Cardiologists and abdominal obesity: lost in translation? | Heart

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Cardiologists and abdominal obesity: lost in translation?

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Waist circumference; a waste of time?
Patricia CE de Groot
Published on: 3 September 2009
Daily variability in waist circumference
Clive F M Weston
Published on: 16 July 2009

Published on: 3 September 2009
Waist circumference; a waste of time?
- Patricia CE de Groot, Post-Doc, Department of Physiology, Radboud University Nijmegen Medical Center, the Netherlands
- Other Contributors:
  Dick Thijssen, PhD; Maria Hopman, MD, PhD
To the editor: With great interest, we read the articles of a recent issue of Heart addressing the important role of abdominal obesity in relation to cardiovascular risk and the metabolic syndrome. [1, 2] The metabolic syndrome, considered the ailment of the 20th century, emerges from clustering and interactions of multiple cardiovascular risk factors affecting a large proportion of the population. The presence of the m...
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To the editor: With great interest, we read the articles of a recent issue of Heart addressing the important role of abdominal obesity in relation to cardiovascular risk and the metabolic syndrome. [1, 2] The metabolic syndrome, considered the ailment of the 20th century, emerges from clustering and interactions of multiple cardiovascular risk factors affecting a large proportion of the population. The presence of the metabolic syndrome in children is of particular interest given the rapid and alarming increase in prevalence in the past decade. Classification of body weight in children is challenging, since body proportions vary considerably during growth. A uniform definition of the metabolic syndrome in the pediatric population would not only be relevant for early diagnosis and treatment, but also for scientific and public health purposes. Current metabolic syndrome criteria for children as recommended by the International Diabetes Federation [3] define childhood obesity as the 90th percentile of waist circumference, which has important and unacceptable drawbacks.
First, prevalence of obesity among children has increased 3-fold fold in the past 30 years. [4] Using the 90th percentile of waist circumference to define obesity, raises the problem of a moving cut-off point to define obesity, which will potentially mask the impact of the problem. For example, a child who was defined obese five years ago may not reach the cut-off value for obesity today, but instead falls within the normal range which could lead to an incorrect conclusion that obesity prevalence is declining. In addition, the prevalence of being overweight and obese differs markedly among children from different countries and populations. A previously-published systemic review in school-aged youth from 34 (mostly European) countries illustrates a large variation in overweight and obesity prevalence rates; i.e. the two countries with the highest prevalence of overweight and obesity were Malta and the US (25.4% and 7.9%; 25.1% and 6.8%, respectively), while the lowest prevalence rates were found in Lithuania (5.1% and 0.4%) and Latvia (5.9% and 0.5%). [5] These numbers clearly demonstrate that using the 90th percentile of waist circumference to define childhood obesity makes international comparison between populations and studies extremely difficult.
As body composition and proportions change during childhood, we are aware of the highly challenging task to obtain a universal measure to define childhood obesity. However, we strongly believe that efforts should be made to obtain gender and age-dependent absolute cut of points to define the degree of obesity in the pediatric population in the future.
1.Despres, J.P., Targeting abdominal obesity and the metabolic syndrome to manage cardiovascular disease risk. Heart, 2009. 95(13): p. 1118-24.
2.Poirier, P., Cardiologists and abdominal obesity: lost in translation? Heart, 2009. 95(13): p. 1033-5.
3.Steinberger, J. and S.R. Daniels, Obesity, insulin resistance, diabetes, and cardiovascular risk in children: an American Heart Association scientific statement from the Atherosclerosis, Hypertension, and Obesity in the Young Committee Circulation, 2003. 107(10): p. 1448-53.
4.Hedley, A.A., et al., Prevalence of overweight and obesity among US children, adolescents, and adults, 1999-2002. Jama, 2004. 291(23): p. 2847 -50.
5.Janssen, I., et al., Comparison of overweight and obesity prevalence in school-aged youth from 34 countries and their relationships with physical activity and dietary patterns. Obes Rev, 2005. 6(2): p. 123- 32.
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Conflict of Interest:
None declared.
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Published on: 16 July 2009
Daily variability in waist circumference
- Clive F M Weston, Cardiologist
- Other Contributors:
  E Pellowe, K Salako, S Snelling, C Urdaibay,
To the editor: A recent issue of Heart contained two articles concerning abdominal obesity.[1,2] Both describe waist circumference (WC) as a proxy measure of central fat distribution, linked to athero- thrombotic inflammatory abnormalities seen in the ‘metabolic syndrome’, associated with adverse cardiovascular events.
This “vital sign in clinical cardiology”[2] needs accurate assessment. Standardised measureme...
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To the editor: A recent issue of Heart contained two articles concerning abdominal obesity.[1,2] Both describe waist circumference (WC) as a proxy measure of central fat distribution, linked to athero- thrombotic inflammatory abnormalities seen in the ‘metabolic syndrome’, associated with adverse cardiovascular events.
This “vital sign in clinical cardiology”[2] needs accurate assessment. Standardised measurement techniques are more complex than one might think. WC can vary substantially and rapidly during the respiratory cycle (between 91.0 and 94.1 cm in one subject) and through volitional alteration of abdominal distension (between 86.5 and 94.6 cm in another).[3] To negate this the World Health Organisation recommends marking the mid-point between the bottom rib and the iliac crest with a pen, placing the measuring tape in a horizontal plane at that level, and then measuring WC at the end of normal expiration, with the patient’s arms relaxed by their sides. The measuring tape should be directly on the skin – snug but not compressing.[4]
Yet despite this, personal experience suggests that involuntary changes in WC occur throughout the day, due to the effects of food, faeces and flatus. We performed three small studies in hospital inpatients (n=50) who were mobile, eating a ‘normal diet’, free of malignancy or oedematous states and not clinically dehydrated. In 48 patients the WC at 08.00 (pre- breakfast) was smaller than that measured at 14.00 (post lunch). This difference was significant (paired t-test, p<0.001) for absolute values (1.99 cm, 95% CI 1.53-2.45 cm) and percentage change (2.16%, 1.69-2.64%). The maximum absolute change was 5.8 cm and maximum percentage change 6.5%.
These differences are unlikely to be of relevance in epidemiological studies, but become important for individuals who may cross the boundary for diagnostic cut-off criteria over the course of a normal day. Both authors comment that there is no scientific rationale for the use of thresholds or ‘cut-points’ for WC – which like systolic blood pressure has a continuous positive relationship with risk. Yet such ‘cut-points’ are used in the diagnosis of the metabolic syndrome – being a mandatory criterion in the International Diabetes Federation guidelines[5]. Perhaps it is time to stipulate the use of a fasting or pre-prandial early morning WC in the diagnosis of the metabolic syndrome.
E Pellowe, K Salako, S Snelling, C Urdaibay, C Weston
Correspondence to: Dr CFM Weston. Singleton Hospital, Sketty Lane, Swansea. SA2 8QA, Wales; c.f.m.weston@swansea.ac.uk
References
[1] Poirer P. Cardiologists and abdominal obesity: lost in translation. Heart 2009;95:1033-35.
[2] Deprés JP. Targeting abdominal obesity and the metabolic syndrome to manage cardiovascular disease risk. Heart 2009;95:1118-24.
[3] Imafuku Y. Evaluation of the measurement of waist circumference. Rinsho Byori 2007;55:1097-102.
[4] World Health Organisation. Stepwise approach to surveillance (STEPS): Guide to physical measurements. at: http://www.who.int/chp/steps/Part3_Section3.pdf [accessed 9th July 2009]
[5] Alberti KG, Zimmet P, Shaw J. The metabolic syndrome – a new worldwide definition. Lancet 2005;366:1059-62.
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Conflict of Interest:
None declared.
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