International Journal of Obesity (2003) 27, 610–616
& 2003 Nature Publishing Group All rights reserved 0307-0565/03 $25.00
www.nature.com/ijo
PAPER
Waist-to-height ratio, a simple and practical index for
assessing central fat distribution and metabolic risk in
Japanese men and women
SD Hsieh1*, H Yoshinaga2 and T Muto3
1
Medical Center of Health Science, Toranomon Hospital, Tokyo, Japan; 2Department of Internal Medicine, Ebina General Hospital,
Kanagawa, Japan; and 3Department of Public Health, Dokkyo University, School of Medicine, Tochigi, Japan
OBJECTIVE: The normal body mass index (BMI) range, as defined by the World Health Organization (WHO), is quite wide, and
some people within this range may have excessive central fat accumulation and elevated metabolic risks. We hypothesize that
the waist-to-height ratio (W/Ht), an effective index for assessing central fat distribution among Japanese people, can be used to
identify subjects who are at higher metabolic risk within the normal as well as the overweight range.
METHODS: We investigated: (1) the values of BMI, waist circumference, and W/Ht in 6141 men and 2137 women at various
age intervals and calculated gender (female to male) ratios for all these anthropometric indices; (2) the relation between age and
each anthropometric index, between age and morbidity index for coronary risk factors (sum of the scores for hyperglycemia,
hypertension, hypertriglyceridemia, hypercholesterolemia, and low HDL cholesterol; one point for each condition if present),
and between morbidity index for coronary risk factors and each anthropometric index; (3) the distributions of the subjects, using
various proposed indices of waist circumference (those suggested by WHO, the Japan Society for the Study of Obesity, and the
Asia-Pacific perspective), and our proposed boundary value, W/Ht 0.5, among the WHO categories based on BMI; (4) the
metabolic risks (coronary risk factors, hyperuricemia, high g-glutamyltransferase, and fatty liver diagnosed by ultrasonography),
and exercise habits among normal-weight subjects with W/Hto0.5 or Z0.5.
RESULTS: (1) For the various anthropometric indices in all age groups, the gender ratio for W/Ht was closest to 1, indicating that
a single set of values for W/Ht can be used for men and women. (2) Height correlated negatively with age. Among the
anthropometric indices, only W/Ht correlated positively with age for both men and women, while age and all anthropometric
indices, except height, correlated positively with the morbidity index for coronary risk factors. For both men and women, the
highest correlation coefficient was between W/Ht and the morbidity index for coronary risk factors. (3) Nearly all overweight
men and women (BMIZ25) had W/HtZ0.5 (98.5% of men and 97.5% of women). None of the underweight subjects had W/
HtZ0.5. However, 45.5% of men and 28.3% of women of normal weight (BMI 18.5–o25) had W/HtZ0.5. W/Ht, of all the
indices investigated, was the best index for signaling metabolic risk in the normal-weight subjects as well as the overweight
subjects. (4) Age- and BMI-adjusted odds ratios for multiple metabolic risks, and history of no habitual exercise were significantly
higher in normal-weight men and women with W/HtZ0.5 than in others of normal weight.
CONCLUSIONS: Waist circumference is improved by relating it to height to categorized fat distribution of different genders and
ages. W/Ht is a simple and practical anthropometric index to identify higher metabolic risks in normal and overweight Japanese
men and women.
International Journal of Obesity (2003) 27, 610–616. doi:10.1038/sj.ijo.0802259
Keywords: metabolic risks; overweight; normal BMI; waist circumference; waist-to-height ratio
Introduction
*Correspondence: Dr SD Hsieh, Medical Center of Health Science,
Toranomon Hospital, Toranomon 2-2-2, Minato-ku, Tokyo 105-8470,
Japan.
E-mail: [email protected]
Received 24 September 2001; revised 2 May 2002;
accepted 9 December 2002
Body mass index (BMI) is an index widely used to define
obesity. The World Health Organization (WHO) sets a BMI
range of 18.5–24.99 kg/m2 as normal1. Guidelines generally
imply that those with BMIs falling in the normal range do
not need to lose weight, so the normal-weight individuals
may pay little attention to their lifestyles even if they are
inappropriate. Although Asians constitute a large proportion
Waist-to-height ratio and metabolic risk
SD Hsieh et al
611
of the world’s population, the majority of Asians, including
the Japanese, are not clearly obese according to the WHO
classification,2,3 despite rapid westernization of lifestyles and
a corresponding increase in metabolic risks.
BMI does not always accurately indicate the degree of
fatness.4 An increasing number of papers indicate that the
degree of central fat distribution may be more closely tied to
metabolic risks than BMI.5–7 Measurement of the degree of
central fat distribution thus appears to be important for the
early detection of subsequent health risks, even among those
of normal weight.8–10 However, medical authorities have not
yet established a single, simple standard that can be applied
to both men and women to identify simultaneously both
those who are overweight and those of normal weight who
nevertheless face higher metabolic risks from central fat
distribution. The criteria for waist circumference proposed
by WHO (midpoint between the lower border of the rib cage
and the iliac crest) were based on studies of Caucasians, who
generally have a higher BMI than many other ethnic
groups.1 In 2000, the Japan Society for the Study of Obesity
(JASSO) proposed that those with BMIZ25 kg/m2 should be
considered obese, also stating that obese individuals whose
waist circumference (umbilical level) was Z85 cm (men) or
90 cm (women) faced a higher risk of visceral fat accumulation.11 However, JASSO prescribed no particular guidelines
for normal-weight individuals with larger waist circumferences. Also in 2000, the experts on obesity in the Asia-Pacific
region in a conference entitled ‘The Asia-Pacific perspective:
Redefining obesity and its treatment’ (Asia-Pacific perspective) proposed that the BMI level indicating excessive weight
should be set to 23 or above, going on to state that even
those of normal weight whose waist circumference (measured at the same level as WHO) was Z90 cm (men) or 80 cm
(women) faced increased health risks.12 Thus, the standard
for the assessment of health risks associated with central fat
accumulation differs between organizations, and differs
between men and women.
Several reports from Asia indicate that waist-to-height
ratio (W/Ht) corresponds better to metabolic risk than BMI,
waist circumference, waist-to-hip ratio, or skinfold measures
(based on data gathered on over 48 000 persons in all related
investigations).10,13–17 There are also reports that the cutoff
value for W/Ht (0.5) appears to offer a simple but effective
index for identifying overweight individuals and those of
normal weight who face higher risks,8,10 while W/Ht near 0.5
may also help identify Japanese with higher metabolic risks
on an ROC curve.15 The index may represent a potentially
useful guideline for preventive health care.
Further evidence for the effectiveness of all these anthropometric indices for both Japanese men and women is
needed. We observed the relations of age, obesity indices,
and coronary risk factors and noted the similarities for men
and women in anthropometric indices for various age
groups. As a result, we hypothesize that W/Ht may be a
more effective index than BMI and waist circumference,
capable of identifying higher metabolic risks not only in
those Japanese who are overweight but also in normalweight subjects.
Methods
Procedure and subjects
Toranomon Hospital is a large general hospital located in
central Tokyo providing health services, including routine
health checkups, primarily to government employees and
their families. The subjects of this study included 6141 men
(age, mean7s.d.: 49.578.9 y) and 2137 women (age,
mean7s.d.: 51.979.0 y) who underwent health examinations at the Medical Center of Health Science, Toranomon
Hospital, from 1996 to 1999. The self-reported histories of
current medications for metabolic risks and habitual exercise
were obtained during the examinations.
Measurement
Height and weight were measured after overnight fasting,
and BMI was calculated on the basis of these measurements.
Waist circumference was measured at the umbilical level,8,10,13–16,18 with subjects standing and breathing normally during the physical examination, after which W/Ht
was calculated. Blood pressure was measured with the
subjects in a seated position. Levels of plasma glucose, serum
triglycerides, cholesterol, HDL cholesterol, uric acid, and gglutamyltransferase were measured by enzymatic methods.
Abdominal ultrasonography for the diagnosis of fatty liver
was performed by specialists.19 Table 1 gives definitions for
metabolic risks, morbidity index for coronary risk factors,
and history of no regular exercise. A cutoff value of highgglutamyltransferase was based on mean+2 s.d. by a logistic
Table 1 Definitions for metabolic risks, no regular exercise, and morbidity
index for coronary risk factorsa
Hyperglycemia
Hypertension
Hypertriglyceridemia
Hypercholesterolemia
Low HDL cholesterol
Hyperuricemia
High gglutamyltransferase
Fatty liver
No regular exercise
Fasting plasma glucose: Z110 mg/dl and/or
receiving current medication for this condition
Systolic blood pressure: Z140 mmHg and/or
diastolic blood pressure Z90 mmHg and/or
receiving current medication for this condition
Serum triglyceride: Z150 mg/dl and/or
receiving current medication for this condition
Serum cholesterol: Z220 mg/dl and/or
receiving current medication for this condition
Serum HDL cholesterol: o40 mg/dl
Serum uric acid: >7 mg/dl and/or receiving
current medication for this condition
Serum g-glutamyltransferase: Z110 IU/l
By ultrasonography
Without regular exercise lasting for
30 min or more at least once a week
a
The sum of the scores of the following items; one point for each item, if
present: hyperglycemia, hypertension, hypertriglyceridemia, hypercholesterolemia, and low HDL cholesterol.
International Journal of Obesity
Waist-to-height ratio and metabolic risk
SD Hsieh et al
612
method, in comparison to individuals considered to be
healthy (mostly hospital employees).
We investigated: (1) the values for height, weight, BMI,
waist circumference, and W/Ht for various age groups (o30,
30–39, 40–49, 50–59, 60–69, and Z70 y) and calculated
gender ratios (female to male) for BMI, waist circumference,
and W/Ht; (2) the relations between age and each anthropometric index, age and morbidity index for coronary risk
factors, and also between each anthropometric index and
the morbidity index for coronary risk factors; (3) the
distributions of subjects, using the proposed indices of waist
circumference (WHO,1 JASSO,11 and the Asia-Pacific perspective12) and W/Ht (0.5)10 among the underweight,
normal, and overweight, according to WHO classifications
based on BMI1; and (4) the metabolic risks and history of no
regular exercise of those with W/Hto0.5 and Z0.5 among
normal-weight subjects.
Statistics
The prevalence of metabolic risks and history of no regular
exercise of those with W/Hto0.5 and Z0.5 among normalweight subjects were compared by the w2 method. The ageand BMI-adjusted odds ratios for metabolic risks and history
of no regular exercise of those with W/Hto0.5 and Z0.5
among normal-weight subjects were compared by logistic
regression.
RESULTS
Anthropometric indices and gender ratios (female to
male) of indices in relation to various age groups
As shown in Table 2, anthropometric indices for women
were always lower than those for men for height, weight,
BMI, waist circumference, and W/Ht in all age groups, except
Table 2
Anthropometric indices in relation to various age groups
Age (y)
o30
30–39
40–49
50–59
60–69
International Journal of Obesity
651
157.0
53.6
21.8
74.1
0.47
903
155.2
52.7
21.9
75.7
0.49
340
153.1
52.0
22.2
78.2
0.51
Correlations between age and each anthropometric
index, between age and morbidity index for coronary
risk factors, and between morbidity index for coronary
risk factors and each anthropometric index (Table 3)
Height and weight correlated negatively with age, while W/
Ht correlated positively with age for both men and women.
BMI correlated negatively with age in men, but positively in
women. Waist circumference correlated positively with age
only among women. Height also correlated negatively with
the morbidity index for coronary risk factors, while age and
obesity indices all correlated positively with the morbidity
index for coronary risk factors for both men and women.
Among the correlations between the morbidity index for
coronary risk factors and other items, including age and
various obesity indices, W/Ht had the highest correlation
coefficient for both men and or women.
Distributions of subjects using proposed indices of
central fat accumulation among underweight, normal
weight, and overweight individuals, according to WHO
definitions based on BMI (Table 4)
Most of the examinees were in the normal-weight range. The
W/Ht index (Z0.5) successfully identified 98.5% of overweight men (BMI 425) and 97.5% of overweight women. In
contrast, the indices based on waist circumference alone
identified fewer of the overweight group. The JASSO index11
identified only 39.1% of overweight women, while the AsiaPacific perspective index12 identified 78.6% of overweight
men. The WHO waist circumference index1 identified only
45.6% of overweight men. Among normal-weight (BMI
18.5–o25 kg/m2) subjects, 45.5% of men and 28.3% of
women had W/HtZ0.5. In summary, more subjects were
identified by the W/Ht boundary value of 0.5 than by any of
the other proposed indices of central fat distribution.
Z70
Men
n
48
771
2,378
2,183
644
117
Height (cm)
171.3 171.4
170.0
167.6 165.8 164.9
Weight (kg)
68.1
68.5
67.7
65.6
62.7
60.1
BMI (kg/m2)
23.2
23.3
23.4
23.3
22.8
22.1
Waist circumference 81.8
84.4
85.7
85.8
85.0
84.0
(cm)
W/Ht
0.48
0.49
0.50
0.51
0.51
0.51
Women
n
17
174
Height (cm)
159.7 159.1
Weight (kg)
52.7
51.9
BMI (kg/m2)
20.6
20.5
Waist circumference 69.4
70.6
(cm)
W/Ht
0.43
0.44
for W/Ht in the age brackets 60–69 y and Z70 y. As shown in
Figure 1, the obesity index for which the gender ratio was
closest to 1 in all age groups was W/Ht.
52
150.3
48.7
21.5
78.2
0.52
Clinical features, prevalence of metabolic risks, and
history of no regular exercise in normal BMI subjects
classified as W/Hto0.5 or Z0.5 (Table 5)
The prevalence of all measured metabolic risks and history of
no regular exercise were significantly higher among both
men and women of W/HtZ0.5 compared to those with W/
Hto0.5, except for hyperuricemia and high g-glutamyltransferase in women.
Odds ratios for metabolic risks and history of no regular
exercise in normal BMI subjects classified as W/Hto0.5
or Z0.5, adjusted by age and BMI (Table 6)
Odds ratios adjusted by age and BMI were significantly
higher among men of W/Ht Z 0.5 (with the exception of the
item hypercholesterolemia), and significantly higher in
Waist-to-height ratio and metabolic risk
SD Hsieh et al
613
BMI
Waist circumference
1.05
Waist-to-height ratio
Gender ratio
1.00
0.95
0.90
0.85
0.80
< 30
30~39
40~49
50~59
60~69
70
Age (y)
Figure 1
Gender ratios (female to male) of anthropometric obesity indices in relation to various age groups.
Table 3 Correlation coefficients between age and each anthropometric
index, between age and morbidity index for coronary risk factors, and
between morbidity index for coronary risk factors and each anthropometric
index
Men
Age
Age
Morbidity index
Height
Weight
BMI
Waist circumference
W/Ht
F
0.12*
0.30*
0.22*
0.07*
0.02
0.15*
Morbidity index
0.12*
F
0.06*
0.25*
0.33*
0.35*
0.37*
Women
Age
F
0.37*
0.36*
0.08*
0.10*
0.24*
0.34*
Morbidity index
0.37*
F
0.16*
0.20*
0.30*
0.36*
0.39*
*Po0.0005.
women of W/Ht Z 0.5 for the items hypertension,
hypertriglyceridemia, low HDL cholesterol, fatty liver, and
history of no regular exercise.
Discussion
Although the health risks associated with central fat
distribution are now universally recognized, practical measurement of this parameter, nearly a half-century after the
risks were first reported,20 remains less common throughout
the world than that of BMI. Waist-to-hip ratio is the most
popular index for assessing central obesity. However, variations in measurement levels,18,21 differences in cutoff values
between men and women and among various ethnic
groups,22 and the possibility of embarrassment to examiners
and examinees of different genders when measuring the hip
area may limit its global prevalence.
Recently, various organizations have proposed indices of
waist circumference to assess central obesity.1,11–12 However,
screening implementation has drawn criticism for its effectiveness compared with the present BMI classification.23
Moreover, as with waist-to-hip ratio, measurement methods
and cutoff values differ between men and women and
among various ethnic groups.1,24
Height is an important parameter that should be considered before adopting an obesity index, since height may
influence the observation of fat accumulation and/or
distribution. The early-age nutritional environments differed
dramatically among the Japanese subjects among generations, and height correlated inversely with age. As in our
previous study,25 the accumulation of fat related to age was
more difficult to observe by BMI in men than in women for
the following reasons: (1) The increase in the amount of fat
with age may be less pronounced in men than in women. (2)
The increase in weight due to fat may be offset to a greater
degree by a decrease in lean body mass, such as muscle and
mineral components, among men than in women,26,27 and
may also be offset by a decrease in subcutaneous fat in men
with advancing age25,28 (3) Younger people may have higher
BMIs due to better early-age nutritional environments than
older individuals. In men, increases in waist circumference
with age may be masked by the following factors:
(1) The baselines for waist circumference may differ, in
that younger individuals may be taller and have larger waist
circumferences due to better early-age nutritional environments. (2) An increase in intra-abdominal fat may be offset
by a decline in subcutaneous fat among older men.25,28
Thus, the increase in intra-abdominal fat from middle age on
may be difficult to detect by waist circumference without
height adjustments. As in this study, height correlated
negatively with age and with the morbidity index for
International Journal of Obesity
Waist-to-height ratio and metabolic risk
SD Hsieh et al
614
Table 4 Distributions of subjects using proposed indices of central fat accumulation among underweight, normal, and overweight individuals, according to WHO
definitions based on BMI
Men BMI (kg/m2)
Women BMI (kg/m2)
o18.5
18.5–o25
o18.5
Z25
18.5–o25
n
Hsieh et al.: W/HtZ0.5
JASSO: Waist circumference Z85 cm
Asia-Pacific perspective: Waist circumference
Z90 cm
WHO: Waist circumference Z94 cm
n
158
4510
0
0
0
45.5%
42.6%
12.5%
98.5%
97.8%
78.6%
0
1.9%
45.6%
1473
Table 5 Clinical features, prevalence of metabolic risks, and history of no
regular exercise in normal BMI subjects classified by W/Ht ratio o0.5 or Z0.5
Men
Hsieh et al.: W/HtZ0.5
JASSO: Waist circumference Z90 cm
Asia-Pacific perspective, WHO: Waist
circumference Z80 cm
209
1644
284
0
0
0
28.3%
0.9%
19.7%
97.5%
39.1%
93.7%
Table 6 Odds ratios (95% CI) for metabolic risks, and history of no regular
exercise in normal BMI subjects classified by W/Hto0.5 or Z0.5, adjusted by
age and BMI
Women
Men
W/Ht
n
Age (y) (mean7s.d.)
Hyperglycemia (%)
Hypertension (%)
Hypertriglyceridemia (%)
Hypercholesterolemia (%)
Low HDL cholesterol (%)
Hyperuricemia (%)
High g-glutamyltransferase (%)
Fatty liver (%)a
No regular exercise (%)
o0.5
Z0.5
o0.5
Z0.5
2460
2050
1178
466
47.878.7 51.878.7 50.478.6 56.078.4
7.0
15.2
14.3
24.1
11.8
13.1
7.4
12.8
65.2
12.3*
27.6*
30.9*
32.0*
20.9*
20.4*
14.4*
35.3*
71.7*
2.8
13.9
3.4
36.3
1.9
0.2
1.3
3.7
65.5
7.5*
28.1*
12.9*
49.6*
6.4*
0.9
2.6
22.6*
70.6**
*Po0.0001, **Po0.05; aFew examinees did not receive ultrasonography for
their options; the number of subjects receiving ultrasonography was 2434 for
men with W/Hto0.5, 2025 for men with W/HtZ0.5, 1150 for women with
W/Hto0.5, and 447 for women with W/HtZ0.5.
coronary factors, while age correlated positively with the
morbidity index for coronary factors. In other words, use of a
single index of waist circumference for the assessment of
metabolic risks for both young and old may minimize the
apparent risks among older individuals. Even following
adjustment for age, shorter people may still face higher
metabolic risks than taller people with similar waist
circumferences.29 For these reasons, W/Ht correlated more
closely with the morbidity index for coronary factors than
other indices in this study. Some reports indicate that height
is inversely correlated with coronary heart disease, which
holds true after adjustment for confounders.30–31 Thus, the
potential independent effect of height on coronary heart
disease, apart from age and other risk factors, may make
W/Ht a better index for prospective study.
Among the recommended cutoff values and indices set as
action levels for central fat accumulation and related
metabolic risks, only W/Ht was able to identify almost all
International Journal of Obesity
Z25
W/Ht
Hyperglycemia
Hypertension
Hypertriglyceridemia
Hypercholesterolemia
Low HDL cholesterol
Hyperuricemia
High g-glutamyltransferase
Fatty liver
No regular exercise
o0.5
1
1
1
1
1
1
1
1
1
Z0.5
1.34
1.28
2.26
1.18
1.61
1.43
1.99
1.91
2.20
(1.02–1.77)
(1.05–1.56)
(1.86–2.75)
(0.99–1.40)
(1.30–2.00)
(1.15–1.76)
(1.54–2.60)
(1.57–2.32)
(1.85–2.61)
Women
o0.5
Z0.5
1
1
1
1
1
1
1
1
1
1.63 (0.86–3.10)
1.43 (1.01–2.02)
2.96 (1.73–5.13)
1.06 (0.80–1.42)
2.15 (1.05–4.50)
3.12 (0.36–33.35)
1.84 (0.67–5.08)
2.97 (1.86–4.77)
1.41 (1.05–1.90)
overweight men and women. This suggests that almost all
the overweight Japanese men and women have excessive
central fat accumulation according to the W/Ht index. Here
we should note that the location of the measurement of
waist circumference by JASSO and ourselves was different
from that of the WHO and Asia-Pacific perspective, but the
conclusions may not differ if the measurements are
performed by the same method. According to our experience, the average of waist circumferences measured at the
umbilical level may be slightly larger than measured at the
midpoint between the lower border of the rib cage and the
iliac crest. Thus, the cutoff values applied by WHO and AsiaPacific here might actually be increased if based on their
method, and therefore might identify even fewer subjects in
Table 4. Anyway, the difference between the two measuring
methods requires further study.
The majority of our examinees were of normal weight, as
defined by the WHO classification, but nevertheless faced a
high prevalence of metabolic risks. Moreover, the relative
risks were significantly higher among normal-weight examinees with W/Ht Z 0.5, even after adjusting for age and BMI.
This observation confirms that not just the amount of fat,
Waist-to-height ratio and metabolic risk
SD Hsieh et al
615
but also central fat distribution, results in increased health
risks in both men and women.
W/Ht may also be a better proxy index of the lack of
physical activity than BMI.32,33 In this study, normal-weight
subjects who exceeded the proposed W/Ht cutoff value also
tended to be more sedentary and were more likely to
consume excessive calories from various sources such as
consuming excessive alcohol, which might be related to the
high g-glutamyltransferase.34
A very small number of people in our study were assessed
as overweight, but nevertheless exhibited a W/Ht below 0.5.
These people may have histories of more extensive exercise,
and consequently bear more muscular body tissue and
exhibit higher BMIs.10 The metabolic risks of this group
require further study.
In summary, W/Ht may offer the following advantages
over other anthropometric indices consisting of waist
circumference alone: (1) closer agreement of values between
men and women at all ages; (2) more accurate tracking of fat
distribution and accumulation by age; (3) closer correlation
with morbidity index for coronary risk factors; (4) more
comprehensive identification of overweight individuals and
those of normal weight facing higher risks; (5) greater
simplicity, in that a single rule (keep your waist circumference
below half your height) may be applied to both men and
women, enabling busy physicians and other professionals to
screen and counsel examinees who face higher metabolic
risks during physical examinations. In this way, the index
can serve as a ‘second stethoscope’.
European studies also indicate the usefulness of W/Ht.35–38
Thus, this index may also apply effectively to people outside
Asia, especially in the screening of those of normal weight
facing higher risks, enabling early preventive health education. W/Ht has also been reported to be useful in screenings
for cardiovascular risk factors among children in both
Europe and Japan,38–39 allowing examiners to ignore variations in individual height that make it difficult to specify a
single cutoff value for waist circumference among children.
These reports suggest that W/Ht may be globally applicable,
as well as the effectiveness of the index for observing fat
distributions and related metabolic risks from childhood
through old age. Our hope is that additional investigations,
including prospective studies, will be undertaken in this
important field.
Acknowledgements
We thank Mitsui Chemical Industries, Ltd for providing
financial support for this study.
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