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Cardiovascular and all-cause mortality in relation to various anthropometric measures of obesity in Europeans

Background and aims: Cardiovascular and all-cause mortality in relation to various anthropometric measures of obesity is still controversial.

Methods and results: Body mass index (BMI), waist circumference (WC), waist-to-height ratio (WHtR), waist-to-hip ratio (WHR), A Body Shape Index (ABSI) and waist-to-hip-to-height ratio (WHHR) were measured at baseline in a cohort of 46 651 European men and women aged 24-99 years. The relationship between anthropometric measures of obesity and mortality was evaluated by the Cox proportional hazards model with age as a time-scale and with threshold detected by a piecewise regression model. Over a median follow-up of 7.9 years, 2381 men and 1055 women died, 1071 men (45.0%) and 339 women (32.1%) from cardiovascular disease (CVD). BMI had a J-shaped relationship with CVD mortality, whereas anthropometric measures of abdominal obesity had positive linear relationships. BMI, WC and WHtR showed J-shaped associations with all-cause mortality, whereas WHR, ABSI and WHHR demonstrated positive linear relationships. Accordingly, a threshold value was detected at 29.29 and 30.98 kg/m2 for BMI, 96.4 and 93.3 cm for WC, 0.57 and 0.60 for WHtR, 0.0848 and 0.0813 m11/6 kg-2/3 for ABSI with CVD mortality in men and women, respectively; 29.88 and 29.50 kg/m2 for BMI, 104.3 and 105.6 for WC, 0.61 and 0.67 for WHtR, 0.95 and 0.86 for WHR, 0.0807 and 0.0765 for ABSI in men and women, respectively, and 0.52 for WHHR in women with all-cause mortality.

Conclusion: All anthropometric measures of abdominal obesity had positive linear associations with CVD mortality, whereas some showed linear and the others J-shaped relationships with all-cause mortality. BMI had a J-shaped relationship with either CVD or all-cause mortality. Thresholds detected based on mortality may help with clinical definition of obesity in relation to mortality.


Alex’s Notes: This is an example of an epidemiological study that I really find interesting. The authors used data from the Diabetes Epidemiology: Collaborative analysis of Diagnostic criteria in Europe (DECODE) study to investigate the associations (or lack of) between cardiovascular disease (CVD) and all-cause mortality (death) with various anthropometric variables.

The variables used include waist circumference (WC), waist-to-height ratio (WHtR), BMI, waist-to-hip ratio (WHR), and a body-shape index (ABSI). The DECODE study includes 40 studies from 14 European countries, and thus the data is based on Caucasians. So if you aren’t white, then just be more cautious in your interpretation of the results. Overall, 46,651 men and women aged 24-99 from Finland, Sweden, Turkey, and UK was included in the analysis. In addition to their medical examination to collect the anthropometric variables, each also filled out a questionnaire on smoking history and physical activity (self-reported). Reading, watching TV, house work, sewing, and walking <1 km daily was defined as leisure-time physically inactive, and all other higher levels of physical activity were defined as physically active.

All the analyses were adjusted for smoking status and physical activity. The relationship for each variable appears in the table below.




Hazard Ratio for CVD (men & women)

Hazard Ratio for all-cause (men & women)




29.3 & 31 kg/m2

29.9 & 29.5 kg/m2




96.4 & 93.3 cm

104.3 & 105.6 cm




0.57 & 0.6

0.61 & 0.67





0.95 & 0.86




0.085 & 0.081

0.08 & 0.077

 Okay, I’m sure you are wondering what all the stuff in the table means, so let’s go through it piece by piece. The “J-shaped” indicates that the risk of death from CVD or all-cause followed a “J-shaped” distribution pattern. If going upwards indicated greater risk of death and you throw a J on the graph, then it would become clear that risk is greater with a smaller value and this risk decreases until a nadir is hit, after which the risk increases exponentially. BMI is a great example and indicates that CVD and all-cause mortality are greater with too low and too high of a BMI. For all-cause mortality, this is also the case with waist circumference and the waist-to-height ratio.

“Linear” simply means a straight line, and thus indicates that larger values are worse. This is the case with all the variables except BMI for CVD, and is the case with the ABSI and waist-to-hip ratio for all-cause mortality.

The hazard ratios indicate the point at which there is a 95% chance that increasing values will increase your risk for CVD or all-cause mortality. Thus, they can be seen as a “threshold” after which point you are statistically significantly at risk, and the farther you go past the threshold, the greater the risk will be.

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