Body Fat Distribution and Risk of Coronary Heart Disease in Men and Women in the European Prospective Investigation Into Cancer and Nutrition in Norfolk Cohort: A Population-Based Prospective Study
Abstract
Background— Body fat distribution has been cross-sectionally associated with atherosclerotic disease risk factors, but the prospective relation with coronary heart disease remains uncertain. Methods and Results— We examined the prospective relation between fat distribution indices and coronary heart disease among 24 508 men and women 45 to 79 years of age using proportional hazards regression. During a mean 9.1 years of follow-up, 1708 men and 892 women developed coronary heart disease. The risk for developing subsequent coronary heart disease increased continuously across the range of waist-hip ratio. Hazard ratios (95% CI) of the top versus bottom fifth of waist-hip ratio were 1.55 (1.28 to 1.73) in men and 1.91 (1.44 to 2.54) in women after adjustment for body mass index and other coronary heart disease risk factors. Hazard ratios increased with waist circumference, but risk estimates for waist circumference without hip circumference adjustment were lower by 10% to 18%. After adjustment for waist circumference, body mass index, and coronary heart disease risk factors, hazard ratios for 1-SD increase in hip circumference were 0.80 (95% CI, 0.74 to 0.87) in men and 0.80 (95% CI, 0.69 to 0.93) in women. Hazard ratios for body mass index were greatly attenuated when we adjusted for waist-hip ratio or waist circumference and other covariates. Conclusions— Indices of abdominal obesity were more consistently and strongly predictive of coronary heart disease than body mass index. These simple and inexpensive measurements could be used to assess obesity-related coronary heart disease risk in relatively healthy men and women.
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Literature shows that individuals with a healthy weight but high visceral fat are at higher cardiovascular risk than those with a higher BMI.
“Literature shows that individuals with a healthy weight, but high visceral fat, are at higher cardiovascular risk than those with a higher BMI (Canoy et al., 2007; Stefan & Schulze, 2023).”
From Long-term cardiometabolic effects of early institutionalization and foster care: Evidence from the Bucharest Early Intervention Project (2026) · cites this paper as Canoy et al., 2007
The Results report that lean participants with a higher waist–hip ratio had more than 50% higher coronary heart disease risk than lean participants with a lower ratio. That supports elevated risk at a healthy BMI, but the comparison is not with people who have a higher BMI. The paper also uses waist–hip ratio as an indicator of fat distribution rather than directly measuring visceral fat, and its outcome is coronary heart disease rather than cardiovascular risk generally. (LLM, conf=0.88)
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Adult obesity complications: challenges and clinical impact
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Estimates of excess deaths associated with body mass index and other anthropometric variables
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Ectopic fat and cardiometabolic and vascular risk
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“tions [4,5].”
Distribution of body fat and risk of coronary heart disease in men and women
Canoy, D. (2008) · Current Opinion in Cardiology · doi:10.1097/hco.0b013e328313133a · Cited by 171 · see citing works
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Self-citationRelation Between Body Mass Index, Waist Circumference, and Death After Acute Myocardial Infarction
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Comparison of Overall Obesity and Body Fat Distribution in Predicting Risk of Mortality
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“BMI is a poor indicator of body fat distribution (3), and as such, measures of abdominal adiposity have shown strong and positive associations with numerous adverse health outcomes, including risk of type 2 diabetes and cardiovascular disease (4,5).”
BackgroundO’Doherty, M. G., Freedman, N. D., Hollenbeck, A. R., Schatzkin, A. G., & Abnet, C. C. (2011) · Gut · doi:10.1136/gutjnl-2011-300551 · Cited by 156 · see citing works
Nutrition and human health from a sex–gender perspective
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“Several epidemiological studies suggest that a high waist-to-hip ratio is a better predictor of all-cause and cardiovascular disease mortality than a large waist circumference alone (Canoy et al., 2007; Yusuf et al., 2005).”
BackgroundDevelopments in Obesity Genetics in the Era of Genome-Wide Association Studies
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“on the EPICNorfolk study (16) suggest, however, that there may well be a role for obesity measures in risk prediction models if both waist and hip circumferences are considered together (16,37).”
BackgroundWang, H., Chen, Y., Sun, G., Jia, P., Qian, H. R., & Sun, Y. (2018) · Postgraduate Medicine · doi:10.1080/00325481.2018.1444901 · Cited by 149 · see citing works
“Current evidence has revealed that the clinical risk attributable to obesity depends not simply on the extent but, importantly, the distribution of the excess adiposity [11,12].”
BackgroundPark, D., Lee, J.-H., & Han, S. W. (2017) · Medicine · doi:10.1097/md.0000000000008769 · Cited by 138 · see citing works
Interdisziplinäre Leitlinie der Qualität S3 zur „Prävention und Therapie der Adipositas”
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“Enger als mit dem BMI ist die KHK mit der abdominellen Adipositas vergesellschaftet (41).”
BackgroundInfluentialAnthropometry, Body Fat, and Venous Thromboembolism
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“Recent data indicate that waist and hip circumference have opposite associations with coronary artery disease; the risk for developing coronary artery disease increased with waist circumference, but the risk was lowered by increasing hip circumference (52).”
Peters, S. A. E., Bots, S. H., & Woodward, M. (2018) · Journal of the American Heart Association · doi:10.1161/jaha.117.008507 · Cited by 129 · see citing works
“8 The EPIC study including 360 000 individuals demonstrated that higher waist circumference (both sexes) and waist-to-hip ratio (women only) were associated with a higher risk of coronary death, independent of BMI.”
Arsenault, B. J., Rana, J. S., Lemieux, I., Després, J., Kastelein, J. J. P., Boekholdt, S. M., Wareham, N. J., & Khaw, K. (2009) · International Journal of Obesity · doi:10.1038/ijo.2009.229 · Cited by 124 · see citing works
Self-citationFukuda, T., Bouchi, R., Takeuchi, T., Tsujimoto, K., Minami, I., Yoshimoto, T., & Ogawa, Y. (2018) · Cardiovascular Diabetology · doi:10.1186/s12933-018-0700-5 · Cited by 125 · see citing works
“In particular, visceral adiposity is reported to have greater impact on metabolic abnormalities [2], CVD [3], and mortality [4], compared with total adiposity as usually represented by body mass index (BMI).”
BackgroundRothney, M. P., Martin, F., Xia, Y., Beaumont, M., Davis, C., Ergun, D. L., Fay, L. B., Ginty, F., Kochhar, S., Wacker, W. K., et al. (2012) · Journal of Clinical Densitometry · doi:10.1016/j.jocd.2012.02.009 · Cited by 122 · see citing works
Abdominal obesity: The cholesterol of the 21st century?
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Increased Glucose Uptake in Visceral Versus Subcutaneous Adipose Tissue Revealed by PET Imaging
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“Waist circumference (WC), which reflects abdominal visceral besity, is an important component of themetabolic syndrome and oronary artery disease (CAD) [1].”
BackgroundThe influence of hip circumference on the relationship between abdominal obesity and mortality
Cameron, A. J., Magliano, D. J., Shaw, J. E., Zimmet, P., Carstensen, B., Alberti, K. G. M. M., Tuomilehto, J. O., Barr, E., Pauvaday, V., Kowlessur, S., et al. (2012) · International Journal of Epidemiology · doi:10.1093/ije/dyr198 · Cited by 119 · see citing works
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Cardiac Adiposity and Global Cardiometabolic Risk New Concept and Clinical Implication
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Genome-wide discovery of genetic loci that uncouple excess adiposity from its comorbidities
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Self-citationAdipose tissue changes in obesity and the impact on metabolic function
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Gender differences in risk factors for coronary heart disease
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“In many studies, the association between VAT and disease remains significant after statistical adjustments for other measures of obesity and regional adiposity, such as BMI and waist circumference, suggesting that VAT may have an independent effect in determining overall cardiometabolic disease risk (3,18).”
BackgroundArteriolar Function in Visceral Adipose Tissue Is Impaired in Human Obesity
Farb, M. G., Ganley-Leal, L. M., Mott, M. M., Liang, Y., Ercan, B., Widlansky, M. E., Bigornia, S., Fiscale, A. J., Apovian, C. M., Carmine, B. J., et al. (2011) · Arteriosclerosis Thrombosis and Vascular Biology · doi:10.1161/atvbaha.111.235846 · Cited by 102 · see citing works
Excess Visceral Adipose Tissue/Ectopic Fat
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Body mass index and mortality: results of a cohort of 184,697 adults in Austria
Klenk, J., Nagel, G., Ulmer, H., Strasak, A. M., Concin, H., Diem, G., Rapp, K., & The VHM&PP Study Group (2009) · European Journal of Epidemiology · doi:10.1007/s10654-009-9312-4 · Cited by 101 · see citing works
Abdominal obesity and risk of CVD: a dose–response meta-analysis of thirty-one prospective studies
Xue, R., Li, Q., Geng, Y., Wang, H., Wang, F., & Zhang, S. (2021) · British Journal Of Nutrition · doi:10.1017/s0007114521000064 · Cited by 101 · see citing works
“underestimate the risk of CVD(45,46), which reminded us that”
BackgroundReil (2009) · Vascular Health and Risk Management · doi:10.2147/vhrm.s5207 · Cited by 99 · see citing works
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Racial differences in body fat distribution among reproductive-aged women
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“Body fat, in particular, central fat deposition, has been associated with cardiovascular disease (CVD), hypertension, diabetes mellitus, glucose intolerance, and insulin resistance in both men and women [1-15].”
BackgroundLitwin, S. E. (2008) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2008.05.017 · Cited by 98 · see citing works
Marques, M. D., Santos, R. D., Parga, J. R., Rocha-Filho, J. A., Quaglia, L. A., Miname, M. H., & de Ávila, L. F. R. (2009) · Atherosclerosis · doi:10.1016/j.atherosclerosis.2009.10.023 · Cited by 96 · see citing works
“Our results do not invalidate previously conecrated and easily obtainable and inexpensive measurements of diposity like the BMI or waist circumference [1–9].”
BackgroundResultAl-Raddadi, R. M., Bahijri, S., Jambi, H., Ferns, G., & Tuomilehto, J. O. (2019) · Therapeutic Advances in Chronic Disease · doi:10.1177/2040622319878997 · Cited by 88 · see citing works
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“Central fat accumulation provides an explanation for the higher risk of coronary heart disease, that persists after accounting for BMI and common risk factors [3].”
BackgroundOverall Obesity and Abdominal Adiposity as Predictors of Mortality in U.S. White and Black Adults
Reis, J. P., Araneta, M. R. G., Wingard, D. L., Macera, C. A., Lindsay, S. P., & Marshall, S. J. (2009) · Annals of Epidemiology · doi:10.1016/j.annepidem.2008.10.008 · Cited by 83 · see citing works
Recent Advances in Preventive Cardiology and Lifestyle Medicine
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“However, abdominal fat, regardless of BMI, is a reliable predictor of individual risk of comorbidities such as metabolic syndrome [31,32,33].”
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“To date, substantial evidence shows that MetS is associated with diabetes [6,7], dyslipidaemia, cardiovascular disease [7,8], specific types of cancer [3,9], and many other conditions.”
BackgroundPerirenal Adipose Tissue—Current Knowledge and Future Opportunities
Grigoraş, A., Balan, R. A., Căruntu, I.-D., Giuşcă, S. E., Lozneanu, L., Avădănei, E. R., Rusu, A., Riscanu, L., & Amălinei, C. (2021) · Journal of Clinical Medicine · doi:10.3390/jcm10061291 · Cited by 79 · see citing works
“An increased waist circumference size is considered by some guidelines as a factor associated with the cardiovascular risk [49].”
BackgroundKanerva, N., Kaartinen, N. E., Schwab, U., Lahti‐Koski, M., & Männistö, S. (2012) · British Journal Of Nutrition · doi:10.1017/s0007114512001262 · Cited by 79 · see citing works
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Britton, K. A., Pedley, A., Massaro, J. M., Corsini, E. M., Murabito, J. M., Hoffmann, U., & Fox, C. S. (2012) · Journal of the American Heart Association · doi:10.1161/jaha.112.004200 · Cited by 78 · see citing works
“Body fat distribution may be a cardiovascular risk factor even after accounting for generalized adiposity.(2) One component of abnormal body fat deposition involves the deposition of adipose tissue, so-called ectopic fat, around organs and the vasculature.”
BackgroundBurton, J. O., Gray, L. J., Webb, D. R., Davies, M. J., Khunti, K., Crasto, W., Carr, S. J., & Brunskill, N. J. (2012) · Nephrology Dialysis Transplantation · doi:10.1093/ndt/gfr574 · Cited by 77 · see citing works
“One example of a recent prospective study of >25 000 participants in the UK demonstrated that WHR was independently and more consistently predictive of coronary heart disease than either BMI or WC [34].”
BackgroundIn Central Obesity, Weight Loss Restores Platelet Sensitivity to Nitric Oxide and Prostacyclin
Russo, I., Traversa, M., Bonomo, K., Salve, A. D., Mattiello, L., Mese, P. D., Doronzo, G., Cavalot, F. L., Trovati, M., & Anfossi, G. (2009) · Obesity · doi:10.1038/oby.2009.302 · Cited by 77 · see citing works
“The INTERHEART and the Norfolk cohort studies underlined the role of central obesity in the risk of coronary heart disease, compelling to conclude that waist circumference should be preferred to BMI in the evaluation of the cardiovascular risk (3,4).”
MethodHigh prevalence of metabolic disturbances in patients with bipolar disorder in Taiwan
Chang, H. H., Chou, C. H., Chen, P. S., Gean, P. W., Huang, H. C., Lin, C. Y., Yang, Y. K., & Lu, R. B. (2009) · Journal of Affective Disorders · doi:10.1016/j.jad.2008.12.018 · Cited by 76 · see citing works
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“The stronger associations for BMI in men compared with women may also be explained by a greater tendency of men to deposit fat around their abdomen(39); excess abdominal fat has been linked with metabolic abnormalities, including a higher risk of diabetes and cardiovascular disease.(40-42) One large prospective study…”
BackgroundPrevention of Overweight/Obesity as a Strategy to Optimize Cardiovascular Health
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Android and gynoid fat percentages and serum lipid levels in U nited S tates adults
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Lipodystrophy: A paradigm for understanding the consequences of "overloading" adipose tissue
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“Increased adiposity is a key risk factor for type 2 diabetes, dyslipidaemia and cardiovascular disease, and is associated with many other conditions, including osteoarthritis, certain types of cancer, mental health, and increased mortality [8-13].”
BackgroundHerrera, V., Casas, J. P., Miranda, J. J., Perel, P., Pichardo, R. N., González, A., Sanchez, J., Catterina Ferreccio, R., Aguilera, X., Silva, E., et al. (2009) · International Journal of Obesity · doi:10.1038/ijo.2009.35 · Cited by 66 · see citing works
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“…obesity, particularly with a higher WHR, is associated with a higher risk for CVD and CHD (de Koning et al., 2007; Canoy, 2008), independently of body mass index (BMI), as well as other classic cardiovascular risk factors, even among nonobese individuals (BMI<30 kg/m2) (Canoy et al., 2007).”
BackgroundHip Hip Hurrah! Hip size inversely related to heart disease and total mortality
Heitmann, B. L., & Lissner, L. (2010) · Obesity Reviews · doi:10.1111/j.1467-789x.2010.00794.x · Cited by 65 · see citing works
“Several years later this issue was addressed in a UK cohort, and it was once again confirmed that a smaller hip circumference predicted excess risk of coronary heart disease in both sex groups, after controlling for both BMI and waist circumference (7).”
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Munro, I., & Garg, M. L. (2011) · Obesity Research & Clinical Practice · doi:10.1016/j.orcp.2011.11.001 · Cited by 65 · see citing works
- Authors
- Canoy, D., Boekholdt, S. M., Wareham, N., Luben, R., Welch, A., Bingham, S., Buchan, I., Day, N., & Khaw, K.-T.
- Affiliations
- University of Cambridge (GB)
- ORCID
- Venue
- Circulation
- Published
- 2007-12-18
- Volume
- 116
- Issue
- 25
- Pages
- 2933-2943
- ISSN
- 0009-7322 (ISSN-L)
- 1524-4539
- OpenAlex
- W1995930672
- Cited by
- 472
- References
- 59
- Citations by year
- 2026: 5 · 2025: 9 · 2024: 17 · 2023: 11 · 2022: 19 · 2021: 30 · 2020: 10 · 2019: 18 · 2018: 22 · 2017: 24 · 2016: 13 · 2015: 27 · 2014: 39 · 2013: 50 · 2012: 37
- FWCI
- 22.98
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Circulation (publishedVersion)
- PubMed (publishedVersion)
- Research Explorer (The University of Manchester) (publishedVersion)
- Data Archiving and Networked Services (DANS) (submittedVersion)
- Pure Amsterdam UMC (submittedVersion)
- UEA Digital Repository (University of East Anglia) (submittedVersion)
- Funders
- Wellcome Trust
- Topics
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes, Cardiovascular Risks, and Lipoproteins
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Disease and Adiposity
- Health Sciences › Medicine › Oncology › Cancer Risks and Factors
- Keywords
- body fat distribution, coronary artery disease, waist-to-hip ratio, waist circumference, hip circumference, abdominal obesity, body mass index, cardiovascular risk, sex differences, EPIC-Norfolk cohort
- MeSH terms
- Aged, Coronary Disease, Female, Follow-Up Studies, United Kingdom, Humans, Male, Middle Aged, Myocardial Infarction, Obesity, Predictive Value of Tests, Prospective Studies, Risk Factors, Cohort Studies, Proportional Hazards Models, Sex Distribution, Waist-Hip Ratio, Body Fat Distribution
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