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Review ArticlePractice

Normal-weight central obesity

Unique hazard of the toxic waist

N. John Bosomworth
Canadian Family Physician June 2019, 65 (6) 399-408;
N. John Bosomworth
Honorary Lecturer in the Department of Family Practice at the University of British Columbia in Vancouver.
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  • For correspondence: jbosomworth@gmail.com
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  • Figure 1.
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    Figure 1.

    Plasma lipoproteins comparing hepatic synthesis and lipid trajectory of TG-rich particles: A) With and B) without insulin resistance.

    HbA1c—hemoglobin A1c, HDL—high-density lipoprotein cholesterol, IDL—intermediate-density lipoprotein cholesterol, LDL—low-density lipoprotein cholesterol, TG—triglyceride, VLDL—very low-density lipoprotein cholesterol.

  • Figure 2.
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    Figure 2.

    Comparison of mortality rates in non-smokers by BMI or WHtR deciles over 20 years

    BMI—body mass index, WHtR—waist-to-height ratio.

    Data from Ashwell et al.40

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    Figure 3.

    Adjusted mortality HRs (with 95% CIs represented by error bars) for waist circumference comparing highest and lowest values by category of BMI

    BMI—body mass index, HR—hazard ratio. Data from Cerhan et al.53

Tables

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    Table 1.

    Anthropometric measures of body fat distribution: A) Mass-based and B) distribution-based measures.

    A)
    MASS-BASED MEASUREDEFINITIONCOMMENTS
    Body mass index11Weight in kg divided by the square of the height in mDoes not distinguish between lean and fat tissue mass
      • Underweight< 18.5 kg/m2Associated with higher mortality
      • Normal weight
      • Overweight
    18.5–24.9 kg/m2
    25.0–29.9 kg/m2
    Lowest mortality associated with these categories
      • Obesity class 130.0–34.9 kg/m2No consistent association with increased mortality
      • Obesity class 2
       • Obesity class 3
    35.0–39.9 kg/m2
    ≥ 40.0 kg/m2
    Direct association with increased mortality
    B)
    DISTRIBUTION-BASED MEASURESVALUES REPRESENTING INCREASED RISKSURROGATE MEASURES OF CENTRAL OR VISCERAL ADIPOSITY
    Waist circumferenceFemales ≥ 80 cm
    Males ≥ 95 cm
    Cut points vary according to ethnicity, sex, and age12
    Waist-to-hip ratioFemales ≥ 0.85
    Males ≥ 0.95
    Cut points not well established for ethnicity13
    Waist-to-height ratioIncreased risk 0.50–0.60
    Substantial risk > 0.60
    Cut points the same for ethnicity, sex, and age12
    Best predicts visceral fat mass14,15
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    Table 2.

    Characteristics of subcutaneous and visceral fat

    VARIABLESCHARACTERISTICS
    SUBCUTANEOUS FATVISCERAL FAT
    Clinical measurementBody mass indexWaist circumference, waist-to-height ratio, waist-to-hip ratio
    Association with cardiometabolic disease16Association with mortality is inconsistentDirect linear association with mortality
    Function15,18Metabolic sink and longer-term energy storageShort-term energy source
    Cardiac risk23ModerateHigh
    Metabolic risk24ModerateHigh
    Inflammation22ModerateHigh
    Catecholamine response22ModerateRapid
    Insulin sensitivity17ModerateLow
    Metabolic flux18LowHigh
    Trend with age25Increased to age 65 y, then reducedGradual increase
    Storage duration26LongShort
    Effect of exercise27High levels needed for weight changeLow levels effective for cardiometabolic benefit
    Adverse effects of refined carbohydrate28ModerateHigh
    • View popup
    Table 3.

    Prospective observational studies and related SRs and MAs of studies relating normal-weight central obesity to mortality

    STUDY AND YEARSTUDY TYPE (DURATION)STUDY OBJECTIVESNO. AND AGE OF PARTICIPANTSRESULTSCOMMENTS
    Coutinho et al, 201343SR of prospective observational studies and collaborative analysis (0.5–7.4 y)Relation of measures of central obesity to mortality15 923 patients with known CAD Mean (SD) age 65.7 (11.5) yHighest mortality category combined lowest BMI with highest WHR or WC; HR = 1.7Central obesity associated with equal increase in mortality risk in lean and obese patients. Increased BMI was associated with reduced risk in these patients
    Kramer et al, 201344MA of prospective observational studies (3–30 y)Relation of cardiometabolic risk and BMI category to CVD events and all- cause mortality61 386 adults from the general population
    Mean age range 44–60 y
    Highest mortality or CVD event rate was similar in metabolically unhealthy normal-weight and obese participants; HR = 2.65 compared with those of normal weight and metabolic healthDid not specifically consider central obesity. Metabolic health was based on absence of metabolic syndrome components, insulin resistance, or inflammatory markers
    Carmienke et al, 201339SR and regression MA of prospective cohorts (5–24 y)Relation of measures of abdominal obesity parameters to mortality689 465 healthy adults
    Age ≥ 18 y
    Highest mortality category combined lowest BMI with highest WHR or WCWHR, WC, or WHtR combined with BMI gives best mortality prediction. In participants > 65 y there was a non-significant or negative association with increasing BMI, WC, and WHR
    Folsom et al, 200045Prospective observational study (11–12 y)Relation of BMI, WC, and WHR to mortality, cancer, diabetes, hypertension, and fracture31 702 healthy US women
    Age 55–69 y
    Highest mortality category combined lowest BMI with highest WHRWHR had the best mortality prediction
    Pischon et al, 200846Prospective observational study (9.7 y)Association of distribution of adiposity with risk of death359 387 participants from general European population
    Age 25–70 y
    Highest mortality associated with lowest BMI percentile having highest WC or WHRAssociation of BMI with mortality is J shaped.
    Measures of central obesity showed positive linear association with mortality when adjusted for BMI
    Zhang et al, 200847Prospective observational study (16 y)Relation of abdominal adiposity to premature death44 636 US women from the Nurses’ Health Study
    Age 30–55 y
    Highest mortality category combined highest BMI and highest WC or WHR. Risk was only slightly lower for normal BMI with high central obesityWC and WHR were both directly associated with mortality
    Koster et al, 200848Prospective observational study (9 y)Relation of WC to all-cause mortality245 533 US adults
    Age 51–72 y
    Normal weight with high WC increased mortality by 22%.
    Exceeded only by class 2 and 3 obesity with high WC
    WC used as measure of central obesity in mortality prediction
    Reis et al, 200949Prospective observational study (12 y)Relation of BMI, WHR, and WTR to mortality13 065 participants from the general US population
    Age 30–102 y
    Highest mortality category combined lowest BMI with highest WHR or WTRWHR or WTR had the best mortality prediction. No association at > 65 y of age
    Romero-Corral et al, 200950Prospective observational study (8.8 y)Relation of body fat percentage to cardiovascular mortality and metabolic dysregulation in participants with normal BMI6171 US patients with normal BMI and CAD
    Age ≥ 20 y
    High body fat percentage and WC were associated with increased risk of metabolic syndrome. CVD mortality increased in normal-weight obese women (HR = 2.20) compared with nonobese womenBody fat measured by bioimpedance. Body fat percentage did not correlate with all-cause mortality in women or men at any BMI
    Staiano et al, 201251Prospective observational study (13 y)Relation of BMI, WC, and WHR to CVD and all-cause mortality8061 Canadian adults
    Age 18–74 y
    No mortality increase with WC in normal-weight adults. Highest mortality in highest WC terciles of obese adultsWC had the best association with CVD and all-cause mortality
    Thomas et al, 201352Prospective observational study (mean [SD] 5.6 [2.4] y)Relation of obesity measured by BMI or WC on mortality at differing ages119 010 French participants with BMI > 20 kg/m2
    Age 17–85 y
    Mortality at BMI 20–25 kg/m2 and WC ≥ 102 cm ...
    • increased 2-fold at age < 55 y and

    • increased 5-fold at age 55–65 y


    No association at age > 65 y
    Mortality risk higher for central obesity in normal BMI range than in class 2 and 3 obesity. WC gives best mortality prediction at < 65 y of age. Neither WC nor BMI are useful in the elderly
    Cerhan et al, 201453Pooled data from 11 prospective observational studies (median 9 y, maximum 21 y)Relation of WC to mortality across entire range of BMI categories650 386 non-Hispanic white adults
    Age 20–83 y
    Highest mortality associated with BMI ranges < 20 and ≥ 35 kg/m2 in those with highest WC. Highest WC in those with BMI 20–22.5 kg/m2 had higher mortality than those with class 1 obesity at highest WCWC should be assessed in combination with BMI even in those in normal BMI range. WC is directly associated with mortality at all levels of BMI
    Sahakyan et al, 201554Prospective observational study (14.3 y)Relation of central obesity and survival in adults of normal body weight16 124 US adults with BMI ≥ 18.5 kg/m2
    Age 18–90 y
    Men with normal-weight central obesity had higher mortality risk than any other BMI and WHR combination.
    Similar women had 40% and 32% relative risk increase compared with overweight and obese women without central obesity
    WHR used as measure of central obesity in mortality prediction
    Klingberg et al, 201555Prospective observational study (average 6 y)Relation of baseline WC and change in WC to morality and CVD2492 healthy Danish and Swedish women
    Age 44–74 y at baseline
    Association of mortality with both high baseline WC and large increase in WC over time; particularly high in those with BMI < 25 kg/m2WC used in mortality prediction. Hip circumference was unrelated to mortality
    Sharma et al, 201656Prospective observational study (average 7.1 y)Relation of WC or WHR and BMI to mortality in elderly patients with CVD7057 elderly patients with CAD
    Mean age 73 y
    Highest mortality in patients with normal BMI and central obesityHighlights importance of including WC or WHR along with BMI when making adiposity-related mortality assessment
    Hamer et al, 201757Prospective observational study (average 9 y)Determine whether WHR is more predictive of mortality than BMI is42 702 UK adults
    Mean age 57.7 y
    Normal weight with central obesity showed highest mortality; HR = 1.22 for deathWHR used as measure of central obesity in mortality prediction
    • BMI—body mass index, CAD—coronary artery disease, CVD—cardiovascular disease, HR—hazard ratio, MA—meta-analysis, SR—systematic review, UK—United Kingdom, US—United States, WC—waist circumference, WHR—waist-to-hip ratio, WHtR—waist-to-height ratio, WTR—waist-to-thigh ratio.

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Canadian Family Physician: 65 (6)
Canadian Family Physician
Vol. 65, Issue 6
1 Jun 2019
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Normal-weight central obesity
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Canadian Family Physician Jun 2019, 65 (6) 399-408;

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