The hypertriglyceridemic waist phenotype among women

doi:10.1016/j.atherosclerosis.2003.07.008

Atherosclerosis

Volume 171, Issue 1, November 2003, Pages 123-130

https://doi.org/10.1016/j.atherosclerosis.2003.07.008 Get rights and content

Abstract

Background: Elevated plasma triglycerides (TG) and waist girth (hypertriglyceridemic waist (HTGW)) has been associated with elevated insulin, small dense low-density lipoprotein (sLDL) particles, and Apo B in men. The HTGW has not been reported for women and the effect of cardiorespiratory fitness (“fitness”) on associations between HTGW and coronary risk factors is unknown. Purpose: To determine the prevalence of HTGW and the influence of fitness on the relationship between HTGW and coronary risk among 137 healthy women (54±9 year; body mass index (BMI)=28±6 kg/m²). Methods: HTGW was defined as waist girth >88 cm and TG >150 mg/dl. The metabolic triad was defined as insulin >31 pmol/l, Apo B >69 mg/dl and LDL-C >84 mg/dl. Fitness was assessed with a maximal treadmill exercise test. Results: The sample prevalence of HTGW (n=15) was 11% (95% CI=5.7–16.0%). Apo B (P=0.04) and insulin (P=0.0001) increased across quintiles of waist girth, and LDL-C (P=0.004) increased across quintiles of TG. Metabolic triad prevalence was highest (67%, n=10) among HTGW women and lowest (22%, n=26) among non-HTGW women. A trend for higher coronary heart disease CHD risk factors was observed among HTGW compared with non-HTGW women. Among the HTGW group, a trend for lower CHD risk factors was observed among fit (≥6.5 METs, n=7) versus unfit women (<6.5 METs, n=8). Sample size limitations prohibited meaningful tests of significant differences in CHD risk factors when stratified simultaneously on HTGW and fitness status. Conclusions: HTGW is associated with increased coronary risk factors similarly among women as reported for men. Higher fitness may improve the CHD risk profile among women with HTGW.

Introduction

Despite progress in its prevention, detection and treatment, coronary heart disease (CHD) continues to exact an enormous economic and public health toll as the leading cause of death among US adults [1]. The latest report of the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP-III [2]) indicates that all CHD risk factors contribute to coronary disease similarly in women and men, and that most premature CHD in women occurs among those with co-existing risk factors [3]. Additional concern exists over increases in obesity and type 2 diabetes rates among women and minorities [1], [4]. Clustering of CHD risk factors accompanies both conditions [5], [6] and multiplicatively increases the risk of coronary events [7], [8]. For many individuals, sudden death or nonfatal myocardial infarction is the first symptom of CHD [9]. Therefore, leading health organizations have called for the development of clinical assessment strategies to identify high-risk individuals without established CHD in order to initiate aggressive primary preventive therapies [1], [9].

Lemiuex et al. [10] described a hypertriglyceridemic waist phenotype (HTGW) among men in the Quebec Cardiovascular Study, and suggested that this measurement might be an inexpensive clinical method of identifying elevated CHD risk among asymptomatic individuals. Lemiuex et al. [10] characterized the HTGW as a waist girth ≥90 cm and a plasma triglyceride (TG) concentration ≥177 mg/dl. Among 185 healthy Canadian men, the atherogenic metabolic triad of elevated plasma insulin, apolipoprotein B (Apo B), and small dense low-density lipoprotein particles (sLDL) was highly prevalent among men with (84%) versus men without (10%) the HTGW. The presence of angiographically defined CHD was nearly four times more likely among men with the HTGW versus men without HTGW. While elevated TG and waist circumference have previously been associated with increased risk for CHD and diabetes among women [11], [12], [13], it is unknown if the HTGW predicts increased risk for CHD and diabetes similarly in women as men.

The objective of this study was to examine cross-sectional data for the presence of the HTGW phenotype and its relationship with CHD risk factors among a tri-ethnic sample of healthy middle-aged women. We also investigated the influence of cardiorespiratory fitness on the relationship between the HTGW and selected CHD risk factors.

Section snippets

Study participants

This study consisted of 44 African–American (AA), 45 native American (NA), and 46 Caucasian (CA) women enrolled in the Cross-Cultural Activity Participation Study (CAPS). CAPS was a 5-year study funded by the National Institutes of Health and Centers for Disease Control and Prevention as part of the Community Trials arm of the Women’s Health Initiative [14]. The primary objective of CAPS was to develop culturally sensitive physical activity surveys for use in epidemiological studies of health

Results

Participants were middle-aged, overweight, and had relatively low CHD risk factors (Table 1). AA women were older, had larger BMIs, higher systolic blood pressure, insulin, HDL-C and CRP concentrations, and lower fitness compared with NA and CA women. Estrogenic medication use was highest among AA and CA women. Among all women, Spearman correlations revealed waist girth was associated with insulin (r=0.62, P<0.01), TG (r=0.36, P<0.01), HDL-C (r=−0.44, P<0.01), and fitness (r=−0.60, P<0.01). TG

Discussion

The American Heart Association has called for development of clinical methods to identify asymptomatic individuals at high-risk for new onset CHD [9]. Lemieux et al. [10] recently reported that two simple measures, waist girth >90 cm and fasting TG >177 mg/dl (the “hypertriglyceridemic waist phenotype”), might be an inexpensive clinical method for identifying men with elevated insulin, Apo B and sLDL concentrations, and hence, increased CHD and diabetes risk. The current study was undertaken to

Acknowledgements

The authors express gratitude to Drs. Vivian Heyward, Lisa Stolarczyk, Cheryl Addy, Jennifer Hootman, Melinda Irwin, and Melicia Whitt, and Ms. Angela Morgan, for their work in collecting, compiling, and managing the CAPS data set. This work was supported by NIH WHI-SIP # 22W-U48/CCU409664 awarded to Dr. Ainsworth.

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Cited by (64)

Hypertriglyceridaemic waist phenotype for Chronic Kidney Disease population: NEFRONA cohort
2020, Nefrologia
Citation Excerpt :
On extending the stratification by CKD stages, the interaction only remained significant in the G4-5 stage subgroup (Table 3). With regard to the cut-off points selected to define HWP in the Europids population (triglycerides above 177 mg/dl in men or 133 mg/dl in women, together with a waist greater than 90 cm in men or 85 cm in women),3,10 in this work we observed that levels above 143 mg/dl combined with a waist greater than 102 cm in men or 94 cm in women render it possible to optimise this tool’s diagnostic performance in the population with CKD. This variation could have several explanations.
The hypertriglyceridaemic waist (HTW) phenotype is defined for the general population. Chronic kidney disease (CKD) tends to bring on changes in body composition, is associated with higher comorbidity than the general population and, furthermore, shows reverse epidemiology with related prognostic variables like cholesterol and body mass index. Our objective was to identify cut-off points in the population with CKD and to analyse its relationship with cardiovascular risk (CVR).
We included 2,271 CKD patients from the NEFRONA cohort. Triglyceride and waist cut-off points were selected through quintiles analysis and receiver operating characteristic (ROC) curves evaluation, using the presence of moderate to severe atherosclerosis score (AS 2-3) as outcome variable. Then, we analysed HTW prevalence and its association with other cardiovascular risk factors, and we measured the magnitude of its effect on AS 2-3 and cardiovascular event or death (CVEoD) by multivariate regression analysis.
We selected the cut-off points: triglyceride concentrations ≥143 mg/dl with waist circumference values >102 cm in men and 94 cm in women (sensitivity 26%; specificity 87%). Specific HTW prevalence was 22.4%, without significative differences between CKD stages. The multivariate regression analysis shows specific HTW as an independent AS 2-3 (OR 1.61; 95% CI: 1.12-2.32, p = 0.011) and CVEoD (HR 3.08; 95% CI: 1.66-5.72, p = 0.000) risk factor. An interaction between phosphorus level and specific HTW was identified.
Adapting the HTW definition might improve specificity to assess cardiovascular risk in the population with CKD. It identifies an additional CVR in a population in which other screening methods have not proven to be useful, and it is easily clinically accessible. Its interaction with phosphorus levels suggests an association between HTW and bone-mineral metabolism regulation.
El fenotipo de cintura hipertrigliceridémica (FCH) se define para población general. La Enfermedad Renal Crónica (ERC) asocia cambios en la composición corporal, elevada comorbilidad y una epidemiología reversa en relación con el colesterol y el índice de masa corporal. Nuestro objetivo fue identificar los puntos de corte en población con ERC y analizar su relación con el riesgo cardiovascular (RCV).
Incluimos 2271 enfermos renales de la cohorte NEFRONA. Seleccionamos los puntos de corte de triglicéridos y cintura mediante análisis de quintiles y curvas ROC, utilizando presencia de enfermedad ateroesclerótica moderada-severa (EA2-3) como variable resultado. Analizamos la prevalencia del mismo y su asociación con otros factores de riesgo cardiovascular, incluimos análisis de regresión multivariable para medir la magnitud de su efecto frente a las variables EA2-3 y evento o muerte cardiovascular (EoMCV).
Seleccionamos los puntos de corte: Triglicéridos ≥ 143 mg/dl con cintura > 102 cm en varones o 94 cm en mujeres (Sensibilidad 26%; Especificidad 87%). La prevalencia del FCH específico fue 22.4%, sin diferencias entre estadios de ERC. Asoció aumento de riesgo independiente frente a EA2-3 (OR 1.61; IC 95%: 1.12-2.32, p = 0.011) y EoMCV (HR 3.08; IC 95%: 1.66-5.72, p = 0.000). Identificamos una interacción entre FCH y fósforo.
Adaptar la definición del FCH en la población con ERC mejora su rendimiento diagnóstico. Identifica un RCV adicional en una población donde otros métodos de cribado no han mostrado utilidad, siendo de fácil acceso clínico. Su interacción con los niveles de fósforo podría reflejar un papel en la regulación del metabolismo óseo-mineral.
Lipid accumulation product in relation to 10-year cardiovascular disease incidence in Caucasian adults: The ATTICA study
2018, Atherosclerosis
Citation Excerpt :
This apparent inconsistency with our findings may be attributed to the fact that this community-based study included only adults with BMI <25 kg/m2, whilst other significant differences in the cohort characteristics of this Iranian study are also present (e.g., different ethnic background and higher minimum age at recruitment, since these participants were of Persian ancestry and at least 30 years old) [18]. It is noteworthy that, Després et al., first introduced the concept of the “hypertriglyceridemic waist” as a dichotomous cardiometabolic risk marker/indicator, which proved to be a good predictor of CVD outcomes and mortality [31–35]. However, obesity is a continuous process rather than dichotomous, whilst both circulating TG and WC as single continuous variables are associated with CVD risk [9,35–37].
The lipid accumulation product (LAP) is an index describing lipid over-accumulation based on waist circumference (WC) and fasting triglycerides, and can outperform the body mass index (BMI) in recognizing cardiovascular disease (CVD) risk. We aimed to explore the association of LAP with long-term CVD risk and compare its CVD-predictive value against common anthropometric indices/ratios of obesity.
ATTICA is a prospective, population-based cohort that recruited 3042 adults without pre-existing CVD from the Greek general population (age 18–89 years; 1514 men). The 10-year study follow-up (2011–2012) captured the fatal/non-fatal CVD incidence in 2020 participants (50% men). Baseline LAP (cm·mmol/L) was calculated and analyzed in relation to the 10-year CVD incidence.
In total, 317 CVD cases (15.7%) were documented during the follow-up. Baseline LAP showed a significant positive association with the 10-year CVD incidence, even after adjusting for hypertension, diabetes, hypercholesterolemia, smoking, physical activity, Mediterranean diet adherence, and key pro-inflammatory biomarkers (Hazard Ratios per 10 cm·mmol/L of LAP ranging from 1.1 to 1.21, p = 0.04). Moreover, LAP predicted the 10-year CVD study incidence better than common obesity indices (BMI, WC, waist-to-hip, waist-to-height ratio).
These findings support a positive association between LAP and long-term CVD incidence in CVD-free Caucasian adults from the general population.
Increased association of coronary artery calcification in apparently healthy Korean adults with hypertriglyceridemic waist phenotype: The Kangbuk Samsung Health Study
2015, International Journal of Cardiology
Citation Excerpt :
From a clinical or public health perspective, MetS is useful only if it identifies individuals at high risk of disease. The Quebec Cardiovascular Study group introduced “hypertriglyceridemic waist,” defined as both hypertriglyceridemia and increased WC, as a marker of atherogenic metabolic profile in men and demonstrated its value in estimating the 5-year risk for cardiovascular events [3–5]. A 7.5-year prospective study of 3430 middle-aged men, using low WC and low TG concentrations as a reference group, reported that the risk of developing CVD over the follow-up period was significantly increased only among men with the hypertriglyceridemic waist (HTGW) phenotype [6].
Hypertriglyceridemic waist phenotype is a simple screening parameter to identify people at increased risk for cardiovascular disease. We evaluated whether hypertriglyceridemic waist (HTGW) phenotype increases the risk for coronary artery calcification (CAC) in apparently healthy Korean adults.
A total of 32,186 participants (mean age 41.3, 80.2% men) in a health screening program, in whom the coronary artery calcium score (CACS) was measured, were analyzed. Subjects were divided into four groups: 1) normal waist circumference (WC)–normal triglyceride (TG) (NWNT), 2) normal WC–high TG (NWHT), 3) enlarged WC–normal TG (EWNT), and 4) enlarged WC–high TG (EWHT). Enlarged WC was defined as WC ≥ 90 cm for men and ≥ 85 cm for women; high serum TG was defined as TG ≥ 150 mg/dL. The presence of CAC was defined by CACS > 0, and CACS was analyzed in a logarithmized form of CACS plus 1 {ln(CACS + 1)}.
A total of 14.9% of the participants had CAC. The EWHT group showed the highest mean value for ln(CACS + 1) among the four groups. The EWHT group showed the highest odds ratio for CAC, with NWHT group the second, and with EWNT group the third compared with the NWNT group after adjusting for confounding variables (1.579, 1.302, and 1.266 vs. NWNT).
The EWHT group showed the highest association for CAC, suggesting this HTGW phenotype as a useful marker for the detection of subjects with high cardiometabolic risk in healthy Korean adults.
The hypertriglyceridemic-waist phenotype is associated with the Framingham risk score and subclinical atherosclerosis in Canadian Cree
2015, Nutrition, Metabolism and Cardiovascular Diseases
Citation Excerpt :
A proposed surrogate marker of visceral obesity is the hypertriglyceridemic-waist phenotype (HTGW), which combines at-risk triglycerides with at-risk waist circumference measurements [13,14]. The HTGW has received much attention over recent years for its association with CVD risk factors including risk factors used to calculate the FRS [13–19] and for its association with coronary artery disease [14,17]. Although the HTGW has been studied in Canadian indigenous populations such as the Ojee-Cree [18] and Inuit [19], it has not been evaluated for its' association with carotid ultrasound measures of preclinical atherosclerosis, which has been useful in predicting CVD [20,21].
For primary prevention of cardiovascular disease (CVD), Canadian guidelines recommend that asymptomatic Canadians with abdominal obesity undergo Framingham risk score (FRS) assessment, and that in Indigenous Peoples, indicators of metabolic syndrome also be used to identify at-risk individuals. The hypertriglyceridemic-waist phenotype (HTGW) has been proposed to be a surrogate marker of visceral obesity and a simple proxy measure for metabolic syndrome. The primary aim of this study was to evaluate whether the HTGW and the FRS associated with sub-clinical atherosclerosis.
Asymptomatic Cree participants in a cross-sectional study conducted 2005–2009 (n = 446, 18–81 y) were assessed for the HTGW using NCEP-ATP-III gender-specific-cutoffs (waist circumference: for men, ≥102 cm; for women ≥88 cm) and fasting triglycerides ≥1.7 mmol/L. Sub-clinical atherosclerosis was defined by the presence of a high sex-specific common-carotid-intimal-medial-wall-thickness (≥75th percentile). HTGW was present in 26.7% and a 10-y FRS greater than 10% was present in 18.8% of participants. The multivariate adjusted OR (95% CI) for sub-clinical atherosclerosis associated with an FRS greater than 10% was 4.10 (2.20–7.50) while that associated with the HTGW phenotype was 1.74 (95% CI 1.61–1.88) from a model including age, body mass index, alcohol consumption, FRS and the HTGW.
The HTGW phenotype is prevalent in the Cree. Our findings support further study on the utility of combining the HTGW with the FRS in the prediction of cardiovascular disease outcomes and in health screening and intervention programs among indigenous peoples.
Hypertriglyceridemic waist phenotype and risk of cardiovascular diseases in China: Results from the Kailuan Study
2014, International Journal of Cardiology
Citation Excerpt :
The hypertriglyceridemic waist (HTGW) phenotype (defined as increased WC and hypertriglyceridemia), proposed by Lemiuex and colleagues, has been suggested to be an inexpensive and effective tool for clinicians to identity people who have the greatest amount of visceral fat and thus have the greatest risk of abnormal metabolism and CVDs [7,12,13]. Also, the HTGW phenotype has been associated with insulin resistance [14], atherogenic and diabetogenic risk factors [15,16], coronary artery disease [12,17–19], and diabetes [20–22]. While some case–control studies have showed the association between HTGW phenotype and CVD events [23], there are few data regarding this association in cohort studies [24], especially in Asian populations that have a higher prevalence of central obesity than other populations [25].
While some case–control studies have showed the correlation between the hypertriglyceridemic waist (HTGW) phenotype (increased WC and hypertriglyceridemia) and cardiovascular disease (CVD) events, there are few data regarding this correlation in cohort studies, especially in Asian populations that have a higher prevalence of central obesity than other populations.
The aim of this study was to explore the relationship between HTGW phenotype and risk of incident CVD events among men and women in China.
We analyzed 95,015 participants (18–98 years old) in the Kailuan Study. CVDs developed in 1958 people during follow-up. The cutoffs for defining HTGW phenotype were a waist circumference (WC) of 90 cm or more and a triglyceride level of 2.0 mmol/L or more for men and a WC of 85 cm or more and a triglyceride level of 1.5 mmol/L or more for women. Hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated from Cox regression models.
Compared with participants who had a normal WC and a normal triglyceride level (NWNT), those with HTGW phenotype had a higher WC, body mass index, prevalence of hypertension and diabetes mellitus; and a lower level of high-density lipoprotein cholesterol. The HTGW group had an unadjusted HR of 1.76 (95% CI = 1.55–1.99) for future CVDs compared with the NWNT group. After adjustment for confounders, the HR still remained significant (HR = 1.24, 95% CI = 1.07–1.44).
HTGW phenotype was associated with the risk of CVDs independently. HTGW phenotype might be a simple but useful tool to screen the individuals at a high risk for future CVDs, and it might be recommended in most clinical practices.
The association between adherence to diet quality index and cardiometabolic risk factors in overweight and obese women: a cross-sectional study
2023, Frontiers in Public Health

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The hypertriglyceridemic waist phenotype among women

Abstract

Introduction

Section snippets

Study participants

Results

Discussion

Acknowledgements

Am. J. Cardiol.

J. Lipid. Res.

Ann. Biochem.

Am. J. Clin. Nutr.

Trends and disparities in coronary heart disease, stroke, and other cardiovascular diseases in the United States

Circulation

Cardiovascular disease in women

Circulation

The continuing epidemics of obesity and diabetes in the United States

JAMA

Prevalence of the metabolic syndrome among US adults

JAMA

Risk variable clustering in the insulin resistance syndrome

Diabetes

Syndrome X and mortality: a population-based study

Am. J. Epidemiol.

Clustering of metabolic factotrs and coronary heart disease

Arch. Intern. Med.

Improving coronary heart disease risk assessment in asymptomatic people

Circulation

Hypertriglyceridemic waist. A marker of the atherogenic metabolic triad (hyperinsulinemia; hyperapolipoprotein B; small, dense LDL) in men?

Circulation

Larger hip circumference independently predicts health and longevity in a Swedish female cohort

Obes. Res.

Features of the metabolic syndrome predict higher risk of diabetes and impaired glucose tolerance

Diabetes Care

The prevention research centers program: collaboration in women’s health

J. Women’s Health