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Abdominal Obesity Defined As a Larger Than Expected Waist Girth Is Journal of Human Hypertension (2001) 15, 307–312 2001 Nature Publishing Group All rights reserved 0950-9240/01 $15.00 www.nature.com/jhh ORIGINAL ARTICLE Abdominal obesity defined as a larger than expected waist girth is associated with racial/ethnic differences in risk of hypertension IS Okosun, S Choi, MM Dent, T Jobin and GEA Dever Department of Community Medicine, Mercer University School of Medicine 1550 College Street Macon, GA, USA Objective: Waist circumference (WC) cut-points of Results: Relative to white, black race/ethnicity was у102 cm and у88 cm for men and women, respectively, associated with ෂ1.8 and ෂ2.7 greater risk of hyperten- representing abdominal obesity have been recom- sion in men and women, respectively, adjusting for mended for determining obesity related co-morbidities. abdominal obesity, age, smoking and alcohol consump- However, these cut-points carry the component of gen- tion. Having larger than expected waist girths were eralised obesity estimated by body mass index (BMI). associated with 1.58 and 1.39 increased risk of hyper- The aim of this investigation was to determine whether tension in black men and black women, respectively, abdominal obesity free of the influence of overall heavi- adjusting for confounders. Population attributable risks ness is associated with increased risk of hypertension of hypertension due to abdominal obesity were approxi- in a representative sample of white and black Amer- mately 24.9% and 15.9%, in black men and black icans. women, respectively. from the Third US National Conclusions: In Americans, hypertension is a public (11114 ؍ Methods: Data (n Health and Nutrition Examination Survey were used in health problem that is closely linked to abdominal adi- this investigation. Standardised residual values from posity. An important research challenge therefore is to the linear regression of WC on BMI were used to define determine the best way to regulate body weight under abdominal obesity status. The risk of hypertension conditions of food abundance. There is a need to clarify associated with abdominal obesity was estimated from how lifestyle habits promote large waist sizes leading the logistic regression model, adjusting for age, smok- to abdominal adiposity and associated cardiovascular ing and alcohol. We also estimated the public health disease in the US, particularly among black Americans. consequences of abdominal obesity from the popu- Journal of Human Hypertension (2001) 15, 307–312 lation attributable fraction of hypertension. Keywords: waist circumference; abdominal obesity; ethnicity Introduction ometry. However, these imaging methods are not practical in large-scale field epidemiology. They are Although the link between abdominal adiposity and laborious and expensive, and their use carries risk cardiovascular diseases (CVD) is well documented 1–8 of radiation. Hence, there is a need to establish a in the epidemiologic literature, there is no con- relatively cheap and risk-free surrogate marker of sensus on the most reliable anthropometric variable these imaging techniques. for abdominal adiposity. Ideally, the best method for The two most commonly employed anthropo- determining abdominal obesity is by imaging tech- metric surrogates for imaging techniques in niques such as computerised tomography, magnetic determining abdominal adiposity are ratios of waist- resonance imaging or dual energy X-ray absorpti- to-hip girths (WHR) and waist circumference (WC). WHR has many shortcomings, including inherent weakness as a ratio index9,10 and strong influence Correspondence: Ike S Okosun, PhD, MPH, FRIPHH, Department by pelvic structure. Also, WHR is an unsatisfactory of Community Medicine, Mercer University School of Medicine, measure of abdominal fat mass, especially in non- 1550 College Street Macon, Georgia, 31207, USA 11 E-mail: okosunFiȰmercer.edu obese individuals. Indeed, non-obese and obese Received 26 June 2000; revised 19 September 2000; accepted 30 subjects can have the same WHR values. Further- November 2000 more, the sensitivity of WHR in detecting changes Abdominal obesity and hypertension IS Okosun et al 308 in body adiposity is low because gluteal fat and sub- uals aged 17–90 yeas for whom weight, height, cutaneous abdominal fat can be decreased in some waist, diastolic blood pressure (DBP) and systolic subjects with weight loss.12 blood pressure (SBP) were obtained. Weight was WC has been endorsed as the best anthropometric measured at a standing position using a Toledo self- surrogate of abdominal adiposity.13,14 WC is an zeroing weight scale. Height was measured at an aggregate measurement of the actual amounts of upright position with a standiometer. Waist abdominal fat accumulation and is a crucial corre- measurement was made to the nearest 0.1 cm at the late of abnormal metabolic syndromes found among natural waist midpoint between the bottom of the obese and overweight subjects.15 Measurement of rib cage and above the top of the iliac crest. WC is simple and requires only a flexible tape meas- In NHANES III, three blood pressure measure- ure, furthermore, measurement error is low due to ments were obtained from each subject using a stan- large circumference. In addition, WC is more highly dard mercury sphygmomanometer at a 60-second correlated with visceral adipose tissue accumulation interval between inflation cuffs. The average of the than WHR.16 Visceral adiposity is the component of three readings was utilised for this analysis. Smok- body composition that is most highly associated ing and alcohol intake were assessed by self-report. with many metabolic abnormalities such as hyper- Smoking was categorised as 1 and 0, for current tension, glucose intolerance, hyperinsulinaemia, smokers and non-smokers, respectively. Alcohol use hypercholesterolaemia, hypertriglyceridaemia, and was graded as 1 for current drinkers and 0 for non- high levels of low-density lipoprotein cholesterol.17–20 current drinkers. For this analysis, hypertension was Indeed, many are now advocating WC as a valid defined as DBP у90 mm Hg, SBP у140 mm Hg or anthropometric variable for health promotion and current treatment with prescribed anti-hyperten- the basis for alerting those at risk of CVD.21,22 sion medication.25 In a recent publication, the United States National Institute Health (NIH) expert panels recommended у у the WC cut-points of 102 cm and 88 cm, in men Statistical analysis and women as values representing risks for obesity- related comorbidities.13 These cut-points were Statistical programmes available in SPSS version determined after the review of published data ger- 10.0 for Windows were utilised for this analysis.26 mane to abdominal obesity in various journals pub- Racial/ethnic differences for continuous and categ- lished between 1980 and 1997. However, because orical variables were assessed with the Student’s t- these recommended WC cut-points do not account test and chi-squared statistics, respectively. The for overall body heaviness, there is a need to rede- standardised residual values from the linear fine WC corresponding to abdominal obesity devoid regression of WC on BMI were utilised to establish of generalised obesity. The aims of this investigation abdominal obesity status. Abdominal obesity was were therefore to define abdominal obesity free of thus defined as WC larger than expected WC as pre- the influence of overall heaviness as determined by dicted from BMI.27 These predicted WC values cor- body mass index (BMI), and to investigate if such respond to WC adjusted for BMI. measure is associated with increased risk of hyper- Predicted WC values were derived from residuals tension in a representative sample of white and obtained from linear regression of WC on BMI.27 For black Americans. We also sought to examine if white men the residuals were obtained from the equ- abdominal obesity free of the influence of general- ation: WC = 2.49*BMI + 31.31. The corresponding ised obesity was associated with racial/ethnic differ- residuals for white women were obtained from WC ences in the risk of hypertension. = 2.21*BMI + 31.34. For black subjects, the residuals were obtained from WC = 2.56*BMI + 24.07 for men, and were obtained from WC = 2.11*BMI + 32.34 for Materials and methods women. The positive residuals represent abdominal 27 Data source adiposity adjusted for BMI. We estimated the risk of hypertension that was Data from the Third US National Health and associated with abdominal obesity by classifying the Nutrition Examination Survey (NHANES III), as pro- residuals from regression of WC on BMI.27 Negative vided by the National Center for Health Statistics, residual values (less than expected) were coded as were used in this investigation. The sampling and 0 and positive values (greater than expected) were measurement procedures have been described in coded as 1, and utilised as an independent variable detail by other investigators.23,24 Briefly, NHANES in the race/ethnicity and gender specific logistic III is a multistage probability sample of non-insti- regression model, adjusting for age, smoking and tutionalised US population groups defined and alcohol. Radical/ethnic differences in the risk of examined in two phases between 1988 and 1994. hypertension associated with abdominal obesity Only subjects identified as non-Hispanic white and were determined by comparing blacks with whites non-Hispanic black Americans were eligible for in gender-specific logistic linear regression models this investigation. adjusting for age, smoking and alcohol consump- This study was further confined to 11114 individ- tion. The prevalence of hypertension and abdominal Journal of Human Hypertension Abdominal obesity and hypertension IS Okosun et al 309 obesity were age-adjusted by direct methods using the 1990 US population census data. To estimate the public health consequences of abdominal obesity, we calculated the population attributable fraction percentage (PAF%) of hyperten- sion. The population attributable fraction per cent was estimated28 as: − = PE (OR 1) PAF% + − * 100 1 PE (OR 1) where PE is the proportion of subjects who were abdominally obese, and OR is the odds ratio com- paring subjects who had abdominal obesity with those who did not.
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