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Lancet. 2011 Mar 26;377(9771):1085-95. doi: 10.1016/S0140-6736(11)60105-0.

Separate and combined associations of body-mass index and abdominal adiposity with cardiovascular disease: collaborative analysis of 58 prospective studies.

Collaborators (176)

Folsom AR, Chambless LE, Stevens J, Panagiotakos DB, Pitsavos C, Chrysohoou C, Stefanadis C, Atkins R, Barr EL, Shaw JE, Zimmet PZ, Whincup PH, Wannamethee SG, Morris RW, Kiechl S, Willeit J, Oberhollenzer F, Mayr A, Ebrahim S, Lawlor DA, Yarnell J, Gallacher J, Nietert PJ, Sutherland SE, Bachman DL, Keil JE, Mukamal KJ, Kizer JR, de Boer IH, Tybjærg-Hansen A, Nordestgaard BG, Frikke-Schmidt R, Giampaoli S, Palmieri L, Panico S, Vanuzzo D, Pilotto L, Gómez de la Cámara A, Rubio MA, Blazer DG, Guralnik JM, Phillips CL, Khaw KT, Salomaa V, Harald K, Jousilahti P, Vartiainen E, D'Agostino RB Sr, Vasan RS, Fox CS, Pencina MJ, Dankner R, Chetrit A, Lubin F, Wilhelmsen L, Eriksson H, Svärdsudd K, Welin L, Rosengren A, Wilhelmsen L, Lappas G, Eriksson H, Björkelund C, Lissner L, Bengtsson C, Strandberg TE, Salomaa V, Tilvis RS, Miettinen TA, Kiyohara Y, Arima H, Doi Y, Ninomiya T, Dekker JM, Nijpels G, Stehouwer CD, Rimm EB, Pai JK, Iso H, Kitamura A, Yamagishi K, Noda H, Deeg D, Poppelaars JL, Folsom AR, Psaty BM, Shea S, Döring A, Koenig W, Meisinger C, Verschuren WM, Blokstra A, Bueno-de-Mesquita HB, Wilhelmsen L, Rosengren A, Lappas G, Fletcher A, Gillum RF, Mussolino M, Rimm EB, Hankinson SE, Manson JE, Pai JK, Davidson KW, Kirkland S, Shaffer JA, Korin MR, Kitamura A, Iso H, Sato S, Bakker SJ, Gansevoort RT, Hillege HL, Amouyel P, Arveiler D, Evans A, Ferrières J, Barrett-Connor E, Wingard DL, Bettencourt R, Witteman J, Kardys I, Tiemeier H, Hofman A, Tunstall-Pedoe H, Tavendale R, Lowe GD, Woodward M, Howard BV, Zhang Y, Best L, Umans J, Onat A, Hergenç G, Can G, Nakagawa H, Sakurai M, Nakamura K, Morikawa Y, Njølstad I, Mathiesen EB, Løchen ML, Wilsgaard T, Ärnlöv J, Sundström J, Risérus U, Ingelsson E, Wassertheil-Smoller S, Manson JE, Brunner E, Shipley M, Ridker P, Buring J, Walker M, Watson S, Alexander M, Butterworth AS, Collins R, Di Angelantonio E, Franco OH, Gao P, Gobin R, Haycock P, Kaptoge S, Kondapally Seshasai SR, Lewington S, Pennells L, Sarwar N, Thompson A, Thompson SG, Walker M, Watson S, White IR, Wood AM, Wormser D, Danesh J.

Author information

  • 1Emerging Risk Factors Collaboration Coordinating Centre, Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Cambridge CB1 8RN, UK. erfc@phpc.cam.ac.uk



Guidelines differ about the value of assessment of adiposity measures for cardiovascular disease risk prediction when information is available for other risk factors. We studied the separate and combined associations of body-mass index (BMI), waist circumference, and waist-to-hip ratio with risk of first-onset cardiovascular disease.


We used individual records from 58 cohorts to calculate hazard ratios (HRs) per 1 SD higher baseline values (4.56 kg/m(2) higher BMI, 12.6 cm higher waist circumference, and 0.083 higher waist-to-hip ratio) and measures of risk discrimination and reclassification. Serial adiposity assessments were used to calculate regression dilution ratios.


Individual records were available for 221,934 people in 17 countries (14,297 incident cardiovascular disease outcomes; 1.87 million person-years at risk). Serial adiposity assessments were made in up to 63,821 people (mean interval 5.7 years [SD 3.9]). In people with BMI of 20 kg/m(2) or higher, HRs for cardiovascular disease were 1.23 (95% CI 1.17-1.29) with BMI, 1.27 (1.20-1.33) with waist circumference, and 1.25 (1.19-1.31) with waist-to-hip ratio, after adjustment for age, sex, and smoking status. After further adjustment for baseline systolic blood pressure, history of diabetes, and total and HDL cholesterol, corresponding HRs were 1.07 (1.03-1.11) with BMI, 1.10 (1.05-1.14) with waist circumference, and 1.12 (1.08-1.15) with waist-to-hip ratio. Addition of information on BMI, waist circumference, or waist-to-hip ratio to a cardiovascular disease risk prediction model containing conventional risk factors did not importantly improve risk discrimination (C-index changes of -0.0001, -0.0001, and 0.0008, respectively), nor classification of participants to categories of predicted 10-year risk (net reclassification improvement -0.19%, -0.05%, and -0.05%, respectively). Findings were similar when adiposity measures were considered in combination. Reproducibility was greater for BMI (regression dilution ratio 0.95, 95% CI 0.93-0.97) than for waist circumference (0.86, 0.83-0.89) or waist-to-hip ratio (0.63, 0.57-0.70).


BMI, waist circumference, and waist-to-hip ratio, whether assessed singly or in combination, do not importantly improve cardiovascular disease risk prediction in people in developed countries when additional information is available for systolic blood pressure, history of diabetes, and lipids.


British Heart Foundation and UK Medical Research Council.

Copyright © 2011 Elsevier Ltd. All rights reserved.

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