1250
Waist to Hip Ratio in Middle-Aged Women
Associations With Behavioral and Psychosocial
Factors and With Changes in Cardiovascular Risk Factors
Rena R. Wing, Karen A. Matthews, Lewis H. Kuller, Elaine N. Meilahn, and Pam Plantinga
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Waist to hip ratio (WHR) was measured in 487 middle-aged women participating in the Healthy
Women Study. Upper body fat distribution was found to be associated with numerous behaviors
that affect cardiovascular risk, including smoking, low exercise levels, weight gain during
adulthood, and higher caloric intake. Moreover, WHR was also associated with higher levels of
anger, anxiety, and depression and lower levels of perceived social support. Women with upper
body fat obesity had higher systolic blood pressure, total cholesterol, low density lipoprotein
cholesterol, triglycerides, and apolipoprotein B and lower levels of high density lipoprotein
(HDL) and the HDL subfractions 2 and 3. These associations remained significant after
adjusting for body mass index. Among 108 women who had repeat measurements of WHR,
changes in WHR over a 3-year period were significantly correlated with changes in activity and
with decreases in HDL,. Thus, WHR appears to be an integral component of the cardiovascular
risk profile. WHR is related to those behaviors and psychosocial attributes that influence
cardiovascular risk. (Arteriosclerosis and Thrombosis 1991;ll:1250-1257)
R
ecent studies suggest that the distribution of
body fat may be a stronger predictor of
coronary heart disease (CHD) than the
total amount of body fat.1"4 For example, in the Paris
Prospective study, men who had an upper body fat
distribution were at increased risk for CHD, independent of body mass index (BMI).1 Similarly, in a
prospective study conducted in Sweden2-3 the waist to
hip ratio (WHR) was found to be positively associated with the incidence of myocardial infarction,
stroke, and death from all causes in both men and
women, after adjusting for BMI.
The effect of upper body fat distribution on atherosclerotic disease may be mediated by the effect on
cardiovascular risk factors. WHR has been associated with increased blood pressure,5-6 increased triglycerides,3-6-8 and decreased high density lipoprotein (HDL) cholesterol.7"10 Body fat distribution has
also been related to fasting and stimulated levels of
glucose and insulin11-13 and to increased rates of
diabetes.14
To date, there have been few studies that have
systematically investigated the behavioral or psychosocial factors associated with WHR. Smoking has
From the Departments of Psychiatry (R.R.W., K.A.M.) and
Epidemiology (R.R.W., K.A.M., L.H.K., E.N.M., P.P.), University
of Pittsburgh, Pittsburgh, Pa.
Supported by a grant from the National Heart, Lung, and Blood
Institute (HL-28266).
Address for reprints: Rena R. Wing, PhD, Western Psychiatric
Institute and Clinic, 3811 O'Hara Street, Pittsburgh, PA 15213.
Received January 15, 1991; revision accepted May 29, 1991.
been related to increased upper body fat distribution
in both men and women,15"18 and a recent study
showed that men who started to smoke had an
increase in WHR.16 Activity level may also be related
to WHR18-20; men and women who reported more
intense leisure-time activity were found to have lower
WHRs,19 and exercise training has been shown to
decrease WHR.20 Alcohol intake has also been related to WHR, with both positive17 and negative18
associations noted.
We are not aware of any previous studies that have
examined the association between psychosocial variables and body fat distribution. Experimental studies
with monkeys have shown that stress results in redistribution of fat to the abdominal area.21 Bjorntorp22
hypothesized that the same may be true for humans
and that those individuals who experience a great
deal of stress or who have difficulty coping with stress
may experience higher cortisol levels and consequently may deposit more body fat in the abdominal
area.
The purpose of the present article is to examine
the behavioral and psychosocial correlates of WHR
in a population-based sample of middle-aged women
who were participating in the Healthy Women Study.
In addition, we assessed the relation between WHR
and cardiovascular risk factors in these women.
Moreover, 108 of these women also had measures of
WHR completed 3 years previously. Consequently,
we could determine the relation between changes in
behavior and changes in WHR and the association
Wing et al WHR and CV Risk Factors
between changes in WHR and changes in cardiovascular risk factors.
Methods
Subjects
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Subjects in this study were participants in the
Healthy Women Study, a prospective investigation of
changes in biologic and behavioral characteristics
during the climacteric. Women were recruited into
the study during 1983-1984 from a random sample of
licensed drivers in Allegheny County, Pennsylvania.
Eligibility criteria included age 42-50 years; menstruating within the past 3 months; no surgical menopause; diastolic blood pressure less than 100 mm Hg;
and not taking insulin, thyroid medication, lipidlowering drugs, estrogens, antihypertensive drugs, or
psychotropic drugs.
Eighty-nine percent of women who were contacted
agreed to a telephone interview, and 60% of those
who were eligible volunteered to participate. A total
of 541 women entered the study. Comparisons of
participants with those who declined participation
have been published previously23; participants were
better educated and were employed in higher-paying
jobs than either those who were ineligible or those
who declined participation.
All women were invited to be restudied in 1987
after an average of 3 years in the study. The 487
women who completed the full reexamination form
the sample for the present study. Of these 487
women, 282 were still premenopausal at follow-up
and 62 were considered to be naturally postmenopausal, defined as not having menstruated for at least
12 months, not having undergone surgical menopause, and not having received hormone therapy in
the past year. The remaining women were in the
perimenopausal period (n=92), were using hormones (n=32), or had undergone surgical menopause (n=19).
WHR was added late to the baseline protocol and
was measured on the final 120 women. One hundred
eight of these women completed the follow-up assessment as well, and they form the subsample for
the analyses of changes in WHR over time. The
women who had WHR assessed at baseline were
older (/?<0.0001), had lower HDL cholesterol
(/?<0.05), and had higher apolipoprotein (apo) A-II
(p<0.0l) and apo B (/><0.0001) levels than did
those for whom WHR was not assessed.
Procedures
Subjects were evaluated in the morning after a
12-hour fast for the following measures.
Lipids and apolipoproteins. Serum cholesterol,24
total HDL cholesterol,25 the subfractions 2 and 3 of
HDL (HDL2 and HDL3),26 and triglycerides27 were
assessed. Low density lipoprotein (LDL) cholesterol
levels were estimated with the Friedewald equation
(Friedewald et al28). Apos A-I and B29 were assessed
1251
by electroimmunoassay, and apo A-II was assessed by
enzyme-linked immunoabsorbent assay.30
Glucose and insulin. Glucose and insulin were
measured in the fasting state and 2 hours after a
75-g oral glucose load. Glucose was analyzed by
enzymatic assay (Yellow Springs Glucose Analyzer,
Yellow Springs, Ohio), and insulin was analyzed by
radioimmunoassay.31
Blood pressure. Blood pressure was measured twice
by the random-zero muddler method32 by observers
certified according to the Multiple Risk Factor Intervention Trial protocol.33
Height, weight, and body mass index. Height and
weight were obtained with a balance beam scale, and
BMI, a measure of body fat, was obtained by dividing
body weight in kilograms by height in meters
squared. Subjects were asked to report what they had
weighed at age 20.
Waist to hip ratio. The waist was measured at the
smallest circumference and the hips at the largest
circumference. A nonstretchable tape measure was
used.
Measures of health habits. Cigarette smoking was
defined by the total number of cigarettes smoked per
day. The Paffenbarger activity questionnaire (Paffenbarger et al34) was used to obtain a measure of
kilocalories per week spent in leisure-time activity. A
24-hour recall was used to obtain a measure of
calories consumed and percent of calories from fat;
the data were analyzed by use of a computerized
nutrient data base.35-36
Standardized tests of personality and behavior. Subjects also completed a battery of tests of personality
and behavior, including the Framingham Type A,
Anger-Discuss, and Tension (Haynes et al37) scales;
the Beck Depression Inventory (Beck et al38); and
the Spielberger Trait Anger Anxiety Questionnaire
(Spielberger et al39).
Results
Table 1 shows the basic characteristics of the sample. WHR averaged 0.77±0.07 (mean±SD), with a
range from 0.45 to 0.99, and was significantly correlated with body weight (r=0.35, /?<0.001) and BMI
(r=0.40,/?<0.001). WHR was higher in those with less
education, but after adjusting for differences in BMI,
there was no effect of education on WHR. WHR was
not significantly related to age (r=0.04).
Determinants of Waist to Hip Ratio
WHR differed significantly as a function of menopausal status. Women who had remained premenopausal (n=282) had a WHR of 0.760 compared with
a WHR of 0.787 in women who had experienced
natural postmenopause and who were not receiving
hormone therapy (n=62) (/?<0.01). Thus, postmenopausal women had more upper body fat distribution.
The difference remained significant (p<0.05) after
adjusting for BMI.
WHR was also affected by smoking, as has been
reported previously.1516 The correlation between
1252
Arteriosclerosis and Thrombosis
Vol 11, No 5 September/October 1991
TABLE 1. Characteristics of Sample (n=487)
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Variable
Mean
Waist to hip ratio
BMI (kg/m2)
Weight (lb)
Age (yr)
SBP (mm Hg)
DBP (mm Hg)
Cholesterol (mg/dl)
HDL cholesterol (mg/dl)
HDL 2 (mg/dl)
HDL 3 (mg/dl)
Triglycerides (mg/dl)
LDL cholesterol (mg/dl)
Fasting glucose (mg/dl)
2-Hour glucose (mg/dl)
Fasting insulin (/i.units/ml)
2-Hour insulin (/i,units/ml)
Apo A-I (mg/dl)
Apo A-II (mg/dl)
Apo B (mg/dl)
0.77
25.9
150.3
50.1
108.3
72.0
195.5
58.6
18.6
39.8
91.9
118.5
88.0
93.4
10.6
60.7
148.3
50.4
102.1
Wam/Hip Kalio
SD
0.07
5.0
30.3
1.6
13.1
8.7
32.4
14.0
Former
Never
Smoking Status
9.7
Waltt/Hlp Ratio
7.5
55.6
30.8
12.1
31.7
6.9
54.4
20.8
11.5
23.4
1337-1750
BMI, body mass index; SBP, systolic blood pressure; DBP,
diastolic blood pressure; HDL, high density lipoprotein; LDL, low
density lipoprotein; apo, apolipoprotein.
number of cigarettes smoked per day and WHR was
r=0.13,/?<0.01. The correlation increased to r=0.14,
/><0.001, after adjusting for BMI. Current smokers
had an average WHR of 0.780±0.07 versus a WHR
of 0.765±0.07 in former smokers and of 0.762±0.07
in those who had never smoked (/?<0.05). The effect
become more significant (/?<0.01) after adjusting for
BMI (Figure 1).
Another correlate of WHR was weight change
since age 20 (r=-0.38, p<0.0001), indicating that
women who gained the most weight since age 20 had
the highest WHR. The correlation was of borderline
significance (r=-0.07, p=0.07) after adjusting for
current BMI.
WHR was also correlated with current caloric
intake, r=0.15, /?<0.0001. Caloric intake was unrelated to BMI (r=0.04), and hence the correlation
between caloric intake and WHR remained significant after adjusting for BMI (r=0.15, p<0.001).
Analysis of variance comparing women in the four
quartiles of caloric intake showed that women who
consumed more calories had higher WHRs (Figure
1), even after adjusting for BMI (p<0.01).
The relation between activity and WHR is also
shown in Figure 1. Women were divided into quartiles according to their self-reported activity levels
(0-500, 501-999, 1,000-1,999, and >2,000 kcal/
week). As shown, women who reported the lowest
levels of activity had the highest WHR. After adjusting for differences in BMI, the differences between
quartiles remained marginally significant (p=0.08).
The difference between the lowest exercise quartile
1750-2213
) 2213
Calorie Intake
Walsl/Hlp Ratio
0-500
500 ?Vv
100G i>9 y
, iCGC
Calories Expended in Exercise
FIGURE 1. Bar graphs showing waist/hip ratio as a function
of smoking status (upper panel), calorie intake after adjusting
for body mass index (middle panel), and activity level (lower
panel).
and the other three quartiles was significant (0.784 vs.
0.766, p<0.05, after adjusting for BMI).
Stepwise multiple regression examining the effect
of these behavioral attributes on WHR indicated that
change in weight since age 20, number of cigarettes
smoked per day, and calorie intake all contributed
independently to the prediction of WHR. However,
together these variables explained only 17% of the
variance in WHR.
Waist to Hip Ratio and Psychosocial Variables
Table 2 shows the correlations between WHR and
psychosocial variables. As shown in the table, upper
body fat distribution was associated with more tension and anxiety, more frequent angry feelings and
expression of those feelings, higher levels of depressive symptomatology, and lower levels of perceived
social support. Most of these associations remained
significant when nonparametric correlations were
used, after adjusting for BMI, or when the analyses
Wingetal
TABLE 2. Relation Between Waist to Hip Ratio and Psychosocial
Measures (n=487)
WHR
Bortner Type A
Social anxiety
Low self-esteem
Spielberger trait anger
Spielberger trait anxiety
Anger expression
Anger in
Anger out
Framingham
Anger-Discuss
Social support
Framingham Tension
Pessimism
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Stress
Depression
BMI
-0.02
-0.03
0.07 -0.03
0.09* 0.03
0.14$
0.14$
0.04
0.10*
0.12t
0.12t
0.06
0.03
0.07
0.11*
-0.03 -0.04
-0.10* -0.06
0.14* 0.09*
0.09* 0.06
0.07
0.17*
0.03
0.16*
BMI,
WHR,
controlling controlling
for BMI for WHR
-0.01
0.09*
0.08*
O.llt
0.13t
-0.03
-0.06
-0.01
0.07
0.01
0.03
0.07
0.08*
0.01
0.04
-0.02
-0.08*
-0.07
-0.03
-0.03
0.04
0.03
0.06
0.01
0.12t
o.iot
O.llt
0.07
WHR, waist to hip ratio; BMI, body mass index.
V<0.05, t/><0.01, :*p< 0.001.
were restricted to premenopausal women only. The
psychosocial variables appeared to be more closely
associated with WHR than with BMI.
Waist to Hip Ratio and Coronary Heart
Disease Risk Factors
Pearson correlation coefficients were computed to
examine the relation between WHR and CHD risk
factors. These analyses were restricted to the women
who remained premenopausal at the final clinic visit
(n=282), as menopausal status appears to affect both
WHR and CHD risk factors.40 As shown in Table 3,
WHR was positively correlated with blood pressure,
triglycerides, cholesterol, apo B, glucose, and insulin
(the latter two measures both in the fasting state and
2 hours after the glucose load). WHR was negatively
correlated with HDL cholesterol and its subfractions.
Partial correlations showed that both WHR and BMI
were independently related to systolic blood pressure, total HDL cholesterol and its subfractions,
triglycerides, 2-hour glucose, and fasting and 2-hour
insulin. Figures 2 and 3 show the effects of both BMI
and WHR on cholesterol HDL and insulin levels,
after dividing the women into tertiles for each of
these measures. It is notable that WHR was independently associated with both total cholesterol and
LDL cholesterol, but BMI was not.
Change in Waist to Hip Ratio From Baseline to
Final Follow-up
One hundred eight women had measures of WHR
completed at entry into the study and again at the
final followup. For these 108 subjects there was a
nonsignificant increase in WHR over the 3 years
(0.007±0.065). However, there were significant increases in both the waist circumference (79.1 ±12.1 to
WHR and CV Risk Factors
1253
TABLE 3. Correlation of Waist to Hip Ratio With Coronary Heart
Disease Risk Factors in Premenopausal Women
Variable
SBP
DBP
Total cholesterol
Total HDL
HDL 2
HDL 3
Triglyce rides*
LDL cholesterol*
Fasting
2-Hour
Fasting
2-Hour
glucose
glucose
insulin*
insulin*
Apo A-I
Apo A-II
Apo B
WHR
BMI
WHR,
controlling
for BMI
0.19*
0.28§
0.13t
0.13t
0.15§
-0.29§
-0.28§
0.26§
0.04
0.07
0.14*
-0.35§
-0.39§
-0.22§
-0.20*
-0.18*
0.35§
0.09
0.29§
0.25§
0.56§
-0.13t
0.40§
-0.15*
-0.02
0.16*
0.16*
-0.02
-0.17*
0.35§
0.19*
0.15*
0.23§
0.27§
0.25§
-0.06
0.05
0.20§
0.29§
0.17*
0.08
0.17*
0.16*
0.06
0.16*
BMI,
controlling
for WHR
0.24§
0.24§
0.00
-0.30§
-0.34§
-0.14*
0.29§
0.04
0.26§
0.21*
0.52§
0.36§
-0.14*
-0.04
0.12t
*These variables were logarithmically transformed for analysis.
WHR waist to hin ratio- RMT hndv mass index: ??RP svstnlif!
blood pressure; DBP, diastolic blood pressure; HDL, high density
lipoprotein; LDL, low density lipoprotein; Apo, apolipoprotein.
tp<0.05, *p<0.01, §p<0.001.
80.9±12.8 cm,^<0.01) and in the hip circumference
(101.0±11.0 to 102.5+12.0 cm, /?<0.05) considered
separately.
Of these 108 women, 58 had remained premenopausal and 31 had experienced natural menopause.
There were nonsignificant changes in WHR over
time for both groups, and there was no evidence that
menopausal status affected the change.
On average, the women gained 5.1 ±9.8 lb during
the 3-year interval. Change in weight was unrelated
to change in WHR (r=-0.03). However, change in
weight was significantly related to change in waist
and hip circumferences considered separately
(r=0.42 and 0.53, respectively;/><0.001 for both).
Table 4 presents the correlation between changes
in WHR and changes in CHD risk factors. Pearson
correlation coefficients, adjusting for changes in
BMI, showed that those women who had the greatest
increases in WHR had the greatest decreases in
HDL2 cholesterol (r=-0.24,/?<0.01) and the greatest increases in triglycerides (r=0.16,/?=0.053). The
correlation between change in WHR and change in
HDL2 cholesterol remained significant when only
women who were still premenopausal were considered (r=-0.31, p<0.01, unadjusted; and r=-0.32,
p<0.0l, adjusted for BMI).
Change in activity level was significantly correlated
with change in WHR (r= -0.18, p< 0.05). The correlation remained significant after adjusting for change
in BMI (r=-0.18,/><0.05). Change in intake was not
related to change in WHR. Onlyfivewomen changed
from smoking to nonsmoking status, precluding
analysis of the effect of this factor on WHR.
1254
Arteriosclerosis and Thrombosis
Vol 11, No 5
September/October 1991
HDL-T
70
65.53
mm
mm
60 -
II§§§§
so -
mni
40
low
•
63.71
63.01
61.24
60.05.
II
1ii11
61.1
•
5739
1
I
1
I
IS
ill!
1 —1 • •
ill
ill
53J
50.62
•ll
Merf BUI (23J-25.8)
n-47
High BM1 025.8)
Body Mass Index
30
FIGURE 2. Bar gra/?/w showing total high density
lipoprotein cholesterol (HDL-T) and HDL2 (HDL-2)
as a function of body mass index (BMI) and waist to
hip ratio (WIH).
HDL-2
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2528
25 22.35
20 •
15
10
ii
illI
I
...11•
21J2
•
n-17
Low BMI ((23.1)
mm
miI
II
2027 20.2
17.73
17.35
n-M
J B
Mod BMI (23J-2S.8)
12.79
High BMI 025.8)
Body Mass Index
,ov W/H «.732)
^ M e d W/H (.732-789)
C D High W/H 0.783)
W/H • WOUI/HIp
Discussion
This study suggests that WHR, independent of
BMI, is related to cardiovascular risk factors. WHR
was found to be significantly and independently
related to systolic blood pressure, total cholesterol,
LDL cholesterol, HDL cholesterol and its subfractions, glucose, insulin, triglycerides, and apo B.
Moreover, this study is the first to suggest that
changes in WHR, independent of changes in BMI,
may be related to changes in HDL2 cholesterol;
however, the change in WHR was not related to
change in other cardiovascular risk factors.
Second, this study shows that various behaviors,
including smoking, activity, and caloric intake, are
related to WHR and that the change in activity is
related to a change in the WHR. Upper body fat
obesity was also associated with higher tension and
anxiety scores and greater reports of anger, lower
social support, and more depressive symptomatology.
Previous studies with samples of premenopausal 51113 and postmenopausal710 women have
shown that WHR is positively associated with triglycerides, blood pressure, apo B, glucose, and insulin
levels. Moreover, these studies have shown a negative
association between WHR and HDL cholesterol and
the HDL2 subfraction. Although these correlations
are not observed in all studies, the majority of the
evidence does seem to suggest that WHR, independent of BMI, affects these CHD risk factors. The
present study confirms these findings in one of the
largest premenopausal cohorts of women studied to
date.
The correlation between WHR and BMI was 0.40,
p< 0.001, and was extremely similar to the relation
observed by others. 174142 Moreover, those who had
the greatest weight gain since age 20 had greater
upper body fat distribution. Previous studies have
shown that abdominal obesity is associated with fat
cell hypertrophy,43 characteristic of those with adultonset obesity.44 However, we found no evidence that
the weight changes exhibited over the 3 years of the
study were related to changes in WHR, despite the
fact that the women had gained 5 lb on average and
24 of the 108 women had gained 10 lb or more. In
contrast, we found that there were significant increases in both the waist and hip circumferences
considered separately and that the changes in these
circumference measures were related to weight
Wingetal
20
WHR and CV Risk Factors
1255
Fasting Insulin
16.87
IS
)
1
7.57
7.5 |
m
7.99
i
a-17 |
low BUI «231)
•
9.06
8J3
9.95
0.3.
Med BUI (23.1-25.8)
n-47
High BUI ()25.8)
Body Mass Index
2 Hoar Insulin
120112.5
FIGURE 3. Bar graphs showing fasting insulin (upper panel) and 2-hour insulin (lower panel) as a
function of body mass index (BMI) and waist to hip
ratio (WIH).
Downloaded from http://atvb.ahajournals.org/ by guest on June 16, 2017
100 -
Low BUI ((23J)
Ued BUI (23J-25J)
High BUI Q2S.8)
Body Mass Index
8LOWW/HC<732)
^ M e f l W / H (.732-789)
CDHlgh W/H <>.769>
W/H • Wam/Hlp
change (usually weight gain). Thus, women during
the perimenopausal period appear to be gaining
weight but to be depositing it in both their waist and
hip areas. Several other studies have examined the
effect of weight change on WHR, with conflicting
results.45-46 Wadden et al,46 for example, studied 68
female participants in a weight control program after
a weight loss of 12.3 kg. These women showed
decreases in WHR, from 0.827 to 0.817. Others have
found no change in WHR with weight loss.45
Results regarding the effect of menopause on
WHR were unclear. When the total sample of
women who had undergone natural menopause was
compared with the sample who had remained premenopausal, significant differences were observed,
indicating a higher WHR in postmenopausal women.
However, when we used a within-subject analysis and
examined the 31 women who were measured initially
when premenopausal and then again later when
postmenopausal, we found no significant change in
WHR over time. The small sample of menopausal
women may have obscured an effect of menopause;
alternatively, differences between the group of premenopausal and postmenopausal women, other than
their menopausal status, may have affected the between-group comparison. Furthermore, length of
time since cessation of menses may also affect WHR.
Previous data on the effect of menopause on WHR
have also been unclear. Haffner et al47 found a weak
relation between menopausal status and WHR, with
menopausal status explaining 0.4% of the variance in
WHR. Lanska et al48 found that menopausal status
explained 0.07% of the variance.
Recent studies suggest that when female monkeys
are exposed to standardized stressors, they respond
with hyperinsulinemia, hyperlipidemia, hypertension,
and increased abdominal body fat distribution.21 Likewise, Bjorntorp22 reported that men and women with
abdominal body fat distribution have a number of
symptoms suggestive of difficulty coping with stress,
including psychosomatic disease. From these data,
Bjorntorp hypothesized that increased stress, resulting
in increased levels of catecholamines and adrenal cortical hormones, may lead to symptoms of hypercortisolism, including abdominal body fat. We examined this
hypothesis indirectly by looking at the relation between
WHR and several standard psychosocial questionnaires
measuring variables related to stress. In support of the
1256
Arteriosclerosis and Thrombosis
Vol 11, No 5
TABLE 4. Correlation Between Change in Waist to Hip Ratio and
Change in Coronary Heart Disease Risk Factors
CHD
risk factor
Total cholesterol
Total HDL
HDL2
HDL3
L.DL cholesterol
Triglycerides
SBP
DBP
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Apo A-I
Apo A-II
Apo B
Fasting insulin
2-Hour insulin
Fasting glucose
2-Hour glucose
Correlation
with change
inWHR
0.04
-0.10
-0.24*
0.15
0.03
0.15
0.09
-0.04
-0.06
0.09
-0.02
0.06
0.04
0.02
-0.01
Correlation with change
in WHR adjusting for
change in BMI
0.05
-0.11
-0.24*
0.15
0.03
0.16t
-0.08
-0.02
-0.06
0.09
-0.02
0.07
0.05
0.02
-0.01
CHD, coronary heart disease; WHR, waist to hip ratio; BMI,
body mass index; HDL, high density lipoprotein; LDL, low density
lipoprotein; SBP, systolic blood pressure; DBP, diastolic blood
pressure; Apo; apolipoprotein.
*p=0.007, tp=0.053.
hypothesis, we found that WHR, independent of BMI,
was associated with tension, anger, depressive symptomatology, and low social support. However, we did
not find that WHR was correlated with a measure of
current perceived stress.
Negative emotions and lack of social support have
been related to the risk for CHD morbidity and
mortality.49"51 The finding that WHR is related to
standardized test scores measuring similar behaviors
raises the possibility that the pathogenic influences of
negative emotions and lack of social support may be
due in part to their effects on body fat distribution.
Finally, we find that activity, caloric intake, and
smoking habits are all related to body fat distribution
and that those individuals who increased their activity level showed decreases in WHR. These findings
are of interest because they suggest that by changing
behavior, it may be possible to improve WHR. However, the effect of a change in WHR on a change in
cardiovascular risk factors is less clear. Change in
WHR was associated with decreased HDL2 cholesterol and marginally with increased triglycerides. It is
possible that with greater changes in weight or activity, there would be larger changes in WHR, making
an association between change in WHR and change
in risk factors more apparent. Alternatively, it is
possible that WHR is to some extent modifiable, but
that it is the genetic52 or nonmodifiable component of
WHR that is related to cardiovascular disease. Further studies are needed to investigate the relation
between changes in WHR and changes in cardiovascular risk factors.
Thus, in conclusion, WHR seems to be an integral
part of the cardiovascular risk profile and is affected
September/October 1991
by behavioral and psychosocial variables previously
found to be associated with CHD.
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KEY WORDS • menopausal status • cardiovascular risk factors
• waist to hip ratio • psychosocial factors • behavioral factors
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Waist to hip ratio in middle-aged women. Associations with behavioral and psychosocial
factors and with changes in cardiovascular risk factors.
R R Wing, K A Matthews, L H Kuller, E N Meilahn and P Plantinga
Arterioscler Thromb Vasc Biol. 1991;11:1250-1257
doi: 10.1161/01.ATV.11.5.1250
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