SOLUTION: Circumference on Risk of Death | My Assignment Tutor

Journal of the American Heart AssociationJ Am Heart Assoc. 2020;9:e015189. DOI: 10.1161/JAHA.119.015189 1ORIGINAL RESEARCHCombined Influence of Waist and HipCircumference on Risk of Death in a LargeCohort of European and Australian AdultsAdrian J. Cameron, PhD*; Helena Romaniuk, PhD*; Liliana Orellana, PhD; Jean Dallongeville, PhD;Annette J. Dobson, PhD; Wojciech Drygas, MD; Marco Ferrario, MD; Jean Ferrieres, MD; Simona Giampaoli, MD;Francesco Gianfagna, MD; Licia Iacoviello, PhD; Pekka Jousilahti, PhD; Frank Kee, MD; Marie Moitry, MD;Teemu J. Niiranen, MD; Andrzej Pająk, PhD; Luigi Palmieri, PhD; Tarja Palosaari, MSc; Männistö Satu, PhD;Abdonas Tamosiunas, PhD; Barbara Thorand, PhD; Ulla Toft, PhD; Diego Vanuzzo, MD; Salomaa Veikko, MD;Giovanni Veronesi, PhD; Tom Wilsgaard, PhD; Kari Kuulasmaa, PhD; Stefan Söderberg, PhDBACKGROUND: Waist circumference and hip circumference are both strongly associated with risk of death; however, their jointassociation has rarely been investigated.METHODS AND RESULTS: The MONICA Risk, Genetics, Archiving, and Monograph (MORGAM) Project was conducted in 30 cohorts from 11 countries; 90 487 men and women, aged 30 to 74 years, predominantly white, with no history of cardiovasculardisease, were recruited in 1986 to 2010 and followed up for up to 24 years. Hazard ratios were estimated using sex-specificCox models, stratified by cohort, with age as the time scale. Models included baseline categorical obesity measures, age,total and high-density lipoprotein cholesterol, systolic blood pressure, antihypertensive drugs, smoking, and diabetes mellitus. A total of 9105 all-cause deaths were recorded during a median follow-up of 10 years. Hazard ratios for all-cause deathpresented J- or U-shaped associations with most obesity measures. With waist and hip circumference included in the samemodel, for all hip sizes, having a smaller waist was strongly associated with lower risk of death, except for men with the smallest hips. In addition, among those with smaller waists, hip size was strongly negatively associated with risk of death, with≈20% more people identified as being at increased risk compared with waist circumference alone.CONCLUSIONS: A more complex relationship between hip circumference, waist circumference, and risk of death is revealedwhen both measures are considered simultaneously. This is particularly true for individuals with smaller waists, where havinglarger hips was protective. Considering both waist and hip circumference in the clinical setting could help to best identify thoseat increased risk of death.Key Words: hip circumference ■ mortality ■ obesity ■ waist circumferenceThe prevalence of obesity is high or rapidly in creasing in most countries, with serious health and economic consequences.1 Body mass index-(BMI) is the most commonly used measure of obesity;however, it does not capture the differential effectsof adipose tissue from different parts of the body2–8or visceral and subcutaneous adipose tissue.9 Bodyshape differences mean that people with the sameBMI can vary widely in their body fat distribution.10BMI also does not distinguish between fat mass andfat-free mass, the latter having a strong inverse relationship with morbidity and mortality.8 The cost of theCorrespondence to: Adrian J. Cameron, PhD, Global Obesity Centre, Institute for Health Transformation, Deakin University, 221 Burwood Hwy, Burwood, VIC3125, Australia. E-mail: adrian.cameron@deakin.edu.auSupplementary Materials for this article are available at https://www.ahajournals.org/doi/suppl/10.1161/JAHA.119.015189*Prof Cameron and Dr Romaniuk contributed equally to this work.For Sources of Funding and Disclosures, see page 13.© 2020 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley. This is an open access article under the terms of the CreativeCommons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited andis not used for commercial purposes.JAHA is available at: www.ahajournals.org/journal/jahaDownloaded from http://ahajournals.org by on July 2, 2020J Am Heart Assoc. 2020;9:e015189. DOI: 10.1161/JAHA.119.015189 2Cameron et al Waist and Hip Circumference and Risk of Deathimaging methods required to accurately assess fat distribution is prohibitive in many settings. From a publichealth perspective, it is therefore important to identifysimple anthropometric measures that reflect adiposetissue distribution and are closely related to morbidityand premature death.Waist circumference (WC) and hip circumference(HC) are commonly used and easily understood measures of abdominal (upper-body) and gluteofemoral(lower-body) body size, respectively. WC is primarily a measure of visceral/ectopic and subcutaneousadipose tissue around the waist, whereas HC measures both adipose tissue and lower-body musclemass. Numerous studies have shown that larger WCis strongly related to morbidity and premature death,while there is some evidence that larger HC is protective for these same outcomes.2,6,8,9,11 The effectsof different fat depots in the upper and lower bodyare increasingly explained by variation in lipid storageand release11,12 and the secretion of adipose tissuerelated proteins.5,11 Given their opposite relationshipswith metabolic health, the ratio of WC to HC (WHR)was conceptualized as an overall measure of obesity,13with the waist/height ratio also proposed as a wayof capturing the distribution of body fat.14,15 WHRand waist/height ratio have a simple interpretationwhen the relationship between the 2 variables is linear, but lack interpretation otherwise.16 Furthermore,they can be identical for individuals of vastly differentbody shape.17 There is no conclusive evidence thatWC alone or WHR is more strongly related to riskof premature death than BMI.18,19 Both, however, arepredictors of death when added to a model also including BMI, meaning they are clearly identifying different components of obesity-related risk.18 “A bodyshape index” (ABSI) that incorporates WC, height,and BMI has also been proposed in an attempt toidentify an optimal body size measure associatedwith mortality.10A 2013 systematic review identified only 5 studiespredicting premature death using statistical modelsthat included separate measures of both WC and HC.7In each case, the model including both measures wassuperior to a model including only one of them. Thesewere single population studies with either a maximumfollow-up of 12 years or 90 000 individuals (from 11 countries) who were followed up for up to 24 years.What Are the Clinical Implications?• Among those with smaller waists (who wouldnot normally have been identified as being athigher risk of death on the basis of their bodysize), having smaller hips was strongly associated with increased risk of death.• Considering both waist and hip circumferencesimultaneously identifies almost 20% morepeople as being at higher risk of death compared with using waist circumference alone,and is a simple and cost-effective way of identifying body shapes associated with increasedrisk of premature death. Nonstandard Abbreviations and Acronyms ABSI a body shape indexBMI body mass indexCVD cardiovascular diseaseHC hip circumferenceMORGAM MONICA Risk, Genetics, Archiving,and Monograph ProjectWC waist circumferenceWHR waist/hip ratioDownloaded from http://ahajournals.org by on July 2, 2020J Am Heart Assoc. 2020;9:e015189. DOI: 10.1161/JAHA.119.015189 3Cameron et al Waist and Hip Circumference and Risk of Deathharmonized according to the Monitoring of Trends andDeterminants in Cardiovascular Disease (MONICA)and MORGAM manuals.21,23,24Our study is based on data from 30 MORGAMcohorts from 17 participating centers located in 10European countries plus Australia, which included111 318 participants recruited between 1986 and2010 who were followed up for up to 24 years.Participants were excluded if they were aged 2 SDs above the mean). Theranges of values for the categories are shown inTable S1.Associations between the categorical anthropometric measures and the risk of all-cause and cardiovascular death were estimated separately for menand women using Cox proportional-hazards models,stratified by cohort, with age as the time scale, afterpartial and further adjustment. These associationswere estimated in models including each individualanthropometric measure or a model including bothWC and HC. Partially adjusted models included ageat baseline (