WHR (waist hip ratio) as risk factor irrespective of body mass index
ORIGINAL ARTICLE
WHR (waist hip ratio) as risk factor irrespective of body mass
index (BMI ) among patients of noninsulin dependent diabetes
mellitus (NIDDM)
Sweta T. Gamit1*, Amit L. Gamit2, Tinkal C. Patel3, Parul Bhatt4, Vipul P. Chaudhari5
1,2Assistant
Professor, 3,4Associate Professor, Department of Medicine, Government Medical College, Surat, 5Assistant
Professor, Department of Community Medicine, Government Medical College, Surat.
ABSTRACT
BACKGROUND: Type-2 diabetes mellitus has increased exponentially in urban populations and that even the
underprivileged are not exempt. Changing societal structures and lifestyles are accelerating it. Proximate causes for
this epidemic are excessive consumption of calories and declining physical activity, which leads to increasing in
obesity, especially central obesity. MATERIAL & METHODS: A cross sectional study was conducted from
October 2010 to October 2012. Waist Hip Ratio was correlated with the disease. Total 120 cases were studied.
RESULTS: Out of 120 patients 88 (73.33%) are male and 32 (26.66%) are female. most common age period in
which prevalence of diabetes found in each sub groups is 40-59years. Lean and Ideal body weight (IBW) patients
are having abnormal WHR despite having BMI of <25. More than half (52.5%) of lean patients and 82.5% of IBW
patients are having abnormal high WHR where as in obese group all patients (100%) are having abnormal WHR.
CONCLUSION: Central obesity, as measured by the WHR, is importantly and independently associated with
NIDDM irrespective of BMI.
Key Words: WHR (waist hip ratio), body mass index (BMI ), noninsulin dependent diabetes mellitus (NIDDM)
INTRODUCTION
Type 2 Diabetes mellitus is one of the
modern pandemics. It is estimated to affect
320 million people by the year 2020
worldwide. Diabetes today is an important
single disease in the medical specialty and
a chronic illness that requires continuing
medical care and ongoing patient selfmanagement education and support to
prevent acute complications and to reduce
the risk of long-term complication.1
Epidemiologic studies reveal that the
prevalence of type 2 diabetes mellitus has
increased
exponentially
in
urban
populations
and
that
even
the
underprivileged are not exempt. Changing
societal structures and lifestyles are
accelerating the epidemic of Diabetes
*Corresponding Author:
Dr. Sweta T. Gamit
206, pancham residency,
Opp., karan park row house,
Kalpnachawla marg, adajan
Surat -395009
Contact No: 09687603583 / 09925665725
Email: [email protected]
68
Int J Res Med. 2017; 5(4); 68-72
mellitus in South Asian countries.
Proximate causes for this epidemic are
excessive consumption of calories and
declining physical activity, which leads to
increasing in obesity, especially truncal
obesity (high waist to hip ratio).
Interaction of genetic predisposition,
environmental influences, and multiple
risk factors initiates a cascade that
culminates in DM.2 Weight plays a central
role in the etiology and pathology of type
2 diabetes. The increased risk for type 2
diabetes in individuals with obesity is
considerable. Lower Body mass index
thresholds for overweight and obesity have
been proposed for the Asia-Pacific region
since this population appears to be at-risk
at lower body weights for glucose and
lipid abnormalities.3,4 Interestingly, almost
80% of Indian Type 2 diabetic patients are
non-obese whereas 60–80% of such
diabetics in the West are obese. Clinical
pattern and phenotype profile of patients
with Type 2 diabetes (T2DM) are very
different in India as well as in certain
developing countries of Asia and Africa as
compared to the West.5 Increased visceral
e ISSN:2320-2742
p ISSN: 2320-2734
WHR (waist hip ratio) as risk factor irrespective of body mass index
fat in Indians lead to dyslipidemia,
spine. Hip measurement was taken as
increased insulin resistance even with
maximum diameter at the greater
lesser Body Mass Index (BMI) as
trochanter. Waist to hip ratio (WHR) was
compared to western population[6].Studies
calculated in each patient. Body mass
in different parts of India has shown that
index was calculated in kg/m2and based on
Type 2 DM-lean patients had a marked
BMI, the patients were divided into the
lower incidence of hypertension, CAD,
following groups:
nephropathy and higher prevalence of
Lean: BMI of < 18.5
retinopathy and a markedly higher
Ideal body weight(IBW): BMI of 18.5incidence of peripheral neuropathy and
24.9
infections.7,8 Type 2 diabetes mellitus
Obese/overweight: BMI of
≥ 25
presents in a varied form in the Indian
Minimum 40 patients were taken in each
population compared to the west. Thus a
group.
need arises to further characterize and
RESULTS
analyze its epidemiology in the Indian
Table: 1 Distribution of study
population especially in relation to
population according to age, sex of
markers of obesity; i.e., Body mass index,
having Type 2 Diabetes.
LEAN
IBW
OBESE
waist circumference and waist to hip ratio.
(n= 40)
(n= 40)
(n= 40)
MATERIAL AND METHODS
This cross sectional study was carried out
SEX
among purposively selected 120 patients
29(72.5%)
32(80%)
27(67.5%)
Male
of type 2 diabetes mellitus at Department
11(27.5%)
8(20%)
13(32.5%)
Female
of Medicine, New Civil Hospital, Surat
AGE (YEARS)
during October 2010 to October 2012.
5(12.5%)
5(12.5%)
2(5%)
18-39
Inclusions Criteria:
23(57.5%)
22(55%)
19(47.5%)
40-59
 K/C/O type-2 DM both male &female.
12(30%)
13(32.5%) 19(47.5%)
≥60
 Age > 18 years.
Exclusions Criteria:
Out of 120 patients 88 (73.33%) are male
 Freshly detected case of type 2 Diabetes
and 32 (26.66%) are female. In lean group,
 Patient who had abrupt onset of Diabetes
out of 40 patients 29(72.5%) are male and
with acute weight loss or require insulin
11 (27.5%) are female. In IBW group, out
at the time of diagnosis.
of 40 patients 32(80%) are male and 8
 Patients with diseases of exocrine pancreas(20%) are female. In Obese group, out of
pancreatitis, pancreatectomy, neoplasia, cystic
40 patients 27(67.5%) are male and
fibrosis, hemochromatosis, fibrocalculous
pancreatopathy(FCPD)
13(32.5%) are female. Above table shows,
 Patients
with
endocrinopathiesmost common age period in which
acromegaly,
cushing’ssyndrome,
prevalence of diabetes found in each sub
glucagonama,
pheochromocytoma,
groups is 40-59years. Higher diabetes risk
hyperthyroidism,
somatostatinoma,
is found in early age group 18-39yrs is
aldosteronoma.
12.5% in lean & IBW as compared to 5%
 Gestational diabetes mellitus(GDM)
in obese. while there is no significant
History and Clinical Examination: The
difference between 3 sub group at the age
detailed history was taken of patients
enrolled in study. All findings were
between
40-59yrs
57.5%,
55%,
recorded on predesigned questionnaire.
47.5%respectively. In our study, higher
Anthropometric
measurements
diabetes risk is found in early age group
including
height
(in
cm.),
18-39yrs because of weight gain in early
weight(kg.),waist
circumference,
hip
adulthood is related to a higher risk of type
circumference
were
taken.
Waist
2 diabetes than was later weight gain in
measurements were taken as abdominal
both normal and overweight.9
circumference at midpoint between the
costal margin and anterior superior iliac
69
Int J Res Med. 2017; 5(4); 68-72
e ISSN:2320-2742
p ISSN: 2320-2734
WHR (waist hip ratio) as risk factor irrespective of body mass index
WHR< 0.80 and remaining 7 (87.5%) are
Table: 2 Distribution of study
having WHR of≥0.80. In Obese group no
population
according
to
Waist
female patient is having WHR< 0.80 and
Circumference and Waist Hip Ratio.
LEAN
IBW
OBESE
all 13(100%) are having WHR ≥0.80
Waist Circumference
coincides with obesity. So, out of 40 lean
25(86.2%) 12(37.5%) 2(7.4%)
Male
≤90
4(13.8%) 20(62.5%) 25(92.6%)
>90
patients; 21(52.5%) are having abnormal
Waist Circumference
WHR despite being a lean and in IBW
9(81.8%) 2(25%)
0
Female ≤80
2(18.2%) 6(75%)
13(100%)
>80
patients33 (82.5%) patients are having
Waist Hip Ratio Male
abnormal WHR where as in obese group
18(62%)
6(18.75%)
0
<0.95
11(38%)
26(81.25%) 27(100%)
≥0.95
all patients are having abnormal WHR.
Waist Hip Ratio Female
DISCUSSION
1(9%)
1(12.5%)
0
<0.80
10(91%)
7(87.5%)
13(100%)
≥0.80
The prevalence of type 2 diabetes mellitus
Among Male patients belong to lean
is rapidly rising all over the globe at an
group,
86.2%
are
having
waist
alarming rate.1 Over the past 30 years, the
circumference ≤ 90 cm. and 13.8 % are
status of diabetes has changed from being
having waist circumference >90 cm. In
considered as a mild disorder of the elderly
IBW
group, 37.5% male patients are
to one of the major causes of morbidity
having waist circumference ≤90 cm. and
and mortality affecting the youth and
62.5% are having waist circumference >90
middle aged people. 60 % to 80% of the
cm. Out of 27 male patients of obese
diabetics in developed countries are obese
group, only 2(7.4%) patients is having
whereas in India most patients fall in
waist circumference ≤ 90 cm. and
normal weight group and some even lean.8
remaining 25(92.6%) are having waist
Since obesity does contribute in a
circumference >90 cm. Mean waist
considerable way to complications of
circumference in obese male is highest
diabetes, it is worthwhile to study if BMI
than others coinciding with their obesity.
has any implications on the complications
Among female patients belong to lean
of type 2 diabetes mellitus.10 In our study,
group
81.8%
are
having
waist
out of 120 patients, 40 patients are divided
circumference ≤ 80 cm. and 18.2 %are
in each subgroup according to their BMI.
having waist circumference >80 cm. In
Out of 120 patients 88 (73%) are males
IBW group, 25% female patients are
and 32 (27%) are females. Table:1 Sex
having waist circumference≤80cm.and
distribution was also not significantly
75% are having waist circumference >80
different in subgroups of previous studies
cm. Out of 13 female patients of obese
conducted
by
Mukhayprana
and
group, none is having waist circumference
V.Mohan.11,12 Most common age period in
≤ 80 cm. and all patients 13 (100%) are
which prevalence of diabetes found in
having waist circumference >80 cm. In
each sub groups is 40-59years. Higher
females also those belong to obese group
diabetes risk is found in early age group
are
having
highest
mean
waist
18-39yrs is 12.5% in lean & IBW as
circumference than others. Among Male
compared to 5% in obese. while there is no
patients belong to lean group, 18(62%) are
significant difference between 3 sub group
having WHR< 0.95 and 11(38 %) are
at the age between 40-59yrs 57.5%, 55%,
having WHR≥0.95. In IBW
group,
47.5%respectively. Study done by Anja
6(18.75%) male patients are having
Scheienkiewitz-POstsdam
Study1’2’3’9
WHR≤ 0.95 and 26(81.25%) are having
observation was weight gain in early
WHR ≥ 0.95. In Obese group no male
adulthood between 25-40yrs is related to a
patient is having WHR< 0.95 and all
higher risk and earlier onset of type 2
27(100%) are having WHR ≥0.95
diabetes than is weight gain between 40
coincides with obesity. Among female
and 55yrs of age. In our study, higher
patients belong to lean group only 1 is
diabetes risk is found in early age group
(9%) having WHR< 0.80 and remaining
18-39yrs because of weight gain in early
10(91%) despite being a lean; are having
adulthood is related to a higher risk of type
WHR of ≥0.80. In IBW group also only
2 diabetes than was later weight gain in
one female patient (12.5%) is having
70
Int J Res Med. 2017; 5(4); 68-72
e ISSN:2320-2742
p ISSN: 2320-2734
WHR (waist hip ratio) as risk factor irrespective of body mass index
both normal and overweight.9 Excess
conducted by Mukhayprana, the abnormal
abdominal fat, assessed by measurement
WHR was present in 48% of lean and 79%
of waist circumference is independently
of normal weight patients which was low
associated with higher risk for diabetes
in lean and normal weight patients
mellitus and cardiovascular disease.13
respectively as compared to our study.12
Despite having lower prevalence of
CONCLUSIONS
obesity as defined by body mass
 In our study we found that lean and
index(BMI), Asian Indians tend to have
IBW patients are having abnormal
greater waist circumference and waist to
WHR in both gender despite having
hip ratios14 thus having a greater degree of
BMI of <25. In our study 52.5% of lean
central obesity. Again, Asian Indians have
patients and 82.5% of IBW patients are
more total abdominal and visceral fat for
having abnormal high WHR where as in
any given BMI15 and for any given body
obese group all 100% patients are
16
fat they have increased insulin resistance.
having abnormal WHR.
Central
Moreover, they have lower levels of the
obesity, as measured by the WHR, is
protective adipokine adiponectin and have
importantly
and
independently
increased levels of adipose tissue
associated with NIDDM.
metabolites17 In our study population 85%
 In our study 10(91%) female having
of lean patients are having normal waist
abnormal WHR in lean group. Thus
circumference where as in obese group
abnormal WHR is risk factor for
95% patients are having abnormal waist
female.
circumference coincides with their obese
 In our study, we reported that among
body characteristics. [Table:2] Out of 13
lean and IBW patients despite of
female patients of obese group, none is
BMI<25 there is abnormal waist
having waist circumference ≤ 80 cm. and
circumference and abnormal WHR.
all patients 13 (100%)are having waist
Thus Central obesity, as measured by
circumference >80 cm.[Table:2]In Ibw
the WHR, is importantly and
group 35% are having normal waist
independently associated with NIDDM
circumference, 65% of IBW patients and
Funding: Nil.
15% of lean diabetics are having abnormal
Conflict of interest: None.
waist circumference despite having body
REFERENCES
mass index of <25. [Table:2] Body
1. International Diabetes Federation
Composition of Asian Indians when
Diabetes Atlas. Unwin N, Whiting D,
Compared with Caucasians they had less
Gan D, Jacqmain O, Ghyoot G,
BMI,
muscle
mass
and
waist
editors. IDF Diabetes Atlas. 4 th ed.
circumference but high total fat, waist to
Belgium:
International
Diabetes
hip ratio and truncal skin folds[18].,In our
Federation; 2009. P. 11-3.
study out of 40 lean patients; 52.5% are
2. Wild S, Roglic G, Green A, Sicree R,
having abnormal WHR despite being a
King H. Global prevalence of diabetes:
lean and in IBW patients 82.5% patients
Estimates for the year 2000 and
are having abnormal WHR where as in
projections for 2030. Diabetes Care
obese group all patients are having
2004;27:1047-53 Popkin BM.
abnormal WHR. [Table:2] Among female
3. The Shift in Stages of the.Nutrition
patients belong to lean group only 1
Transition in the Developing World
patient is
having WHR≤0.80 and
Differs from Past Experiences!. Public
remaining 10 despite being a lean ;are
Health Nutr 2002;5:205-14.
having waist to hip ratio >0.80 [Table:2] .
4. Mohan V, Deepa M, Deepa R,
Genetic factors that determine body fat
Shanthirani CS, Farooq S, Ganesan A,
distribution and glucose metabolism have
et al. Secular trends in the prevalence
to be fully elucidated for the better
of diabetes and impaired glucose
understanding of the biochemical and
tolerance in urban South India-the
molecular mechanisms behind the
Chennai Urban Rural Epidemiology
aetiopathogenesis of diabetes. In study
71
Int J Res Med. 2017; 5(4); 68-72
e ISSN:2320-2742
p ISSN: 2320-2734
WHR (waist hip ratio) as risk factor irrespective of body mass index
Study (CURES-17). Diabetologia
et al.Clinical profile of lean NIDDM in
2006;49:1175-8.
South India. Diabetes Res ClinPract
5. Ramachandran A, Snehalatha C, Vijay
1997;38:101–8.
V. Low risk threshold for acquired
12. PrabhuMUkhyaprana,
diabetogenic factors in Asian Indians.
sudhavidyasagar,ShashikiranU;clinical
Diabetes Res ClilnPract 2004;25:189profile of type 3 diabetes mellitus and
95.
body mass index-is there any
6. Nakagami T, Qiao Q, Carstensen B,
correlation?Calicut Med J 2004;2:e3
Nhr-Hansen C, Hu G, Tuomilehto J, et
13. Harrison’s principles of internal
al. Age, body mass index and type 2
medicine seventeenth edition(2275diabetes association modified by
2304)
ethnicity. Diabetologia 2003;46:106314. Ramachandran A, Snehalatha C,
70.
ViswanathanV,Viswanatha M, Haffner
7. Epidemiology of type 2 diabetes:
SM. Risk of non insulin dependent
Indian scenario; V. Mohan, S.
diabetes mellitus conferred by obesity
Sandeep, R. Deepa, B. Shah* & C.
and central adiposity in different ethnic
Varghese; Indian J Med Res 125,
groups: a comparative analysis
March 2007, pp 217-230
between Asian Indians, Mexican
8. Alberti
KGMM,
Zimmet
PZ.
Americans and Whites. DiabetesRes
Definition, diagnosis and classification
ClinPract1997; 36: 121-5.
of
diabetesmellitus
and
its
15. Raji A, Seely EW, Arky RA,
complications.Part 1.Diagnosis and
Simonson DC. Body fat distribution
classification
of
diabetesmellitus
and insulin resistance in healthy Asian
provisional report of a WHO
Indians
and
Caucasians.J
consultation.Diabet Med 1998;15:539–
ClinEndocrinolMetab2001; 86 : 536653.
71.
9. Anja Schienkiewitz, Mattias B
16. 124. Chandalia M, Abate N, Garg A,
Schulze, Kurt Hoffman,Anja Kroke,
Stray-Gunderson J, Grundy SM.
and Heiner Boeing.Body mass index
Relationship between generalized and
history and risk of type 2
upper body obesity to insulin
diabetes:results from the European
resistance in Asian Indian men. J
Prospective Investigation in to cancer
ClinEndocrinolMetab1999; 84 : 2329and
Nutrition(EPIC)-Potsdam
35.
Study1’2’3.Am J Clin Nutr August
17. 125. Abate N, Chandalia M, Snell PG,
2006 vol.84 no. 2 427-433.
Grundy
SM.
Adipose
tissue
10. Insulin resistance. A multifaceted
metabolites and insulin resistance in
syndrome responsible for NIDDM,
nondiabetic Asian Indian men. J
obesity, hypertension, dyslipidemia,
ClinEndocrinolMetab2004; 89 : 2750and atherosclerotic cardiovascular
5.
disease.
AU
DeFronzo
RA;
18. MIsraA,VikramNk, et al. Waist
FerranniniE SO Diabetes Care 1991
circumference cut off points and action
Mar;14(3):173-94.
levels for Asian Indians for
11. Mohan V, Vijayaprabha R, Rema M,
identification of abdominal obesity.Int
Premlatha G, Poongothai S, Deepa R,
J obesity(London) 2006;30:106-111
72
Int J Res Med. 2017; 5(4); 68-72
e ISSN:2320-2742
p ISSN: 2320-2734