International Journal of Obesity (2000) 24, 1026±1031
ß 2000 Macmillan Publishers Ltd All rights reserved 0307±0565/00 $15.00
www.nature.com/ijo
Critical value for the index of body fat
distribution based on waist and hip
circumferences and stature in obese girls
K Asayama1*, T Oguni2, K Hayashi3, K Dobashi1, Y Fukunaga2, K Kodera1, H Tamai3 and S Nakazawa1
1
Department of Pediatrics, Yamanashi Medical University, Tamahocho, Nakakomagun, Yamanashi, Japan; 2Department of Pediatrics,
Osaka Medical University, Takatsuki, Osaka, Japan; and 3Department of Basic Allied Medicine, School of Health Sciences, Faculty of
Medicine, Gunma University, Maebashi, Gunma, Japan
OBJECTIVE: To determine the critical value for the standard deviation score (SDS) of waist ± hip ratio (WHR)=height
(Ht), as an age-adjusted measure of body fat distribution, in relation to occurrence of biochemical complications in
obese girls.
DESIGN: Cross-sectional, clinical study. The (WHR=Ht)-SDS was calculated as described previously. Obese girls were
classi®ed into two groups according to the occurrence of abnormal values in either serum triglyceride, alanine
aminotransferase or insulin level. The criteria for obesity were subjected to the receiver operating characteristic (ROC)
analysis.
SUBJECTS: One-hundred and twenty-four outpatient Japanese obese girls, ranging in age from 9 to 15 y.
MEASUREMENTS: Height, body weight, waist girth and hip girth as anthropometric measures. Percentage overweight, waist girth, WHR and (WHR=Ht)-SDS as criteria for obesity. Clinical laboratory analysis for fasting blood
samples of obese children.
RESULTS: Fifty-nine girls were classi®ed into the no complication group, and 65 girls into the complication group.
Those with complications were older, more obese, and their waist girth and WHR were larger, than the girls without
complications. The (WHR=Ht)-SDS was >2-fold higher and lipoprotein pro®le was more atherogenic in the complication group than in the no complication group. Among the four criteria of obesity, (WHR=Ht)-SDS gave the ROC curve
skewed furthest into the top left corner of the diagram. Both sensitivity and speci®city for (WHR=Ht)-SDS were >80%
at the critical value of 2.00. The sensitivity for waist girth was as high as that for speci®city for the rest of the criteria
were < 80%.
CONCLUSION: Only (WHR=Ht)-SDS showed high enough sensitivity and speci®city to predict metabolic derangement
in the present obese girls. (WHR=Ht)-SDS can serve as the diagnostic criterion that classi®es obesity in Japanese
adolescent girls into two types.
International Journal of Obesity (2000) 24, 1026±1031
Keywords: obesity; body fat distribution; lipoproteins; insulin; fatty liver; children and adolescents
Introduction
Hypertriglyceridemia, hyperinsulinemia and an elevation of serum transaminase level due to fatty liver are
the most common abnormalities in clinical blood
biochemistry associated with childhood obesity.1
Metabolic derangement induced by obesity is more
signi®cantly linked to accumulation of visceral fat
than to that of subcutaneous fat.2 ± 4 The body fat
patternings such as upper body obesity and abdominal
obesity re¯ect visceral fat accumulation. Anthropometric measures such as waist girth,5 ± 8 abdominal
sagittal diameter9,10 and waist ± hip ratio (WHR)11 ± 13
have been recognized as useful alternatives to visceral
fat measurement in epidemiological studies.
*Correspondence: K Asayama, Department of Pediatrics,
Yamanashi Medical University, 1110 Shimokato, Tamahocho,
Nakakomagun, Yamanashi 409 ± 3898, Japan.
E-mail: [email protected]
Received 8 September 1999; revised 25 January 2000; accepted
7 April 2000
The normal value of WHR changes depending on
the age of children and adolescents,1,14 discouraging
the use of this measure as anthropometric standard in
this age group. We previously assumed that standardization of the criteria for obesity in children and
adolescents should be based on the actual measures of
body build observed in a large population including
nonobese and obese subjects.15 In such large population (n ˆ 1057) of Japanese school children, standard
deviation scores (SDS) of WHR=height (Ht) turned
out to be an index of body fat distribution adjusted for
children between 6 and 15 y of age.15 This index was
deduced from the result of the principal component
analysis. WHR=Ht, representing a body shape measure adjusted by the general size of an individual,
gave a highly robust linear regression equation for age
by gender. The age-dependence of the criteria for
obesity was evaluated in the control children by
each sex.16 The waist girth and WHR were considered
to be age-dependent variables, but percentage overweight and WHR=Ht SDS were age-independent
variables.16 The height-dependence of the waist girth
Critical value for (WHR/Ht)-SDS in girls
K Asayama et al
and WHR=Ht SDS was also evaluated by log=log
regression. The contribution of height to the variation
of WHR=Ht SDS was only 5%, while that of waist
girth was approximately 40% in both sexes.16 Further,
(WHR=Ht)-SDS more strikingly distinguished obese
children with biochemical complications from those
without it than percentage overweight, WHR and
waist girth did.16
Male-type obesity17,18 is more closely related to the
complications than female-type obesity. Metabolic
derangement is more common in boys than in girls
of the same degree of obesity.19 The degree of overweight and adiposity had less impact on metabolic
derangement than that of body fat distribution in
obese girls.1,16 In general, biochemical complications
as well as excess weight in obese children tend to
worsen during growth. Thus, determining a critical
value of an index of body fat distribution for occurrence of abnormal blood biochemistry is of particular
importance in adolescent girls.
The present study was designed to further characterize the clinical utility of (WHR=Ht)-SDS in obese
girls aged 9 ± 15 y. By the analysis of the receiver
operating characteristic (ROC) curve of (WHR=Ht)SDS along with those of other criteria for obesity, we
calculated a critical value for each criterion and then
evaluated which anthropometric index was most
powerful in detecting the occurrence of biochemical
abnormalities in these children.
Materials and methods
Subjects
A total of 124 obese Japanese girls who visited the
Clinic for Obese Children in either Yamanashi Medical University, Yamanashi, or Hirakata Municipal
Hospital, Osaka, Japan were enrolled in the present
study. A child was considered to be obese when the
body weight exceeded 120% of the standard body
weight, which is de®ned as the mean body weight
corresponding to the height for that age obtained from
national statistics for Japanese school children. The
age of the subjects ranged from 9 to 15 y. They had no
endocrine, metabolic or renal diseases other than
obesity. They were instructed to visit the clinic in
the morning, after an overnight fast. Blood was then
drawn and, at the same time, they were subjected to
anthropometric measurements including height, body
weight, waist girth and hip girth.
The Human Study Committee of Yamanashi Medical University approved this study. Informed consent
was obtained either from each subject or from his or
her parents as appropriate.
Anthropometric measurements
Anthropometric measurements were performed, as
described previously.1,15,16 In brief, height was mea-
sured to the nearest 0.1 cm and body weight to the
nearest 0.1 kg using a stadiometer. A plastic measuring tape was used to determine the waist girth at the
level of the umbilicus, and hip girth at the level of
maximum extension of the buttocks, to the nearest
0.1 cm, with the subject standing and following a
normal expiration. The percentage overweight was
calculated using a small programmed calculator
(Pocket Growth Checker GEN-185, Sumitomo Pharmaceuticals Co., Osaka, Japan), based on the data
collected in a 1990 nationwide survey of school
children. The (WHR=Ht)-SDS was calculated for
each sex, according to the previously described
method.16 The formulas used in the calculations
were as follows: [(WHR=Ht (m)-(0.9667-0.0338 Age (year)))=0.04107] for boys and [(WHR=Ht
(m) ± (0.9557 ± 0.0358 Age (year)))= 0.03619] for
girls.
1027
Biochemical analyses
Serum total cholesterol (TC), triglyceride (TG), highdensity lipoprotein-cholesterol (HDL-C), apolipoproteins A1, A2, and B, and serum insulin were measured
in the clinical laboratories of both hospitals. Normal
values for these biochemical data differed minimally
between the laboratories of the both hospitals. Lowdensity lipoprotein-cholesterol (LDL-C) was calculated from the Friedwald equation (LDL-C ˆ
TC 7 HDL-C 7 TG=2.18).21 The reference values
of the serum biochemical indices were obtained
from fasting samples of 121 nonobese children as
described previously.22 This group consisted of 69
boys and 52 girls, ranging in age from 6 to 15 (mean
10.0) y and with no history of endocrine, metabolic or
renal diseases. There were no appreciable genderrelated differences among the clinical laboratory
data in these children. The normal range was de®ned
as the values between the 10 and 90 percentile levels
of the reference samples. TG >1.28 mmol=l, alanine
aminotransferase (ALT) >29 U=l and insulin >115
pmol=l were considered to be abnormal. Obese girls
were classi®ed into two groups according to the
occurrence of abnormal values in either serum TG,
ALT or insulin level. Those who had abnormal
values in at least one of these three indices were
assigned to complication group and those without it to
no complication group. This criteria for classi®cation
of the patients was the same as in our previous
paper.16
Statistical methods
Data are presented as the means and standard errors of
means (s.e.m.). Since the data for TG, ALT and
insulin were signi®cantly skewed, they were transformed logarithmically before performing a statistic
analysis. The difference between the two means was
estimated by the unpaired Student's t-test. The values
were considered to be statistically signi®cant at
P < 0.05. The receiver operating characteristic
International Journal of Obesity
Critical value for (WHR/Ht)-SDS in girls
K Asayama et al
1028
(ROC) curves were analyzed by MedCalc software
version 4.20.021, provided from Dr Frank Schoonjans, Mariakerke, Belgium. The rest of statistical
analyses were performed using SPSS version 8.01J
(SPSS Inc., Chicago, IL).
Table 1
Age (y)
Ht (cm)
Body weight (kg)
Waist (cm)
Hip (cm)
Percentage overweight
WHR
WHR=Ht
(WHR=Ht)-SDS
Results
Anthropometric data for obese girls
No complication
(n ˆ 59)
Complications
(n ˆ 65)
10.6 0.2
142.3 1.1
48.9 1.5
76.1 1.0
85.5 1.1
38.3 1.6
0.888 0.007
0.629 0.008
1.36 0.14
11.8 0.2**
146.9 1.2*
60.7 1.9**
87.9 1.4**
93.5 1.3**
53.1 2.4**
0.938 0.006**
0.644 0.008
3.08 0.16**
Data are mean s.e.m. Student's t-test (unpaired). *P < 0.01;
**P < 0.001.
Fifty-nine of 124 girls were classi®ed into no complication group, and 65 girls into complication group
(Table 1). The girls with complications were older
than those without it. The body sizes including height,
body weight, waist girth and hip girth were also larger
in the girls with complications than those without it.
The girls with complications were more obese, and
their WHR were larger, than those without complications were. The (WHR=Ht)-SDS was > 2-fold higher
in the complication group than in the no complication
group.
complication group (Table 2). The levels of TC, LDLC and apo A2 were similar in both groups.
Relationship between the criteria for obesity and
biochemical ®ndings
Table 3 summarizes the age-adjusted correlation
between the criteria for obesity and biochemical
data in all obese girls. All four criteria for obesity
were closely correlated with ALT, insulin and TG.
Both WHR and (WHR=Ht)-SDS were also closely
related with TC, LDL-C, apo A2, apo B and apo B=
apo A1, whereas percentage overweight and waist
girth were less closely associated with such biochemical parameters. HDL-C were inversely correlated
with percentage overweight but not with other indices.
Apo A1 was correlated with neither of the criteria for
obesity.
Biochemical data for obese girls
According to the selection criteria, TG (1.17 0.07 vs
0.69 0.03 mmol=l), ALT (36 3 vs 17 1 U=l) and
insulin (165 14 vs 75 4 pmol=l) were approximately 2-fold higher in the complication group than
in the no complication group. The HDL-C and apo A1
were lower, and conversely apo B and apoB=apo A1
were higher, in the complication group than in the no
Table 2
Anthropometric data for the obese girls
Biochemical data for the obese girls
No complication (n ˆ 59)
Complications (n ˆ 65)
Normal rangea
4.54 0.11
1.48 0.05
2.75 0.11
46.7 1.0
17.7 0.3
1.34 0.05
2.93 0.12
4.66 0.10
1.25 0.03**
2.88 0.09
44.0 0.9*
17.9 0.3
1.60 0.05**
3.71 0.12**
3.41 ± 5.06
1.09 ± 1.73
1.91 ± 3.14
36.2 ± 54.6
15.3 ± 22.4
1.02 ± 1.60
2.25 ± 3.67
Total cholesterol (mmol=l)
HDL-cholesterol (mmol=l)
LDL-cholesterol (mmol=l)
Apo A1 (mmol=l)
Apo A2 (mmol=l)
Apo B (mmol=l)
Apo B=Apo A1 (102)
HDL, high-density lipoproteins; LDL, low-density lipoproteins. Data are mean s.e.m. Student's t-test
(unpaired). a10 and 90 percentile values for 121 nonobese children.22 *P < 0.05; **P < 0.001.
Table 3
Correlation between the criteria for obesity and biochemical data in the obese girls (n ˆ 124)
Correlation coefficients (r)a
b
ALT
Insulinb
Triglycerideb
Total cholesterol
HDL-cholesterol
LDL-cholesterol
Apo A1
Apo A2
Apo B
Apo B=Apo A1
a
Percentage overweight
Waist
WHR
(WHR=Ht)-SDS
0.390***
0.314**
0.299**
0.157
70.193*
0.176
70.069
0.073
0.226*
0.241*
0.427***
0.383***
0.243**
0.216*
70.114
0.2181*
70.041
70.135
0.281**
0.265**
0.474***
0.418***
0.310**
0.328***
70.092
0.299**
0.037
0.289**
0.366***
0.322**
0.436***
0.294**
0.297**
0.329***
70.078
0.295**
0.047
0.400***
0.346***
0.294**
Correlation was adjusted for age as a covariate.
Data were transformed logarithmically before performing a correlation analysis.
*P < 0.05; **P < 0.001; ***P < 0.001.
b
International Journal of Obesity
Critical value for (WHR/Ht)-SDS in girls
K Asayama et al
ROC analysis of the criteria for obesity
Figure 1 depicts the ROC curves for the four criteria
of obesity. Among all criteria, (WHT=Ht)-SDS gives
the curve skewed furthest into the top left corner of
the diagram. The results of ROC analysis are summarized in Table 4. Again (WHR=Ht)-SDS has the
largest area under the ROC curve among the four
criteria studied. Waist girth has the second largest area
under the ROC curve among the four criteria studied.
Waist girth has the second largest area under the curve
(AUC). The AUC for percentage overweight and
WHR are smaller than those for the waist girth and
(WHR=Ht)-SDS. The AUC for (WHR=Ht)-SDS was
signi®cantly larger than those for percentage overweight and WHR. The AUC for waist girth was also
signi®cantly larger than that for percentage overweight, but the difference between the AUC for
waist girth and that for WHR was not signi®cant.
Both sensitivity and speci®city for percentage overweight and WHR at the given respective cut-off points
were < 80%. On the other hand, those for (WHR=Ht)SDS were > 80% at the critical value of 2.00, which
was obtained as the best ®t model. The sensitivity for
waist girth was as high as that for (WHR=Ht)-SDS,
whereas the speci®city for waist girth was similar to
those for percentage overweight and WHR.
Figure 1 Receiver operating characteristic curves of the criteria
for obesity. The obese girls (n ˆ 124) were classi®ed into two
groups according to the occurrence of abnormal values in either
triglyceride, alanine aminotransferase or insulin. The curves
were depicted by MedCalc software. Thick hatched line: percentage overweight; thin solid line: waist ± hip ratio (WHR); thick
solid line: (WHR=Ht)-SDS; and thin hatched line: waist girth.
Table 4
1029
Discussion
The obese girls with complications were older and
more obese than those without complication, conforming to the previous observations20 that biochemical complications as well as excess weight in obese
children tend to worsen during growth. Their
(WHR=Ht)-SDS value was much higher than that of
the no complication group, indicating that they were
more centrally obese, and that abdominal obesity was
linked to metabolic derangement in these obese girls.
In our previous study, WHR=Ht SDS was independent
of age and minimally affected by the height in control
children while it was closely correlated with age in
obese children.16 Thus, the correlation pro®le between
age and anthropometric indices in the obese children
differed from that in the control. The results suggested
that the type of obesity changes with age in obese
children. The older obese children tended to gain
more fat at the umbilical level than the younger
ones, and this was considered as the general worsening of body build during growth in obese children.
The present ®nding that girls with complications are
older than those without complication re¯ects the
worsening of body fat distribution during growth.
The levels of TC and LDL-C were similar in both
groups. However, the lipoprotein pro®le was more
atherogenic in the complication group than in the no
complication group, because HDL-C and apo A1 were
lower, apo B and apo B=apo A1 ratio were higher in
the former than in the latter.
Impact of abdominal visceral fat accumulation on
metabolic derangement is now under extensive study
in adults.5 ± 11,23,24 Abdominal visceral fat has recently
been measured in children.25,26 These studies have
suggested that deleterious effects of visceral adipose
tissue on lipid=lipoprotein risk factors seen in adults
are already present in children. Predicting visceral fat
from anthropometric measures such as waist girth,
WHR and sagittal diameter has been attempted in both
adults8,10,27 and children.28,29
Several recent adult studies have proposed that the
waist girth better re¯ects visceral adipose tissue area,5
insulin sensitivity30 and glucose tolerance31 than the
WHR. Other investigators have suggested that sagittal
diameter is a better correlate to visceral fat area than
ROC analysis of the criteria for obesity
a
The AUC
Cut-off valueb
Sensitivity (%)
Speci®city (%)
Probability for comparison of ROC curves
Percentage overweight
Waist
WHR
(WHR=Ht)-SDS
Percentage overweight
Waist (cm)
WHR
WHR=Ht)-SDS
0.746 0.044
37.9
76.9
66.1
0.828 0.037
77.0
84.6
67.8
0.747 0.044
0.915
67.7
69.5
0.860 0.033
2.00
84.6
81.4
Ð
0.021
Ð
0.979
0.108
Ð
0.016
0.410
0.010
Ð
a
Area under the ROC (receiver operating characteristic curves (mean s.e.m.).
The cut-off values were calculated as the best ®t model by MedCalc software.
b
International Journal of Obesity
Critical value for (WHR/Ht)-SDS in girls
K Asayama et al
1030
waist girth or WHR is.10 However, WHR is still
considered to be a good anthropometric surrogate of
visceral adipose tissue in certain recent epidemiological studies in adults.11,13,32 To date, no single anthropometric index has yet been generally accepted
to be superior to others as a surrogate of visceral
fat measurement.11,27,29 WHR33 but not visceral fat
area33,34 correlated with resting metabolic rate,
suggesting that the anthropometric indices for body
fat distribution are not just the alternatives to visceral
fat measurement but also represent some aspect of
physical ®tness.
In univariate correlation analysis, all four criteria
for obesity were equally well related to ALT, insulin
and TG in the present obese girls. The normal value
for WHR decreases sharply with growth in the girls of
this age group.14 Such physiological variability of the
absolute value makes this index unsuitable for use as
the clinical standard. Recently waist girth has been
more commonly accepted as the anthropometric standard of abdominal obesity in adult studies than
WHR.5 ± 8,30,31,35 By calculating the optimal index
powers minimizing the effect of Ht by linear regression analysis of log height vs log (waist girth), Han
et al 36 reported that the height had no appreciable
effect on the waist girth in adults. However, our
previous study16 revealed that the height signi®cantly
contributed to the variance in waist girth in children
aged 6 ± 15 y. Thus, both waist girth and WHR are of
limited use in children and adolescents because the
normal values change depending on the age of subjects.
The present ROC curves clearly indicated that
(WHR=Ht)-SDS and waist girth were more optimal
as the diagnostic criteria than percentage overweight
or WHR. The data of speci®city and sensitivity
showed that (WHR=Ht)-SDS was a better criterion
than the waist girth. (WHR=Ht)-SDS displayed by far
the widest margin of difference between the two
groups (ie greater than 2-fold) among all the criteria.
The wide margin was certainly favorable for drawing
a more optimal cut-off line of this index than in the
case of the other indices. In fact, cut-off values for
percentage overweight and waist girth, which were
obtained as the computer best ®t model, were almost
as low as the respective mean values for the no
complication group, thereby giving low speci®city to
those indices.
In conclusion, ROC analysis revealed that
(WHR=Ht)-SDS was the best criterion of obesity
among the four criteria studied here. Only
(WHR=Ht)-SDS showed high enough sensitivity and
speci®city for predicting metabolic derangement in
the present obese girls. Thus, (WHR=Ht)-SDS can
serve as the diagnostic criterion that classi®es the
obesity in Japanese adolescent girls into two types.
Acknowledgements
This work is supported in part by Health Science
Research Grants (Research on Children and Families)
International Journal of Obesity
from Ministry of Health and Welfare, Japan, and a
grant from the Tanita Health and Body Weight Fund.
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