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Journal Article Ppublish 7 citations

PubMed: 42583989 DOI: 10.1016/j.jacc.2026.05.050

Risk Reclassification Beyond BMI by Waist Circumference and Waist-to-Hip Ratio Across 9 Cardiovascular Outcomes: Results From the Cross-Cohort Collaboration.

J Am Coll Cardiol 88(6):670-684

Authors: Zeina A Dardari, Zhiqi Yao, Jianjun Zhang, Giorgos Bakoyannis, Hongmei Nan, Lisa K Staten, Kunal K Jha, Erfan Tasdighi, Yara Jelwan, Semenawit Burka, Kunihiro Matsushita, Joao A C Lima, Bruce M Psaty, Amanda M Fretts, Rozenn N Lemaitre, Debbie L Cohen, Lawrence J Appel, Amit Khera, Amil M Shah, Michael E Hall, Suzanne E Judd, Monika M Safford, Shelley A Cole, Ramachandran S Vasan, Emelia J Benjamin, Peggy M Cawthon, Eric Orwoll, Michael J LaMonte, Charles B Eaton, Samar R El Khoudary, Elizabeth A Jackson, Imke Janssen, Paulo A Lotufo, Isabela M Bensenor, Márcio Sommer Bittencourt, Ankeet S Bhatt, Ana C Ricardo, Michael J Blaha

Affiliations

  • Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Baltimore, Maryland, USA; Department of Epidemiology, Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana, USA.
  • Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Baltimore, Maryland, USA.
  • Department of Epidemiology, Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana, USA.
  • Division of Cardiovascular Medicine, University of Louisville School of Medicine, Louisville, Kentucky, USA.
  • Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, USA.
  • Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Baltimore, Maryland, USA; Department of Epidemiology, Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
  • Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA.
  • Cardiovascular Health Research Unit, Departments of Medicine, Epidemiology, and Health Systems and Population Health, University of Washington, Seattle, Washington, USA.
  • Renal, Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
  • Department of Epidemiology, Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
  • University of Texas Southwestern, Division of Cardiology, Dallas, Texas, USA.
  • Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA.
  • Department of Biostatistics, University of Alabama at Birmingham School of Public Health, Birmingham, Alabama, USA.
  • Department of Medicine, Weill Medical College of Cornell University, New York, New York, USA.
  • Population Health Program, Texas Biomedical Research Institute, San Antonio, Texas, USA.
  • University of Texas School of Public Health, San Antonio, Texas, USA.
  • Department of Medicine, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA.
  • California Pacific Medical Center Research Institute, San Francisco and Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA.
  • Division of Endocrinology, Diabetes and Clinical Nutrition, School of Medicine, Oregon Health and Science University, Portland, Oregon, USA.
  • Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University at Buffalo, Buffalo, New York, USA.
  • Center for Primary Care and Prevention, Department of Family Medicine, Department of Epidemiology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.
  • University of Pittsburgh School of Public Health, Department of Epidemiology, Pittsburgh, Pennsylvania, USA.
  • Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA.
  • Department of Family and Preventive Medicine Rush University Medical Center, Chicago, Illinois, USA.
  • Center for Clinical and Epidemiologic Research, Hospital Universitario, University of Sao Paulo, Sao Paulo, Brazil.
  • Department of Medicine, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA.
  • Center for Clinical and Epidemiologic Research, Hospital Universitario, University of Sao Paulo, Sao Paulo, Brazil; Department of Medicine, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA.
  • Department of Medicine, Stanford School of Medicine, Palo Alto, California, USA; Kaiser Permanente San Francisco Medical Center and Division of Research, San Francisco, California, USA.
  • Department of Medicine, Division of Nephrology, University of Illinois, Chicago, Illinois, USA.
  • Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Baltimore, Maryland, USA.

Abstract

BACKGROUND

Body mass index (BMI) is commonly used to assess total adiposity, yet does not provide insight into overall body composition, potentially obscuring meaningful heterogeneity in cardiovascular disease (CVD) risk. Waist circumference (WC) and waist-to-hip ratio (WHR) are surrogate measures of central adiposity that are commonly discordant with BMI and may provide additional prognostic information.

OBJECTIVES

The purpose of this study was to quantify the reclassification and misclassification of traditional normal weight/overweight/obesity categories using central adiposity and to evaluate the prognostic implications for CVD risk using the CCC (Cross-Cohort Collaboration).

METHODS

We included 259,388 participants from 15 cohorts of the CCC with harmonized data on either WC or WHR data and at least 1 of 9 outcomes: time to first fatal and nonfatal myocardial infarction, fatal and nonfatal stroke, heart failure, atrial fibrillation, total coronary heart disease, total CVD, coronary heart disease mortality, CVD mortality, and all-cause mortality. Multivariable Cox proportional hazards models were used to estimate the HR of higher WC and WHR for each outcome across BMI categories.

RESULTS

Our sample included 259,351 individuals with WC data and 218,984 with WHR data, with a median follow-up of 20.0 years (95% CI: 12.7-23.5 years). Among individuals with normal weight, 5% had high WC and 18% had high WHR; among those with overweight, 39% had high WC and 40% had high WHR. Among those with obesity, 9% had low WC and 45% had low WHR. Among individuals with normal weight or overweight, clinically defined high WC or WHR was associated with 15% to 50% greater risk for most outcomes. Among those with obesity, low WC was not associated with a significantly different risk compared with normal weight and low WC, except for all-cause mortality, for which risk was significantly lower. In contrast to men, women with obesity but low WHR retained significantly higher risk for all outcomes compared with normal weight and low WHR; however, the HRs were smaller compared with those with obesity and high WHR. Among individuals with obesity, the population attributable risk associated with elevated WC or WHR ranged from 13% to 49%, with the highest estimates observed for elevated WC in heart failure and atrial fibrillation.

CONCLUSIONS

WC and WHR identifies misclassification of conventional BMI categories and reclassifies CVD risk across normal weight, overweight, and obesity, adding diagnostic and prognostic value.

MeSH

Waist-Hip Ratio, Mortality, Heart Diseases, Heart Failure, Heart, Cardiovascular Diseases, Atrial Fibrillation, Adiposity, Obesity, Coronary Disease, Overweight, Waist Circumference