International Journal of Obesity (2000) 24, 10051010

2000 Macmillan Publishers Ltd All rights reserved 03070565/00 $15.00

www.nature.com/ijo

Waist circumference and abdominal sagittal

diameter as surrogates of body fat distribution
in the elderly: their relation with cardiovascular
risk factors

E Turcato1, O Bosello1, V Di Francesco1, TB Harris2, E Zoico1, L Bissoli1, E Fracassi1 and M Zamboni1*

1
Institute of Geriatric Medicine, University of Verona, Verona, Italy; and 2Ofce of Geriatric Epidemiology, Epidemiology, Demography
and Biometry Program, National Institute of Health, National Institute of Aging, Bethesda, Maryland, USA

OBJECTIVE: To evaluate the relationship between supine sagittal abdominal diameter (SAD) and other indicators of
body fat distribution with cardiovascular (CVD) risk factors in the elderly.
SUBJECTS: One-hundred and forty-six women aged from 67 to 78 y with a body mass index (BMI) ranging from 18.7 to
50.6 kg=m2 and 83 men aged between 67 and 78 y with BMI ranging from 19.8 to 37.1 kg=m2.
MEASUREMENT: Body fat distribution was assessed using anthropometric indicators: waist circumference, SAD,
waist-to-hip ratio (WHR), waist-to-height ratio and SAD-to-thigh ratio.
RESULTS: In women, there was a negative correlation between HDL-cholesterol and body weight, BMI, waist, SAD,
WHR, waist-to-height ratio and SAD-to-thigh ratio. A signicant association was found between triglycerides, basal
glucose, 2 h glucose during oral glucose tolerance test (OGTT), systolic blood pressure (SBP), diastolic blood pressure
(DBP) and anthropometric variables. In men a negative correlation was found between HDL-cholesterol and all the
anthropometric variables. A signicant association was found between triglycerides, DBP and body weight, BMI,
waist, SAD and waist-to-height ratio. In women, after adjusting for age and BMI, a signicant correlation was
observed between waist and HDL-cholesterol, triglycerides and basal glucose. This was also seen with SAD and SAD-
to-thigh ratio and triglycerides, basal and 2 h glucose. In men, after adjusting for age and BMI a signicant correlation
was found between SAD and HDL-cholesterol and triglycerides. When adjustments were made for age and waist, the
correlations between BMI and metabolic variables as well between BMI and SBP and DBP were no longer signicant.
CONCLUSIONS: Our study shows that indicators of body fat distribution are associated with CVD risk factors in the
elderly independently of BMI. Our data also show that waist and SAD are the anthropometric indicators of fat
distribution which are most closely related to CVD risk factors in old age.
International Journal of Obesity (2000) 24, 10051010

Keywords: body fat distribution; aging; waist; sagittal diameter; metabolic variables

Introduction Imaging techniques such as magnetic resonance

Alterations in carbohydrate and lipid metabolism
increase with age.1 In younger populations these
alterations are associated with central fat or the
increase of visceral fat.2,3 Cross-sectional and long-
itudinal studies show age-related changes in body fat
distribution.4 6 Whether this shift in fat distribution in
old age accounts for the age-related increase in
carbohydrate and lipid abnormalities is unclear.
Therefore, evaluation not only of the degree of
obesity, but also of body fat distribution seems to be
very important in elderly subjects.
*Correspondence: M Zamboni, Institute of Geriatric Medicine,
University of Verona, Ospedale Maggiore, Piazzale Stefani 1,
37126 Verona, Italy.
E-mail: Zamboni@borgoroma.univr.it
Received 17 September 1999; revised 29 February 2000;
accepted 5 April 2000
imaging (MRI) and computerized tomography (CT)
are the standard methods used to evaluate visceral
adipose tissue quantity, but are costly and not readily
available; they are therefore not useful in epidemio-
logical and clinical studies.7
Several studies have used waist girth, waist-to-hip
ratio (WHR) and sagittal abdominal diameter (SAD)
for classifying different types of fat distribution and to
predict visceral fat accumulation.7 14 Recently it was
shown that waist circumference and SAD show closer
association with visceral abdominal adipose tissue
accumulation than WHR does.8,12,14
SAD by anthropometry has been shown to be
related to cardiovascular (CVD) risk factors,15 17
but only one study evaluated the relationship between
anthropometrically determined SAD and metabolic
variables in elderly subjects.18
The aim of our study was to analyse the relation-
ships between waist, sagittal diameter and several
anthropometrically assessed indicators of regional
 Fat distribution, aging and metabolic alterations
E Turcato et al
1006
body fat distribution and cardiovascular risk factors in
elderly subjects, and to identify the anthropometric
indicator which is most closely related to CVD risk
factors in geriatric patients.
Methods
We studied 146 women aged from 67 to 78 y with a
body mass index (BMI; kg=m2) ranging from 18.7 to
50.6 (mean  s.d.: 26.7  4.9) and 83 men aged 67
78 y with BMI ranging from 19.8 to 37.1 (mean s.d.:
27.4 3.5), selected from the general population in
down-town Verona. All the subjects were volunteers
and gave their consent to the study, whose protocol
was approved by our Institute's Ethical Committee.
None of the subjects were diabetic and none were
taking lipid- or glucose-lowering drugs. Subjects
selected for this study did not suffer from congestive
heart disease or uid retention, as determined by
medical history and physical examination and did
not show uctuations in body weight of more than
2 kg over the 6 months before the study. Current
medication used was assessed by asking participants
to show the containers of the medicines they were
using.
Anthropometric measurements
The following anthropometric variables were evalu-
ated in all subjects: weight, height, BMI, waist, thigh
and hip circumferences and SAD. Body weight was
measured to the nearest 0.2 kg (Salus scale, Milan)
and height to the nearest 0.5 cm using a stadiometer
(Salus stadiometer, Milan). BMI, an indicator of body
fatness, was calculated as body weight adjusted for
stature (kg=m2).
Circumferences were measured to the nearest
0.5 cm using a 1 cm-wide metal measuring tape. The
waist circumference was measured in standing sub-
jects as the minimum abdominal circumference
between the xyphoid process and the umbilicus.
When it was impossible to measure the minimum
abdominal circumference (in the case of a few sub-
jects in our study sample), the waist was measured in
the midline between the iliac crest and the rib edge.
The hip circumference was measured at the outermost
points on the greater trochanters. WHR is the ratio of
these two circumferences. The right thigh circumfer-
ence was measured in standing subjects at midway
between the lateral inguinal fold and midpatella.
SAD was measured with a portable, sliding-beam,
abdominal caliper while the subjects were in a supine
position; this instrument was hand-made under our
supervision by an artisan. The SAD was measured as
the largest supine anteroposterior diameter between
the xyphoid process and the umbilicus. Subjects were
asked to inhale and exhale gently, and the arm of the
caliper was brought down to touch the abdominal wall
International Journal of Obesity
without compression. All subjects were examined in a
at standard hospital bed. The measurements of SAD
were taken with hips fully exed at the end of
expiration.14
Oral glucose tolerance test (OGTT)
Patients were given a 75 g glucose load. Blood sam-
ples for determining glucose levels were taken at 0
and 120 min. Plasma glucose was measured using a
compact chemistry analyser method: the Ektachem
DT-60 (Eastman Kodak Inc., Rochester, NY). This
method has an interassay coefcient of variation of
2%.19
Lipids
A venous blood sample was taken after an overnight
fast. Cholesterol and triglycerides were determined
using a compact chemistry analyzer method: the
Ektachem DT-60 (Eastman Kodak Inc., Rochester,
NY); this method has an interassay coefcient of
variation of 2.2% for triglycerides and 2% for cho-
lesterol.20 Dextran magnesium precipitation was
used for high-density lipoprotein (HDL) separation.21
External quality control was performed daily for all
chemical analyses.
Blood pressure
Blood pressure was measured three times over a
period of 30 min in the left arm with the subject
seated using a sphygmomanometer. Systolic blood
pressure (SBP) was recorded as the pressure level at
which the rst regular sounds appeared. The level
where sounds completely disappeared was recorded
as diastolic blood pressure (DBP). The average of
the three blood pressure readings was used for all
analyses.
Data analysis
Results are presented as mean  s.d. Student's t-test
for unpaired data was used to compare differences
between sexes. Triglycerides, basal glucose and 2 h
glucose during OGTT did not present normal value
distributions and consequently were transformed into
natural logarithms for statistical tests. To test the
association between different variables, simple and
partial correlation analyses were performed.
Results
The characteristics of the study sample are presented
in Table 1. No signicant differences were found
between women and men regarding age and BMI.
Waist circumference and SAD values as well as waist-
to-height ratio, WHR and SAD-to-thigh ratio were
signicantly higher in men than in women.
 Fat distribution, aging and metabolic alterations
E Turcato et al
1007
Table 1 Study sample characteristics SAD-to-thigh ratio. A signicant association was
Women (n 146), Men (n 83), found between triglycerides, basal glucose, 2 h glu-
mean  s.d. mean  s.d. P cose during OGTT, SBP, DBP and anthropometric
Age (y) 72.0  2.5 71.8  2.2 NS
variables.
Body weight (kg) 65.5  11.7 78.9  11.3 <0.001 Table 3 shows correlations between age, body
Height (m) 1.56  0.02 1.70  0.07 <0.001 weight, BMI, fat distribution indicators and CVD
BMI (kg=m2) 26.7  4.9 27.4  3.5 NS risk factors in men. A negative correlation was
Thigh (cm) 46.3  5.1 47.4  5.4 NS
Hip (cm) 99.4  8.4 99.1  6.0 NS found between all the anthropometric variables and
Waist (cm) 84.1  11.0 96.1  8.9 <0.001 HDL-cholesterol. A signicant association was found
SAD (cm) 20.8  2.8 23.0  3.2 <0.001 between triglycerides, DBP and body weight, BMI,
WHR 0.85  0.07 0.97  0.05 <0.001
Waist-to-height ratio 53.8  7.2 56.6  5.3 <0.01 waist, SAD and waist-to-height ratio. A signicant
SAD-to-thigh ratio 0.45  0.05 0.48  0.06 <0.001 association was also found between basal glucose,
Cholesterol (mmol=l) 6.37  0.88 5.90  1.01 <0.001 body weight and BMI.
HDL-choesterol (mmol=l) 1.64  0.36 1.44  0.38 <0.01 Table 4 shows partial correlations adjusted for age
Triglycerides (mmol=l) 1.59  0.77 1.59  0.71 NS
Basal glucose (mmol=l) 5.35  0.98 5.57  0.98 <0.05 and BMI between indicators of fat distribution and
2 h glucose OGTT 7.32  2.75 6.81  2.76 NS CVD risk factors. In women a signicant correlation
(mmol=l) was observed between waist and HDL-cholesterol,
SBP (mmHg) 139  16 141  16 NS
DBP (mmhg) 81  9 81  11 NS triglycerides and basal glucose, and between SAD
and triglycerides, basal and 2 h glucose. In men a
BMI, body mass index; WHR, waist-to-hip ratio; SAD, sagittal
abdominal diameter; OGTT, oral glucose tolerance test; SBP,
signicant correlation was found between SAD and
systolic blood pressure; DPB, diastolic blood pressure. HDL-cholesterol and triglycerides.
When adjustments were made for both age and
No signicant differences were observed between waist, the correlations between BMI and CVD risk
the two groups with regards to triglycerides, 2 h factors were no longer signicant in women or in men
glucose during OGTT, SBP and DBP. Total choles- (data not shown in table).
terol and HDL-cholesterol were signicantly higher in
women, while basal glucose was signicantly higher
in men.
Table 2 shows correlations between age, body
Discussion
weight, BMI, fat distribution indicators and CVD
risk factors in women. A negative correlation was Our study shows that body fat distribution indicators
found between HDL-cholesterol and body weight, are associated with CVD risk factors in the elderly
BMI, waist, SAD, WHR, waist-to-height ratio and independently of BMI. Our data also conrm that

Table 2 Simple correlations between age, anthropometric and cardiovascular risk factors in women (n 146)

Body Waist-to-height SAD-to-thigh

Age weight BMI Hip Waist SAD WHR ratio ratio

Cholesterol 0.07 70.04 70.03 70.06 70.03 70.03 0.02 70.03 70.02
HDL-cholesterol 70.07 70.27 70.26 70.19 70.30 70.27 70.24 70.29 70.20
Triglycerides 0.09 0.23 0.21 0.20 0.29 0.26 0.22 0.27 0.24
Basal glucose 0.05 0.25 0.19 0.14 0.23 0.24 0.19 0.19 0.13
2 h glucose OGTT 0.10 0.30 0.30 0.22 0.32 0.34 0.24 0.32 0.30
SBP 0.14 0.28 0.31 0.25 0.30 0.32 0.20 0.31 0.14
DBP 0.01 0.33 0.33 0.27 0.30 0.32 0.18 0.29 0.15

BMI, body mass index; WHR, waist-to-hip ratio; SAD, sagittal abdominal diameter; OGTT, oral glucose tolerance test; SBP,
systolic blood pressure; DBP, diastolic blood pressure. r values > 0.16 are P < 0.05; r values > 0.21 are P < 0.01;
r values > 0.27 are P < 0.001.

Table 3 Simple correlations between age, anthropometric and cardiovascular risk factors in men (n 83)

Body Waist-to- SAD-to-

Age weight BMI Hip Waist SAD WHR height ratio thigh ratio

Cholesterol 70.08 0.01 0.11 0.09 0.08 0.03 0.02 0.14 0.01
HDL-cholesterol 70.12 70.31 70.34 70.26 70.35 70.44 70.30 70.33 70.41
Triglycerides 70.03 0.21 0.30 0.25 0.32 0.37 0.25 0.35 0.30
Basal glucose 70.11 0.22 0.26 0.23 0.20 0.14 0.07 0.20 0.11
2 h glucose OGTT 70.04 70.03 0.04 0.05 0.05 0.01 70.16 0.01 0.05
SBP 0.03 0.10 0.19 0.23 0.18 0.18 0.08 0.22 0.05
DBP 70.10 0.23 0.24 0.27 0.28 0.29 0.17 0.24 0.16

BMI, body mass index; WHR, waist-to-hip ratio; SAD, sagittal abdominal diameter; OGTT, oral glucose tolerance test; SBP,
systolic blood pressure; DBP, diastolic blood pressure. r values > 0.21 are P < 0.05; r values > 0.28 are P < 0.01;
r values > 0.35 are P < 0.001.

International Journal of Obesity

 Fat distribution, aging and metabolic alterations
E Turcato et al
1008
Table 4 Partial correlations between body fat distribution indicators and cardiovascular risk factors adjusted for age and
BMI in women and men

Women (n 146) Men (n 83)

Waist-to- SAD-to- Waist-to- SAD-to-

Waist SAD WHR height ratio thigh ratio Waist SAD WHR height ratio thigh ratio

Cholesterol 0.01 0.06 0.01 70.01 0.02 70.06 70.08 70.06 0.07 70.06
HDLcholesterol 70.16 70.06 70.16 70.11 70.11 70.16 70.30 70.17 70.02 70.28
Triglycerides 0.24 0.18 0.16 0.18 0.20 0.12 0.22 0.11 0.14 0.17
Basal glucose 0.23 0.21 0.21 0.09 0.18 0.06 70.10 70.06 70.05 70.01
Glucose 2 h OGTT 0.15 0.18 0.15 0.08 0.23 70.20 70.04 70.22 70.09 0.02
SBP 0.07 0.10 0.08 0.07 0.07 0.06 0.05 0.01 0.14 70.04
DBP 0.03 0.07 0.05 70.02 0.05 0.17 0.17 0.08 0.09 0.06

BMI, body mass index; WHR waist-to-hip ratio; SAD, sagittal abdominal diameter; OGTT, oral glucose tolerance test; SBP,
systolic blood pressure; DBP, diastolic blood pressure. In women r values > 0.16 are P < 0.05; r values > 0.21 are P < 0.01.
In men r values > 0.22 are P < 0.05; r values > 0.28 are P < 0.001.

body fat distribution is signicantly different between
the sexes in old age, and that waist and SAD are the
anthropometric indicators of body fat distribution
which are most closely related to CVD risk factors
in old age.
A strong correlation between central obesity and
CVD risk factors in middle2,3,13,15 17 and old
age18,22 25 has previously been demonstrated. Ward
et al 22 reported that waist-to-hip ratio is related to
triglycerides independently of BMI and insulin levels
in middle-aged and older people. Seidell et al 18 using
981 male participants of the Baltimore Longitudinal
Study on Aging (BLSA) showed sagittal diameter
anthropometrically determined to be signicantly
associated with triglycerides and glucose levels,
even after adjusting for age and BMI.
Haarbo et al 23 in 95 postmenopausal women, aged
between 55 and 75 y showed that central fat distribu-
tion indicators were correlated independently of BMl
and body weight to lipid levels.
Our ndings show that in both women and men,
waist or SAD by anthropometry correlate with CVD
risk factors, independently of BMI. In both women
and men BMI correlate with CVD risk factors, but this
association is no longer signicant after age and waist
adjustments.
These results are in line with those of Obisesan et
al,24 who found that indicators of fat distribution
rather than total fat adiposity (as evaluated by under-
water weighing) were predictors of plasma lipids in
elderly subjects. If our data is taken together with that
of Obisesan et al,24 it supports the view that also in the
elderly, fat distribution more than overall obesity is
related to CVD risk factors.
The relationships between age-related changes in
body fat and or visceral fat with those of CVD risk
factors are not yet understood, but seem to be very
interesting because both cross-sectional and longitu-
dinal studies showed age-related increase in visceral
fat.4,26
Siervogel et al,27 evaluating serial data from a wide
sample of the Fels Longitudinal Study, reported a
signicant association between changes in total cho-
lesterol and LDL-cholesterol and concurrent changes
International Journal of Obesity
in measures of adiposity in young, middle-aged and
middle-aged to-older subjects.
In 134 women ranging in age from 18 to 72 y we
found that after adjusting for age-related visceral fat
increase, no signicant differences in metabolic vari-
ables except for cholesterol were found across ages.4
CT and MRI are the gold standard methods used to
evaluate fat distribution,7 but waist and WHR are the
indicators most commonly used to predict visceral fat
accumulation in epidemiological studies;7 9 in the
elderly, such methods for evaluating body fat distri-
bution may lead to problems. Waist-to-hip ratio seems
to be a poor method to assess fat distribution in the
elderly.28 In geriatric age groups, waist circumference
measurements may be inaccurate, since the laxity of
the abdominal muscles which is typical in the elderly
is likely to undermine the predictive value of abdom-
inal circumferences. It is also possible that measure-
ments of circumferences taken in the standing position
may lead to inaccurate evaluation in older subjects.
Clinical studies have already supported the useful-
ness of SAD by anthropometry as a good proxy of
visceral adipose tissue 15,29,30 and evaluated its rela-
tionship with CVD risk factors.16 18 We have pre-
viously shown that SAD is a good and reliable method
to evaluate fat distribution in the elderly.14
In the BLSA18 coronary heart disease mortality
rates, adjusted for age, height and BMI, increased
with increasing sagittal diameter in younger men
(age <55 y) but not in older men (age >55 y). Kahn
et al 29 observed in subjects with ages ranging from 29
to 67 y, that the abdominal diameter index (supine
sagittal abdominal diameter divided by the mid-thigh
circumference) was associated with sudden coronary
death even after adjusting for age and BMI. Discre-
pancies between these two studies may be explained
by the fact that in the former SAD was evaluated in
standing people18 while the latter was determined in
supine people.29
Our ndings show a signicant correlation between
both waist and SAD with cardiovascular risk factors
and thus suggest that both waist and SAD are use-
ful indicators of fat distribution in the elderly. Cut-
off points for waist in men and women have been

identied, but no different cut-off points for waist
have been shown in older subjects, and no cut-off
points have been identied for SAD.31
Evaluation of fat distribution may be of clinical
relevance in the elderly because fat distribution may
explain some of the unanswered relations between
obesity, morbidity and mortality in the elderly. Our
data show that up to 10% of the variance in CVD risk
factors in the elderly can be explained by using
anthropometric indicators of fat distribution. Similar
results have been observed in middle aged men and
women.16,17
From a population health perspective, the ability to
explain even 10% of variance of CVD risk factors in
the elderly seems to be an important nding. However
it seems noteworthy to identity the best predictor of
fat distribution in the elderly. In our study we tested
different anthropometric indicators of fat distribution.
We evaluated waist as the minimum abdominal
circumference between the xifoid process and the
umbilicus. However the waist measurement in the
midline between iliac crest and the rib edge is usually
considered the most stable landmark. There is no
universally accepted method to measure waist
and discrepancies in the modality of anthropometric
measurement may induce different results.
Further studies will be needed to compare the
reliability of waist and SAD in the elderly, as well
as to test the best way to measure the waist in the
elderly.
In conclusion our study shows that body fat dis-
tribution indicators are associated with cardiovascular
risk factors in the elderly independently of BMI, and
that waist and SAD are the anthropometric indicators
which are most closely related to CVD risk factors in
old age.
Acknowledgements
This study was supported by grants from Regione
Veneto, Giunta Regionale, Ricerca Sanitaria Finaliz-
zata, 730=01=96, Venezia, Italia and from the
MURST project `Pathophysiology, Pharmacology
and Clinical Aspects of Obesity, 806241798.
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