This week’s contribution from “lifestyle epidemiology” was the report — from a huge study of 359,387 participants from nine countries in Europe — that spare tires, love handles, and bulges (the kind you battle) just ain’t good for you. The scientific term for this term is “abdominal adiposity.” Thus, the title of the paper, General and abdominal adiposity and risk of death in Europe (N Engl J Med. 2008;359:2105-20), by T. Pischon and 46 other authors. This is also related to the concept that being shaped like a pear is healthier than being shaped like an apple. Apples, beware!

Once upon a time, nutritional epidemiologists and other anthropometric scientists thought that the measure of a man (or woman) was the BMI — the body mass index. The body mass index is computed by dividing a person’s weight in kilograms (W) by the square of height in meters (H): BMI = W ÷ H2. For weight in pounds and height in inches, the formula is BMI = 703.07 x W ÷ H2. Thus, the existence of BMI tables; online programs for automatically computing your BMI by inputting your height and weight; the NCHS/CDC/NIH/American standard medical categories of BMI:

    Underweight = <18.5

    Normal weight = 18.5-24.9

    Overweight = 25-29.9

    Obesity = BMI of 30 or greater;

and the voluminous medical literature showing that (1) overweight and obesity are increasing problems in the United States, the United Kingdom, much of the industrialized world and developing world, and (2) being overweight is bad for your health and being obese is much worse.· Indeed, it seems that as BMI increases upward from normal weight, not only are there monotonically increased risks of mortality and cardiovascular disease, there are also positive associations with dementia, cancers of the esophagus and gastric cardia (the gastroesophageal junction adjacent to the esophagus), and breast cancer.

To measure abdominal adiposity —appleness, if you will — in their New England Journal study, Pischon et al. measured waist circumference and waist-to-hip ratio. The 350,000+ participants were followed up for about ten years and 14,723 died. The authors reported that, “after adjustment for BMI, waist circumference and waist-to-hip ratio were strongly associated with the risk of death.” The relative risk among men with waist circumferences above the 95th percentile (>102.6 cm) was 2.1; the relative risk among women with waist circumferences·above the 95th percentile (>88.9 cm) was 1.8. For men with waist-to-hip ratios above the 95th percentile (>0.98), the relative risk of death was 1.7; for women with waist to hip ratios above the 95th percentile (>0.84), the relative risk was 1.5. The authors point out that even men and women with low-risk BMI’s had a relatively high probability of dying if their waist circumference or waist-to-hip ratio was high.

As with body mass index, there’s a rather large medical literature on abdominal adiposity and its association with health. It’s related to coronary heart disease, pulmonary function, insulin resistance, type 2 diabetes, gallstone disease, and metabolic syndrome. And a time trend study of NCHS’s National Health and Nutrition Examination Surveys (NHANES) between 1960 and 2000 shows an increase in the prevalence of abdominal obesity in the United States, which has “…ominous public health implications across the entire population, particularly among normal weight subjects.” But cheer up. (Or not.) Evidence suggests that exercise does reduce abdominal adiposity.

Those of you with a more practical, activist frame of mind may be interested in The Ashwell Shape Chart. In 1995 the British Medical Journal (BMJ) published a paper by Lean, Han & Morrison arguing that waist circumference — rather than BMI — could be used in health promotion programs to identify individuals who should seek and be offered weight management. Men with waist circumference >/=94 cm and women with waist circumference >/=80 cm should gain no further weight; men with waist circumference >/=102 cm and women with waist circumference >/=88 cm should reduce their weight. In another paper in the BMJ in 1995 Han, van Leer, Seidell, & Lean reported that larger waist circumferences did identify people with increased prevalences of cardiovascular risks (i.e., high risk total plasma cholesterol concentrations, high density lipoprotein cholesterol concentrations, and blood pressures) in a cross-sectional study. In true BMJ fashion, this naturally resulted in the spontaneous generation of a multitude of Letters to the Editor, three of which were: “Ratio of waist circumference to height may be better indicator of need for weight management” by Ashwell & Lejeune; “Ratio of waist circumference to height is strong predictor of intra-abdominal fat” by Ashwell, Cole & Dixon; and “Ratio of waist circumference to height is better predictor of death than body mass index” by Cox & Whichelow. In the first letter the authors·used data from the 1992 health survey to show that the ratio of waist circumference to height was more highly correlated with the risk of coronary heart disease than any other anthropometric measure in both men and women — and much more highly than BMI. In the second letter, the authors used computed tomography data to show that “the ratio of waist circumference to height is the best simple anthropometric predictor of intra-abdominal fat in men and women.” In the third letter, the authors used data from a prospective longitudinal follow-up of British adults to establish that, “there was a linear trend with the ratio of waist circumference to height for both all cause mortality and cardiovascular mortality in women and for cardiovascular mortality in men.” There was, however, no consistent trend observed for body mass index.

Waist height #1

The first author of two of these BMJ letters and creator of the Ashwell Shape Chart mentioned above is Dr. Margaret Ashwell. Dr. Ashwell·is a British nutrition researcher who has taken the argument that the ratio of waist circumference to height is superior to BMI to its logical conclusions, both scientifically, in the form of journal articles, and practically, in the form of the Ashwell Shape Chart.

I would love to discuss these issues in more detail, but I’m still having computer problems. I thought I had fixed my wireless router, but it keeps semi-crashing, and I’m afraid it’s going to crash completely before I post this article. For an iconoclastic, more critical viewpoint on the BMI, obesity, etc, check out the series of articles by Patrick Basham and John Lui here, here, here, here, here, here, here, here, and elsewhere on Spiked Online. I’d be interested in hearing your opinions.

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47 Responses to “Weekend Love Handles Blues (courtesy of the New England Journal of Medicine)”  

  1. 1 Ken

    Main question is whether BMI etc are simply a bad measure of physical fitness. They use physical activity as a covariate in one of the models but how much reliance can you put on a questionnaire? It would be nice if they had some other measure but when you have 360,000 participants it is going to be expensive. Validation on a subset may be a good guide.

    An annoyance is these multi-multi-author papers. They can’t all have had a significant role in authorship. Only in medicine and physics (everyone who designed part of the accelerator gets authorship) does this seem accepted.

  2. 2 Ren

    If I use BMI, I’m in pretty bad shape… If I use the finisher medals for the marathons and half-marathons that I have run over the years, the latest this past October, then I’m in pretty good shape.

    My rule of thumb: If I get winded walking up three flights of stairs to my office, then I need to hit the road and the gym. Being under 30, I’m not obsessing over my blood lipid profile yet. Yet.

  3. 3 Dr. T

    The literature I’ve read indicates that intra-abdominal fat correlates with ‘bad things’ (atherosclerosis, hypertension, and insulin-resistant diabetes mellitus) more strongly than other fat-related indicators. However, I am puzzled by this paper: “Ratio of waist circumference to height is strong predictor of intra-abdominal fat.” Why would any clinician use such a ridiculous indirect technique for estimating intra-abdominal fat? Just put a tape measure around your patient’s waist and skinfold-thickness calipers on your patient’s subcutaneous waist fat. That will tell you how much of the increased girth is intra-abdominal.

  4. 4 andrea

    Uh-oh, I’m down to 18.6 … I sure hope the answer was in one of those ten vials of blood they drew last week…

  5. 5 EpiWonk


    Sounds like you might be a “chilli.” According to Dr. Ashwell, that means you should “take care.”

  6. 6 HCN

    Oh, that Ashwell chart makes much more sense than something I saw which was a waist to hip measure ratio. I started a fitness regime about five years ago, and I did lose some weight. The problem was that while reduced both my waist and hip measurements, the hip part decreased more than the waist.

    So apparently, that ratio got less healthy! I no longer have a butt… but still have the giving birth to baby pooch. sigh

    Still working on it.

    But at least my back no longer goes out. Swimming 2000 yards two to three times a week tends to strengthen those muscles. Plus I no longer get winded going up the hillside that is my dad’s back yard (it is part of a mountain side and includes a cave that used to be part of a mine).

  7. 7 Uncle Dave

    I have viewed the BMI for many many years as quite worthless in my case and especially for many athletes. I played football in college and My body fat was measured using the skin fold caliper method not the fluid submersion method (more accurate?) and found to be around 2% body fat. My waist size was about 32″
    I was 6′3″ and 211 lbs at that time which gave me a 26.4 BMI. I had a metabolism that could have been measured in a Khz scale meaning I could eat just about anything in mass quantities without being impacted in weight gain.

    I am now at 50, and 6′2″ 6′3″ depending on the moon phases (just kidding) and 201-203 lbs. Although the weight is clearly not distributed as it was when I was in my early 20’s (some of the 200lbs. has transferred from muscle mass to flabo-mass around my waist -about 36″) my BMI index is still in the 26 range. There are likely many people with a greater BMI than I, yet are far greater than I fitness wise.

    In my case the BMI is clearly lacking in critical information. Though I am still a 26 in BMI, I have clearly changed with a greater waist circumference to height as well as cholesterol count around 200 total from under 140 total in my 30’s-early 40’s.

  8. 8 Uncle Dave

    I would not even want to venture at
    how they arrived at
    drawing a line where your BMI is considered
    normal weight and over weight. I was never
    overwieght and yet the BMI Index said that I was
    when I was in my teens with a 32″ waist and extremely fit.
    Much like REN, BMI in my case was actually
    very misleading.

    The Ashwell shape chart appears to
    be in my instance, a bit more accurate assesement
    of my gradual shape change and relationship
    to weight distribution. Even though I have lost a few
    pounds from my twenties (unfortunetly as reduced muscle mass), my waist
    has expanded.

    However as Dr. T points out;
    “Just put a tape measure around your patient’s waist and
    skinfold-thickness calipers on your patient’s subcutaneous
    waist fat. That will tell you how much of the increased
    girth is intra-abdominal.”

    That would seem to be far more informational than any chart
    I have seen to date (along with REN’s personal “in shape” meter method).

  9. 9 Michael


    I can’t help feeling that you’re missing the point.

    Of course the BMI will be “useless” when it comes to assessing people who are not, in other parts of their lifestyle, representative of the population as a whole. The purpose of a BMI index (like most of epidemiology) is not to dichotomise people into those who are “at risk” and “not at risk”, but to provide a general indication for the majority of the population.

    I would very much hope that out of those who walk into your office with a BMI of >30, you as a professional physician don’t diagnose the 1% who happen to be pro-football players as being clinically obese. But for those people who don’t have the technical ability to “put a tape measure around your patient’s waist and skinfold-thickness calipers on your patient’s subcutaneous waist fat”, or aren’t pro-football players, the high BMI might encourage them to visit the doc on the off-chance that there may be a problem - which in most cases there will be.

  10. 10 Uncle Dave

    Eric wrote;

    “I would very much hope that out of those who walk into your office with a BMI of >30, you as a professional physician don’t diagnose the 1% who happen to be pro-football players as being clinically obese.”

    First let me establish and put everyone on ease that I’m not a doctor, nor have I ever played one on TV. Not even close. I took first aid training a long time ago, so if pressed I am sure I could perform a sliver removal with tweezers without risk of malpractice (that may be going a bit to far).

    I didn’t mean to sophmorically portray the BMI index, however if it is used as a statistical method “site unseen” to catagorize people, it would likely be a woefully inadequate data point for many people (maybe I shouldn’t say many if I do not really know).

  11. 11 Uncle Dave

    Oops, Sorry,
    I quoted from Michael.

  12. 12 keiner

    Body fat! That’s an interesting point, I guess. How dose the data look like for the body fat content, is there any correlation (coupled to the BMI) to health status/survival? What should be the target value?

  13. 13 Sir Oculus E.P. Demiology

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  31. 31 Jamie

    “My body fat was measured using the skin fold caliper method not the fluid submersion method (more accurate?) and found to be around 2% body fat.”
    That’s… not likely to be true. essential body fat is 1-3%. even professional bodybuilders at a meet don’t get that low.

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