Body mass index versus waist circumference as predictors of mortality in Canadian adults
Open accessAbstract
Background Elevated body mass index (BMI) and waist circumference (WC) are associated with increased mortality risk, but it is unclear which anthropometric measurement most highly relates to mortality. We examined single and combined associations between BMI, WC, waist-hip ratio (WHR) and all-cause, cardiovascular disease (CVD) and cancer mortality.Methods We used Cox proportional hazard regression models to estimate relative risks of all-cause, CVD and cancer mortality in 8061 adults (aged 18-74 years) in the Canadian Heart Health Follow-Up Study (1986-2004). Models controlled for age, sex, exam year, smoking, alcohol use and education.Results There were 887 deaths over a mean 13 (SD 3.1) years follow-up. Increased risk of death from all-causes, CVD and cancer were associated with elevated BMI, WC and WHR (P<0.05). Risk of death was consistently higher from elevated WC versus BMI or WHR. Ascending tertiles of each anthropometric measure predicted increased CVD mortality risk. In contrast, all-cause mortality risk was only predicted by ascending WC and WHR tertiles and cancer mortality risk by ascending WC tertiles. Higher risk of all-cause death was associated with WC in overweight and obese adults and with WHR in obese adults. Compared with non-obese adults with a low WC, adults with high WC had higher all-cause mortality risk regardless of BMI status.Conclusion [corrected] BMI and WC predicted higher all-cause and cause-specific mortality, and WC predicted the highest risk for death overall and among overweight and obese adults. Elevated WC has clinical significance in predicting mortality risk beyond BMI.
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Abdominal adiposity is independently associated with all-cause mortality and is recognized as a better predictor of obesity-related conditions than either body weight or BMI.
“Beyond total body fat, abdominal adiposity is independently associated with all‐cause mortality and is recognized as a better predictor of obesity‐related conditions than either BW or BMI. 83 , 84 , 85”
From What exercise prescription is optimal to improve body composition and cardiorespiratory fitness in adults living with obesity? A network meta‐analysis (2021) · cites this paper as [85]
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Kidy, F., Dhalwani, N. N., Harrington, D. M., Gray, L. J., Bodicoat, D. H., Webb, D. R., Davies, M. J., & Khunti, K. K. (2017) · Mayo Clinic Proceedings · doi:10.1016/j.mayocp.2017.02.009 · Cited by 24 · see citing works
Heterogeneity in Metabolic Responses to Dietary Fructose
Hou, R., Panda, C., & Voruganti, V. S. (2019) · Frontiers in Genetics · doi:10.3389/fgene.2019.00945 · Cited by 22 · see citing works
“BMI reflects the overall fatness and does not differentiate lean mass from fat mass, whereas waist circumference is more indicative of abdominal fat (Staiano et al., 2012).”
BackgroundSeyedhoseinpour, A., Barzin, M., Mahdavi, M., Valizadeh, M., Azizi, F., Ghareh, S., & Hosseinpanah, F. (2023) · BMC Public Health · doi:10.1186/s12889-023-16190-w · Cited by 21 · see citing works
“Also, in individual BMI categories, people with higher WC represent a higher risk for CVD and mortality [15, 16].”
BackgroundKhadir, A., Tiss, A., Kavalakatt, S., Behbehani, K., Dehbi, M., & Elkum, N. B. (2015) · Mediators of Inflammation · doi:10.1155/2015/512603 · Cited by 21 · see citing works
“Indeed, themajority of studies suggest thatWC is a better indicator of CVD risk than BMI and has been proven to be an appropriate clinical measure of the pathogenic potential of adipose tissue amongst populations [28–30].”
BackgroundPoorthuis, M. H. F., Sherliker, P., de Borst, G. J., Carter, J. L., Lam, H. K. B., Jones, N. R., Halliday, A. W., Lewington, S., & Bulbulia, R. A. (2021) · Journal of the American Heart Association · doi:10.1161/jaha.120.019025 · Cited by 21 · see citing works
“24 14 When pooled in a meta-analysis, these results appeared to show a roughly linear relationship with a summary risk ratio for a 10 cm increase in WC of 1.18 (95% CI, 1.12– 1.25).”
InfluentialYoo, H. J. (2017) · Journal of Obesity & Metabolic Syndrome · doi:10.7570/jomes.2017.26.1.3 · Cited by 20 · see citing works
Rheenen, T. E. V., McIntyre, R. S., Balanzá‐Martínez, V., Berk, M., & Rossell, S. L. (2020) · Journal of Affective Disorders · doi:10.1016/j.jad.2020.09.104 · Cited by 20 · see citing works
Salse‐Batán, J., Sánchez-Lastra, M. A., Suárez-Iglesias, D., & Ayán, C. (2022) · Journal of Intellectual Disability Research · doi:10.1111/jir.12928 · Cited by 19 · see citing works
Nordic Walking for Overweight and Obese People: A Systematic Review and Meta-Analysis
Sánchez-Lastra, M. A., Miller, K. J., Lemos, R. I. M., Giráldez, A., & Ayán, C. (2020) · Journal of Physical Activity and Health · doi:10.1123/jpah.2019-0357 · Cited by 18 · see citing works
Waist circumference and mortality or cardiovascular events in a general Korean population
Song, D. K., Hong, Y. S., Sung, Y., & Lee, H. (2022) · PLoS ONE · doi:10.1371/journal.pone.0267597 · Cited by 18 · see citing works
“In the Canadian Heart Health Follow-up Study, WC positively predicted all-cause, CVD, and cancer mortality over a mean 13-year follow-up among 8,061 adults (aged 18–74 years) [26].”
BackgroundYoneyama, S., Yao, J., Guo, X., Fernández‐Rhodes, L., Lim, U., Boston, J., Bůžková, P., Carlson, C., Cheng, I. C., Cochran, B. J., et al. (2016) · International Journal of Obesity · doi:10.1038/ijo.2016.207 · Cited by 18 · see citing works
“4 In the U.S., while the increase in overall obesity prevalence has slowed, 5 the average WC continues to increase 6 and obesity (overall and central) continues to disproportionally burden minority groups such as African Americans.”
Influence of Waist Circumference Measurement Site on Visceral Fat and Metabolic Risk in Youth
Lee, S., Kim, Y., & Han, M. (2022) · Journal of Obesity & Metabolic Syndrome · doi:10.7570/jomes22046 · Cited by 17 · see citing works
Staiano, A. E., Bouchard, C., & Katzmarzyk, P. T. (2013) · Obesity Facts · doi:10.1159/000354712 · Cited by 17 · see citing works
Self-citationMaternal prepregnancy BMI or weight and offspring's blood pressure: Systematic review
Ludwig‐Walz, H., Schmidt, M., Günther, A. L. B., & Kroke, A. (2017) · Maternal and Child Nutrition · doi:10.1111/mcn.12561 · Cited by 16 · see citing works
“This could be misleading because also fat mass, fat distribution, waist circumference, or waist‐to‐hip ratio might also be relevant indicators (Czernichow, Kengne, Stamatakis, Hamer, & Batty, 2011; Dhana et al., 2016; Staiano et al., 2012).”
BackgroundGeng, S., Chen, X., Shi, Z., Bai, K., & Shi, S. (2022) · PLoS ONE · doi:10.1371/journal.pone.0276216 · Cited by 18 · see citing works
Buch, A., Keinan‐Boker, L., Kis, O., Carmeli, E., Izkhakov, E., Ish‐Shalom, M., Berner, Y., Shefer, G., Marcus, Y., & Stern, N. (2018) · Clinical Interventions in Aging · doi:10.2147/cia.s176446 · Cited by 16 · see citing works
“Interaction of high BMI and high WC was also examined, since WC is an independent and good predictor of total mortality, particularly among overweight and obese adults, and may have prognostic value with respect to mortality and frailty risk, beyond that of BMI per se.(16,17) Eventually, we used the 75th percentile as…”
Zhang, J., Li, M., Wang, T., Tian, W., Ju, J., & Xu, H. (2025) · Frontiers in Endocrinology · doi:10.3389/fendo.2025.1523731 · Cited by 15 · see citing works
Aneni, E. C., Bittencourt, M. S., Teng, C., Cainzos‐Achirica, M., Osondu, C. U., Soliman, A., Al-Mallah, M. H., Buddoff, M. J., Parise, E. R., Santos, R. D., et al. (2020) · American Journal of Preventive Cardiology · doi:10.1016/j.ajpc.2020.100097 · Cited by 15 · see citing works
“Several large epidemiologic studies indicate that waist circumference is a better predictor of CVD and all-cause mortality [27, 28].”
BackgroundAhn, H. S., Kim, H. J., Suh, J. S., Kazmi, S. Z., Kang, T. U., & Choi, J. Y. (2023) · Clinics in Orthopedic Surgery · doi:10.4055/cios22238 · Cited by 14 · see citing works
“23,24) WC can be a surrogate marker of abdominal adiposity (visceral fat and/or subcutaneous abdominal adipose tissue), while BMI does not represent the pattern of fat distribution.”
Aguiar, C., MacLeod, J. B., Yip, A. M., Melville, S., Légaré, J., Pulinilkunnil, T., Kienesberger, P. C., Brunt, K. R., & Hassan, A. (2019) · BMJ Open · doi:10.1136/bmjopen-2018-023418 · Cited by 14 · see citing works
Interpretation of the “obesity paradox”: A 30-year study in patients with cardiovascular disease
Iozzo, P., Rossi, G., Michelassi, C., Landi, P., & Carpeggiani, C. (2012) · International Journal of Cardiology · doi:10.1016/j.ijcard.2012.09.061 · Cited by 12 · see citing works
“Previous reports had indicated that abdominal adiposity does not differ from BMI in the association with mortality in cardiac patients [22,23], though a most recent publication supports themeasurement of waist circumference as a better indicator of mortality, as compared with the BMI [24].”
ResultNilsson, G., Hedberg, P., Leppert, J., & Öhrvik, J. (2018) · Journal of Obesity · doi:10.1155/2018/3839482 · Cited by 12 · see citing works
Saadati, H. M., Sabour, S., Mansournia, M. A., Mehrabi, Y., & Nazari, S. S. H. (2021) · Arquivos Brasileiros de Cardiologia · doi:10.36660/abc.20200231 · Cited by 11 · see citing works
“11,05 (9,21, 12,88) RCQ 4,27 (0,36, 8,17) 61 (52,69)”
Firouzi, F., Tehrani, F. R., Kaveh, A., Mousavi, M., Azizi, F., & Behboudi‐Gandevani, S. (2024) · Frontiers in Endocrinology · doi:10.3389/fendo.2024.1389330 · Cited by 11 · see citing works
Influence of Obesity on Heart Rate Variability in Nurses with Age and Shift Type as Moderators
Chang, W., Wang, C., & Lin, Y. (2021) · BioMed Research International · doi:10.1155/2021/8119929 · Cited by 11 · see citing works
“Including WC can mitigate the inadequacies of BMI and also determine the amount of fat accumulation in the abdomen [32].”
BackgroundBaumert, J. J., Heidemann, C., Paprott, R., Du, Y., & Scheidt‐Nave, C. (2018) · BMC Endocrine Disorders · doi:10.1186/s12902-018-0319-2 · Cited by 11 · see citing works
Saadati, H. M., Sabour, S., Mansournia, M. A., Mehrabi, Y., & Nazari, S. S. H. (2021) · Diabetes & Metabolic Syndrome Clinical Research & Reviews · doi:10.1016/j.dsx.2021.02.024 · Cited by 10 · see citing works
Hazewinkel, A.-D., Richmond, R. C., Wade, K., & Dixon, P. (2021) · Economics and Human Biology · doi:10.1016/j.ehb.2021.101088 · Cited by 5 · see citing works
“In the first instance, BMI (a marker of overall body fat) and WHR (a marker of regional adiposity) have been shown to be associated with increased incidence of various diseases (Corbin et al., 2016; Dale et al., 2017; Dalton et al., 2003; Folsom et al., 2000; Hu et al., 2007; Lyall et al., 2017; Staiano et al., 2012;…”
BackgroundThe role of body height as a co‐factor of excess weight in Switzerland
Rickenbacher, M., Gültekin, N., Stanga, Z. G., Bender, N., Staub, K., Wells, J. C. K., Matthes, K. L., & Reber, E. (2022) · American Journal of Human Biology · doi:10.1002/ajhb.23754 · Cited by 10 · see citing works
“…type II or cardiovascular diseases (Clair et al., 2011; De Koning et al., 2007; Dis Ineke et al., 2009; Henneberg & Veitch, 2005; Lee et al., 2008; McCarthy & Ashwell, 2006; H. J. Schneider et al., 2010; Staiano et al., 2012; Wietlisbach et al., 2013; Xiao et al., 2006; Yusuf et al., 2005).”
BackgroundKoufakis, T., Liberopoulos, E. N., Kokkinos, A. D., Zebekakis, P. E., & Kotsa, K. (2023) · Drugs · doi:10.1007/s40265-023-01852-1 · Cited by 9 · see citing works
“An additional problem is that body mass index, which is the most widely used tool to assess changes in body weight, is poorly correlated with central adiposity and represents a crude estimate of CV risk, with other metrics, such as waist circumference, being better predictors of mortality [23].”
Lee, J. S., Lee, J. E., Hong, S., Lee, C., Yoo, B., Oh, J. S., & Kim, Y. (2020) · Therapeutic Advances in Musculoskeletal Disease · doi:10.1177/1759720x20936822 · Cited by 9 · see citing works
Samuel, L. J., Szanton, S. L., Wolff, J. L., & Gaskin, D. J. (2021) · Preventive Medicine · doi:10.1016/j.ypmed.2021.106678 · Cited by 9 · see citing works
Association of waist circumference and BMI with premature death in young and middle-aged population
Hu, L., Han, X., Chen, M., & Zhang, T. (2024) · Frontiers in Public Health · doi:10.3389/fpubh.2024.1389766 · Cited by 8 · see citing works
“Some studies have reported findings similar to this research, indicating increased mortality in adults living with obesity (79).”
ResultSotiropoulos, C., Giormezis, N., Pertsas, V., & Tsirkas, T. (2024) · Life · doi:10.3390/life14091197 · Cited by 8 · see citing works
“The main disadvantage of BMI is that, unlike WC, it does not accurately estimate abdominal obesity, which plays an equally or even more significant role than BMI in various diseases, such as MetS and CVDs [24–27].”
BackgroundLudwig‐Walz, H., Nyasordzi, J., Weber, K. S., Buyken, A. E., & Kroke, A. (2021) · Nutrition Metabolism and Cardiovascular Diseases · doi:10.1016/j.numecd.2021.11.011 · Cited by 8 · see citing works
Cardiovascular Disease Risk Score: Results from the Filipino–American Women Cardiovascular Study
Ancheta, I. B., Battie, C. A., Volgman, A. S., Ancheta, C. V., & Palaniappan, L. P. (2015) · Journal of Racial and Ethnic Health Disparities · doi:10.1007/s40615-015-0196-6 · Cited by 8 · see citing works
Abazid, R. M., Kattea, M., Sayed, S., Saqqah, H., Qintar, M., & Smettei, O. A. (2015) · Avicenna Journal of Medicine · doi:10.4103/2231-0770.160242 · Cited by 7 · see citing works
“com BMI.[7,8] At older ages, excessive visceral adipose tissue (VAT) measured by computed tomography angiography (CTA) is an independent predictor of CAD severity, coronary artery calcifications (CAC), and may contribute to the atherosclerosis extension.”
Habitual Exercise May Maintain Endothelium-dependent Dilation in Overweight Postmenopausal Women
Sanders, K., Maresh, C. M., Ballard, K. D., Creighton, B. C., Pryor, J. L., Kraemer, W. J., Volek, J. S., & Anderson, J. M. (2014) · Journal of Aging and Physical Activity · doi:10.1123/japa.2012-0251 · Cited by 7 · see citing works
Anthropometric Predictors of Heart Rate Variability in Overweight Individuals: A Comparative Study
Gandhi, N. S., Sorte, S. R., Chatur, D. K., & Rathod, S. B. (2024) · Cureus · doi:10.7759/cureus.69434 · Cited by 6 · see citing works
“These considerations provide a more comprehensive evaluation of an individual's overall health and the associated risks related to obesity [4].”
BackgroundValidation of the Chilean version of the Yale food addiction scale 2.0 in a non-clinical sample
Díaz, X., Palacio, A., Valenzuela, C. A., Verges, A. J., & Gearhardt, A. N. (2024) · Eating and Weight Disorders - Studies on Anorexia Bulimia and Obesity · doi:10.1007/s40519-024-01691-3 · Cited by 6 · see citing works
“This is also relevant given that elevated WC has clinical significance in predicting mortality risk beyond BMI [48].”
BackgroundReges, O., Test, T., Dicker, D., & Karpati, T. (2024) · Nutrients · doi:10.3390/nu16070961 · Cited by 6 · see citing works
“The association between BMI and mortality is well established [6,16,17,28,31,32].”
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Wang, H., Zhao, M., Magnussen, C. G., & Xi, B. (2021) · Nutrition Metabolism and Cardiovascular Diseases · doi:10.1016/j.numecd.2021.04.027 · Cited by 6 · see citing works
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- Authors
- Staiano, A. E., Reeder, B. A., Elliott, S., Joffres, M. R., Pahwa, P., Kirkland, S. A., Paradis, G., & Katzmarzyk, P. T.
- Affiliations
- Pennington Biomedical Research Center (US)
- University of Saskatchewan (CA)
- University of Waterloo (CA)
- Simon Fraser University (CA)
- Dalhousie University (CA)
- McGill University (CA)
- Corresponding author
- Katzmarzyk, P T
- Venue
- International Journal of Obesity
- Published
- 2012-01-17
- Volume
- 36
- Issue
- 11
- Pages
- 1450-1454
- ISSN
- 0307-0565 (ISSN-L)
- 1476-5497
- PMC
- PMC4120111
- OpenAlex
- W1987552839
- Cited by
- 143
- References
- 24
- Citations by year
- 2026: 1 · 2025: 4 · 2024: 11 · 2023: 12 · 2022: 13 · 2021: 16 · 2020: 13 · 2019: 10 · 2018: 12 · 2017: 6 · 2016: 11 · 2015: 13 · 2014: 9 · 2013: 8 · 2012: 4
- FWCI
- 10.50
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Licence
- www.springer.com/tdm (tdm)
- Locations
- International Journal of Obesity (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institutes of Health
- Health Canada
- National Institute of Diabetes and Digestive and Kidney Diseases (T32DK064584)
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Obesity, Physical Activity, Diet
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes, Cardiovascular Risks, and Lipoproteins
- Health Sciences › Medicine › Physiology › Body Composition Measurement Techniques
- Keywords
- body mass index, waist circumference, waist-to-hip ratio, anthropometric measures, all-cause mortality, cardiovascular mortality, cancer mortality, obesity, overweight, mortality prediction
- MeSH terms
- Adolescent, Adult, Aged, Alcohol Drinking, Canada, Cardiovascular Diseases, Cause of Death, Educational Status, Female, Follow-Up Studies, Humans, Longitudinal Studies, Male, Middle Aged, Obesity, Predictive Value of Tests, Surveys and Questionnaires, Smoking, Body Mass Index, Proportional Hazards Models, Risk Assessment, Waist-Hip Ratio, Waist Circumference
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