Predicting cardiometabolic risk: waist-to-height ratio or BMI. A meta-analysis

Figures & data

Figure 1 Flow diagram of study selection.

Table 1 Characteristics of included studies

Author	Ethnicity	Ethnic group	Sex	Number of participants	Age range or mean age ± SD (years)	BMI and WHtR cutoff selection	Outcome
Cross-sectional studies with optimal cutoffs
Al-Odat et al^Citation41	Jordanian	Non-Asian	M, F	212; 288	20–85	Optimal	MetS
Berber et al^Citation21	Mexican	Non-Asian	M, F	2,426; 5,939	>20	Optimal	DM, Dys, EBP
Craig et al^Citation22	Tongan	Non-Asian	M, F	314; 453	>15	Optimal	DM, EBP
Deshmukh et al^Citation36	Indian	Asian	M, F	1,059; 1,641	>18	Optimal	EBP
Dong et al^Citation23	Chinese	Asian	M, F	1,522; 1,484	20–74	Optimal	DM, Dys, EBP, MetS
He et al^Citation42	Chinese	Asian	M, F	430; 638	>40	Optimal	MetS
Ho et al^Citation24	Hong Kong Chinese	Asian	M, F	1,412; 1,483	27–74	Optimal	DM, Dys, EBP
Hsu et al^Citation35	Taiwanese	Asian	M, F	1,147; 1,212	40–94	Optimal	Dys, EBP, MetS
Khader et al^Citation37	Jordanian	Non-Asian	M, F	1,128; 3,462	>18	Optimal	EBP
Ko et al^Citation25	Hong Kong Chinese	Asian	M, F	910; 603	36.6 ± 9.2	Optimal	DM, Dys, EBP
Li et al^Citation26	US	Non-Asian	M, F	2,994; 3,283	>20	Optimal	DM
Li and McDermott^Citation27	Australian Aboriginal	Non-Asian	M, F	760; 881	15–74	Optimal	DM, Dys, EBP
Li et al^Citation28	Taiwanese	Asian	M, F	21,038; 15,604	37.2 ± 9.4	Optimal	DM, EBP
Lin et al^Citation29	Chinese	Asian	M, F	26,359; 29,204	37.3 ± 10.9	Optimal	DM, Dys, EBP
Mansour and Al-Jazairi^Citation30	Iraqi	Non-Asian	M, F	6,693; 6,293	>18	Optimal	DM, EBP
Nakamura et al^Citation43	Japanese	Asian	M, F	330; 514	40–69	Optimal	MetS
Park et al^Citation31	Korean	Asian	M, F	2,327; 3,102	>20	Optimal	DM, EBP
Pua and Ong^Citation32	Singaporean	Asian	F	566	18–68	Optimal	DM, Dys, EBP
Rodrigues et al^Citation38	Brazilian	Non-Asian	M, F	759; 896	25–64	Optimal	EBP, MetS
Schneider et al^Citation33	German	Non-Asian	M, F	2,016; 3,361	20–79	Optimal	DM, Dys, MetS
Silva et al^Citation39	Brazilian	Non-Asian	M, F	754; 928	20–59	Optimal	EBP
Singh et al^Citation40	Indian	Asian	M, F	3,118	>30	Optimal	EBP
Tseng et al^Citation34	Taiwanese	Asian	M, F	2,280; 2,403	44.5 ± 11.9	Optimal	DM, Dys, EBP
Wakabayashi and Daimon^Citation44	Japanese	Asian	M, F	37,697; 19,891	35–70	Optimal	MetS
Prospective studies
Aekplakorn et al^Citation50	Thai	Asian	M	2,536	35–59	Optimal	Incident CVD
Chei et al^Citation45	Japanese	Asian	M, F	974; 1,998	40–69	Percentiles	Incident DM
Gelber et al^Citation51	US	Non-Asian	M, F	16,332; 32,700	40–84; ≥45	Percentiles	Incident CVD
Huerta et al^Citation46	Spanish	Non-Asian	M, F	14,019; 23,714	30–65	Optimal	Incident DM
Jia et al^Citation47	Chinese	Asian	M, F	48,015; 13,688	18–85	Optimal	Incident DM
Petursson et al^Citation53	Norwegian	Non-Asian	M, F	26,461; 30,510	20–79	Percentiles	All-cause mortality, CVD mortality
Sargeant et al^Citation48	Jamaican	Non-Asian	M, F	290; 438	25–74	Optimal	Incident DM
Welborn and Dhaliwal^Citation54	Australian	Non-Asian	M, F	4,508; 4,698	20–69	Optimal	All-cause mortality, n CVD mortality
Xu et al^Citation49	Chinese	Asian	M, F	1,384; 1,647	>35	Optimal	Incident DM
Zhang et al^Citation52	Chinese	Asian	F	67,083	40–70	Percentiles	Incident CVD

Abbreviations: BMI, body mass index; CVD, cardiovascular disease; DM, diabetes mellitus; Dys, dyslipidemia; EBP, elevated blood pressure; MetS, metabolic syndrome; SD, standard deviation; WHtR, waist-to-height ratio.

Table 2 Summary of optimal exposure cutoffs from cross-sectional studies

Outcome	Asians		Non-Asians
	Number of data units	Median (min, max)	Number of data units	Median (min, max)
Waist-to-height ratio
Diabetes mellitus	15	0.510 (0.480, 0.530)	12	0.560 (0.500, 0.620)
Dyslipidemia	13	0.480 (0.450, 0.520)	6	0.526 (0.500, 0.600)
Elevated blood pressure	20	0.510 (0.450, 0.530)	14	0.528 (0.490, 0.600)
Metabolic syndrome	10	0.520 (0.500, 0.540)	6	0.550 (0.530, 0.610)
Body mass index (kg/m^2)
Diabetes mellitus	15	24.3 (23.2, 25.5)	12	26.1 (23.8, 35.0)
Dyslipidemia	13	23.7 (22.1, 25.0)	6	25.2 (23.9, 26.8)
Elevated blood pressure	20	24.1 (21.2, 26.3)	14	26.2 (23.6, 31.7)
Metabolic syndrome	10	24.3 (22.6, 26.0)	6	26.7 (25.8, 30.3)

Figure 2 Forest plot for discrimination of diabetes mellitus in cross-sectional studies with optimal BMI and WHtR cutoffs.

Abbreviations: BMI, body mass index; CI, confidence interval; RE, random effects; WHtR, waist-to-height ratio.

Figure 3 Forest plot for discrimination of dyslipidemia in cross-sectional studies with optimal BMI and WHtR cutoffs.

Abbreviations: BMI, body mass index; CI, confidence interval; RE, random effects; WHtR, waist-to-height ratio.

Figure 4 Forest plot for discrimination of elevated blood pressure in cross-sectional studies with optimal BMI and WHtR cutoffs.

Abbreviations: BMI, body mass index; CI, confidence interval; RE, random effects; WHtR, waist-to-height ratio.

Figure 5 Forest plot for discrimination of metabolic syndrome in cross-sectional studies with optimal BMI and WHtR cutoffs.

Abbreviations: BMI, body mass index; CI, confidence interval; RE, random effects; WHtR, waist-to-height ratio.

Figure 6 Forest plot for discrimination of incident diabetes mellitus, incident CVD, CVD mortality, and all-cause mortality in prospective studies with BMI and WHtR.

Abbreviations: BMI, body mass index; CI, confidence interval; CVD, cardiovascular disease; RE, random effects; WHtR, waist-to-height ratio.

Table 3 Study heterogeneity and publication biases

Outcome, origin	Study type	Number of data units	I^2 (95% CI)	Asymmetry test* (z statistic)
				BMI	WHtR
Diabetes mellitus	Cross-sectional
All		27	78.8 (60.7, 87.6)	2.439*	2.163*
Asians		15	74.4 (47.7, 88.2)	2.078*	1.865*
Non-Asians		12	79.3 (52.4, 92.5)	0.980	0.809
Dyslipidemia	Cross-sectional
All		19	96.2 (93.2, 98.3)	0.383	1.247
Asians		13	39.5 (0, 75.7)	0.206	0.527
Non-Asians		6	98.2 (95.3, 99.7)	0.384	1.549
Elevated blood pressure	Cross-sectional
All		34	92.5 (87.7, 95.6)	1.150	1.651
Asians		20	80.0 (61.7, 92.4)	1.694	1.680
Non-Asians		14	95.3 (90.7, 98.1)	−1.466	−0.316
Metabolic syndrome	Cross-sectional
All		16	0 (0, 67.3)	1.089	0.069
Asians		10	0.02 (0, 92.4)	1.236	0.102
Non-Asians		6	0 (NA)	−0.037	−0.044
Incident diabetes mellitus	Prospective
Asians		6	0.1 (0, 95.7)	−1.322	−1.353
Non-Asians		4	18.2 (1.0, 92.8)	0.214	0.378
Incident CVD	Prospective
Asians		2	0 (0, 99.8)	NA	NA
Non-Asians		2	0 (0, 98.3)	NA	NA
CVD mortality	Prospective
Non-Asians		4	17.8 (0, 93.1)	2.173*	1.229
All-cause mortality	Prospective
Non-Asians		4	71.3 (12.1, 98.1)	1.285	0.525

Note:

* P-value for z statistic <0.05.

Abbreviations: BMI, body mass index; CI, confidence interval; CVD, cardiovascular disease; NA, not applicable; WHtR, waist-to-height ratio.

Table S1 Quality assessment of prospective studies based on the Newcastle-Ottawa scale

Prospective study	Selection				Comparability		Outcome			Total stars
	1	2	3	4	5	6	7	8	9
Aekplakorn et al^Citation50	*	*	*	–	*	–	*	*	*	7
Chei et al^Citation45	*	*	*	*	*	*	*	*	–	8
Gelber et al^Citation51	–	*	*	*	*	–	*	–	–	5
Huerta et al^Citation46	*	*	*	*	*	–	*	–	–	6
Jia et al^Citation47	*	*	*	*	*	*	*	–	*	8
Petursson et al^Citation53	–	*	*	*	*	*	*	*	*	8
Sargeant et al^Citation48	–	*	–	*	*	*	*	*	*	7
Welborn and Dhaliwal^Citation54	*	*	*	*	*	–	*	*	*	8
Xu et al^Citation49	*	*	*	*	*	–	*	*	*	8
Zhang et al^Citation52	*	*	*	*	*	–	*	*	–	7

Notes: 1: Representativeness of the exposed cohort; 2: selection of the non-exposed cohort; 3: ascertainment of exposure; 4: demonstration that outcome of interest was not present at start of study; 5: comparability of cohorts on the basis of the design or analysis; 6: comparability of cohorts on the basis of the design or analysis; 7: assessment of outcome; 8: was follow-up long enough for outcomes to occur; 9: adequacy of follow-up of cohorts. More information available from: http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp.¹⁷

Table S2 Quality assessment of cross-sectional studies

Cross-sectional study	Representative sample	Ascertainment of exposure	Selective reporting	Incomplete outcome data	Assessment of outcome	Total score (maximum 5)
Al-Odat et al^Citation40	–	*	*	*	*	4
Berber et al^Citation21	–	*	*	–	*	3
Craig et al^Citation22	*	*	*	*	*	5
Deshmukh et al^Citation36	*	*	*	–	*	4
Dong et al^Citation23	*	*	*	*	*	5
He et al^Citation42	–	*	*	*	*	4
Ho et al^Citation24	–	*	*	*	*	4
Hsu et al^Citation35	*	*	*	*	*	5
Khader et al^Citation37	*	*	*	*	*	5
Ko et al^Citation25	–	*	*	*	*	4
Li et al^Citation26	*	*	*	*	*	5
Li and McDermott^Citation27	–	*	*	*	*	4
Li et al^Citation28	–	*	*	*	*	4
Lin et al^Citation29	–	*	*	*	*	4
Mansour and Al-Jazairi^Citation30	*	*	*	*	*	5
Nakamura et al^Citation43	–	*	*	*	*	4
Park et al^Citation31	–	*	*	*	*	4
Pua and Ong^Citation32	–	*	*	*	*	4
Rodrigues et al^Citation38	–	*	*	*	*	4
Schneider et al^Citation33	–	*	*	*	*	4
Silva et al^Citation39	*	*	*	*	*	5
Singh et al^Citation40	–	*	*	*	*	4
Tseng et al^Citation34	–	*	*	–	*	3
Wakabayashi and Daimon^Citation44	–	*	*	*	*	4

Table S3 Random effects meta-regression analysis for cross-sectional studies using predefined study covariates

	Estimated coefficients (95% CI)* for covariates used in multivariable meta-regression analysis
	Origin	Sex	Optimal BMI cutoff	Optimal WHtR cutoff	Interaction term origin × sex
Diabetes mellitus	0.33 (−3.69, 4.70)	0.17 (−0.34, 0.68)	0.05 (−0.10, 0.21)	−4.63 (−16.54, 7.28)	−0.07 (−0.84, 0.70)
Dyslipidemia	0.55 (−0.05, 1.16)	0.10 (−0.24, 0.44)	0.03 (−0.19, 0.24)	−4.20 (−12.09, 3.69)	−0.08 (−0.69, 0.53)
Elevated blood pressure	0.28 (−0.18, 0.74)	−0.01 (−0.43, 0.42)	−0.01 (−0.12, 0.12)	−1.42 (−7.59, 4.75)	−0.02 (−0.75, 0.70)
Metabolic syndrome	0.01 (−0.29, 0.29)	0.05 (−0.08, 0.18)	−0.03 (−0.10, 0.04)	1.66 (−2.36, 5.69)	−0.02 (−0.31, 0.27)

Note:

* None of the estimated coefficients reached statistical significance (all P>0.05).

Abbreviations: BMI, body mass index; CI, confidence interval; WHtR, waist-to-height ratio.

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