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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 (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
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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 98
“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 89
Pergola, G. D., Campobasso, N., Nardecchia, A., Triggiani, V., Caccavo, D., Gesualdo, L., Silvestris, F., & Manno, C. (2015) · BMC Cardiovascular Disorders · doi:10.1186/s12872-015-0101-6 · Cited by 86
“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 82
Recent Advances in Preventive Cardiology and Lifestyle Medicine
Franklin, B. A., & Cushman, M. (2011) · Circulation · doi:10.1161/circulationaha.110.981613 · Cited by 82
Wald, D., Teucher, B., Dinkel, J., Kaaks, R., Delorme, S., Boeing, H., Seidensaal, K., Meinzer, H., & Heimann, T. (2012) · Journal of Magnetic Resonance Imaging · doi:10.1002/jmri.23775 · Cited by 79
Faure, C., Dupont, C., Baraibar, M. A., Ladouce, R., Cédrin‐Durnerin, I., Wolf, J. P., & Lévy, R. (2014) · PLoS ONE · doi:10.1371/journal.pone.0086300 · Cited by 81
“However, abdominal fat, regardless of BMI, is a reliable predictor of individual risk of comorbidities such as metabolic syndrome [31,32,33].”
BackgroundCai, X., Li, X., Fan, W., Yu, W., Wang, S., Li, Z., Scott, E. M., & Li, X. (2016) · Nutrients · doi:10.3390/nu8040183 · Cited by 80
“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
“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
Kadakia, M. B., Fox, C. S., Scirica, B. M., Murphy, S. A., Bonaca, M. P., & Morrow, D. A. (2011) · Heart · doi:10.1136/heartjnl-2011-300231 · Cited by 78
Tan, S., Wang, J., Cao, L., Guo, Z., & Wang, Y. (2014) · Clinical Physiology and Functional Imaging · doi:10.1111/cpf.12217 · Cited by 78
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
“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
“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 79
“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
Kitahara, C. M., Berndt, S. I., de González, A. B., Coleman, H. G., Schoen, R. E., Hayes, R. B., & Huang, W. (2013) · Journal of Clinical Oncology · doi:10.1200/jco.2012.48.4691 · Cited by 80
“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
Cornier, M., Marshall, J. A., Hill, J. O., Maahs, D. M., & Eckel, R. H. (2011) · Circulation · doi:10.1161/circulationaha.110.968461 · Cited by 74
Ix, J. H., Allison, M., Denenberg, J. O., Cushman, M., & Criqui, M. H. (2008) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2008.03.022 · Cited by 73
Android and gynoid fat percentages and serum lipid levels in U nited S tates adults
Min, K., & Min, J. (2014) · Clinical Endocrinology · doi:10.1111/cen.12505 · Cited by 76
Lipodystrophy: A paradigm for understanding the consequences of "overloading" adipose tissue
Lim, K., Haider, A., Adams, C., Sleigh, A., & Savage, D. B. (2020) · Physiological Reviews · doi:10.1152/physrev.00032.2020 · Cited by 71
van Vliet‐Ostaptchouk, J. V., Nuotio, M.-L., Slagter, S. N., Doiron, D., Fischer, K., Foco, L., Gaye, A., Gögele, M., Heier, M., Hiekkalinna, T., et al. (2014) · BMC Endocrine Disorders · doi:10.1186/1472-6823-14-9 · Cited by 623
“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
Sherpa, L. Y., Deji, Stigum, H., Chongsuvivatwong, V., Luobu, O., Thelle, D. S., Nafstad, P. H. J., & Bjertness, E. (2011) · High Altitude Medicine & Biology · doi:10.1089/ham.2010.1050 · Cited by 67
“…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
“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).”
BackgroundRastogi, D., Bhalani, K., Hall, C. B., & Isasi, C. R. (2014) · Annals of the American Thoracic Society · doi:10.1513/annalsats.201311-403oc · Cited by 65
Munro, I., & Garg, M. L. (2011) · Obesity Research & Clinical Practice · doi:10.1016/j.orcp.2011.11.001 · Cited by 65
Metadata
- 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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