Diabetes Metab J.  2015 Jun;39(3):253-263. 10.4093/dmj.2015.39.3.253.

Optimal Waist Circumference Cutoff Value Based on Insulin Resistance and Visceral Obesity in Koreans with Type 2 Diabetes

• Lim JS
• Choi YJ
• Kim SK
• Huh BW
• Lee EJ
• Huh KB

• KMID: 2281539
• DOI: http://doi.org/10.4093/dmj.2015.39.3.253

Abstract

BACKGROUND
Visceral obesity is the most powerful contributor to the development of metabolic syndrome (MetS) and cardiovascular diseases. In light of visceral obesity, however, there is a paucity of data on the appropriate cutoff point of waist circumference (WC) in subjects with type 2 diabetes. The aim of this study was to investigate the optimal cutoff value for WC that signals insulin resistance (IR) and visceral obesity in Koreans with type 2 diabetes.
METHODS
We evaluated 4,252 patients with type 2 diabetes (male 2,220, female 2,032, mean age 57.24 years) who visited our clinic between January 2003 and June 2009. WC was measured at the midpoint between the lower rib and the iliac crest, and insulin sensitivity was assessed by the rate constant of plasma glucose disappearance (Kitt %/min) using an insulin tolerance test. Visceral fat thickness was measured using ultrasonography. Statistical analysis was performed using receiver operating characteristic curve.
RESULTS
The optimal cutoff points for WC for identifying the presence of IR and visceral obesity, as well as two or more metabolic components, were 87 cm for men and 81 cm for women. Moreover, these cutoff points had the highest predictive powers for the presence of visceral obesity. The MetS defined by new criteria correlated with the increased carotid intima-media thickness in female subjects.
CONCLUSION
Our results suggest that the optimal cutoff values for WC in Koreans with type 2 diabetes should be reestablished based on IR and visceral obesity.

Keyword

Diabetes mellitus, type 2; Insulin resistance; Obesity, abdominal; Waist circumference

MeSH Terms

Blood Glucose
Cardiovascular Diseases
Carotid Intima-Media Thickness
Diabetes Mellitus, Type 2
Female
Humans
Insulin
Insulin Resistance*
Intra-Abdominal Fat
Male
Obesity, Abdominal*
Ribs
ROC Curve
Ultrasonography
Waist Circumference*
Insulin

Figure

• 

  Fig. 1 Receiver operating characteristic analysis of waist circumference (WC) to detect the presence of two or more metabolic components, visceral obesity, and insulin resistance (IR) in (A) men and (B) women with type 2 diabetes. The higher the area under the curve, the greater the predictive power. A WC of 87 cm for men (black circles) and 81 cm for women (black triangles) was chosen as the discriminating value to predict two or more metabolic components, and the presence of visceral obesity and IR. These cutoff points had the highest predictive powers for the presence of visceral obesity. Moreover, they had higher sensitivity and specificity compared to the previous criteria—90 cm for men (black squares) and 85 cm for women (black diamonds)—proposed by the Korean Society for the Study of Obesity. Visceral obesity was defined as a visceral fat thickness of greater than 47.6 mm for men and 35.5 mm for women, and IR was defined as the low tertile of insulin sensitivity.

• 

  Fig. 2 Differences in the prevalence of metabolic components according to Korean Society for the Study of Obesity (KOSSO) criteria and our criteria in (A) men and (B) women with type 2 diabetes. Compared to metabolic syndrome (MetS) as defined by the KOSSO criteria, the prevalence of each metabolic component, including hypertriglyceridemia (hyper-TG), low high density lipoprotein (HDL) cholesterol, and hypertension (HTN), was significantly greater in both sexes when our criteria were used to define MetS.

Reference

1. Inzucchi SE, Bergenstal RM, Buse JB, Diamant M, Ferrannini E, Nauck M, Peters AL, Tsapas A, Wender R, Matthews DR. Management of hyperglycaemia in type 2 diabetes: a patient-centered approach. Position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia. 2012; 55:1577–1596.

2. Alberti KG, Eckel RH, Grundy SM, Zimmet PZ, Cleeman JI, Donato KA, Fruchart JC, James WP, Loria CM, Smith SC Jr. International Diabetes Federation Task Force on Epidemiology and Prevention. Hational Heart, Lung, and Blood Institute. American Heart Association. World Heart Federation. International Atherosclerosis Society. International Association for the Study of Obesity. Harmonizing the metabolic syndrome: a joint interim statement of the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity. Circulation. 2009; 120:1640–1645.

3. Grundy SM. Metabolic syndrome pandemic. Arterioscler Thromb Vasc Biol. 2008; 28:629–636.

4. Alexander CM, Landsman PB, Teutsch SM, Haffner SM. Third National Health and Nutrition Examination Survey (NHANES III). National Cholesterol Education Program (NCEP). NCEP-defined metabolic syndrome, diabetes, and prevalence of coronary heart disease among NHANES III participants age 50 years and older. Diabetes. 2003; 52:1210–1214.

5. Hayashi T, Boyko EJ, McNeely MJ, Leonetti DL, Kahn SE, Fujimoto WY. Visceral adiposity, not abdominal subcutaneous fat area, is associated with an increase in future insulin resistance in Japanese Americans. Diabetes. 2008; 57:1269–1275.

6. Miller MR, Pereira RI, Langefeld CD, Lorenzo C, Rotter JI, Chen YD, Bergman RN, Wagenknecht LE, Norris JM, Fingerlin TE. Levels of free fatty acids (FFA) are associated with insulin resistance but do not explain the relationship between adiposity and insulin resistance in Hispanic Americans: the IRAS Family Study. J Clin Endocrinol Metab. 2012; 97:3285–3291.

7. Bergman RN, Kim SP, Hsu IR, Catalano KJ, Chiu JD, Kabir M, Richey JM, Ader M. Abdominal obesity: role in the pathophysiology of metabolic disease and cardiovascular risk. Am J Med. 2007; 120:2 Suppl 1. S3–S8.

8. Fujioka S, Matsuzawa Y, Tokunaga K, Tarui S. Contribution of intra-abdominal fat accumulation to the impairment of glucose and lipid metabolism in human obesity. Metabolism. 1987; 36:54–59.

9. Chan JM, Rimm EB, Colditz GA, Stampfer MJ, Willett WC. Obesity, fat distribution, and weight gain as risk factors for clinical diabetes in men. Diabetes Care. 1994; 17:961–969.

10. Klein S, Allison DB, Heymsfield SB, Kelley DE, Leibel RL, Nonas C, Kahn R. Association for Weight Management and Obesity Prevention. NAASO. Obesity Society. American Society for Nutrition. American Diabetes Association. Waist circumference and cardiometabolic risk: a consensus statement from shaping America's health: Association for Weight Management and Obesity Prevention; NAASO, the Obesity Society; the American Society for Nutrition; and the American Diabetes Association. Diabetes Care. 2007; 30:1647–1652.

11. Kim HI, Kim JT, Yu SH, Kwak SH, Jang HC, Park KS, Kim SY, Lee HK, Cho YM. Gender differences in diagnostic values of visceral fat area and waist circumference for predicting metabolic syndrome in Koreans. J Korean Med Sci. 2011; 26:906–913.

12. Alberti KG, Zimmet P, Shaw J. Metabolic syndrome: a new world-wide definition. A Consensus Statement from the International Diabetes Federation. Diabet Med. 2006; 23:469–480.

13. McKeigue PM, Shah B, Marmot MG. Relation of central obesity and insulin resistance with high diabetes prevalence and cardiovascular risk in South Asians. Lancet. 1991; 337:382–386.

14. Lee SY, Park HS, Kim DJ, Han JH, Kim SM, Cho GJ, Kim DY, Kwon HS, Kim SR, Lee CB, Oh SJ, Park CY, Yoo HJ. Appropriate waist circumference cutoff points for central obesity in Korean adults. Diabetes Res Clin Pract. 2007; 75:72–80.

15. Matsuzawa Y. Metabolic syndrome: definition and diagnostic criteria in Japan. J Atheroscler Thromb. 2005; 12:301.

16. Zhou BF. Cooperative Meta-Analysis Group of the Working Group on Obesity in China. Predictive values of body mass index and waist circumference for risk factors of certain related diseases in Chinese adults: study on optimal cut-off points of body mass index and waist circumference in Chinese adults. Biomed Environ Sci. 2002; 15:83–96.

17. Park JY, Kim HK, Kim MS, Park KS, Kim SY, Cho BY, Lee HK, Koh CS, Min HK. Body weight changes of non-insulin dependent diabetic patients in Korea. J Korean Diabetes Assoc. 1993; 17:51–58.

18. Kim DJ, Lee MS, Kim KW, Lee MK. Insulin secretory dysfunction and insulin resistance in the pathogenesis of Korean type 2 diabetes mellitus. Metabolism. 2001; 50:590–593.

19. Bonora E, Moghetti P, Zancanaro C, Cigolini M, Querena M, Cacciatori V, Corgnati A, Muggeo M. Estimates of in vivo insulin action in man: comparison of insulin tolerance tests with euglycemic and hyperglycemic glucose clamp studies. J Clin Endocrinol Metab. 1989; 68:374–378.

20. Young RP, Critchley JA, Anderson PJ, Lau MS, Lee KK, Chan JC. The short insulin tolerance test: feasibility study using venous sampling. Diabet Med. 1996; 13:429–433.

21. Alberti KG, Daly ME, Robinson A, Marshall SM, Mathers JC. The short insulin tolerance test is safe and reproducible. Diabet Med. 1999; 16:352–353.

22. Kim SK, Kim HJ, Hur KY, Choi SH, Ahn CW, Lim SK, Kim KR, Lee HC, Huh KB, Cha BS. Visceral fat thickness measured by ultrasonography can estimate not only visceral obesity but also risks of cardiovascular and metabolic diseases. Am J Clin Nutr. 2004; 79:593–599.

23. Kim SK, Choi YJ, Huh BW, Kim CS, Park SW, Lee EJ, Cho YW, Huh KB. Ratio of waist-to-calf circumference and carotid atherosclerosis in Korean patients with type 2 diabetes. Diabetes Care. 2011; 34:2067–2071.

24. Oh SW. Obesity and metabolic syndrome in Korea. Diabetes Metab J. 2011; 35:561–566.

25. Lim H, Nguyen T, Choue R, Wang Y. Sociodemographic disparities in the composition of metabolic syndrome components among adults in South Korea. Diabetes Care. 2012; 35:2028–2035.

26. Kim TH, Kim DJ, Lim S, Jeong IK, Son HS, Chung CH, Koh G, Lee DH, Won KC, Park JH, Park TS, Ahn J, Kim J, Park KG, Ko SH, Ahn YB, Lee I. Prevalence of the metabolic syndrome in type 2 diabetic patients. Korean Diabetes J. 2009; 33:40–47.

27. Ludvik B, Nolan JJ, Baloga J, Sacks D, Olefsky J. Effect of obesity on insulin resistance in normal subjects and patients with NIDDM. Diabetes. 1995; 44:1121–1125.

28. Ruderman NB, Schneider SH, Berchtold P. The "metabolically-obese," normal-weight individual. Am J Clin Nutr. 1981; 34:1617–1621.

29. Karelis AD, Faraj M, Bastard JP, St-Pierre DH, Brochu M, Prud'homme D, Rabasa-Lhoret R. The metabolically healthy but obese individual presents a favorable inflammation profile. J Clin Endocrinol Metab. 2005; 90:4145–4150.

30. Meigs JB, Wilson PW, Fox CS, Vasan RS, Nathan DM, Sullivan LM, D'Agostino RB. Body mass index, metabolic syndrome, and risk of type 2 diabetes or cardiovascular disease. J Clin Endocrinol Metab. 2006; 91:2906–2912.

31. Kim DJ, Song KE, Park JW, Cho HK, Lee KW, Huh KB. Clinical characteristics of Korean type 2 diabetic patients in 2005. Diabetes Res Clin Pract. 2007; 77:Suppl 1. S252–S257.

32. Hanley AJ, Wagenknecht LE, Norris JM, Bryer-Ash M, Chen YI, Anderson AM, Bergman R, Haffner SM. Insulin resistance, beta cell dysfunction and visceral adiposity as predictors of incident diabetes: the Insulin Resistance Atherosclerosis Study (IRAS) Family study. Diabetologia. 2009; 52:2079–2086.

33. WHO Expert Consultation. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet. 2004; 363:157–163.

34. Kim HK, Kim CH, Park JY, Lee KU. Lower waist-circumference cutoff point for the assessment of cardiometabolic risk in Koreans. Diabetes Res Clin Pract. 2009; 85:35–39.

35. Baik I. Optimal cutoff points of waist circumference for the criteria of abdominal obesity: comparison with the criteria of the International Diabetes Federation. Circ J. 2009; 73:2068–2075.

36. Park SW, Kim SK, Cho YW, Kim DJ, Song YD, Choi YJ, Huh BW, Choi SH, Jee SH, Cho MA, Lee EJ, Huh KB. Insulin resistance and carotid atherosclerosis in patients with type 2 diabetes. Atherosclerosis. 2009; 205:309–313.

37. Kishida K, Funahashi T, Matsuzawa Y, Shimomura I. Visceral adiposity as a target for the management of the metabolic syndrome. Ann Med. 2012; 44:233–241.

38. Takahara M, Katakami N, Kaneto H, Noguchi M, Shimomura I. Statistical reassessment of the association between waist circumference and clustering metabolic abnormalities in Japanese population. J Atheroscler Thromb. 2012; 19:767–778.

39. Seo JA, Kim BG, Cho H, Kim HS, Park J, Baik SH, Choi DS, Park MH, Jo SA, Koh YH, Han C, Kim NH. The cutoff values of visceral fat area and waist circumference for identifying subjects at risk for metabolic syndrome in elderly Korean: Ansan Geriatric (AGE) cohort study. BMC Public Health. 2009; 9:443.