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ORIGINAL RESEARCH |
From the Departments of Pathological Biochemistry, Obstetrics, Haematology, and Nutrition, Glasgow Royal Infirmary University National Health Service Trust, Glasgow, Scotland, United Kingdom.
Address reprint requests to: Naveed Sattar, MRCPath University Department of Pathological Biochemistry Glasgow Royal Infirmary University NHS Trust Glasgow, Scotland G31 2ER United Kingdom E-mail: nsattar{at}clinmed.gla.ac.uk
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Abstract |
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Methods: Pregnant women with singleton pregnancies (n = 1142, median age 29 years, interquartile range 25–32 years, 387 primigravidas) were recruited at their first antenatal visits. Using standardized methods, midwives determined the weights, heights (for calculation of body mass index [BMI]), and waist circumferences of all women. Eighty-two women developed pregnancy-induced hypertension, and 21 developed preeclampsia (hypertension with proteinuria).
Results: The median waist circumference between 6 and 16 weeks’ gestation was 79 cm (interquartile range 72–84 cm), and there was no significant relationship between waist circumference and gestational age. Greater waist circumference was noted in subjects who subsequently developed pregnancy-induced hypertension (median 81 versus 77 cm, Mann-Whitney U test, P = .002) or preeclampsia (median 80 versus 77 cm, P = .02). The conventional, nonpregnant waist circumference action level of 80 cm gave a Mantel-Haenszel odds ratio (OR) for pregnancy-induced hypertension of 1.8 (95% confidence interval [CI] 1.1, 2.9) and for preeclampsia of 2.7 (95% CI 1.1, 6.8), compared with waists of less than 80 cm. Body mass index values were higher in women who developed pregnancy-induced hypertension (median 26 versus 24, P = .001) or preeclampsia (median 26 versus 24, P = .02). The conventional action limit for a BMI of 25 had an OR for pregnancy-induced hypertension of 2.0 (95% CI 1.2, 3.4) and for preeclampsia of 1.9 (95% CI 0.7, 4.8). Results were similar when the analysis was restricted to data from primigravidas.
Conclusion: We conclude that waist circumference up to 16 weeks’ gestation can predict pregnancy-induced hypertension and preeclampsia. Therefore, waist circumference could form the basis for health promotion involving raising awareness of the importance of or urging weight reduction for women planning pregnancies.
Body mass index (BMI) assessed when women first present for antenatal care predicts increased risk of hypertensive disorders in pregnancy1–3 and before pregnancy4,5 and is independent of baseline systolic and diastolic blood pressure (BP) measurements.1 Many health professionals are familiar with BMI, but most members of the public cannot calculate their indices to establish their risk or need for weight management. Height must be measured accurately, because small errors in the denominator are exaggerated by squaring.
Waist circumference correlates as well as other simple anthropometric measures, such as BMI, with body fat6 and fat distribution (intra-abdominal fat measured by computed tomography)7 in nonpregnant women. Waist circumference predicts cardiovascular risk,8,9 and changes in waist circumference predict changes in intra-abdominal fat and cardiovascular risk factors.10 Waist circumference measurement is recommended as a screening tool for health risks such as risks of cardiovascular disease, Type 2 diabetes, respiratory insufficiency, low back pain, and reduced physical function (National Institutes of Health guidelines and Scottish Intercollegiate Guidelines Network.)11 Waist circumference has not been assessed as a predictor of hypertensive disorders in pregnancy. We hypothesized that waist circumference would be as sensitive as BMI for predicting risk of pregnancy-induced hypertension or preeclampsia and could form the basis for health promotion involving raising awareness of the importance of or urging weight reduction for women planning pregnancies.
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Materials and Methods |
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Gestational age was estimated from the date of the last menstrual period and was confirmed by ultrasound scanning in the late first trimester. Duplicate measurements were done in all cases between 6 and 16 weeks’ gestation by three trained midwives using standard techniques12: waist circumference midway between the lowest rib and the iliac crest at the end of gentle exhalation; weight with digital scales to within 100 g, without heavy clothing; and height barefoot by portable stadiometer to within 0.5 cm. Intraobserver and inter-observer coefficients of variation for waist measurement, assessed for the first 100 women, were less than 3% in this study. We used 80 cm as a cutoff because this valve previously had been shown by us, using receiver operator characteristic curve (ROC) analysis in nonpregnant women, to identify with high sensitivity and specificity women with BMIs of at least 25 and waist-to-hip ratios of at least 0.80.12–14
Case records were examined 6 weeks after delivery to determine pregnancy outcomes. Women who were normotensive at the time of recruitment and who had no histories of hypertension were considered to have pregnancy-induced hypertension if diastolic BP was greater than 90 mmHg on at least two occasions, 4 hours apart. Preeclampsia was defined as pregnancy-induced hypertension with more than 2+ proteinuria on urinary dipsticks or more than 0.3 g/24 hours in the absence of infection. Fifteen women with histories of preexisting hypertension were excluded from analysis. Three other women presented with diastolic BPs greater than 90 mmHg at first visit and were excluded.
Waist circumferences of women who developed pregnancy-induced hypertension and preeclampsia were compared with those of women with uncomplicated pregnancies, using Mann-Whitney U test. Comparison of anthropometric data based on cutoffs for waist circumference of 80 cm and for BMI of 25 was done by Mantel-Haenszel odds ratio (OR) analysis; ORs are reported with 95% confidence intervals (CIs).
Univariable and multivariable analyses were used to investigate the relationship between waist circumference, BMI, and demographic details (age, parity, and smoking status) and pregnancy-induced hypertension and preeclampsia. Results of analyses are reported with coefficients of the logistic function. Positive coefficient values are associated with a higher probability of preeclampsia in the current (index) pregnancies. The z value (a measure of the probability associated with the logistic regression coefficient) and associated P values of the analyses are reported. Analyses were completed using Minitab for Windows 11.21 statistical software.
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Results |
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. The median waist circumference between 6 and 16 weeks was 79 cm (interquartile range 72–84 cm). There was no relationship between waist circumference (between 6 and 16 weeks) and gestation (Figure 1); however, there was a significant correlation between waist circumference and BMI at the time of enrollment (r = .79, P < .001).
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The Mantel-Haenszel ORs for pregnancy-induced hypertension and preeclampsia for waist circumference and BMI cutoffs of 80 cm and 25, respectively, are given in Table 2. Odds ratios for primigravidas also are shown.
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Discussion |
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The simplicity of waist circumference measurement and the relation of waist circumference to weight and fat distribution are major advantages of waist circumference over BMI and waist-to-hip ratio. Self-measurement of waist circumference is relatively simple and measurements are reproducible, and the technique was found to be acceptable in recent epidemiologic studies.18,19 We also noted that self-reported waist circumference measurement is improved further when a tape with different colors indicating cutoff levels is used.20 In that case, women correctly classified themselves as having waist circumferences less than or greater than 80 cm with sensitivity of 96% and specificity of 97%.20 Seidell21 also reviewed anthropometric methods to assess abdominal fat, concluding that waist circumference measurement alone was probably the most practical measurement for use in health promotion.
Health promotion and bathroom scales have made no impact hitherto on the upward trend in overweight and obesity. Given the complex interactions between cosmetic and health effects of body shape and size, a waist circumference reduction is a rewarding consequence of dieting and has been suggested as a better motivator than weight change (Egger G, O’Neill M, Bolton A, Freeman D. Results of an abdominal obesity reduction program for men only: The GutBuster ‘waist’ loss program [abstract]. Int J Obes 1995;19[suppl 2]:37).
It is often considered that height might relate to waist measurement and therefore be a potential confounder. We have examined that question in detail. We showed that the proportion of variance in waist circumference explained by height in women is negligible (0.03%).22 We concluded that height does not have an important effect on variations in waist circumference, especially in people who need weight management. That and the simplicity of using waist circumference argue against the use of more complex measures such as the ratio of waist circumference to height, particularly in public health or health promotion contexts.
Further studies are needed to determine whether waist circumference is as sensitive as BMI for predicting other pregnancy complications of maternal obesity such as macrosomia, cesarean delivery, and neural tube defects.2,5,23 If such is the case, waist circumference could form the basis for health promotion involving raising awareness of the importance of or urging weight reduction for women planning pregnancies.
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Footnotes |
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Received June 26, 2000. Received in revised form October 2, 2000. Accepted October 12, 2000.
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References |
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2. Bianco AT, Smilen SW, Davis Y, Lopez S, Lapinski R, Lockwood CJ. Pregnancy outcome and weight gain recommendations for the morbidly obese woman. Obstet Gynecol 1999;91:97–102.
3. Stone JL, Lockwood CJ, Berkowitz GS, Alvarez M, Lapinski R, Berkowitz RL. Risk factors for severe preeclampsia. Obstet Gynecol 1994;83:357–61.
4. Thadhani R, Stampfer MJ, Hunter DJ, Manson JE, Solomon GC, Curhan GC. High body mass index and hypercholesterolemia: Risk of hypertensive disorders of pregnancy. Obstet Gynecol 1999;94:543–50.
5. Ogunyemi D, Hullett S, Leeper J, Risk A. Prepregnancy body mass index, weight gain during pregnancy, and perinatal outcome in a rural black population. J Matern Fetal Med 1998;7190–3.
6. Lean ME, Han TS, Deurenberg P. Predicting body composition by densitometry from simple anthropometric measurements. Am J Clin Nutr 1996;63:4–14.
7. Pouliot MC, Despres JP, Lemieux S, Moorjani S, Bouchard C, Tremblay A, et al. Waist circumference and abdominal visceral adipose tissue accumulation and related cardiovascular risk in men and women. Am J Cardiol 1994;73:460–8.[Medline]
8. Han TS, van Leer EM, Seidell JC, Lean MEJ. Waist circumference action levels in the identification of cardiovascular risk factors: Prevalence study in a random sample. BMJ 1995;311:1401–5.
9. Sattar N, Tan CE, Han T, Forster L, Shepherd J, Lean M, et al. Association of indices of adiposity with the atherogenic lipoprotein profile. Int J Obes 1998;22:432–9.
10. Han TS, Richmond P, Avenell A, Lean MEJ. Waist circumference reduction and cardiovascular benefits during weight management in women. Int J Obes 1997;21:127–34.
11. Lean MEJ, Han TS, Seidell JC. Impairment of health and quality of life in people with large waist circumference. Lancet 1998;351: 853–6.[Medline]
12. Lean MEJ, Han TS, Morrison CE. Waist circumference as a measure for indicating need for weight management. BMJ 1995; 311:158–61.
13. World Health Organization. Measuring obesity: Classification and distribution of anthropometric data (Nutr UD, EUR/ICP/NUT 125). Copenhagen, Denmark: World Health Organization 1989.
14. Han TS, van Leer EM, Seidell JC, Lean MEJ. Waist circumference as a screening tool for cardiovascular risk factors: Evaluation of receiver operating characteristics (ROC). Obes Res 1996;4:533–47.[Medline]
15. Sattar N, Gaw A, Packard CJ, Greer IA. Potential pathogenic roles of aberrant lipoprotein and fatty acid metabolism in pre-eclampsia. Br J Obstet Gynaecol 1996;103:614–20.[Medline]
16. Roberts JM. Endothelial dysfunction in pre-eclampsia. Semin Reprod Endocrinol 1998;16:5–15.[Medline]
17. Joffe GM, Esterlitz JR, Levine RJ, Clemens JD, Ewell MG, Sibai BM, et al. The relationship between abnormal glucose tolerance and hypertensive disorders of pregnancy in healthy nulliparous women. Calcium for Preeclampsia Prevention (CPEP) Study Group. Obstet Gynecol 1998;179:1032–7.
18. Rimm EB, Stampfer MJ, Colditz GA, Chute GC, Litin LB, Willer WC. Validity of self-reported waist and hip circumferences in men and women. Epidemiology 1990;1:466–73.[Medline]
19. Chan JM, Stampfer MJ, Rimm EB, Walter CW, Colditz GA. Obesity, fat distribution and weight gain as risk factors for clinical diabetes in men. Diabetes Care 1994;9:961–9.
20. Han TS, Lean MEJ. Self-reported waist circumference compared with the ‘Waist Watcher’ tape-measure to identify individuals at increased health risk through intra-abdominal fat accumulation. Br J Nutr 1998;80:81–8.[Medline]
21. Seidell JC. Are abdominal diameters abominable indicators? In: Angel A, Bouchard C, eds. Progress in obesity research. London: Libbey, 1995:303–6.
22. Han TS, Seidell JC, Currall JEP, Morrison CE, Deurenberg P, Lean MEJ. The influences of height and age on waist circumference as an index of adiposity in adults. Int J Obes 1997;21:83–9.[Medline]
23. Kallen K. Maternal smoking, body mass index, and neural tube defects. Am J Epidemiol 1998;47:1103–11.
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