Anthropometric clinical indicators in the assessment of visceral obesity

12 Pages·2016·0.23 MB·English

Nutr. clín. diet. hosp. 2016; 36(2):168-179
Artículo de Revisión
DOI: 10.12873/362carneirororiz
Anthropometric clinical indicators in the assessment
of visceral obesity: an update
Indicadores clínicos antropométricos na avaliação da gordura visceral:
uma atualização
Carneiro Roriz, Anna Karla¹; Santana Passos, Luiz Carlos2; Cunha de Oliveira, Carolina3; Eickemberg, Michaela4;
De Almeida Moreira, Pricilla1; Barbosa Ramos, Lílian1
1SchoolofNutrition,NutritionScienceDepartment.FederalUniversityofBahia.Salvador,Bahia,Brazil.
2FacultyofMedicine,DepartmentofMedicine,FederalUniversityofBahia,Salvador,Bahia,Brazil.
3CenterforNutrition,FederalUniversityofSergipe,Sergipe,Brazil.
4InstituteofCollectiveHealth,FederalUniversityofBahia.CenterofStudiesandInterventioninAgingArea,Salvador,Bahia,Brazil.
Recibido: 12/febrero/2015. Aceptado: 5/febrero/2016.
ABSTRACT diameter index (ADI), conicity index (CI), visceral adi-
posity index (VAI) and the lipid accumulation produc-
Introduction:Visceralobesityisassociatedwithan
tion (LAP) were investigated for their relationship with
increasedriskofmetabolicdisordersandoccurrenceof
visceral fat measured by CT.
chronic diseases. The quantification of the visceral fat
becomes necessary and advantageous in clinical prac- Results: Most indicators have strong correlation
tice, especially through accurate and precise methods (r>0.70) with visceral fat. It was observed that there
in replacement of imaging methods as computed to- are few recent studies evaluating this relationship,
mography (CT). especially with the indices derived of the WC and the
SAD, besides the LAP and the VAI. Most studies in-
Objective:To present the use of anthropometric in-
vestigated the relationship between these indicators
dicators that have been linked to visceral fat.
with the diseases that are consequent of the visceral
Methods: The selection of items was taken in from obesity.
Scopus, Scielo, Lilacs, CAPES journals, PubMed/
Conclusion: The clinical anthropometric indicators
MEDLINE and Google Scholar, in the period between
are accurate in estimating visceral obesity, easy to use
2007 and 2014. Anthropometric and clinical indicators
and has low cost enabling clinical nutritional assess-
as waist circumference (WC), waist- to- height ratio
ment able to intervene earlier and more effectively in
(WHtR), waist-to- thigh ratio (WTR), waist- to- hip ra-
the prevention and/or treatment of this obesity.
tio (WRH), sagittal abdominal diameter (SAD), abdom-
inal diameter height index (SAD/ Height), abdominal
KEYS WORDS
Anthropometry, waist circumference, sagittal abdomi-
naldiameter,computedtomography,abdominalobesity.
Correspondencia:
AnnaKarlaCarneiroRoriz
[email protected]
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NUTRICIÓNCLÍNICAYDIETÉTICAHOSPITALARIA
RESUMO CI: Conicity Index.
Introdução: A obesidade visceral está associada a CT: Computerized Tomography.
um risco maior de distúrbios metabólicos e ocorrência
CVD: Cardiovascular Disease.
de doenças crônicas. A quantificação da gordura visce-
ral torna-se necessária e vantajosa na prática clínica, HDL: High Density Lipoproteins.
sobretudo por métodos acurados e precisos em substi- LAP: Lipid Accumulation Production.
tuição aos métodos por imagem, como a tomografia
SAD: Sagittal Abdominal Diameter.
computadorizada (TC).
SAD/Height: Sagittal Abdominal Diameter Height
Objetivo: Descrever a utilização de indicadores clí-
Index.
nicosantropométricosquetêmsidorelacionadosàgor-
dura visceral. TG: Triglyceride.
Métodos: A seleção dos artigos foi feita no Scopus, VAI: Visceral Adiposity Index.
Scielo, Lilacs, periódicos Capes, Pubmed/Medline e
VAT: Visceral Adipose Tissue.
Google Acadêmico, no período entre 2007 e 2014.
WC: Waist Circumference.
Indicadores clínicos antropométricos como circunferên-
cia da cintura (CC), Razão cintura altura (RCA), Razão WHR: Waist –to-hip Ratio.
cintura coxa (RCCx), Razão Cintura Quadril (RCQ),
WHtR: Waist-to- Height Ratio.
Diâmetroabdominalsagital(DAS),Diâmetroabdominal
altura(DAS/ALT),ÍndiceDiâmetroabdominal(IDA),Ín- WTR: Waist-to-Thigh Ratio.
dice conicidade (IC), Índice de adiposidade visceral
(IAV) e o Produto de acumulação lipídica (PAL) foram INTRODUCTION
investigados quanto sua relação com o tecido adiposo
Visceral obesity is closely associated with insulin re-
visceral medido pela TC.
sistance, hypertension, dyslipidemia, type 2 diabetes
Resultados: A maioria dos indicadores tem forte and with the high risk of cardiovascular diseases and
correlação (r>0.70) com a gordura visceral. Observou- mortality1,2.Studieshavebeenreportingthatthedistri-
se que há poucos estudos recentes que avaliaram essa bution of the body fat is more important than the
relação,sobretudocomosíndicesderivadosdaCCedo amount of fat itself, since abdominal adiposity, espe-
DAS,alémdoPALeoIAV.Amaioriadosestudosinves- cially the visceral one, is having a more expressive as-
tigouarelaçãoentreessesindicadorescomasdoenças sociation with the increase of those morbidities3.
que são consequentes da obesidade visceral.
It is important to consider that, independently of
Conclusão: Os indicadores clínicos antropométricos overweight, individuals may have visceral obesity rep-
são acurados na estimativa da gordura visceral, fáceis resented by the deposition of visceral adipose tissue.
de utilizar e apresentam baixo custo possibilitando uma The more accurate methods for quantifying visceral fat
tomada de decisão na avaliação clínica nutricional ca- are the ones using image, such as magnetic resonance
paz de intervir mais precoce e efetivamente na preven- and computed tomography (CT). CT, the comparison
ção de risco de doenças. method of this work, is considered to be the “golden-
standard”, able to precisely distinguish visceral fat from
PALAVRAS CHAVES subcutaneous fat in any body region. One of the rea-
Antropometria, circunferência da cintura, diâmetro sons for that is due to its high reproductability4,5.
abdominal sagital, tomografia computadorizada, obesi- However,itshighcost,theneedofsophisticatedequip-
dade abdominal. ment, specialized people and the exposition of the indi-
vidual to radiation are the main limitations for its use in
the practice routine and in epidemiological studies5.
ABBREVIATIONS
ADI: Abdominal Diameter Index. Thisway,anthropometryisconsideredlikeanalterna-
tivemethodforestimatingvisceralfat,byindicatorssuch
AUC- ROC: Area under curve- Receiver Operating
asWaistCircumference(WC)andtheSagittalAbdominal
Characteristic.
Diameter (SAD), their respective indexes, Waist-to-
BMI: Body Mass Index. Height Ratio (WHtR), Waist-to-Thigh Ratio (WTR),
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ANTHROPOMETRICCLINICALINDICATORSINTHEASSESSMENTOFVISCERALOBESITY:ANUPDATE
Conicity Index (CI), Sagittal Abdominal Diameter Height After selection, articles were read in full and those
Index (SAD/Height), and the Abdominal Diameter Index that were not within the established criteria were ex-
(ADI),whichareconsideredtobelowcost,non-invasive cluded from the study. For analysis of the studies, data
and easy to measure4,6. The Lipid Accumulation Product was summarized in the tables as follows: work identifi-
(LAP) and the Visceral Adiposity Index (VAI) have been cation(authorandyear),locationofthestudyandsam-
proposed as alternative parameters for evaluating the ple, and information about the anthropometrics clinical
excessoflipidsaccumulation.Bothincludeanthropomet- indicators and the computed tomography and results.
ric and metabolic parameters7-9. Accordingtothepredeterminedinclusioncriteria,twelve
papers were selected for comparison of studies evaluat-
Thereisnoconsensusabouttheanthropometricclin-
ing the relationship between anthropometric clinical in-
ical indicator that better correlates or discriminates vis-
dicators and visceral fat measured by CT.
ceral fat, especially when measured by CT, in both
sexes. Then, it becomes fundamental to have a better
RESULTS AND DISCUSSION
comprehension about the detection of visceral fat, be-
causeitisanadvantageousandneededreplacementin Visceralobesity
the evaluation and follow-up in the individual and col-
Currently the interest about the original observation
lective clinical practice. The objective of this revision is
made by the French doctor Jean Vague10 about the re-
to describe the use of anthropometric clinical indicators
lation between abdominal obesity and development of
that have been related to visceral fat.
chronic diseases is being renovated. Posteriorly, several
studies pointed to an association between abdominal
METHODS adiposity increase with several metabolic disorders and
morbidities,especiallycardiovasculardiseases,showing
Fortheunsystematicrevision,asearchwasperformed
the importance of the localization of fat in detriment of
in the databases: Scopus, Scielo, Lilacs, Periódicos from
the total body obesity3.
CAPES, PubMed/MEDLINE and Google Scholar. The fol-
lowing expressions were searched: abdominal fat, vis- Therefore, the proof that there is a relation between
ceralfat,visceralobesity,abdominalobesity,visceraladi- the excess of abdominal fat tissue and co-morbidities
pose tissue, waist circumference, sagittal abdominal such as hypertension, type 2 diabetes, arthritis, coro-
diameter, Waist-to-Height Ratio, Waist-to-Thigh Ratio, naryarterydisease,sleepapneaandsometypeofcan-
Waist-Hip Ratio, Conicity Index, Sagittal Abdominal cer is not recent. This phenomenon is normally verified
DiameterHeightIndex,AbdominalDiameterIndex,Lipid at any level of total body adiposity2,3,11.
Accumulation Product, Visceral Adiposity Index,
It is increasingly notorious the notion that visceral
Anthropometry and Computed Tomography. The search
obesitymaybeadysfunctionalmarkerofsubcutaneous
expressions were constructed combining those terms or
adipose tissue leading to the deposition of ectopic fat
using them in an isolated way.
(undesirablelipidaccumulationintheheart,liver,skele-
Thesearchcriteriaforselectingstudieswere:descrip- tal muscle and pancreas)2.
tors present in the title, abstract or subject, documents Abdominal adipose tissue is a complex organ that
in paper format and full available version. Identified may be divided into compartments such as subcuta-
studies have been assessed according to the following neous and intra abdominal (or visceral) and this last
inclusion criteria: (1)- population (adults and elderly), one into intraperitoneal (or portal) and retroperitoneal,
(2)- theme (visceral fat measured by CT and anthropo- followed by mesenteric and omental sub-compart-
metrics indicators) and (3)- quantitative approach. ments12. However, between those compartments, the
visceral adipose tissue is considered to be the highly
Searches were limited to studies involving humans,
metabolically active risk marker with greater expressiv-
of both sexes, over 18 years old, from any ethnical
ity for development of the mentioned events.
group, published in Portuguese, English and Spanish,
and the publishing date was established between 2007 From the mechanisms through which visceral obesity
and 2014, besides the incorporation of previously pub- may influence the increase of metabolic and cardiovas-
lishedclassicworksaboutthetheme.Thereferencesof cular risk the highlights are the intense lipolytic activity,
thepaperswerealsoanalyzedinordertofindoutstud- its large adipocytes responsive to lipolytic enzymes and
ies that were not identified using the databases. partiallyresistanttoinsulin,determininganinappropriate
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NUTRICIÓNCLÍNICAYDIETÉTICAHOSPITALARIA
andexcessivereleaseoffreefattyacidsintheportalcir- simply,noninvasiveandoflowcost,suchastheanthro-
culation, finally, triggering a cascade of alterations that pometry. Table 1 presents the main characteristics of
lead to diabetes, hypertension, production of inflamma- anthropometric clinical indicators which were studied in
tory cytokines and disorders in the serum lipid profile13. this paper.
Age, sex, genetics and ethnicity are huge etiological Table2hastheresumeofstudieswhichobservedthe
factors contributing for the variation in the accumula- relation between the nutritional clinical indicators and
tion of visceral adipose tissue. It has been evidenced visceral fat when measured by CT.
that the commonly used methods to measure body fat
are not able to predict the visceral fat in the same way. Waistcircumnference
The quantification or estimative of visceral fat is neces-
The measurement of waist circumference is widely
sary for nutritional clinical evaluation and several meth-
used and has been recommended for estimating the
odsandtechniqueshavebeendevelopedtoevaluateit.
proportion of abdominal adipose tissue. WC also has
theadvantageofbeingsimpleandhavingstrongcorre-
Methodsrelatedwiththeevaluationofvisceral
lation with body mass index and with visceral fat. Its
FAT
mainlimitationconsistsofthedifferentmeasuringtech-
The more clinically convenient for evaluating visceral niques, which require proper training, especially in very
fat are the methods that may be performed quickly, obese individuals. With regards to the different tech-
Table1.Resumeofthemaincharacteristicsoftheanthropometricclinicalindicators.
Anthropometricclinicalindicators Maincharacteristics
-Evaluatescardiovascularriskandvisceralobesityandisoneofthecriteriafor
WaistCircumference(WC)
MetabolicSyndrome.
-WhenWCisoverhalfthevalueoftheindividualheight,itexpressesahealthrisk.
Waist-to-HeightRatio(WHtR) -Hasdiscriminatorypowerforvisceralobesity,cardiovascularrisk,highcoronaryand
mortalityrisk.
-Suggestedasareplacementforthewaist-heightratio
Waist-to-ThighRatio(WTR)
-Abletoestimatevisceralfatanditsrisks.
-Indicatoroffatdistribution.
Waist-to-HipRatio(WHR) -Caremustbetakenwheninterpretingindividualswithweightandcorporaladiposity
variations.
ConicityIndex(CI) -Abletoidentifyfatdistributionandtheriskofdiseases.
-Hasdiscriminatorypowerforvisceralobesity.
SagittalAbdominalDiameter(SAD)
-Indicatoroffatdistribution.
SagittalAbdominalDiameterHeight -Correlateswithcardiovascularriskandmaypredictmortality.
Index(SAD/Height) -Hasdiscriminatorypowerforvisceralobesity.
-Hasdiscriminatorypowerforvisceralobesity.
AbdominalDiameterIndex(ADI)
-Predictorofcardiovasculardiseases.
-Estimatesover-accumulationoflipids.
LipidAccumulationProduct(LAP)
-Expressesacontinuousriskandisapredictorofcardiovasculardiseasesandmortality.
-Expressesthefunctionofvisceralfat.
VisceralAdiposityIndex(VAI)
-Hascorrelationwithcardiometabolicriskassociatedwithvisceralobesity.
WC: Waist Circumference; SAD: Sagittal Abdominal Diameter; WHR: Waist Hip Ratio; WHtR: Waist-to- Height Ratio; WTR: Waist-to-Thigh
Ratio;SAD/Height:SagittalAbdominalDiameterHeightIndex;ADI:AbdominalDiameterIndex;CI:ConicityIndex;LAP:Lipidaccumulation
product;VAI:Visceraladiposeindex.
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ANTHROPOMETRICCLINICALINDICATORSINTHEASSESSMENTOFVISCERALOBESITY:ANUPDATE
Table2.Comparisonofstudiesevaluatingtherelationshipbetweenanthropometricclinicalindicatorsandvisceralfatmeasuredbycom-
putedTomography.
Studies Anthropometricclinicalindicatorsandvisceralfat
WC:M:r=0,73/F:r=0,77
Sampaioetal(2007):92Brazilians,>20years,both
sexes.ExcessVAT=100cm². WHR:M:r=0,58/F:r=0,72
VATmeasuredatL4-L5andWCatthemidpoint
SAD:M:r=0,64;AUC=0,89/F:r=0,80;AUC=0,84
Kandaetal(2007):419Japanesediabetic.
WC:M:r=0,78/F:r=0,82
VATmeasuredatL4-L5.NotreportedtechniqueforWC.
WC:r=0,66
Demura&Sato(2007):112Japonese,bothsexes.
VATmeasuredatL4-L5.WC:umbilicallevel.
WHR:r=0,55
WC:r=0,62
Bouzaetal,(2008):108obese,bothsexes.
VATmeasuredatL4-L5andWCatthemidpoint.
WHR:r=0,61
WC:r=0,823
Wuetal(2009):111Chinesemen(40-60years).
WHtR:r=0,868
VATmeasuredatL4-L5.WC:umbilicallevel.
WHR:r=0,654
WC:M:r=0,84/F:r=0,867
Berkeretal(2010):104bothsexes.
VATmeasuredatL4-L5andWCatthemidpoint.
WHR:M:r=0,739/F:r=0,612
WC:r=0,85
Gradmarketal(2010):16menand13Swedish
women. WHtR:r=0,81
VAT:L4(singlecut).WC:atthemidpoint.
WHR:r=0,81
Yimetal(2010):5257Koreans,bothsexes. WC:M:r=0,705/F:r=0,636
TAV:measuredattheumbilicus.
WC:atthemidpoint. SAD:M:r=0,804/F:r=0,724
WC:M:r=0,75inadultsandr=0,77inelderly/F:r=0,75inadults
andr=0,64inelderly/AUC>0,80
Rorizetal(2011):197Brazilians≥20years,both
WHR:M:r=0,69inadultsandr=0,72inelderly/F:r=0,69inadults
sexes.ExcessVAT≥130cm².
andr=0,49inelderly
VATmeasuredatL4-L5.WCatthemidpoint.
SAD:M:r=0,70inadultsandr=0,78inelderly;AUC>0,79/
F:r=0,74inadultsandr=0,65inelderlyAUC>0,84
WC:r>0,61
Barreiraetal(2012):2.037individualsofabiracial
sample(18-69years). WHtR:r>0,59
VATatL4-L5.WCatthemidpoint.
WHR:r>0,50
WC:WaistCircumference;SAD:SagittalAbdominalDiameter;WHR:WaisttoHipRatio;WHtR:Waist-to-HeightRatio;WTR:Waist-to-Thigh
Ratio;SAD/Height:SagittalAbdominalDiameterHeightIndex;ADI:AbdominalDiameterIndex;CI:ConicityIndex;VAI:Visceraladiposein-
dex; LAP: Lipid accumulation product; VAT: Visceral adipose tissue area (cm²) measured by computed tomography. M: men and F: female.
AUC:Areaundercurve(ROCcurve).Allcorrelactions:p<0,05.
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NUTRICIÓNCLÍNICAYDIETÉTICAHOSPITALARIA
Table 2. continuación. Comparison of studies evaluating the relationship between anthropometric clinical indicators and visceral fat
measuredbycomputedTomography.
Studies Anthropometricclinicalindicatorsandvisceralfat
WC:M:r=0,76inadultsandr=0,74inelderly/F:r=0,75inadults
andr=0,60inelderly
WHtR:M:r=0,79inadultsandr=0,79inelderly/F:r=0,73in
adultsandr=0,64inelderly/AUC>0,81
WTR:M:r=0,64inadultsandr=0,62inelderly/M:r=0,53inadults
Rorizetal(2014):194Brazilians≥20years,both andr=0,35inelderly
sexes.ExcessVAT≥130cm².
VATmeasuredatL4-L5.WCatthemidpoint. SAD:M:r=0,70inadultsandr=0,76inelderly/F:r=0,75inadults
andr=0,62inelderly
SAD/Height:M:r=0,78inadultsandr=0,79inelderly/F:r=0,73
inadultsandr=0,64inelderly/AUC>0,84
ADI:M:r=0,60inadultsandr=0,66inelderly/F:r=0,67inadults
andr=0,48inelderly/AUC>0,73
WHtR:M:r=0,79inadultsandr=0,80inelderly/F:r=0,73inadults
andr=0,64inelderly/AUC>0,81
CI:M:r=0,68inadultsandr=0,82inelderly/F:r=0,72inadultsand
Rorizetal(2014):191Brazilians≥20years,both r=0,47inelderly
sexes.ExcessVAT≥130cm².
VATmeasuredatL4-L5.WCatthemidpoint. LAP:M:r=0,70inadultsandr=0,73inelderly/F:r=0,61inadults
andr=0,60inelderly/AUC>0,78
VAI:M:r=0,50inadultsandr=0,56inelderly/F:r=0,38inadults
andr=0,47inelderly/AUC>0,65
WC:WaistCircumference;SAD:SagittalAbdominalDiameter;WHR:WaisttoHipRatio;WHtR:Waist-to-HeightRatio;WTR:Waist-to-Thigh
Ratio;SAD/Height:SagittalAbdominalDiameterHeightIndex;ADI:AbdominalDiameterIndex;CI:ConicityIndex;VAI:Visceraladiposein-
dex; LAP: Lipid accumulation product; VAT: Visceral adipose tissue area (cm²) measured by computed tomography. M: men and F: female.
AUC:Areaundercurve(ROCcurve).Allcorrelactions:p<0,05.
niques for measuring it, a systematic review of 120 well as for women (r > 0.77). Studies with obese pa-
studies revealed that the place of measurement has no tients21 and in Japanese people22 observed correlation
substantial influence over the association between WC, equal to 0.62 and 0.66 with visceral fat, respectively.
cardiovascular diseases, diabetes and mortality risk14. Berker et al.23 observed correlation over 0.84 for men
However, it is a consensus that the most used tech- and women, however when the sample by total body
nique is the one recommended by the WHO, measured mass was stratified over or below 30kg/m² the correla-
through the mean point between the last rib and the il- tions with visceral fat decreased.
iac crest15,16.
InRorizetal.19studytherewaspositivecorrelationin
Currently, this indicator has been receiving important
adults and elderly, being more strong in elderly men
attention in evaluating cardiovascular risk because it is
(r=0.77). The cutoff points that identified a VAT area of
a strong predictor of visceral fat with a correlation over
risk (≥130cm²) were below the ones recommended by
0.70 with VAT, being also one of the criteria to define
WHO15inmen(adults=90.2cmandelderly=82.2cm)
the metabolic syndrome17-19.
andoverthemamongwomen(adult=92.3cmandeld-
It may be observed, in Table 2, that Kanda et al.20 erly=88.2cm),concludingthatthecutoffpointsofWC
and Sampaio et al.18 studies show significant correla- as a predictor of visceral obesity in elderly are lower
tion between WC and VAT both for men (r > 0.73) as than the ones in adults.
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ANTHROPOMETRICCLINICALINDICATORSINTHEASSESSMENTOFVISCERALOBESITY:ANUPDATE
However using only the waist circumference may ceral fat, in adults and elderly of both sexes and
have an important limitation. For a given measurement showed that when WC was divided by height it had a
of waist circumference, some individuals will have an better discriminatory power for detecting visceral obe-
increased amount of visceral fat, while in others the sity with cutoffs of 0.54 and 0.55 in men and of 0.59
larger content may be subcutaneous, thus, not distin- and 0.58 in adult women and in elderly, respectively.
guishing visceral fat from the subcutaneous one24.
Among the mechanisms which explain the health
Among women in advanced age, for the same WC,
risk previewed by WHtR it is suggested that the risk
there is a larger amount of visceral fat than among
may be explained due to its strong association with el-
younger women6.
evations of abdominal obesity which trigger the men-
tioned morbidities.
Waist–to-heightratio
The value of WC will depend on the individual height Waist-to-thighratio
inordertoexpressahealthrisk.Thus,itsinterpretation
The Waist-to-Thigh Ratio is found by dividing the
must be judicious, especially when individually and iso-
waist circumference by the thigh circumference. It was
latedly evaluated. Thus, by taking height into consider-
suggested as a substitute of the Waist-to-Hip Ratio and
ation, the Waist-to-Height Ratio seems to be better
able to estimate visceral fat and its respective risks39.
than WC for discriminating cardiometabolic risk, espe-
WTR does not considers the proportionality regarding
cially in individuals of short stature25.
the stature, it may remain unchanged if there is a pro-
WHtR is determined by the ratio between WC (cm) portional increase or decrease in the measurement of
and Height (cm), and is considered a simple, fast, low its circumferences.
cost trial tool superior than BMI for evaluating health
There are few studies comparing this index with WC
risksandmortalitybycardiovasculardisease(CVD)and
alone. Most of the studies with WTR investigated its re-
for all the causes26-28.
lationship with diseases in consequence of obesity and
Despitethelimitationrepresentedbytheabsenceof not with visceral fat as this work pretended. Roriz et
a specific cutoff point, the average value of 0.50 was al.37 observed strong correlation of WTR with the vis-
suggested, allowing its use in both sexes, different ceral fat area, except in elderly women and good accu-
age groups and ethnicities for predicting cardiometa- racy in discriminating the excess of this adiposity. Most
bolic risk29-31. This value has been used to support the of the studies related this indicator with other outcom-
simple message of public health “keep your waist cir- ings40-42. In a sample representing 11.437 american
cumference between the half of your height”. adults it was observed that WTR had the stronger as-
However, a meta-analysis found that in non-Asian sociationwithmortalityandthattheincreaseinmortal-
populations the ideal cutoff was higher than in Asian ity risk of men was not specially related with increased
ones25. The different measurement techniques of WC WC,butwitharelativedecreaseofthethighcircumfer-
and the height averages between the population ence43. Reis et al.44 showed that WTR and WHR in-
would justify this variation. crease the prediction of mortality in individuals with
normal weight and in obese ones.
Several studies showed discriminatory power of
WHtR for different morbidities, mainly high cardiovas-
Waist-to-hipratio
cular and coronary risk as well as for mortality6,30,32-34.
However, few studies evaluated the relation between The Waist-to Hip Ratio is determined by the division
WHtR and the VAT area measured by CT. Barreira et between waist circumference and hip circumference. It
al.17 in an study with 2037 individuals between 18 and is an indicator used to identify the type of body fat dis-
29 years old from a biracial sample verified correlations tribution. Values above 1.00 for men and 0.85 for
over 0.59 and Gradmark et al.35 observed high correla- women indicate a distribution of the android type, cen-
tions (r> 0.81) of WHtR and WC with the area of vis- tral or abdominal, considered as risky for development
ceral fat measured by CT in Swedish adults. Wu et al.36 of cardiovascular diseases due to the great concentra-
showed that WHR was a stronger predictor of visceral tion of fat in this region. Values above those cutoffs in-
fat than WC, BMI or WHtR in Chinese men. Studies in dicate a distribution of the gynaecoid type, peripheral
Brazil37,38observedstrongcorrelationof WHtRwith vis- or gluteal-femoral of smaller cardiovascular risk45.
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NUTRICIÓNCLÍNICAYDIETÉTICAHOSPITALARIA
One of the main limitations for its practical use is its Despite existing a relationship between CI and the
incapacity of detecting changes during the follow-up of mentioned morbidities there is a lack of studies using
individuals in treatment for weight loss, since the WC the index as a predictor of visceral obesity.
measurement varies simultaneously with the hip meas-
urement, keeping WHR constant. Also, hip measure- Sagittalabdominaldiameter
ment does not considers variations in the pelvic struc-
Sagittal Abdominal Diameter may be measured an-
turebetweenindividuals,northereductionoftissuesin
thropometricallyorbyimagemethods,suchasCT.SAD
thisareawiththeagingprocess.Thereis,still,incapac-
has been appointed as an important anthropometric in-
ity of WHR in differentiating accumulation of subcuta-
dicator for estimating visceral adipose tissue18,19,52,53.
neous visceral fat46. Independently of body adiposity
the individuals may have equal values of WHR, even Themeasurementinsupinepositionbetterestimates
with substantial inter-individual variation in the total thefattissuesmoreassociatedwithCVDrisk,beingthis
body fat and in the areas of visceral and subcutaneous the more widely used technique by researchers. This
and visceral abdominal adipose tissue47. technique is based in the principle that with individuals
in this position the increase of visceral fat accumulation
Several studies evaluated the correlation between
keeps the abdomen height in the sagittal position while
WHRandvisceralfat observingthatincomparisonwith
subcutaneous abdominal fat reduces abdominal height
other anthropometric indicators, WHR had smaller cor-
due to the force of gravity54.
relationwiththistissue17-19,21-23,35,36.Theuseofthisin-
dicator as a predictor of visceral fat must be cautious, From SAD other anthropometric indexes are derived,
mainly in individuals with variations of weight and body the ratio between SAD and height (SAD/Height) and
adiposity. the ratio between SAD and WTR or the Abdominal
Diameter Index (ADI). SAD/Height has similar or supe-
rior correlation with cardiovascular risk when compared
Conicityindex
withWHRandmaypredictmortalityaswellasSAD47,55.
Conicity index has the objective of identifying the ADI is considered as an effective indicator for estimat-
distribution of fat and the risk of diseases. This index ing visceral adipose tissue, a better predictor of coro-
is based on the idea that the human body changes nary disease than WTR and of risk for cumulative inci-
from a cylindrical shape to a “double cone” with the dence of ischemic CVD56,57.
accumulation of fat around the waist and its theoreti-
However SAD has been studied more as an isolated
calrangevariesfrom1.00to1.73.TheCIiscalculated
measure of fat distribution than its indexes and, when
by the following equation48: WC/0.109 √(BW/H)
related with the other anthropometric indicators or clin-
where: WC = waist circumference (m); BW = body
icalparameters,showstobesuperiorasameasurement
weight (kg); H = height (m).
of visceral obesity and coronary disease index. Stevens
One limitation for using CI in epidemiological studies et al.58 suggested WC and SAD instead of BMI for eval-
is the lack of consensus about cutoffs for identifying uating the cardiovascular risk profile among individuals
cardiovascular risk, besides the difficulty of calculation in different populations and ethnicities. Other studies
proposed by its formula. Pitanga & Lessa49 proposed a show SAD as a marker of risk factors for CVD53,59-61.
table with values for the denominator of the CI equa-
Sampaio et al.18 carried the first study of SAD valida-
tion for the ease of use.
tion in Brazil and observed high reliability (inter-class
Thisindexincreasesaccordingtotheaccumulationof coefficient = 0.99) and high correlation of this measure
abdominal fat increasing the risk of diseases47. Studies and abdominal visceral fat area measured by CT
show that CI has been a good predictor of High (r=0.80 for women and r=0.64 for men). Cutoffs of
Coronary Risk with the Area Under the ROC Curve of 19.3 cm and 20.5 were identified for men and women,
0.80 (95%CI:0.74-0.85) inmen, of cardiovascular risk respectively,withbettersensibilityandspecificitycorre-
and hypertension in adults49-51. A study with 191 sponding to the area of visceral fat excess (> 100cm²).
Brazilians38observedstrongcorrelationandaccuracyof AnotherBrazilianstudy19withalargersampleobserved
CI with the area of visceral adipose tissue measured by correlationsover 0.7between SADandvisceral fat area
CT, especially in adults (r= 0.68) and elderly (r=0.82) and posteriorly SAD indexes were evaluated, with high
men and in adults women ( r= 0.72). correlation being observed between SAD/Height and
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175
ANTHROPOMETRICCLINICALINDICATORSINTHEASSESSMENTOFVISCERALOBESITY:ANUPDATE
ADI and this fat, especially in men, with greater accu- ing the altered production of adipocytokines, increase
racy for SAD/Height (AUC-ROC > 0.84) showing better of lipolysis, plasma and free fatty acids – factors that
influence of height in SAD measurement for discrimi- are not identified by BMI, WC, TG and high density
nating visceral obesity ( VAT area ≥ 130m²)37. lipoproteins (HDL) separately8. In consequence, it is an
index proposed as a substitute marker of dysfunction
Yim et al.62 observed greater correlation of SAD with
and distribution of adipose tissue and independently
visceral fat than WC in 5,257 adult Koreans, in both
correlatedwithcardiometabolicriskassociatedwithvis-
sexes. Kullberg et al.63 showed correlations over 0.78,
ceral obesity. The visceral adiposity index (VAI) is ob-
however, visceral fat was measured by magnetic reso-
tained by formulas proposed by Amato et al.8: for fe-
nance and not CT, the focus of this study.
males VAI = (WC/36.58+(1.89 x BMI)) x (TG/0.81)
AlthoughSADanditsindexesaresimpleandlowcost x (1.52/HDL) and for males, VAI= (WC/39.68+(1.88
methods, it is unlikely that they will replace the indica- x BMI)) x (TG/1.03) x (1.31/HDL).
tors that contemplate circumferences, measured by in-
Knowles et al.67 showed that VAI, WC and WHtR are
elastic tape, of large applicability in clinical practice.
correlated with cardiovascular risk as predictors of
Vasques et al.64 in their revision study with some of
Metabolic Syndrome. Bozorgmanesh et al.68 and Elisha
those indicators verified that, generally, WC and SAD
et al.69 showed that VAI was not superior than anthro-
correlated more with visceral fat than BMI and WHR.
pometric indicators, being a weak indicator for forecast-
ing cardiovascular diseases and for visceral adipose tis-
Lipidicaccumulationproduct
suefunction.Rorizetal.38observedpositivecorrelation,
Lipidic Accumulation Product is a simple indicator de- especially in adult and elderly men, as showed in Table
velopedtoexpressacontinuousriskandpredictorofcar- 2.Astudy70observedhighcorrelationofserumlevelsof
diovasculardiseasesandmortalityandisobtainedbyfor- triglycerides and HDL, mainly in elderly, which com-
mulas proposed by Kahn9. For the masculine sex, LAP = pound VAI formulas and concluded that the average of
(CC[cm] – 65) × (triglycerides [mmol/L]) and feminine, the visceral adipose tissue area was always more ele-
LAP= (CC[cm] –58) × (triglycerides [mmol/L]). It esti- vated when triglycerides values were altered, both in
mates the over-accumulation of lipids and suggests that adults and elderly.
the values of WC and serum triglyceride (TG) are prone
The VAI is proposed as being able to evaluate the
toaccumulatealongtime,inotherwords,theyexpressa
dysfunction of the adipose tissue and its association
functionofconstantriskassociatedwiththecardiovascu-
with cardiometabolic risk, mainly in the absence of a
lar risk among adults9.
manifested metabolic syndrome7.
Kahn9 stated that LAP rises faster according to the
Both LAP and VAI are still few explored about their
age for men than for women, which may contribute for
capacity of discriminating visceral fat excess, especially
the increase of cardiovascular events in younger men.
measured by CT. However, those indicators have large
Studies presented more discriminatory capacity of LAP
possibilities for future investigations.
for the incidence of diabetes similarly to BMI, WHR and
WHtR and for identifying Metabolic Syndrome in men
and women65,66. METHODOLOGICAL LIMITATIONS
Recently, Roriz et al.38, was the first one evaluating Most of the studies used different methodologies re-
the performance of LAP for discriminating visceral fat garding anthropometric techniques and the image
and observed correlations over 0.7 in men and over method for quantifying visceral fat, besides different
0.60 in women, with area under the ROC curve over cutoffs of the TAV area. The lack of standardization be-
0.78 and cutoffs ranging from 26.4 to 37.4 in men and tween the adopted protocols indicates a limiting factor
from 40.6 to 44.0 in women, showing the good accu- when comparing data from the different studies.
racy of this indicator.
CONCLUSION
Visceraladiposityindex
Considering the importance of visceral fat as a deter-
The Visceral Adiposity Index also expresses the func- minant of metabolic changes associated with obesity,
tion of visceral fat and its peculiarity consists in reflect- the replacement of CT by simpler methods of low cost
Nutr.clín.diet.hosp.2016;36(2):168-179
176
NUTRICIÓNCLÍNICAYDIETÉTICAHOSPITALARIA
and free of radiation means an advancement in the di- 5. Van Der Kooy K, Seidell JC. Techniques for the measurement of
agnosis of visceral obesity and in the prevention of visceral fat: a practical guide. Int J Obes Relat Metab Disord,
1993;17(4):187-96.
events associated with this adiposity.
6. Pitanga FJG. Anthropometry for the assessment of abdominal
Most of the studies evaluated the relationship be-
obesity and coronary risk. Rev Bras Cineantropom Desempenho
tween anthropometric clinical indicators with diseases Hum,2011;13(3):238–241.
resulting from visceral obesity, however, this work con-
7. AmatoMC&GiordanoC.VisceralAdiposityIndex:AnIndicatorof
cluded that there are few recent studies evaluating the Adipose Tissue Dysfunction. International Journal of Endocri-
relationship between those indicators and visceral fat nology,2014:1-7.
measured by CT, especially with the ones derived from
8. AmatoMC,GiordanoC,GaliaM,CriscimannaA,VitabileS,etal.
WC and SAD, LAP and VAI. Visceral Adiposity Index: a reliable indicator of visceral fat func-
tion associated with cardiometabolic risk. Diabetes Care, 2010;
In face of the presented studies, the most consistent
33:920–922.
results were fromWC,WHtR,CIandSADbecausethey
9. KahnH.The“lipidaccumulationproduct”performsbetterthanthe
have better correlation and accuracy for estimating vis-
bodymassindexforrecognizingcardiovascularrisk:apopulation-
ceral fat when compared with the other indicators. The
basedcomparison.BMCCardiovascularDisorders,2005;5:26.
remaining indicators have been demonstrating positive
10.Vague J. The degree of masculine differentiation of obesities: a
results, however, WC and WHtR have the advantage of
factor determining predisposition to diabetes, atherosclerosis,
being more practical, fast, simple and not demanding
goutanduriccalculousdisease.AmJClinNutr.,1956;4:20-34.
formulas.
11.PinheiroMAS;WellingtonOLJ;AlvesdeCSH.AbdominalObesity
Generally, the anthropometric clinical indicators are in Elderly with Prostate Cancer of Ceara, Brazil. Nutr Clín Diet
Hosp,2013;33(2):23-29.
accurate for estimating visceral fat. However, caution
must be taken when interpreting those indicators, es- 12.Klein S. Is Visceral Fat Responsible for the Metabolic Abnor-
pecially when evaluated individually and isolatedly. The malities Associated With Obesity? Diabetes Care, 2010; 33 (7):
1693-1994.
investigation about alternative methods which estimate
visceral obesity is essential for the decision taking dur- 13.BjörntorpP.Theassociationsbetweenobesity,adiposetissuedis-
ing the nutritional clinical evaluation able to intervene tributionanddisease.ActaMedScand,1998;723:121-34.
earlier and more effectively in the prevention of dis- 14. Ross R, Berentzen T, Bradshaw AJ, Janssen I, Kahn HS,
eases risk. KatzmarzykPT,etal.Doestherelationshipbetweenwaistcircum-
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ACKNOWLEDGEMENTS
15.World Health Organization - Obesity Preventing and managing
The authors thank the CNPq (Conselho Nacional de the Global Epidemic. Report of a WHO Consultation on Obesity.
Desenvolvimento Científico e Tecnológico) and CAPES Geneva,WHO/NUT/NCD,1998.
Foundation (Ministry of Education of Brazil). 16. AshwellM,BrowningLM.TheIncreasingImportanceofWaist-to-
HeightRatiotoAssessCardiometabolicRisk:APleaforConsistent
Terminology.TheOpenObesityJournal,2011,3,70-77.
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