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Waist-to-Hip Ratio a Better Marker of Subclinical

Atherosclerosis Than BMI and Waist Circumference CME


News Author: Michael O'Riordan
CME Author: Dsire Lie, MD, MSEd
Disclosures

Release Date: August 15, 2007; Valid for credit


through August 15, 2008 Credits Available

Physicians - maximum of 0.25 AMA PRA Category 1


Credit(s) for physicians;
Family Physicians - up to 0.25 AAFP Prescribed
credit(s) for physicians

from Heartwire a professional news service of WebMD

August 15, 2007 The relationship of the waist to hip


measurement is independently associated with prevalent
atherosclerosis, as measured by coronary artery
calcium (CAC) imaging, and is a better discriminator
of subclinical disease than other common measures of
obesity, such as body mass index (BMI) or waist
circumference alone, a new study has shown.[1] Those
with the largest waist-to-hip ratio (WHR) were almost
twice as likely to have calcium deposits in the
coronary arteries compared with those with the least
calcification, report investigators.

"These data confirm what others have shown for


clinical events, that is when you link this data to
some of the large outcome studies, it really does
establish a consistent message that these measures of
body shape waist and the waist-to-hip ratio
predict not just clinical events but also
atherosclerotic burden," senior investigator Dr James
de Lemos (University of Texas Southwestern Medical
Center, Dallas, TX) told heartwire. "It also suggests
that part of the mechanism in which central adiposity
contributes to increased risk is through this
increased atherosclerotic burden."

The results of the study are published in the August


14, 2007 issue of the Journal of the American College
of Cardiology.

Data from the Dallas Heart Study


Speaking with heartwire, de Lemos said the large
INTERHEART study, previously reported by heartwire,
showed that the WHR and waist circumference were
excellent predictors of cardiovascular events. With
this in mind, the group sought to determine the
underlying mechanism responsible for this increased
cardiovascular risk. Some part of this risk is likely
driven by atherosclerosis in the coronaries and the
aorta, although high blood pressure, left ventricular
hypertrophy, or inflammation and thrombosis have all
been proposed as risk factors explaining the increased
morbidity and mortality risk associated with obesity,
explained de Lemos.

Additionally, de Lemos noted there is a complex


relationship between BMI and cardiovascular risk, an
almost J-shaped relationship, where those with a
very-low BMI having greater atherosclerotic burden
than those with a higher BMI. Also, BMI doesn't
reflect obesity, but rather mass, and is not a measure
of central adiposity and cardiovascular risk. The
purpose of this study, he said, was to evaluate the
association between different measures of obesity and
atherosclerosis in addition to determining if obesity
was associated with subclinical cardiovascular
disease.

Investigators obtained data from the Dallas Heart


Study, a large, multiethnic urban population of
patients who successfully completed electron-beam
computed tomography (EBCT) to detect coronary artery
calcium and magnetic resonance imaging (MRI) to detect
aortic plaque. They found that the likelihood of
coronary calcification grew in direct proportion to
increases in the WHR. In multivariate analysis, after
adjusting for standard risk factors, prevalent
coronary artery calcium was more frequent in the fifth
versus first quintile of WHR. Those with the largest
WHR were nearly twice as likely to have calcium
deposits in their coronary arteries as those with the
smallest WHR. There was no independent positive
association observed for BMI or waist circumference.

"The finding that was most striking to me was the


linear association with the waist-to-hip ratio," said
de Lemos. "We don't have huge statistical power here
so this will need to be confirmed in other studies,
but it is interesting that this is a linear, step-wise
association across the quintiles. From a public health
perspective, this is not the sort of thing where we
only look at the guy with the biggest beer belly and
say this guy is the one to worry about. This thing may
have broader implications in the sense that the
average person, even though they are average by US
standards, still appears to have more atherosclerosis
than people with the lowest waist-to-hip ratio."

Among those who underwent MRI, the investigators also


showed that the risk of atherosclerotic plaque in the
aorta was three times as high in those with the
largest WHR compared with those who had the smallest
WHR.

The associations between obesity measurements and


atherosclerosis in this study, said de Lemos, mirror
those observed between obesity and cardiovascular
mortality and suggest that obesity contributes to the
risk via increased atherosclerotic burden. As to why
WHR is a better measure of subclinical disease, de
Lemos said it is an indexed value to lower body girth
and provides a more precise assessment of relative
central adiposity across the body sizes compared with
waist circumference. Additionally, there is some
evidence that fat accumulated in the hips might be
cardioprotective.

"That appears to be the case in this study," said de


Lemos. "Large hips seemed to be protective if you had
a normal or smaller waist. On the other hand, it
didn't appear protective if the waist was greater than
the median value. Having big hips doesn't protect you
if you let your belly get too big."

See R, Abdullah SM, McGuire DK et al. The association


of differing measures of overweight and obesity with
prevalent atherosclerosis. J Am Coll Cardiol
2007;50:752-759.
The complete contents of Heartwire, a professional
news service of WebMD, can be found at
www.theheart.org, a Web site for cardiovascular
healthcare professionals.

Clinical Context
Obesity affects one third of US adults and predisposes
to cardiovascular risk factors including insulin
resistance, hypertension, and dyslipidemia, but it is
unclear whether all the risks can be explained by an
increased burden of atherosclerosis or if other
mechanisms mediate the risk. In addition, BMI has been
used as the primary standard for outcomes of obesity
in studies, alternative measures including WC and WHR
have demonstrated better correlations with
cardiovascular risk than BMI.

This is a multiethnic, population-based study


conducted in 1 US city on subjects who had 3 visits
for 5 to 6 months to examine the correlation between 3
measures of obesity (BMI, WC, and WHR) and measures of
atherosclerosis: CAC and MRI-detected aortic plaque.

Study Highlights
A population-based cohort of 6101 adults aged 18 to 65
years were visited at home for an interview, and 3398
participants aged 30 to 65 years returned for a second
visit for blood and urine tests.
A third visit occurred for 2971 participants who
received a detailed clinical examination,
anthropometric measurements, abdominal MRI for aortic
plaque, and 2 EBCT measurements of CAC.
EBCT scans were performed twice with 40 slices
spanning the entire heart and CAC results averaged and
expressed in Agatston units.
A threshold of 10 Agatston units was used for
diagnosis of atherosclerosis.
Abdominal MRI was performed with 6 total slices of the
infrarenal abdominal aorta, and increased signal
intensity, luminal protrusion, and focal wall
thickening were identified as atherosclerotic plaque.
BMI, WC, hip circumference, and WHR were calculated.
Hypertension was defined as systolic blood pressure of
140 mm Hg or higher, diastolic blood pressure of 90 mm
Hg or higher, or use of antihypertensive medication.
Diabetes was defined by self-report, use of
medications, or fasting glucose levels.
Hypercholesterolemia was defined by use of
lipid-lowering medication or lipid levels for
low-density lipoprotein, total cholesterol, or
triglycerides.
Smoking was defined by smoking cigarettes within 30
days.
Only data were analyzed on participants who completed
all 3 visits with complete imaging data for either
EBCT or MRI.
Participants were divided into sex-specific quintiles
based on BMI, WC, hip circumference, and WHR, and men
and women within each quintile were combined.
Mean age was 45 years, 33% were white, 50% were black,
and 18% were Hispanic.
Mean BMI was 31 kg/m2, 34% had hypertension, mean
systolic blood pressure was 126 mm Hg, and mean
diastolic blood pressure was 78 mm Hg.
12% had diabetes, 25% were current smokers, 12% had
dyslipidemia, and mean total cholesterol was 180
mg/dL.
21% of participants (234 women, 349 men) had
detectable CAC.
The prevalence of CAC increased across quintiles of WC
and WHR, and the odds of prevalent CAC were greater
for each quintile of WC and WHR vs each quintile of
BMI in both men and women.
After adjustment for age, smoking, hypertension,
diabetes, the prevalence of CAC was significantly
increased in the highest quintile of WHR (odds ratio,
1.91; P < .001) but not any quintile of BMI or WC.
WHR consistently predicted CAC compared with either
BMI or WC.
39% of participants (499 women, 477 men) had
detectable aortic plaque.
A 3-fold increase in the prevalence of aortic plaque
was found for the fifth WHR compared with the first
quintiles.
Neither BMI nor WC was significantly associated with
aortic plaque.
WHR demonstrated significantly increased odds for
aortic plaque in the fourth and fifth quintiles.
No positive association was found for BMI or WC for
aortic plaque.
In women, WC less than 88 cm was associated with a
greater prevalence of CAC with higher hip
circumference, but this association was not found in
men.
WHR demonstrated superior discrimination for prevalent
CAC compared with BMI and WC in sex-specific analyses.

Pearls for Practice


Increased BMI and WC are weakly associated with
increased burden of plaque, as measured by prevalent
CAC or aortic plaque.
WHR discriminates aortic plaque and atherosclerosis
more effectively than either BMI or WC.

Medscape Medical News 2007. 2007 Medscape

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