T, Clande B. Estimate of deep abdominal adipose-tissue accumulation from single anthorpometric measurements in men. Am J Clin Nutr 1991; 54: 471 – 477.

20 Hsieh SD, Yoshinaga H. Abdominal fat distribution and coronary heart disease risk factors in men — waist=height ratio as a simple and useful predictor. Int J Obes Relat Metab Disord 1995; 19: 585 – 589.

21 Hsieh SD, Yoshinaga H. Waist=height ratio as a simple and useful predictor of coronary heart disease risk factors in women. Intern Med 1995; 34: 1147 – 1152.

22 Ko GTC, Chan JCN, Woo J, Lau E, Yeung VTF, Chow C-C, Wai HPS, Li JKY, So W-Y, Cockram CS. Simple anthropometric indexes and cardiovascular risk factors in the Chinese. Int J Obes Relat Metab Disord 1997; 21: 995 – 1001.

23 Hsieh SD, Yo Shinaga H, Muto T, Sakurai Y, Kosaka K. Health risks among Japanese men with moderate body mass index. Int J Obes Relat Metab Disord 2000; 24: 358 – 362.

24 Department of Health. Taiwan Public Health Report 1999. DOH: Taipei, 1999.

25 World Health Organization. The Asia-Pacific perspective: redefining obesity and its treatment. WHO: Geneva; 2000.

26 Wang J, Thornton JC, Russell M, Burastero S, Heymsfield S Jr, Pierson RN. Asians have lower body mass index (BMI) but higher percent body fat than do Caucasians: comparisons of anthropo-metric measurements. Am J Clin Nutr 1994; 60: 23 – 28. 27 Deurenberg-Yap M, Yian TB, Kai CS, Deurenberg P, van Staveren

WA. Manifestation of cardiovascular risk factors at low levels of body mass index and waist-to-hip ratio in Singaporean Chinese subjects. Asia Pacific J Clin Nutr 1999; 8: 177 – 183.

28 Wang J, Russell-Aulet M, Mazariegos M et al. Body fat by dual photon absorptiometry (DPA): comparisons with traditional methods in Asians, Blacks and Caucasians. Am J Hum Biol 1992; 4: 501 – 510.

29 Elandt-Johnson RC. Definition of rates: some remarks on their use and misuse. Am J Epidemiol 1975; 102: 267 – 271.

30 Patel S, Unwin N, Bhopal R, White M, Harland J, Ayis SAM, Watson W, Alberti KGMM. A comparison of proxy measures of abdominal obesity in Chinese, European and South Asian adults. Diabetic Med 1999; 16: 853 – 860.

31 Ko GTC, Chan JCN, Cockram CS, Woo J. Prediction of hyperten-sion, diabetes or albuminuria using simple anthropometric indexes in Hong Kong Chinese. Int J Obes Relat Metab Disord 1999; 23: 1136 – 1142.

32 Turcato E, Bosello O, Francesco VD, Harris TB, Zoico E, Bissoli L, Fracassi E, Zamboni M. Waist circumference and abdominal sagittal diameter as surrogates of body fat distribution in the elderly: their relation with cardiovascular risk factors. Int J Obes Relat Metab Disord 2000; 24: 1005 – 1010.

33 Fujioka S, Matsuzawa Y, Tokunaga K, Tarui S. Contribution of intra-abdominal fat accumulation to the impairment of glucose and lipid metabolism in human obesity. Metabolism 1987; 36: 54 – 59.

34 Lean MEJ, Han TS, Morrison CE. Waist circumference as a measure for indicating need for weight management. Br Med J 1995; 311: 158 – 161.