Individual and Combined Performance of Indicators of Overall and Central Obesity to Estimate Coronary Risk in ELSA-Brasil Participants

Almeida, Rogério Tosta de; Matos, Sheila Maria Alvim; Aquino, Estela M. L.

doi:10.36660/abc.20200360

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Arquivos Brasileiros de Cardiologia

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Original Article • Arq. Bras. Cardiol. 117 (4) • Oct 2021 • https://doi.org/10.36660/abc.20200360 copy

Individual and Combined Performance of Indicators of Overall and Central Obesity to Estimate Coronary Risk in ELSA-Brasil Participants

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Background:

Anthropometric indicators have been used in clinical practice and epidemiological studies for screening of health risk factors.

Objectives:

To evaluate the individual discriminatory power of body adiposity index (BAI), body mass index (BMI), waist circumference (WC) and waist-hip-ratio (WHR) to identify individuals at risk for coronary heart disease and to evaluate whether combinations of anthropometric indicators of overall obesity with indicators of central obesity improve predictive ability in adults.

Methods:

A total of 15,092 participants (54.4% women) aged 35-74years were assessed at baseline of the ELSA-Brasil study. Individuals at risk for coronary heart disease were identified using the Framingham risk score and divided into very-high risk (VHR 20%) and high risk (HR10%). Measures of diagnostic accuracy and area under the ROC curves (AUC) were analyzed. Associations were tested using Poisson regression analysis with robust variance, according to age and sex. Statistical significance was set at 5%.

Results:

WHR showed the highest discriminatory power for VHR20% in all groups, with higher predictive ability in women (AUC: 0.802; 95%CI: 0.748-0.856 vs 0.657; 95%CI: 0.630-0.683 in the age range of 35-59 years, and AUC: 0.668; 95%CI: 0.621-0.715 vs 0.611; 95%CI: 0.587-0.635 in the age range of 60-74 years). BAI + WHR and BMI + WHR had the highest predictive power in men and women, respectively. Combinations of indicators of overall obesity with indicators of central obesity were more strongly associated with VHR20% and HR10% in all subgroups.

Conclusion:

Combined indicators had greater predictive ability than indicators taken individually. BAI+ WHR and BMI + WHR were the best estimators of coronary risk in men and women, respectively, and WHR had the best individual performance.

Keywords:
Cardiovascular Disease; Anthropometry; Obesity; Risk Factors; Epidemiology; Adiposity; Body Mass Index; Waist Circumference

	Men		Women
Variable	35-59 years (n= 5,354)	60-74 years (n= 1,527)	35-59 years (n= 6,478)	60-74 years (n= 1,733)
Age, median (IQR)	48 (44-54)^* * p< 0.05 compared with women within the same age group;	65 (62-69)^* * p< 0.05 compared with women within the same age group; ^† † p< 0.05 compared with younger individuals of the same sex.	49 (44-54)	64 (61-68)^† † p< 0.05 compared with younger individuals of the same sex.
Total cholesterol, mean (SD)	214.1 (44.6)	207.1 (42.4)^* * p< 0.05 compared with women within the same age group; ^† † p< 0.05 compared with younger individuals of the same sex.	214.5 (39.8)	224.2 (45.4)^† † p< 0.05 compared with younger individuals of the same sex.
HDL-Cholesterol, median (IQR)	48 (42-56)^* * p< 0.05 compared with women within the same age group;	50 (43-59)^* * p< 0.05 compared with women within the same age group; ^† † p< 0.05 compared with younger individuals of the same sex.	59 (51-70)	62 (52-73)^† † p< 0.05 compared with younger individuals of the same sex.
Systolic blood pressure, mean (SD)	124.0 (15.7)^* * p< 0.05 compared with women within the same age group;	131.1 (19.2)^* * p< 0.05 compared with women within the same age group; ^† † p< 0.05 compared with younger individuals of the same sex.	115.1 (15.3)	127.4 (19.1)^† † p< 0.05 compared with younger individuals of the same sex.
Diastolic blood pressure, mean (SD)	79.2 (10.8)^* * p< 0.05 compared with women within the same age group;	77.9 (10.9)^* * p< 0.05 compared with women within the same age group; ^† † p< 0.05 compared with younger individuals of the same sex.	73.8 (10.2)	74.8 (10.2)^† † p< 0.05 compared with younger individuals of the same sex.
HR,10%, n (%)	1.711 (32.0)^* * p< 0.05 compared with women within the same age group;	1.285 (84.2)^* * p< 0.05 compared with women within the same age group; ^† † p< 0.05 compared with younger individuals of the same sex.	542 (8.4)	613 (35.4%)^† † p< 0.05 compared with younger individuals of the same sex.
VHR,20%, n (%)	340 (6.3)^* * p< 0.05 compared with women within the same age group;	620 (40.6)^* * p< 0.05 compared with women within the same age group; ^† † p< 0.05 compared with younger individuals of the same sex.	52 (0.8)	106 (6.1)^† † p< 0.05 compared with younger individuals of the same sex.
Diabetes, n (%)	1.301 (19.3)^* * p< 0.05 compared with women within the same age group;	569 (37.3)^* * p< 0.05 compared with women within the same age group; ^† † p< 0.05 compared with younger individuals of the same sex.	882 (13.6)	484 (27.9)^† † p< 0.05 compared with younger individuals of the same sex.
Smoking, n (%)	813 (15.2)^* * p< 0.05 compared with women within the same age group;	171 (11.2)^* * p< 0.05 compared with women within the same age group; ^† † p< 0.05 compared with younger individuals of the same sex.	855 (13.2)	138 (7.9)^† † p< 0.05 compared with younger individuals of the same sex.
BAI_1, n (%)	1.521 (28.4)^* * p< 0.05 compared with women within the same age group;	524 (34.3)^† † p< 0.05 compared with younger individuals of the same sex.	2.468 (38.1)	585 (33.8)^† † p< 0.05 compared with younger individuals of the same sex.
BMI₁, n (%)	2.425 (45.3)^* * p< 0.05 compared with women within the same age group;	542 (35.5)^† † p< 0.05 compared with younger individuals of the same sex.	2.269 (35.0)	583 (33.6)
WC_1, n (%)	2.491 (46.5)^* * p< 0.05 compared with women within the same age group;	871 (57.0)^* * p< 0.05 compared with women within the same age group; ^† † p< 0.05 compared with younger individuals of the same sex.	2.346 (36.2)	682 (39.3)^† † p< 0.05 compared with younger individuals of the same sex.
WHR_1, n (%)	1.761 (32.9)^* * p< 0.05 compared with women within the same age group;	892 (58.4)^* * p< 0.05 compared with women within the same age group; ^† † p< 0.05 compared with younger individuals of the same sex.	1.351 (20.9)	598 (34.5)^† † p< 0.05 compared with younger individuals of the same sex.

Indicator	Cutoff point	Categories	Class^* * “0 = normal” and “1 = increased”.
BAI	28 (men) 34 (women 35-59 years) 36 (women 60-74 years)	BAI < 28 (men) or BAI < 34 (women 35-59 years) or BAI < 36 (women 60-74 years)	BAI₀
BAI	28 (men) 34 (women 35-59 years) 36 (women 60-74 years)	BAI ≥ 28 (men) or BAI ≥ 34 (women 35-59 years) or BAI ≥ 36 (women 60-74 years)	BAI₁
BMI	27 (men 35-59 years) 28 (men 60-74 years) 28 (women 35-59 years) 29 (women 60-74 years)	BMI < 27 (men 35-59 years) or BMI < 28 (men 60-74 years) or BMI < 34 (women 35-59 years) or BMI < 36 (women 59-74 years)	BMI₀
BMI		BMI ≥ 27 (men 35-59 years) or BMI ≥ 28 (men 60-74 years) or BMI ≥ 34 (women 35-59 years) or BMI ≥ 36 (women 60-74 years)	BMI₁
WC	95 (men) 90 (women 35-59 years) 93 (women 60-74 years)	WC < 95 (men) or WC < 90 (women 35-59 years) or WC < 93 (women 60-74 years)	WC₀
WC	95 (men) 90 (women 35-59 years) 93 (women 60-74 years)	WC ≥ 95 (men) or WC ≥ 90 (women 35-59 years) or WC ≥ 93 (women 60-74 years)	WC₁
WHR	0.97 (men) 0.90 (women 35-59 years) 0.91 (women 60-74 years)	WC < 0.97 (men) or WC < 0.90 (women 35-59 years) or WC < 0.91 (women 60-74 years)	WHR₀
WHR		WC ≥ 0.97 (men) or WC ≥ 0.90 (women 35-59 years) or WC ≥ 0.91 (women 60-74 years)	WHR₁

	Men 35-59 years (n=5,354)			Men 60-74 years (n=1,527)
Indicators	SEN (%)	SPE (%)	AUC (95%CI)	SEN (%)	SPE (%)	AUC (95%CI)	p
Individual
BAI₁	43.2	72.6	0.578 (0.551 – 0.605)	39.8	69.5	0.547 (0.522 – 0.571)	0.080
BMI₁	62.9	55.9	0.594 (0.568 – 0.621)	43.2	69.8	0.565 (0.541 – 0.590)	0.116
WC₁	64.9	54.7	0.598 (0.572 – 0.624)	64.2	47.9	0.560 (0.535 – 0.585)	0.041
WHR₁	62.2	69.1	0.657 (0.630 – 0.683) ^a a WHR > BAI; ^b b WHR > BMI; ^c c WHR > WC;	71.6	50.6	0.611 (0.587 – 0.635) ^a a WHR > BAI; ^b b WHR > BMI; ^c c WHR > WC;	0.013
Combinations
BAI + WC	70.9	49.3	0.618 (0.589 – 0.647)	70.3	41.7	0.574 (0.549 – 0.601)	0.029
BAI + WHR	75.3	55.7	0.680 (0.652 – 0.707)¹ 1 BAI+WHR > BAI+WC; .³ 3 BAI+WHR > BMI+WC; ^# # best match with best individual.	80.3	40.0	0.624 (0.597 – 0.650)¹ 1 BAI+WHR > BAI+WC; .³ 3 BAI+WHR > BMI+WC;	0.004
BMI + WC	71.2	48.3	0.610 (0.583 – 0.638)	64.6	46.6	0.578 (0.550 – 0.605)	0.010
BMI + WHR	77.9	48.4	0.672 (0.645 – 0.700)² 2 BMI+WHR > BAI+WC; .⁴ 4 BMI+WHR > BMI+WC.	76.0	44.4	0.623 (0.596 – 0.650)² 2 BMI+WHR > BAI+WC; .⁴ 4 BMI+WHR > BMI+WC.	0.013
	Women 35-59 years (n=6,478)			Women 60-74 years (n=1,733)
Indicators	SEN (%)	SPE (%)	AUC (95%CI)	SEN (%)	SPE (%)	AUC (95%CI)	p
Individual
BAI₁	63.5	62.1	0.628 (0.562 – 0.694)	50.9	67.4	0.592 (0.542 – 0.641)	0.389
BMI₁	78.9	65.3	0.721 (0.665 – 0.777)^e^* * with men of the same age group;	58.5	68.0	0.632 (0.584 – 0.681)^* * with men of the same age group;	0.020
WC₁	92.3	64.2	0.783 (0.746 – 0.820)^d d WC > BAI; and BMI> BAI; ^f f WC > BMI; between combinations by sex ^* * with men of the same age group;	68.9	62.6	0.657 (0.611 – 0.703)^d d WC > BAI; and BMI> BAI; ^* * with men of the same age group;	<0.001
WHR₁	80.8	79.6	0.802 (0.748 – 0.856) ^a a WHR > BAI; ^b b WHR > BMI; ^* * with men of the same age group;	66.0	67.6	0.668 (0.621 – 0.715) ^a a WHR > BAI; ^* * with men of the same age group;	<0.001
Combinations
BAI + WC	94.2	51.6	0.777 (0.734 – 0.820)^* * with men of the same age group;	75.5	52.6	0.667 (0.618 – 0.717)^* * with men of the same age group;	0.001
BAI + WHR	98.1	53.2	0.846 (0.810 – 0.882)¹ 1 BAI+WHR > BAI+WC; .³ 3 BAI+WHR > BMI+WC; ^* * with men of the same age group;	85.8	48.1	0.709 (0.663 – 0.754)^* * with men of the same age group;	<0.001
BMI + WC	92.3	59.0	0.786 (0.743 – 0.829)^* * with men of the same age group;	70.8	57.9	0.668 (0.618 – 0.717)^* * with men of the same age group;	<0.001
BMI + WHR	96.2	59.4	0.850 (0.811 – 0.889)² 2 BMI+WHR > BAI+WC; .⁴ 4 BMI+WHR > BMI+WC. ^* * with men of the same age group; ^# # best match with best individual.	82.1	52.1	0.710 (0.663 – 0.757) ⁴ 4 BMI+WHR > BMI+WC. ^* * with men of the same age group; ^# # best match with best individual.	<0.001

	Men				Women
	35-59 years (n=5,354)		60-74 years (n=1,527)		35-59 years (n=6,478)		60-74 years (n=1,733)
Combinations of indicators	n (risk)	PR (95%CI)	n (risk)	PR (95%CI)	n (risk)	PR (95%CI)	n (risk)	PR (95%CI)
BAI₀ + WC₀	2,573 (99)	1.0	562 (184)	1.0	3,321 (3)	1.0	881 (26)	1.0
BAI₁ + WC₀	290 (20)	1.79 (1.13 – 2.85)	94 (38)	1.23 (0.94 – 1.62)	811 (1)	1.36 (0.14 – 13.11)	170 (7)	1.40 (0.62 – 3.16)
BAI₀ + WC₁	1,260 (94)	1.94 (1.47 – 2.55)	441 (189)	1.31 (1.12 – 1.54)	689 (16)	25.70 (7.51 – 87.99)	267 (26)	3.30 (1.95 – 5.58)
BAI₁ + WC₁	1,231 (126)	2.66 (2.06 – 3.43)	430 (209)	1.48 (1.27 – 1.73)	1,657 (32)	21.38 (6.55 – 69.72)	415 (47)	3.84 (2.41 – 6.11)

BAI₀ + WHR₀	2,876 (84)	1.0	485 (122)	1.0	3,420 (1)	1.0	798 (15)	1.0
BAI₁ + WHR₀	717 (44)	2.10 (1.47 – 3.00)	150 (54)	1.43 (1.10 – 1.86)	1,707 (9)	18.03 (2.29 – 142.22)	337 (21)	3.32 (1.73 – 6.35)
BAI₀ + WHR₁	957 (109)	3.90 (2.96 – 5.13)	518 (251)	1.93 (1.61 – 2.30)	590 (18)	104.33 (13.95 – 780.18)	350 (37)	5.62 (3.13 – 10.11)
BAI₁ + WHR₁	804 (102)	4.34 (3.29 – 5.74)	374 (193)	2.05 (1.71 – 2.46)	761 (24)	107.85 (14.62 – 796.13)	248 (33)	7.08 (3.91 – 12.82)

BMI₀ + WC₀	2,521(98)	1.0	642 (219)	1.0	3,795 (4)	1.0	973 (31)	1.0
BMI₁ + WC₀	342 (21)	1.58 (1.00 – 2.50)	14 (3)	0.63 (0.23 – 1.72)	337 (0)	----	78 (2)	0.80 (0.20 – 3.30)
BMI₀ + WC₁	408 (28)	1.76 (1.17 – 2.65)	343 (133)	1.14 (0.96 – 1.35)	414 (7)	16.04 (4.71 – 54.61)	177 (13)	2.31 (1.23 – 4.32)
BMI₁ + WC₁	2,083 (192)	2.37 (1.87 – 3.00)	528 (265)	1.47 (1.28 – 1.69)	1,932 (41)	20.14 (7.22 – 56.19)	505 (60)	3.73 (2.45 - 5.68)

BMI₀ + WHR₀	2,500 (75)	1.0	552 (149)	1.0	3,820 (2)	1.0	866 (19)	1.0
BMI₁ + WHR₀	1,093 (53)	1.62 (1.15 – 2.28)	83 (27)	1.21 (0.86 – 1.69)	1,307 (8)	11.69 (2.48 – 54.99)	269 (17)	2.88 (1.52 – 5.46)
BMI₀ + WHR₁	429 (51)	3.96 (2.82 – 5.57)	433 (203)	1.74 (1.46 – 2.06)	389 (9)	44.19 (9.58 – 203.82)	284 (25)	4.01 (2.24 – 7.18)
BMI₁ + WHR₁	1,332 (160)	4.00 (3.07 – 5.22)	459 (241)	1.95 (1.65 – 2.19)	962 (33)	65.52 (15.75 – 272.60)	314 (45)	6.53 (3.88 – 10.99)

	Men				Women
	35-59 years (n=5,354)		60-74 years (n=1,527)		35-59 years (n=6,478)		60-74 years (n=1,733)
Combinations of indicators	n (risk)	PR (95%CI)	n (risk)	PR (95%CI)	n (risk)	PR (95%CI)	n (risk)	PR (95%CI)
BAI₀ + WC ₀	2,573 (559)	1.0	562 (430)	1.0	3,321 (137)	1.0	881 (213)	1.0
BAI₁ + WC ₀	290 (94)	1.49 (1.24 – 1.79)	94 (77)	1.07 (0.96 – 1.19)	811 (35)	1.05 (0.73 – 1.50)	170 (49)	1.19 (0.92 – 1.55)
BAI₀ + WC ₁	1,260 (485)	1.77 (1.60 – 1.96)	441 (386)	1.14 (1.08 – 1.21)	689 (106)	3.73 (2.93 – 4.74)	267 (132)	2.04 (1.73 – 2.42)
BAI₁ + WC ₁	1,231 (572)	2.14 (1.94 – 2.35)	430 (209)	1.19 (1.13 – 1.26)	1,657 (264)	3.86 (3.17 – 4.71)	415 (219)	2.18 (1.88 – 2.53)

BAI₀ + WHR ₀	2,876 (607)	1.0	485 (345)	1.0	3,420 (125)	1.0	798 (161)	1.0
BAI₁ + WHR ₀	717(239)	1.58 (1.39 – 1.79)	150 (127)	1.19 (1.09 – 1.30)	1,707 (117)	1.88 (1.47 – 2.40)	337 (122)	1.79 (1.47 – 2.19)
BAI₀ + WHR ₁	957 (437)	2.16 (1.96 – 2.39)	518 (471)	1.28 (1.20 – 1.36)	590 (118)	5.47 (4.32 – 6.93)	350 (184)	2.61 (2.20 – 3.09)
BAI₁ + WHR ₁	804 (427)	2.52 (2.29 – 2.77)	374 (342)	1.29 (1.20 – 1.37)	761 (182)	6.54 (5.28 – 8.10)	248 (146)	2.92 (2.45 – 3.47)

BMI₀ + WC ₀	2,521 (562)	1.0	642 (498)	1.0	3,795 (146)	1.0	973 (233)	1.0
BMI₁ + WC ₀	342 (91)	1.19 (0.99 – 1.44)	14 (9)	0.83 (0.56 – 1.23)	337 (26)	2.00 (1.34 – 3.00)	78 (29)	1.55 (1.14 – 2.12)
BMI₀ + WC ₁	408 (154)	1.69 (1.47 – 1.96)	343 (299)	1.12 (1.06 – 1.19)	414 (57)	3.58 (2.68 – 4.78)	177 (85)	2.01 (1.66 – 2.42)
BMI₁ + WC ₁	2,083 (903)	1.94 (1.78 – 2.12)	528 (479)	1.17 (1.11 – 1.23)	1,932 (313)	4.21 (3.49 – 5.09)	505 (266)	2.20 (1.91 – 2.53)

BMI₀ + WHR ₀	2,500 (512)	1.0	552 (401)	1.0	3,820 (131)	1.0	866 (172)	1.0
BMI₁ + WHR ₀	1,093 (334)	1.49 (1.33 – 1.68)	83 (71)	1.18 (1.06 – 1.30)	1,307 (111)	2.48 (1.94 – 3.16)	269 (111)	2.08 (1.71 – 2.53)
BMI₀ + WHR ₁	429 (204)	2.32 (2.05 – 2.63)	433 (396)	1.26 (1.19 – 1.34)	389 (72)	5.40 (4.13 – 7.06)	284 (146)	2.59 (2.17 – 3.08)
BMI₁ + WHR ₁	1,332 (660)	2.42 (2.20 – 2.66)	459 (417)	1.25 (1.18 – 1.33)	962 (228)	6.91 (5.64 – 8.47)	314 (184)	2.95 (2.51 – 3.47)

Very-high risk (VHR20%)
	Men				Women
	35-59 years (n=5,354)		60-74 years (n=1,527)		35-59 years (n=6,478)		60-74 years (n=1,733)
Combinations of indicators	n (risk)	PR (95%CI)	n (risk)	PR (95%CI)	n (risk)	PR (95%CI)	n (risk)	PR (95%CI)
Without risk	2,201 (63)	1.0	421 (111)	1.0	3,079 (1)	1.0	721 (13)	1.0
Overall obesity only	438 (23)	1.83 (1.15 – 2.92)	81 (28)	1.31 (0.93 – 1.84)	850 (1)	3.62 (0.23 – 57.79)	168 (7)	2.31 (0.97 – 5.70)
Central obesity only	585 (55)	3.28 (2.31 – 4.66)	440 (199)	1.72 (1.42 – 2.07)	509 (8)	48.39 (6.06 – 386.16)	303 (25)	4.58 (2.37 – 8.83)
Central + Overall	2,130 (198)	3.25 (2.46 – 4.28)	585 (282)	1.83 (1.53 – 2.19)	2,039 (42)	63.42 (8.73 – 460.51)	541 (61)	6.25 (3.47 – 11.26)

High risk (HR10%)
Without risk	2,201 (425)	1.0	421 (300)	1.0	3,079 (103)	1.0	721 (135)	1.0
Overall obesity only	438 (118)	1.40 (1.17 – 1.66)	81 (63)	1.09 (0.96 – 1.24)	851 (30)	1.05 (0.71 – 1.57)	168 (48)	1.53 (1.15 – 2.03)
Central obesity only	585 (242)	2.14 (1.88 – 2.47)	440 (393)	1.25 (1.17 – 1.34)	509 (80)	4.70 (3.56 – 6.20)	303 (144)	2.54 (2.09 – 3.08)
Central + Overall	2,130 (925)	2.25 (2.04 – 2.48)	585 (529)	1.27 (1.19 – 1.36)	2,039 (329)	4.82 (3.89 – 5.98)	541 (286)	2.82 (2.38 – 3.35)

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