Waist circumference, hip
circumference, body mass index
(BMI) , and ratios: Which best
predicts type 2 diabetes mellitus in
men and women?
Harold E. Bays, MD
Kathleen M. Fox, PhD
Susan Grandy, PhD
for the SHIELD Study Group
NAASO – The Obesity Society Annual Scientific
Meeting, New Orleans
October 24, 2007
Background
Adiposopathy is defined as pathogenic adipose tissue:
• Promoted by positive caloric balance and sedentary lifestyle in
genetically and environmentally susceptible patients
• Anatomically manifested by adipocyte hypertrophy, adipose
tissue accumulation (adiposity) in the visceral region, as well as
ectopic fat (triglyceride) deposition in peripheral organs such as
liver, muscle, and pancreas
• Whose adverse metabolic and immune consequences result in
clinical metabolic disease
Bays HE et al. Future Cardiology. 2005;1(1):39-59
Bays HE. Expert Rev Cardiovas Ther. 2005;3(3):395-404
Background
Bays H, Ballantyne C. Future Lipidology. 2006;1(4):389-420
Background
EFRMD=excessive fat-related metabolic diseases
Bays H, Ballantyne C. Future Lipidology. 2006;1(4):389-420
Background
Bays H, Ballantyne C. Future Lipidology. 2006;1(4):389420
Adiposopathy: Visceral and
Peripheral Adipose Tissue
Bays H, Blonde L, Rosenson R. Expert Rev Cardiovas Ther. 4(6), 871–895 (2006)
SHIELD
• Study to Help Improve Early evaluation and management of
risk factors Leading to Diabetes (SHIELD)
• 5-year, national, longitudinal survey of diabetes, CVD, and
cardiometabolic risk in US adults
• Purpose: To better understand patterns of health behavior,
knowledge and attitudes of people living with type 2 diabetes
(T2DM) and those at high risk for its development
• This analysis assessed anthropometric measures in
predicting type 2 diabetes in men and women
Objective
• To assess gender-specific associations between
type 2 diabetes and adipose tissue parameters
Methods: Identifying Cohorts
• Screening questionnaire mailed to 200,000 nationally
representative US households
– Part of the TNS* (formerly National Family Opinion) consumer
panel
– Responses for 211,097 adults from 127,420 households (64%
response rate)
• Used to identify individuals who self-reported:
– T2DM and other metabolic diseases
– Varying numbers of risk factors (0-5) associated with T2DM
diagnosis
• Follow up 64-item survey was sent to 22,001 people, along
with tape measure and instructions for use
•
Type 1 diabetes (n=1000), T2DM (n=5000), History of gestational
diabetes (n=1000), Control/at risk (n=15,000, ~2400 in each risk
level)
•
Responses from 17,640 adults (80% response rate; 10,466 women
& 6,686 men)
*TNS = Taylor Nelson Sofres
Risk Factor Definitions
Risk Factor
Definition
Abdominal obesity
Men: waist circumference > 97cm
Women: waist circumference >89 cm
BMI
28 kg/m2
Dyslipidemia
Diagnosed with cholesterol problems of any type
Hypertension
Diagnosed with high blood pressure
CV event
One or more CV problems or events (heart
disease/myocardial infarction, narrow or blocked
arteries, stroke, coronary artery bypass graft
surgery/angioplasty/stents/surgery to clear
arteries)
BMI= body mass index; CV=cardiovascular
Adipose Tissue Measures
• Waist circumference (WC): assesses “pathogenic” visceral
adipose tissue
• Body mass index (BMI): assesses overall obesity, with most
of total fat being “protective” subcutaneous adipose tissue
• Hip circumference: “protective” gluteal subcutaneous adipose
tissue
• WC-BMI ratio: pathogenic / ”protective” adipose tissue ratio
• WC-HC ratio: pathogenic / “protective” adipose tissue ratio
Statistical Analyses
• Distribution of measured and reported adipose tissue
parameters by quintiles of all respondents
• Analyses stratified by gender
NHLBI Treatment Guidelines for
Adult Obesity
Bays H, Dujovne C. Curr Atheroscler Rep. 2006;8(2):144-156
Results – T2DM Women
Quintile
n=10466
women
BMI kg/m2
N (%)
n=2212
T2DM
women
1
n=2093
<24.4
162 (7.3)
2
n=2093
24.4 to 28.3
3
n=2094
Quintile
n=9707
WC cm
N (%)
n=2013
T2DM
women
1
n=1942
<83.8
173 (8.6)
361 (16.3)
2
n=1941
83.8 to 94.0
264 (13.1)
28.4 to 32.3
425 (19.2)
3
n=1941
94.1 to 104.1
354 (17.6)
4
n=2093
32.4 to 37.8
536 (24.2)
4
n=1942
104.2 to 116.8
529 (26.3)
5
n=2093
≥37.8
728 (32.9)
5
n=1941
≥116.8
693 (34.4)
The highest percent of women with T2DM occurred at the highest BMI
and at the highest WC.
Results – T2DM Women
Quintile
n=9623
women
WC:BMI
ratio
N (%)
n=1998
T2DM
women
Quintile
n=9558
WC:HC
ratio
N (%)
n=1985
T2DM
women
<0.81
217 (10.9)
1
n=1925
<2.93
484 (24.2)
1
n=1912
2
n=1925
2.93 to 3.17
413 (20.7)
2
n=1911
0.81 to 0.86
295 (14.9)
0.87 to 0.90
384 (19.3)
3
n=1924
3.18 to 3.38
369 (18.5)
3
n=1911
4
n=1924
3.39 to 3.64
363 (18.2)
4
n=1912
0.91 to 0.95
473 (23.8)
369 (18.5)
5
n=1912
≥0.95
616 (31.0)
5
n=1925
>3.64
The highest percent of women with T2DM occurred at the lowest
WC:BMI ratio, and the highest WC:HC ratio.
Results – T2DM Men
BMI kg/m2
N (%)
n=1613
T2DM men
1
n=1337
<25.1
161 (10.0)
2
n=1337
25.1 to 28.2
3
n=1338
Quintile
n=6686 men
Quintile
n=6418
WC cm
N (%)
n=1565
T2DM men
1
n=1284
<91.4
42 (2.7)
408 (25.3)
2
n=1284
91.4 to 101.6
208 (13.3)
28.3 to 30.8
399 (24.7)
3
n=1283
101.7 to
109.2
394 (25.2)
4
n=1338
30.9 to 34.7
366 (22.7)
4
n=1283
109.3 to
119.4
461 (29.5)
5
n=1337
≥34.7
279 (17.3)
5
n=1284
≥119.4
460 (29.4)
The highest percent of men with T2DM occurred at the highest WC.
ATP III: The Metabolic Syndrome
Diagnosis is established when 3 of these risk factors are present.
Risk Factor
Defining Level
Abdominal obesity
(Waist circumference)
Men
Women
TG
HDL-C
Men
Women
Blood pressure
Fasting glucose
>102 cm (>40 in)
>88 cm (>35 in)
150 mg/dL
<40 mg/dL
<50 mg/dL
130/85 mm Hg
110 mg/dL
Expert Panel on Detection, Evaluation, and Treatment of High Blood
Cholesterol in Adults. JAMA 2001;285:2486-2497.
Results – T2DM Men
Quintile
n=6357 men
WC:BMI
ratio
N (%)
n=1548
T2DM men
Quintile
n=6031
WC:HC
ratio
N (%)
n=1470
T2DM men
<0.90
21 (1.4)
1
n=1271
<3.24
99 (6.4)
1
n=1206
2
n=1272
3.24 to 3.46
156 (10.1)
2
n=1206
0.90 to 0.95
46 (3.1)
3
n=1272
3.47 to 3.64
257 (16.6)
3
n=1207
0.96 to 1.00
147 (10.0)
4
n=1271
3.65 to 3.87
414 (26.7)
4
n=1206
1.01 to 1.05
357 (24.3)
5
n=1271
≥3.87
622 (40.2)
5
n=1206
≥1.05
899 (61.2)
The highest percent of men with T2DM occurred at the highest
WC:BMI ratio and the highest WC:HC ratio.
Summary
• In univariate analyses of women, the number of
patients with T2DM gradually increased with
increasing BMI, WC, and WC:HC ratio, but not
WC:BMI, indicated that total peripheral,
subcutaneous adipose tissue may not always be
“protective”
• In men, univariate analyses indicated that WC:HC
ratio was a better predictor of T2DM than WC:BMI,
WC, or BMI, possibly reflecting the pathogenic effects
of having both increased visceral adipose tissue &
relative lack of “protective” gluteal and peripheral,
subcutaneous adipose tissue.
Back up slides
Six “Faces” of Adiposopathy
Bays H, Blonde L, Rosenson R. Expert Rev Cardiovas Ther. 4(6), 871–895 (2006)
Adiposopathy: Treatment
“Finally, an emerging concept is that the development of antiobesity agents must not only reduce fat mass (adiposity) but
must also correct fat dysfunction (adiposopathy)”
Bays HE. Obesity Research 2004; Vol. 12 No. 8:1197-1211.
Adiposopathy: Treatment
Adiposopathy treatments and their effects upon select parameters that promote type 2
diabetes mellitus
Intervention
Diet/Exercise
Visceral
fat
Free fatty
acids
Leptin
Adiponectin Tumor
necrosis
factor alpha
↓
↓
↓
↑
↓
PPAR
gamma
agonists
↓/-
↓
↓/-
↑
↓
Orlistat
↓
↓
↓
↑
↓
Sibutramine
↓
↓
↓
↑/-
?
Cannabinoid
receptor
antagonists
↓
↓
↓
↑
↓
Bays H, Blonde L, Rosenson R. Expert Rev Cardiovas Ther. 4(6), 871–895 (2006)
Adiposopathy: Treatment
Adiposopathy treatments and their effects upon select parameters that promote hyperte
Intervention
Diet/Exercise
Visceral
fat
Free fatty
acids
Leptin
Adiponectin Reninangiotensin
aldosterone
enzymes
↓
↓
↓
↑
↓
PPAR
gamma
agonists
↓/-
↓
↓/-
↑
-
Orlistat
↓
↓
↓
↑
?
Sibutramine
↓
↓
↓
↑/-
?
Cannabinoid
receptor
antagonists
↓
↓
↓
↑
?
Bays H, Blonde L, Rosenson R. Expert Rev Cardiovas Ther. 4(6), 871–895 (2006)
Adiposopathy: Treatment
Adiposopathy treatments and their effects upon select parameters that promote dyslipidemia
Intervention
Diet/Exercise
Visceral
fat
Free fatty
acids
Leptin
Adiponecti
n
Androgen
s
Estrogen
s
↓
↓
↓
↑
↓
(women)
↑ (men)
↓/- (men)
PPAR
gamma
agonists
↓/-
↓
↓/-
↑
↓
↓/- (men)
Orlistat
↓
↓
↓
↑
↓
(women)
?
Sibutramine
↓
↓
↓
↑/-
↓
(women)
?
Cannabinoid
receptor
antagonists
↓
↓
↓
↑
?
?
Bays H, Blonde L, Rosenson R. Expert Rev Cardiovas Ther. 4(6), 871–895 (2006)
Bays H, Ballantyne C. Future Lipidology. 2006;1(4):389-420; Bays H et al. Expert Rev Cardiovasc Ther. 2005;3(5):789-820
Bays H, Ballantyne C. Future Lipidology. 2006;1(4):389-420