Central Obesity: A Better Predictor for Coronary Artery Disease Than BMI

Compared with body mass index (BMI), waist circumference is a better indicator for obstructive coronary artery disease (CAD) risk in postmenopausal women, according to study results published in Menopause.¹

Postmenopausal women are at a higher risk for CAD given a reduction in estrogen levels. In addition, changes in body fat distribution after menopause may increase this risk, though the exact type of adiposity most influential to the development of CAD has not yet been determined. To explore the associations between obesity type and risk for obstructive CAD in women aged >55 years, researchers used data from the Korean Women’s Chest Pain Registry, a prospective nationwide database of 29 participating cardiac centers in Korea. All patients enrolled in the registry presented with chest pain and underwent elective invasive coronary angiography for evaluation of CAD.

Of 659 women included in the study, 311 (47.2%) had obstructive CAD, defined as ≥50% stenosis of ≥1 major epicardial coronary artery. Women with CAD were older (P <.001) and presented with more traditional cardiovascular risk factors (hypertension, diabetes, current smoking status) than those without CAD.

Prevalence of CAD did not differ significantly between patients with vs without overall obesity (44.6% vs 48.5%, respectively; P =.340), but was significantly higher in women with central obesity (waist circumference ≥85 cm) compared with those without central obesity (55.5% vs 41.0%, respectively; P <.001). Further, BMI did not differ in patients with CAD vs those without, but waist circumference was significantly higher (P =.001). Waist circumference was also more closely associated with CAD severity than BMI.

To discuss the clinical applicability of these findings, Endocrinology Advisor checked in with Stephanie Faubion, MD, MBA, medical director of the North American Menopause Society.

Endocrinology Advisor: What lifestyle interventions do you suggest clinicians recommend to patients with excess abdominal fat but a normal BMI to help reduce risk for CAD? Is there a particular way to best advise these patients, who may not be aware of their increased risk given their normal weight according to BMI?

Stephanie Faubion, MD, MBA: The first important point is that clinicians need to measure BMI in order to identify women at increased risk for cardiovascular disease. As far as lifestyle, there is no magic bullet, and the same things that are recommended for weight loss in general apply here as well. Women [should be advised to] eat less and exercise more. Some weight training to build muscle mass will help burn more calories both at rest and with exercise. In terms of diet, reducing intake of simple carbohydrates and increasing intake of fruits and vegetables will help with weight loss.

Endocrinology Advisor: The study researchers stated “additional [waist circumference] measurements should be suggested especially in elderly women.” How often do you recommend clinicians measure waist circumference in postmenopausal women?

Dr Faubion: There is no guideline on how often a waist circumference measurement should be performed, but when women see their providers for routine care and weight, height, and blood pressure are measured, waist circumference should also be measured, and addressed if it is increased.

Endocrinology Advisor: Despite the fact that the research was restricted to an entirely Korean population, do you feel the results are applicable to most populations of postmenopausal women or do you see a need for more research? In addition, this is one study of many with results that indicate that site-specific adiposity may be more accurate than BMI in predicting cardiovascular risk. Do you think a shift in focus toward central obesity as a risk marker, as opposed to BMI, is needed in clinical research?

Dr Faubion: Results likely also apply to other populations. This is not the only study to suggest this finding.² We need to shift the focus toward central obesity as a marker of cardiovascular risk rather than BMI, as you suggest. BMI clearly does not tell the whole story. Where individuals store their fat is more important than the number on the scale.

References

1. Cho JH, Kim HL, Kim MA, et al. Association between obesity type and obstructive coronary artery disease in stable symptomatic postmenopausal women: data from the KoRean wOmen’S chest pain rEgistry (KoROSE) [published online August 28, 2019]. Menopause. doi:10.1097/GME.0000000000001392

2. Sun Y, Liu B, Snetselaar LG, et al. Association of normal-weight central obesity with all-cause and cause-specific mortality among postmenopausal women. JAMA Netw Open. 2019;2(7)e197337.