Measuring heart illness and obesity danger in Indians: Why BMI (physique mass index) need to alter to WHtR (waist to height) ratio

Although obesity has been noted ever due to the fact humans gave up forest meals foraging for farming, the large surge in overweight populations and obesity is a a lot more current malady of maladapted modernity. It has been driven by enhanced consumption of power dense and ultra-processed foods as properly as sugar sweetened beverages coupled with sedentariness and decreased power expenditure. The Planet Heart Federation (WHF) estimates that two.three million kids and adults are at present overweight or obese the planet more than, with a projected rise to two.five billion by 2025.

The standard measure of becoming overweight and obese is the physique mass index (BMI) which relates weight to height via a metric which reads BMI = weight (in Kilograms)/height (in metres) squared. The regular globally applied definition of overweight is a BMI of 25-&lt30 and of obesity 30 or above. A BMI reduce than 18.five is classified as underweight. These reduce-offs are regarded as normally to be predictive of wholesome life expectancy in the ‘normal’ variety involving 18.five and 24.9. Getting overweight and obesity are related with an enhanced danger of cardiovascular illnesses, diabetes, some cancers, osteoarthritis, liver, gallbladder and respiratory difficulties.

BMI DOES NOT Aspect IN RACE Variations

Nonetheless, these ‘universal’ reduce-offs, which had been created in Caucasian populations, proved to be inappropriate for other populations. Recognising that Asian populations manifested a increasing danger of diabetes and cardiovascular illness at reduce levels of BMI, the Planet Wellness Organisation (WHO) encouraged that public well being and clinical action thresholds need to be reset for these populations at BMIs 23 and 27.five, with the excellent variety becoming involving 18.five and 23. Although these are interpreted as Asian reduce-offs for defining overweight and obesity respectively, international comparisons across all nations mainly use reduce-offs of 25 and 30. Reduce BMI reduce-offs are becoming encouraged for Black African and Black Caribbean populations also.

The issue with BMI is that it does not differentiate involving weight contributed by fat, muscle and bone. A extremely muscular person may possibly have a BMI more than 30, inviting the label of becoming obese, even if the physique fat content material is not higher. Similarly, a individual with low muscle mass or low bone weight may possibly have a BMI of 22 but nevertheless be at a higher danger of diabetes, hypertension and heart attacks. Although BMI broadly correlates with the prevalence of cardio-metabolic illnesses at the population level, it does not distinguish properly at the person level.

This issue of misclassification of danger has been especially prominent in South Asians of the Indian sub-continent. It was initially noted amongst Indian migrants studied in unique continents. Their enhanced propensity for diabetes and excess danger of heart attacks was not explained by a higher BMI, as numerous had values inside the ’normal’ variety. They, even so, had higher amounts of physique fat, specifically concentrated about the abdominal organs. Such ‘visceral adiposity’ or ‘abdominal obesity’ poses a higher danger of diabetes and heart illness. Some international algorithms for predicting the danger of a future cardiovascular occasion now use ‘South Asian ethnicity’ as an independent danger marker.


These findings have also been corroborated by a number of research of Indians residing in unique components of India. Far more than BMI, the waist to hip ratio (WHR) has emerged as a much better predictor of diabetes and cardiovascular illness than BMI. This index, which compares the waist circumference to that about the hips, measures the degree of abdominal obesity. Considering the fact that it is not normally effortless to measure the hip circumference, specifically when clothes is interposed involving the tape and the physique, an alternate measure has emerged in current years. This is the waist to height ratio (each expressed in centimetres). This ratio has been shown to be a extremely very good predictor of cardio-metabolic danger, undoubtedly much better than BMI and in some research even much better than WHR. Initially created, validated and applied in kids, it is becoming increasingly employed in adults.

In December 2022, UK’s National Institute for Wellness and Care Excellence (Good) encouraged that waist-to-height ratio be employed rather of BMI. A ratio larger than .five carries an enhanced danger of cardio-metabolic illness. This connection does not seem to be altered by variations in race, age or gender.


1 of the consequences of applying a flawed measure like BMI has been the reporting of an ‘obesity paradox’ exactly where obesity appeared to be protective in some well being circumstances. It was reported that it may possibly defend against deaths from heart failure, stroke and diabetes. These research have been criticised on the ground that the contributions of physique fat, muscle, bone and fluids to the excess weight have not been assessed. Similarly, the higher prevalence of ‘thin diabetes’ in India will seem puzzling if the physique fat content material and visceral adiposity are not taken into account.

A current study, even so, showed that the fallacy about ‘protective obesity’ arose for the reason that BMI was measuring physique weight rather than physique fat, which is primarily accountable for inflammation and illness. Published on March 22, in the ‘European Heart Journal,’ the study looked at the clinical outcomes in persons with chronic heart failure and decreased ejection fraction (pumping capacity) of the heart. Scientists analysed information from six,567 guys and 1,832 females participating in the PARADIGM-HF heart failure trial, which was carried out in 47 nations. Although unadjusted BMI-primarily based evaluation appeared to help the concept of the ‘obesity paradox’, evaluation with adjustment for other variables removed that impact. Far more vital, the use of waist to height ratio showed a constructive correlation with larger mortality danger.

Fluid retention happens in heart failure, adding to physique weight but not reflecting the adipose tissue content material of the physique. Waist to height ratio is unaffected by that altered weight. Immediately after adjustment, each BMI and waist-to-height ratio showed that larger levels had been related with a higher danger of death or hospitalisation for heart failure, but this was a lot more evident for the waist-to-height ratio.


Race or ethnicity associated variations in BMI’s gradient of cardio-metabolic danger have implications for screening of persons at higher danger in a population. A current study, published on March 24, in the American Journal of Preventive Medicine, examined the influence of racial variations on population screening for diabetes in the US. The current recommendations of US Preventive Solutions Activity Force (USPTF) propose screening for pre-diabetes and diabetes in individuals aged 35-70 years, if they are overweight or obese by standard BMI requirements.

The authors of the new study reported that such screening underestimated the numbers with diabetes or pre-diabetes in Asian, Hispanic and non-Hispanic Black adults. The percentage of situations identified amongst persons of Asian ethnicity was considerably reduce amongst the Asians residing in America, compared to other racial groups, when the age cum BMI criteria had been employed, compared to measured blood glucose values. They propose that the BMI primarily based screening criteria be dropped and all adults in the age group of 35-70 be screened. Matthew O’Brien, lead author of the study avers that such a revised tactic would market higher well being equity, by decreasing the impact of racial variations. Maybe the USPTF need to appear at waist-to-height ratio also!

From this welter of details, a clear message emerges for us to use in India. Waist to height ratio more than .five = visceral adiposity = raised danger of obesity associated illnesses. Performs for kids, females and guys.

(Prof K. Srinath Reddy is a cardiologist, epidemiologist and Distinguished Professor of Public Wellness, PHFI)

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