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Weight or waist: which is better for predicting cardiovascular diseases? A review. By Hsin-Jen Chen.

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Presentation on theme: "Weight or waist: which is better for predicting cardiovascular diseases? A review. By Hsin-Jen Chen."— Presentation transcript:

1 Weight or waist: which is better for predicting cardiovascular diseases? A review. By Hsin-Jen Chen

2 Outline Introduction Cross-sectional evidences Prospective evidences Discussion

3 Introduction What is this review for?

4 Obesity as a CVD risk factor Obesity: excess fat accumulation, which could lead to adverse health outcomes. Measuring total body fat –Underwater weighing –Image methods: DEXA –Bio-electrical impedance –Body mass index Measuring fat distribution (esp. at abdomen) –Image methods: CT, MRI… –Waist circumference, waist-hip ratio…

5 Total fat vs. abdominal fat Facts –General obesity (BMI) has been considered as a risk factor for many diseases. –Two types of fat accumulations are correlated. –ATP III adopts abdominal rather than general obesity in the definition of metabolic syndrome.

6 Subjects: Korean Song et al., Stroke Take stroke for instance

7 Total fat vs. abdominal fat Facts –General obesity (BMI) has been considered as a risk factor for many diseases. –Two types of fat accumulations are correlated. –ATP III adopts abdominal rather than general obesity in the definition of metabolic syndrome.

8 Iwao et al., 2001, Obes Res

9 Total fat vs. abdominal fat Facts –General obesity (BMI) has been considered as a risk factor for many diseases. –Two types of fat accumulations are correlated. –ATP III adopts abdominal rather than general obesity in the definition of metabolic syndrome.

10 NCEP ATP III, 2001, JAMA

11 Total fat vs. abdominal fat Facts –General obesity (BMI) has been considered as a risk factor for many diseases. –Two types of fat accumulations are correlated. –ATP III adopts abdominal rather than general obesity in the definition of metabolic syndrome. Questions –Do elevated abdominal fat imposes CVD risk independently from total fat? –Which is better for evaluating CVD risk?

12 Cross-sectional evidences

13 Associations between BMI, waist, and CVD Step 1: –Comparing the correlation coefficients

14 Zhu et al., 2002, Am J Clin Nutr 1.Study: NHANES III 2.Subjects: US white men and women (n=9019) 3.Age: 20~90

15 Associations between BMI, waist, and CVD Step 1: –Comparing the correlation coefficients Step 2: –Taking age into account

16 1.Study: Baltimore Longitudinal Study of Aging (BLSA) 2.Subjects: US white men and women (n=1941) 3.Age: 17~100 (dichotomized at 65 y/o) Iwao et al., 2001, Obes Res

17 1.Study: The Australian Diabetes, Obesity and Lifestyle Study 2.Subjects: Australian residents in non-rural areas (mostly white, n=11247) 3.Age: >=25 y/o Dalton et al., 2003, J Intern Med. Next page

18 Before and after age-adjustment: Dalton et al., 2003, J Intern Med.

19 Associations between BMI, waist, and CVD Step 1: –Comparing the correlation coefficients Step 2: –Taking age into account Step 3: –Controlling BMI and WC/WHR simultaneously

20 Study: Baltimore Longitudinal Study of Aging (BLSA) Iwao et al., 2001, Obes Res

21 1.Study: Canada Heart Health Surveys 2.Subjects: Canadian men and women (n=7981) 3.Age: 20~75 y/o Ardern et al., 2003, Obes Res

22 Summary Focusing on the associations between fatness (BMI, WC, WHR) and other CVD risk factors Data showing the cross-sectional relation between fatness and presence of CVD are rare. –Body compositions in subjects with overt diseases would have been changed Age can explain much of the association between WC and CVD risk factors.

23 Prospective evidences

24 Study & AuthorEligible subjects (No) Age at baseline Years of baseline Follow-up duration Endpoint(s)AnalysesIndex for abdominal fat Nurses ’ Health Study (Rexrode et al.) women yrsCHD eventsCox -jointly WHR WC Physicians ’ Health Study (Rexrode et al.) men yrsCHD eventsCox -jointly WHR WC Health Professionals Follow-up Study (Rimm et al.) men yrsCHD eventsLogistic -jointly WHR WC ARIC (Folsom et al.) M 7852 F yrsCHD eventsCox -jointly WHR Shanghai Women ’ s Health Study (Zhang et al.) women Follow-up after 2 yrs CHD eventsCox -jointly WHR WC Iowa Women ’ s Health Study (Folsom et al.) post menopausal women ~1996/12/31Death (all, CHD, ect) DM, HBP (self report) Cox -non-jointly -jointly WHR (WC) Heart and Estrogen/progestin Replacement Study (Kanaya et al.) 2356 post menopausal women Mean age yrsDeath (all causes, CHD) Cox -jointly WC Diet, Cancer and Health study (Bigaard et al.) Danish M F yrs (median) Death (all causes) Cox -jointly WC

25 Weight or waist predicts better? Jointly comparison –Estimating the effects of BMI and WC (or WHR) on health outcomes in the same model

26 All causes mortality Study & AuthorEligible subjects (No) Age at baseline Years of baseline Follow-up duration Endpoint(s)AnalysesIndex for abdominal fat Nurses ’ Health Study (Rexrode et al.) women yrsCHD eventsCox -jointly WHR WC Physicians ’ Health Study (Rexrode et al.) men yrsCHD eventsCox -jointly WHR WC Health Professionals Follow-up Study (Rimm et al.) men yrsCHD eventsLogistic -jointly WHR WC ARIC (Folsom et al.) M 7852 F yrsCHD eventsCox -jointly WHR Shanghai Women ’ s Health Study (Zhang et al.) women Follow-up after 2 yrs CHD eventsCox -jointly WHR WC Iowa Women ’ s Health Study (Folsom et al.) post menopausal women ~1996/12/31Death (all, CHD, ect) DM, HBP (self report) Cox -non-jointly -jointly WHR (WC) Heart and Estrogen/progestin Replacement Study (Kanaya et al.) 2356 post menopausal women Mean age yrsDeath (all causes, CHD) Cox -jointly WC Diet, Cancer and Health study (Bigaard et al.) Danish M F yrs (median) Death (all causes) Cox -jointly WC

27 All causes mortality Sex specific lines (50~64 y/o) Dashed lines: unadjusted RR Solid lines: mutual adjusted RR

28 CHD mortality Study & AuthorEligible subjects (No) Age at baseline Years of baseline Follow-up duration Endpoint(s)AnalysesIndex for abdominal fat Nurses ’ Health Study (Rexrode et al.) women yrsCHD eventsCox -jointly WHR WC Physicians ’ Health Study (Rexrode et al.) men yrsCHD eventsCox -jointly WHR WC Health Professionals Follow-up Study (Rimm et al.) men yrsCHD eventsLogistic -jointly WHR ARIC (Folsom et al.) M 7852 F yrsCHD eventsCox -jointly WHR Shanghai Women ’ s Health Study (Zhang et al.) women Follow-up after 2 yrs CHD eventsCox -jointly WHR WC Iowa Women ’ s Health Study (Folsom et al.) post menopausal women ~1996/12/31Death (all, CHD, ect) DM, HBP (self report) Cox -non-jointly -jointly WHR (WC) Heart and Estrogen/progestin Replacement Study (Kanaya et al.) 2356 post menopausal women Mean age yrsDeath (all causes, CHD) Cox -jointly WC Diet, Cancer and Health study (Bigaard et al.) Danish M F yrs (median) Death (all causes) Cox -jointly WC

29 CHD mortality

30 Study & AuthorEligible subjects (No) Age at baseline Years of baseline Follow-up duration Endpoint(s)AnalysesIndex for abdominal fat Nurses ’ Health Study (Rexrode et al.) women yrsCHD eventsCox -jointly WHR WC Physicians ’ Health Study (Rexrode et al.) men yrsCHD eventsCox -jointly WHR WC Health Professionals Follow-up Study (Rimm et al.) men yrsCHD eventsLogistic -jointly WHR ARIC (Folsom et al.) M 7852 F yrsCHD eventsCox -jointly WHR Shanghai Women ’ s Health Study (Zhang et al.) women Follow-up after 2 yrs CHD eventsCox -jointly WHR WC Iowa Women ’ s Health Study (Folsom et al.) post menopausal women ~1996/12/31Death (all, CHD, ect) DM, HBP (self report) Cox -non-jointly -jointly WHR (WC) Heart and Estrogen/progestin Replacement Study (Kanaya et al.) 2356 post menopausal women Mean age yrsDeath (all causes, CHD) Cox -jointly WC Diet, Cancer and Health study (Bigaard et al.) Danish M F yrs (median) Death (all causes) Cox -jointly WC

31 CHD mortality

32 CHD incidence Study & AuthorEligible subjects (No) Age at baseline Years of baseline Follow-up duration Endpoint(s)AnalysesIndex for abdominal fat Nurses ’ Health Study (Rexrode et al.) women yrsCHD eventsCox -jointly WHR WC Physicians ’ Health Study (Rexrode et al.) men yrsCHD eventsCox -jointly WHR WC Health Professionals Follow-up Study (Rimm et al.) men yrsCHD eventsLogistic -jointly WHR ARIC (Folsom et al.) M 7852 F yrsCHD eventsCox -jointly WHR Shanghai Women ’ s Health Study (Zhang et al.) women Follow-up after 2 yrs CHD eventsCox -jointly WHR WC Iowa Women ’ s Health Study (Folsom et al.) post menopausal women ~1996/12/31Death (all, CHD, ect) DM, HBP (self report) Cox -non-jointly -jointly WHR (WC) Heart and Estrogen/progestin Replacement Study (Kanaya et al.) 2356 post menopausal women Mean age yrsDeath (all causes, CHD) Cox -jointly WC Diet, Cancer and Health study (Bigaard et al.) Danish M F yrs (median) Death (all causes) Cox -jointly WC

33 CHD incidence Age-adjusted incidence rates

34 CHD incidence

35 Study & AuthorEligible subjects (No) Age at baseline Years of baseline Follow-up duration Endpoint(s)AnalysesIndex for abdominal fat Nurses ’ Health Study (Rexrode et al.) women yrsCHD eventsCox -jointly WHR WC Physicians ’ Health Study (Rexrode et al.) men yrsCHD eventsCox -jointly WHR WC Health Professionals Follow-up Study (Rimm et al.) men yrsCHD eventsLogistic -jointly WHR ARIC (Folsom et al.) M 7852 F yrsCHD eventsCox -jointly WHR Shanghai Women ’ s Health Study (Zhang et al.) women Follow-up after 2 yrs CHD eventsCox -jointly WHR WC Iowa Women ’ s Health Study (Folsom et al.) post menopausal women ~1996/12/31Death (all, CHD, ect) DM, HBP (self report) Cox -non-jointly -jointly WHR (WC) Heart and Estrogen/progestin Replacement Study (Kanaya et al.) 2356 post menopausal women Mean age yrsDeath (all causes, CHD) Cox -jointly WC Diet, Cancer and Health study (Bigaard et al.) Danish M F yrs (median) Death (all causes) Cox -jointly WC

36 CHD incidence Age-adjusted incidence rates

37 CHD incidence Model 2: further adjusted BMI Model 3: further adjusted WHR

38 CHD incidence Study & AuthorEligible subjects (No) Age at baseline Years of baseline Follow-up duration Endpoint(s)AnalysesIndex for abdominal fat Nurses ’ Health Study (Rexrode et al.) women yrsCHD eventsCox -jointly WHR WC Physicians ’ Health Study (Rexrode et al.) men yrsCHD eventsCox -jointly WHR WC Health Professionals Follow-up Study (Rimm et al.) men yrsCHD eventsLogistic -jointly WHR ARIC (Folsom et al.) M 7852 F yrsCHD eventsCox -jointly WHR Shanghai Women ’ s Health Study (Zhang et al.) women Follow-up after 2 yrs CHD eventsCox -jointly WHR WC Iowa Women ’ s Health Study (Folsom et al.) post menopausal women ~1996/12/31Death (all, CHD, ect) DM, HBP (self report) Cox -non-jointly -jointly WHR (WC) Heart and Estrogen/progestin Replacement Study (Kanaya et al.) 2356 post menopausal women Mean age yrsDeath (all causes, CHD) Cox -jointly WC Diet, Cancer and Health study (Bigaard et al.) Danish M F yrs (median) Death (all causes) Cox -jointly WC

39 CHD incidence

40 Study & AuthorEligible subjects (No) Age at baseline Years of baseline Follow-up duration Endpoint(s)AnalysesIndex for abdominal fat Nurses ’ Health Study (Rexrode et al.) women yrsCHD eventsCox -jointly WHR WC Physicians ’ Health Study (Rexrode et al.) men yrsCHD eventsCox -jointly WHR WC Health Professionals Follow-up Study (Rimm et al.) men yrsCHD eventsLogistic -jointly WHR ARIC (Folsom et al.) M 7852 F yrsCHD eventsCox -jointly WHR Shanghai Women ’ s Health Study (Zhang et al.) women Follow-up after 2 yrs CHD eventsCox -jointly WHR WC Iowa Women ’ s Health Study (Folsom et al.) post menopausal women ~1996/12/31Death (all, CHD, ect) DM, HBP (self report) Cox -non-jointly -jointly WHR (WC) Heart and Estrogen/progestin Replacement Study (Kanaya et al.) 2356 post menopausal women Mean age yrsDeath (all causes, CHD) Cox -jointly WC Diet, Cancer and Health study (Bigaard et al.) Danish M F yrs (median) Death (all causes) Cox -jointly WC

41 CHD incidence Quartiles Men BMI: 24.7, 26.9, 29.7 WHR: 0.93, 0.96, 1.00 Women BMI: 23.3, 26.5, 31.0 WHR: 0.84, 0.89, 0.95

42 CHD incidence Study & AuthorEligible subjects (No) Age at baseline Years of baseline Follow-up duration Endpoint(s)AnalysesIndex for abdominal fat Nurses ’ Health Study (Rexrode et al.) women yrsCHD eventsCox -jointly WHR WC Physicians ’ Health Study (Rexrode et al.) men yrsCHD eventsCox -jointly WHR WC Health Professionals Follow-up Study (Rimm et al.) men yrsCHD eventsLogistic -jointly WHR ARIC (Folsom et al.) M 7852 F yrsCHD eventsCox -jointly WHR Shanghai Women ’ s Health Study (Zhang et al.) women Follow-up after 2 yrs CHD eventsCox -jointly WHR WC Iowa Women ’ s Health Study (Folsom et al.) post menopausal women ~1996/12/31Death (all, CHD, ect) DM, HBP (self report) Cox -non-jointly -jointly WHR (WC) Heart and Estrogen/progestin Replacement Study (Kanaya et al.) 2356 post menopausal women Mean age yrsDeath (all causes, CHD) Cox -jointly WC Diet, Cancer and Health study (Bigaard et al.) Danish M F yrs (median) Death (all causes) Cox -jointly WC

43 CHD incidence Shanghai Women’s Health Study

44 Other CVD health outcomes Study & AuthorEligible subjects (No) Age at baseline Years of baseline Follow-up duration Endpoint(s)AnalysesIndex for abdominal fat Nurses ’ Health Study (Rexrode et al.) women yrsCHD eventsCox -jointly WHR WC Physicians ’ Health Study (Rexrode et al.) men yrsCHD eventsCox -jointly WHR WC Health Professionals Follow-up Study (Rimm et al.) men yrsCHD eventsLogistic -jointly WHR ARIC (Folsom et al.) M 7852 F yrsCHD eventsCox -jointly WHR Shanghai Women ’ s Health Study (Zhang et al.) women Follow-up after 2 yrs CHD eventsCox -jointly WHR WC Iowa Women ’ s Health Study (Folsom et al.) post menopausal women ~1996/12/31Death (all, CHD, ect) DM, HBP (self report) Cox -non-jointly -jointly WHR (WC) Heart and Estrogen/progestin Replacement Study (Kanaya et al.) 2356 post menopausal women Mean age yrsDeath (all causes, CHD) Cox -jointly WC Diet, Cancer and Health study (Bigaard et al.) Danish M F yrs (median) Death (all causes) Cox -jointly WC

45 Other CVD health outcomes

46 Summary: CVD events Study & AuthorEligible subjects (No) Age at baselineEndpoint(s)Results: joint analysis & after adjustment Nurses ’ Health Study (Rexrode et al.) women40-65CHD eventsWHR↑ WC↑ (BMI: U shape) Shanghai Women ’ s Health Study (Zhang et al.) women40-70CHD events Younger ( ≦ 55) BMI↑ WC↑ Older (>55) WHR↑ Physicians ’ Health Study (Rexrode et al.) men40-84CHD eventsYoung(<65) BMI↑ Health Professionals Follow-up Study (Rimm et al.) men40-75CHD eventsYounger (<65) BMI↑ Older ( ≧ 65) WHR↑ ARIC (Folsom et al.) M 7852 F 45-64CHD eventsBMI: U shape WHR↑(mostly)

47 Summary: other outcomes Study & AuthorEligible subjects (No) Age at baseline Endpoint(s)Results: joint analysis & after adjustment Iowa Women ’ s Health Study (Folsom et al.) post menopausal women 55-69Death (all, CHD, ect) DM, HBP (self report) Death (all, other than CHD); hip fracture: BMI↓ WHR↑ CHD death; DM, HBP incidence: BMI↑ WC↑ Heart and Estrogen/progestin Replacement Study (Kanaya et al.) 2356 post menopausal women Mean age 66.6 Death (all causes, CHD)BMI↓ WC↑ (CHD: ns) Diet, Cancer and Health study (Bigaard et al.) Danish M F 50-64Death (all causes)BMI↓ WC↑

48 Discussion

49 What we can learn from epi data? Weight and waist predict differently on different outcomes –Mortality From all cause and CVD other than CHD From CHD –Morbidity (CHD) The effects of weight and waist depend on the sex and age –Elderly: WHR –Younger: BMI –Women: waist/WHR –Men: BMI

50 Prospective considerations Age and sex would be better stratified in future research regarding obesity and CVDs. Should the definition of metabolic syndrome take this discrepancy into account? Could these evidences be translated into age- sex specific advices on CVD prevention? Dilemma between concision and precision.

51 Convenient measure, but… Study & AuthorMeasurement of waist and/or hip circumferences Nurses ’ Health Study (Rexrode et al.) W: umbilicus H: largest girth (Self-report) Shanghai Women ’ s Health Study (Zhang et al.) W: 2.5cm above umbilicus H: maximum width of buttocks (by interviewer) Physicians ’ Health Study (Rexrode et al.) W: umbilicus H: largest girth between umbilicus and thighs (Self-report) Health Professionals Follow-up Study (Rimm et al.) W: umbilicus H: largest girth between waist and thighs (Self-report) ARIC (Folsom et al.)W: umbilicus H: maximum buttocks (By technicians) Iowa Women ’ s Health Study (Folsom et al.) W: 2.5cm above umbilicus H: largest girth (Self-report) Heart and Estrogen/progestin Replacement Study (Kanaya et al.) W: max girth between iliac chest & lower ribs H: girth at greatest posterior extension of buttocks (By interviewer) Diet, Cancer and Health study (Bigaard et al.) W: halfway between lower rib and the iliac chest

52 Two critical thinking Age effects on the results –Biological or chronological? Older subjects => subclinical health conditions => weight loss => BMI represents body fat less↓ Older subjects => shorter follow-up time => long- term effects of certain variables will be truncated Is “jointly” (or “mutual adjusted”) analysis demonstrating etiological importance or just statistical significance?

53 Thanks for your attention!


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