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About MyHealth. feedback myhealth. Asian ethnic groups generally have a smaller waist circumference compared with Caucasians, although this is not necessarily true for Asian emigrants who are generally affluent and have more generalized and abdominal obesity.

Secular changes in the prevalence of overweight and obesity as measured by BMI have been reported in many countries over the last decades.

In German adults and in British adolescents, stronger increases over time in the average waist circumference than in relative weight were observed. A more recent study from Sweden observed a significant increase in BMI but not in WHR in the period from to decreased physical activity than the BMI.

The prevalence of abdominal obesity according to these cut-points has been reported for several countries. The worldwide increase in the prevalence of abdominal obesity is alarming because of the associated disease risk, in particular type 2 diabetes and cardiovascular diseases.

Several studies were conducted to compare the contribution of measures of overall obesity BMI and abdominal obesity waist circumference, WHR, SAD with disease risk.

Overall, it can be concluded that persons with a BMI in the normal weight range can still be at increased risk of metabolic disturbances if the WHR or waist circumference is increased, and that the combination of a high BMI and a high WHR results in a particularly high risk of an unfavourable metabolic profile, type 2 diabetes, and cardiovascular diseases.

In the elderly, few studies have directly compared BMI and waist circumference as predictors of metabolic abnormalities. Regarding the comparison of waist circumference and WHR as predictors of metabolic disturbances and the risk of cardiovascular diseases, results have been inconsistent.

Some studies have found waist circumference a stronger correlate of metabolic risk factors and cardiovascular disease than the WHR, 31 , , whereas others found no difference, — or found that the WHR was superior. These studies consistently show that a smaller hip circumference, for a given waist circumference, is related to an increased risk for metabolic disturbances, 49 — 51 , 53 type 2 diabetes, 43 , 50 , 52 , 54 and cardiovascular disease and mortality.

If waist circumference or WHR were compared with the SAD in the prediction of metabolic disturbances and disease risk, some studies found SAD a stronger correlate than waist circumference, WHR, and BMI.

Considering more sophisticated body composition measurements, numerous studies have shown a consistent and strong association of CT-measured visceral fat area in relation to metabolic or disease risk.

Studies using DXA or CT to estimate fat and muscle content at the legs found that in particular more subcutaneous fat at the legs, and to a lesser extent muscle mass at the legs, was associated with a more favourable cardiovascular risk profile for a given amount of abdominal fat.

Results for measures of body fatness and risk of premature mortality are more difficult to interpret than results for disease risk. First, causes of mortality can vary substantially for different populations and the effects of body fatness on these underlying causes will be different.

Second, the induction time for effects of body fatness on mortality is likely to be longer than for effects on the development of diseases. Because BMI can reflect both fat and lean body mass, variation in lean body mass that may be associated with mortality can complicate the interpretation of results for BMI.

Indeed, the U-shaped association between BMI and mortality that has been observed in some studies may reflect the opposite monotonous relations of lean mass beneficial and fat mass detrimental with risk of premature mortality. Studies of body fat distribution and premature mortality have been limited to studies of anthropometric measures of body fat distribution.

In several studies, larger waist circumference, larger WHR, 16 , 44 , larger iliac-to-thigh circumference, larger SAD, and smaller hip circumference 52 , 55 , were substantially associated with risk of premature mortality after adjustment for BMI. Because BMI may also reflect variation in lean body mass, one could argue that these independent associations are owing to incomplete adjustment for overall body fatness.

However, measures of central fat distribution also remained associated with premature mortality after adjustment for overall body fatness assessed by skinfold thickness 44 , or bioelectrical impedance. It should be noted that studies of body fat distribution and mortality have mostly been conducted in white populations.

Large waist circumference was a stronger predictor of premature mortality than BMI in black men, but neither measure was clearly associated with mortality in black women possibly owing to the limited size of the study.

Although the concept that obesity, in particular abdominal obesity, is an important cause of metabolic disturbances is generally accepted, the exact pathophysiological mechanisms are not completely known. It is widely acknowledged that fatty acids play an important role in the development of type 2 diabetes.

The pancreas will compensate the diminished glucose uptake by increasing insulin secretion, but in many of the insulin resistant persons, the beta-cell eventually fails.

Accumulation of fat in non-adipose tissue may further promote insulin resistance and impair beta-cell function, which are the two key features in the development of type 2 diabetes. Visceral fat is more sensitive to lipolytic stimuli, and less sensitive to anti-lipolytic stimuli such as insulin , compared with subcutaneous fat.

Therefore, visceral fat is more likely to release free fatty acids into the circulation causing increased free fatty acid levels, which may lead to ectopic fat storage in muscle, liver, and pancreas.

From epidemiological studies see above it is unclear whether a larger abdominal subcutaneous fat mass also contributes to an increased disease risk, independently of visceral fat. It was demonstrated that the amount of deep subcutaneous adipose tissue had a much stronger association with insulin resistance than superficial subcutaneous fat, which may be due to differences in lipolysis.

As also described in a previous section, recent studies suggest that more peripheral subcutaneous fat in the legs, for a given amount of abdominal fat, may be associated with a more favourable cardiovascular risk profile.

The enzyme lipoprotein lipase LPL plays an important role in the uptake of free fatty acids from the circulation, and particularly in women, the femoral fat depot has a relatively high LPL activity and relatively low rate of basal and stimulated lipolysis.

As a result of FFA uptake in the femoral-gluteal region, detrimental ectopic fat storage in the liver, skeletal muscle, and pancreas, may be prevented. In line with this potential mechanism, transplantation of subcutaneous adipose tissue in lipoatrophic animals reversed elevated glucose levels and subcutaneous lipectomy caused metabolic disturbances in hamsters.

The medical drugs thiazolidinediones increases insulin sensitivity in insulin resistant patients, while a considerable amount of total body fat is accumulated.

These drugs promote preadipocyte differentiation into mature adipocytes, in particular in the gluteal regions. Adipose tissue secretes many signalling proteins and cytokines with broad biological activity and critical functions.

Some of these adipokines may be involved in the development of insulin resistance in obesity. There are known differences in endocrine secretion of leptin, adiponectin, and IL-6 between abdominal subcutaneous fat and visceral fat, — whereas the existence of regional differences in the secretion of plasminogen activator inhibitor-1 PAI-1 and TNF-alpha is controversial.

In addition, there are probably many more yet undiscovered proteins, differently secreted by different fat depots, which might influence metabolic function.

Clearly, more research in this area is needed. There are several factors that may influence body fat patterning as well as the development of metabolic disturbances and may, therefore, underlie or confound the associations between these phenomena.

These factors include behavioural factors smoking, physical activity, diet , hormonal factors disturbances in glucocorticoid metabolism, sex hormones, growth hormone , and demographic factors such as age and gender.

In conclusion, it is supported by mechanistic studies, studies of metabolic risk factors, and studies of cardiovascular disease and premature mortality, that body fat distribution is relevant for the risk of cardiovascular disease and mortality.

Time trend studies have shown that there is a consistent increase over time in the prevalence of obesity and, particularly, abdominal obesity, which is likely to contribute to a higher incidence of type 2 diabetes, cardiovascular disease, and mortality.

Several methods are available to measure body fatness, and the choice largely depends on the purpose. For clinical applications it should be considered that usually no information on body fatness is collected at all and the health problems of being overweight are often not discussed by clinicians with their patients.

For this purpose, BMI can be an adequate measure of body fatness in adults. However, waist circumference may be a simple alternative that also captures information on abdominal fat distribution and may be less affected by variation in lean mass.

The WHR is more difficult to interpret because it may reflect an effect of larger waist as well as a smaller hip circumference. The SAD can be used instead of waist circumference but has not consistently been shown to be superior for the prediction of disease risk.

For large epidemiological studies the BMI can capture most of the relevant variation in body fatness depending on the age of the study population.

However, many studies have shown that the collection of information on body fat distribution waist circumference, WHR, SAD, DXA can provide additional insights. For mechanistic studies and intervention studies with exposures that may affect body fat distribution, accurate methodology to assess fat depots CT, MRI, DXA is necessary.

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