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Abdominal Obesity in the United States: Prevalence and Attributable Risk of Hypertension

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Abdominal Obesity in the United States: Prevalence and Attributable Risk of Hypertension Journal of Human Hypertension (1999) 13, 425–430 1999 Stockton Press. All rights reserved 0950-9240/99 $12.00 http://www.stockton-press.co.uk/jhh ORIGINAL ARTICLE Abdominal obesity in the United States: prevalence and attributable risk of hypertension IS Okosun, TE Prewitt and RS Cooper Department of Preventive Medicine and Epidemiology, Loyola University Medical Center, Stritch School of Medicine, Maywood, IL, USA Objective: The aim of this study was to determine the Results: The prevalences of abdominal obesity were prevalence of abdominal obesity and its impact on the 27.1%, 20.2% and 21.4% in White, Black and Hispanic risks of hypertension in the US adult population. men, respectively. The corresponding values in women Design and methods: Data from the third US National were 43.2%, 56.0% and 55.4%. Abdominal obesity was Health and Nutrition Examination Surveys, 1988–1994, found to be associated with a two to three-fold were utilised. Abdominal obesity was defined as waist increased risk of hypertension in this population. In circumference у102 cm in men and у88 cm in women. men, the attributable risk percent ranged from 20.9% in Hypertension was defined as mean diastolic blood Hispanics to 27.3% in Whites and in women ranged from pressure у90 mm Hg, systolic blood pressure у140 36.5% in Whites to 56.5% in Hispanics. We estimated mm Hg or current treatment with prescribed hyperten- that 24 million adult men and 40 million adult women sion medication. Prevalences of abdominal obesity were of Hispanic and non-Hispanic Black and White ethnicity estimated in non-Hispanic White, non-Hispanic Black were suffering from abdominal obesity. and Hispanic Americans. Gender-specific logistic Conclusions: In this population, hypertension appears regression analysis using empirical waist cut-off points to be associated with abdominal obesity. The estimates was used to determine the risks of hypertension. The of population attributable risks suggest that the risk of impact of abdominal adiposity on risk of hypertension hypertension could be potentially reduced if waist size was estimated from population-attributable risk were reduced to Ͻ102 cm in men and Ͻ88 cm in women. adjusting for age, current smoking and alcohol intake. Keywords: abdominal obesity; hypertension; waist circumference Introduction used and acknowledged as the best anthropometric alternative to WHR, CT and MRI. WC measures sub- The importance of gynoid and android body habitus cutaneous and intra-abdominal adiposity.9 Unlike (now regarded as abdominal or central adiposity) to WHR, WC is easier to interpret and better correlated several diseases was first described by Vague in 10 1 with visceral fat mass. Visceral adiposity is highly 1956. Subsequently, numerous epidemiological correlated with many metabolic complications of studies supporting a positive association between the insulin resistance syndrome, including hyperin- central or abdominal adiposity and cardiovascular 2–8 sulinaemia, hypercholesterolaemia, gluconaemia, diseases (CVD) risk factors have been published. hypertriglyceridaemia and high levels of low-den- While computed tomography (CT) and magnetic res- sity cholesterol.11,12 Compared to WHR, WC is onance imaging (MRI) remain the best methods for strongly correlated with total body adiposity estimating abdominal adiposity, they are imprac- assessed by body mass index (BMI).12 tical in large epidemiological studies because they There is no consensus on the WC cut-off points are laborious and expensive. Hence, anthropometric for abdominal adiposity. The two most cited refer- alternatives are often used in epidemiological stud- ences for WC cut-off points were proposed by Lean ies to determine abdominal obesity. The most com- et al13 and Lemieux et al.14 The generalisability of monly used anthropometric surrogate being the the proposed WC cut-off points of Lean et al13 and waist-to-hip ratio (WHR). Lemieux et al14 is limited on the grounds that the Waist circumference (WC) is increasingly being samples used to derive the cut-off points were from White populations of Scotland and Canada. Recently, the US National Heart, Lung, Blood Correspondence: Dr Ike S. Okosun, Department of Preventive Institute/National Institute of Health (NHLBI/NIH) Medicine and Epidemiology, Loyola University Medical Center, expert panel on the identification, evaluation, and Stritch School of Medicine, 2160 S. First Ave, Maywood, IL 60153, USA the treatment of overweight and obesity in adults Received 9 February 1999; Revised 24 March 1999; Accepted 5 proposed WC cut-off points of 102 cm or more and April 1999 88 cm or more for men and women, respectively.15 Abdominal adiposity and hypertension in US adults IS Okosun et al 426 These cut-off points were recommended in ident- Definition of terms ifying increased relative risk for the development of Hypertension was defined as mean diastolic blood obesity-associated risk factors for most adults with у 2 15 pressure (DBP) 90 mm Hg and systolic blood BMI of 25–34.9 kg/m . The NHLBI/NIH panel у made the recommendations based on a review of pressure (SBP) 140 mm Hg or current treatment with prescribed hypertension medication.21 published scientific literature in MEDLINE from Abdominal obesity was defined as WC у102 cm for 1980 to 1997 of topics identified as key to obesity у 15 evidence model. men and WC 88 cm for women. Alcohol was cat- egorised as 1 and 0, for current drinkers and non- To our knowledge, no studies assessing the preva- lence of abdominal obesity have been carried out drinkers, respectively. Smoking was graded as 1 for using the NHLBI/NIH WC cut-off criteria on a US current smokers and 0 for non-smokers. adult population. Therefore, the present study was undertaken utilising the Third National Health and Statistical methods Nutrition Examination Survey (NHANES III) to esti- mate the prevalence of abdominal obesity in the US Statistical programmes available in SPSS version 8.0 adult population and determine the attributable for Windows and WesVarPC version 2.1 were util- 22,23 risks of hypertension to abdominal obesity. ised for these analyses. One-way analysis of vari- ance was used to compare means of anthropometric variables across ethnic groups. Subjects and methods Prevalence estimates were weighted to account for cluster design and to represent the total civilian Study design non-institutionalised population of the US. The NHANES III was a stratified multistage cluster prob- prevalence of hypertension and abdominal obesity were age-adjusted by direct methods using the 1990 ability sample of the non-institutionalised civilian 24 US population groups examined in two phases US population census data. Gender-specific empirical WC (quartiles of WC, WC у102 for men between 1988 and 1994. The sampling and measure- у ment procedures have been extensively described and WC 88 for women) were used to compare odds elsewhere.16,17 Only subjects identified as non-His- of hypertension for Whites, Blacks and Hispanics panic White, non-Hispanic Black and Hispanic adjusting for age, smoking and alcohol intake. We used the estimates of the prevalence (PE) of abdomi- Americans aged 17–90 years were eligible for this у у investigation. The NHANES III protocol included a nal obesity (WC 102 cm in men and WC 88 cm in women) to calculate population attributable risks home interview followed by a physical examination 25 in a mobile examination centre. This study was (PAR%) as follows: restricted to subjects that were examined in the = + PAR% PE (OR-1)/[PE (OR-1)] 1*100 mobile examination centre and for whom blood pressures and anthropometric measurements were Odds ratio (OR) compares men and women with Ͻ Ͻ available, including weight, height and waist. WC 102 cm and 88 cm women, respectively with those with abdominal obesity, adjusting for age, smoking and alcohol intake in the logistic regression Anthropometric measurements model. The customary P-value of 0.05 was used to indicate statistical significance. Weight was measured in the upright position using a digital scale. Height was measured with a stadi- ometer. Waist measurement was made to the nearest Results 0.1 cm at minimal respiration at midpoint between Means and standard deviations of age and the the bottom of the rib cage and above the top of the anthropometric variables as well as the prevalence iliac crest. Description of measurement precision of hypertension are presented in Table 1. Overall, between technicians has been described else- 6760 Whites, 4713 Blacks and 4621 Hispanics were where.18 BMI was calculated as the measured weight eligible for this investigation. In both men and in kilograms divided by height in metres squared women, the mean BMI was higher than the World (kg/m2). Health Organisation (WHO) recommended value.26 Also, overall mean values of SBP were slightly Blood pressure measurements higher in White men, Black men and Black women than the clinically acceptable values. There were Detailed descriptions of blood pressure measure- significant ethnic differences for most variables. ment techniques have been previously docu- Among men, WC was highest in Whites and among mented.19,20 Briefly, examiners underwent rigorous women WC was highest in Blacks compared to their training on blood pressure measurement techniques. ethnic counterparts. Whites were significantly older Blood pressure measurements were taken in the sit- than Blacks and Hispanics (P Ͻ 0.05). Mean values ting position after 5 min of resting using the stan- for DBP and SBP for Blacks were higher than Whites dard mercury sphygmomanometer. Three blood and Hispanics. Age-adjusted prevalences of hyper- pressures were taken from each participant, with tension were higher in Blacks than Whites and His- intervals of 30–60 sec between cuff inflation. The panics (P Ͻ 0.01). average of the three blood pressure readings was Table 2 presents age-specific mean WC values for used in this analysis. men and women.
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