Table 3.

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

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.