Abstract
Background
To compare the efficiency of bioelectrical indices (visceral fat index [VFI], percentage body fat [PBF]) and anthropometric indices (body mass index, waist circumference, waist‐to‐height ratio, a body shape index ) in the relation to prehypertension (120‐139/80‐89 mm Hg) among the Chinese population.
Methods
Using stratified multistage random sampling method, a general population‐based sample of 11 175 adults in Henan province were selected from 2013 to 2015. The individuals were divided into three categories by blood pressure levels: normotension (<120 and 80 mm Hg), stage 1 prehypertension (120‐129/80‐84 mm Hg) and stage 2 prehypertension (130‐139/85‐89 mm Hg).
Results
VFI and PBF tended to increase with age in men and women. However, for each age‐specific group, men tended to have higher VFI than women (all P < 0.01) and women tended to have greater PBF (all P < 0.0001). The odds ratios (OR) and area under the receiver operating characteristic curves for prehypertension associated with adiposity indices declined with age. VFI and PBF showed higher standardized adjusted ORs for prehypertension in young (~40 years) men (VFI: 2.02‐3.05; PBF: 1.82‐2.80) and young women (VFI: 1.90‐2.58; PBF:1.70‐2.29). Moreover, based on Youden's index, VFI and PBF exhibited the superiority for identifying prehypertension in men (0.20‐0.32) and women (0.31‐0.39), respectively.
Conclusion
In summary, there was stronger association of VFI and PBF with prehypertension in men than in women, respectively, especially for young adults.
Keywords: adiposity, percentage body fat, prehypertension, visceral fat index
ABBREVIATIONS
- ABSI
a body shape index
- AUC
area under the curve
- BMI
body mass index
- BP
blood pressure
- CI
confidence interval
- DBP
diastolic blood pressure JNC‐7: The Seventh Report of the Joint National Committee
- ORs
odds ratios
- PBF
percentage body fat
- SRS
simple random sampling
- SBP
systolic blood pressure
- PPS
probability proportional to size
- ROC
receiver operating characteristics
- WC
waist circumference
- WHtR
waist‐to‐height ratio
- VFI
visceral fat index
1. INTRODUCTION
Prehypertension (120‐139/80‐89 mm Hg) is a common condition that affects 25% to 50% of population in economically developed and developing countries across age, sex, ethnicity and geographical boundaries.1, 2 A cross‐sectional survey showed that 45% of Chinese urban adults had prehypertension, with the prevalence of 47.7% for men and 33.6% for women from 2009 to 2010.3 Studies suggested that blood pressure (BP) in the prehypertension range, especially for young adults, was linked with a higher risk of developing hypertension and an increased of cardiovascular diseases later in life.4, 5 A clinical trial demonstrated that 61% of placebo‐treated individuals with stage 2 prehypertension (130‐139/85‐89 mm Hg) progressed to hypertension over 4 years, and roughly 40% had progressed after 2 years.6
Obesity has become a major threat to public health globally and is also a major modifiable risk factor for cardiovascular diseases.7 In China, the prevalence of overweight/obesity rose from 19.6%/3.3% in 2004 to 21.7%/3.1% in 2007 and 28.0%/5.2% in 2010.8 Body mass index (BMI) is generally used to reflect overall obesity, and waist circumference (WC), waist‐to‐height ratio (WHtR) are widely used to identify abdominal obesity in practice.9, 10 Moreover, percentage body fat (PBF) and visceral fat index (VFI), also play an important role in the progression from prehypertension to hypertension. PBF was calculated as the total mass of fat divided by total body mass. VFI is a novel and accurate and reliable indicator for assessing body fat stored around important internal organs, which is significantly associated with many health‐related outcomes, such as prehypertension, adipose tissue dysfunction, and type 2 diabetes.11, 12, 13 Bioimpedance analysis is a measurement technique based on electrophysiological characteristics of the dielectric and conductive properties of human tissues.14 Another reliable method for measures of subcutaneous and visceral fat volume is the assessment of fat tissue area from tomographic picture by computed tomography or magnetic resonance imaging.15, 16 However, compared with this gold standard, bioelectrical impedance analysis has been widely used because of their economical and noninvasive, particularly in the public health practice. Mixed validation studies for the applicability and reliability of multifrequency bioelectrical impedance to estimate the whole body compassion in health and clinical population can be found in the published literature.17, 18 Previous studies have suggested that PBF provided a better understanding of obesity‐related risks for hypertension or prehypertension, and VFI was a valuable indicator for assessing visceral adipose function.19, 20 However, there is limited information about the direct effects of PBF and VFI on prehypertension in Chinese population. Moreover, standardizing WC for weight and height, Krakauer and Krakauer proposed a new anthropometric index called a body shape index (ABSI).21 Their research indicated that ABSI was positively associated with visceral adiposity.
Associations of these adiposity indices with prehypertension, particularly in Chinese population, have been reported by previous studies. Epidemiology studies indicated that BMI and WC were significantly associated with prehypertension.22, 23 In addition, Ma et al. revealed that WC had a higher predictive value for prehypertension, especially for men, when compared with BMI and WHtR.24 Another recent study showed that excess body fat and visceral fat was highly related to the risk of prehypertension, measurements of VFI or VFI/PBF, and PBF could provide a better understanding of adiposity‐related risk for prehypertension.20 However, compared with BMI, WC, WHtR, and body roundness index (BRI), ABSI exhibited the weakest predictive value for hypertension in Chinese population.25 To the best of our knowledge, there is significant deficit of studies comparatively evaluating the association of various adiposity indices (BMI, WC, WHtR, VFI, PBF, and ABSI) with prehypertension among Chinese population. We further assume that the association between adiposity indices and prehypertension in Chinese population varies by age and gender, which may help us to figure out which populations have high level of adiposity index with greater risk of prehypertension. It is also possible to consider whether age and gender influence the association of adiposity with prehypertension based on a large sample size. Therefore, we made comparative evaluation of adiposity indices with respect to their association with prehypertension by age and gender in a Chinese population.
2. METHODS
2.1. Study design and study participants
A community‐based cross‐sectional survey was conducted from 2013 to 2015 in Henan province, which was a part of the national study on the prevalence and risk factors for cardiovascular disease comprising 31 provinces and 262 counties supported by the National Key R&D Program in the Twelfth Five‐year Plan (No. 2011BAI11B01) from the Chinese Ministry of Science and Technology. The detailed study design of this survey has been described by Wang et al.26 Briefly, a representative sample of 19 000 were recruited from the general population by using stratified multistage random sampling method. Five cities in urban areas and six counties in rural areas were randomly selected in Henan province by using the probability proportional to size method. Using the simple random sampling (SRS) method, two districts or two townships within each region were sampled. Then, SRS method was used to sample three communities or three villages within each district and township, respectively. Finally, a given number of study participants were selected from six urban communities or six rural villages by the SRS methods.
We excluded subjects with missing information on physical examinations, age less than 18 years or participants with hypertension or other cardiovascular disease. Finally, a total of 11 175 eligible participants aged ≥18 years old were enrolled in the current analysis. This study was approved by the Ethical Committee of the Chinese Ministry of Science and Technology. All of the participants were given written informed consent before a questionnaire investigation.
2.2. Data collection
During the investigations, trained staffs interviewed the participants face‐to‐face by a structured questionnaire to collect information on demographic characteristics (such as age, sex, occupation, areas, and so on), smoking, alcohol, physical activity, sedentary behavior, and self‐reported personal and family history of cardiovascular disease. All procedures were carried out under the specific supervisors and staff training programs that mainly addressed the standardized technology for questionnaire investigation and physical examination. The accuracy and reliability of the devices were also regularly checked at every survey site.
2.3. Anthropometric and bioelectrical measurements
Anthropometric measurements were obtained for each individual by trained staffs. Height and WC were determined using strain gauge scale and flexible metric, respectively, in a standing position. Basic metabolism rate, PBF, VFI, and body weight were measured by bioelectrical impedance methods using Omron body fat and weight measurement device (V‐body HBF‐359, Omron, Kyoto, Japan). BP was measured three times on the right arms at 30 seconds intervals after at least resting for 5 minutes in a seated position with OMRON Professional PorTable Blood Pressure Monitor (HBP‐1300, OMRON, Kyoto, Japan). The mean of three systolic blood pressure (SBP) and diastolic blood pressure (DBP) was used to analysis. BMI was calculated as weight (kg)/height (m)2. WHtR was calculated as WC (cm)/height (cm). ABSI was obtained using the following formula21:
2.4. Definition
Subjects were categorized into three groups—normotension, stage 1 prehypertension, and stage 2 prehypertension—based on SBP and DBP levels according to The Seventh Report of the Joint National Committee (JNC‐7).2 Normotension was defined as SBP < 120 mm Hg and DBP < 80 mm Hg. Prehypertension was defined as SBP 120 to 139 mm Hg and/or DBP 80 to 89 mm Hg. Furthermore, we defined the stage 1 prehypertension as SBP 120 to 129 mm Hg and/or DBP 80 to 84 mm Hg, and stage 2 prehypertension as SBP 130 to 139 mm Hg and/or DBP 85 to 89 mm Hg.1, 2
2.5. Statistical analysis
Baseline characteristics were compared by using independent sample t test or Wilcoxon test for continuous variables (height, weight, heart rate, basal metabolism rate, sedentary behavior, pulse pressure, WC, BMI, PBF, VFI, WHtR, and ABSI) and χ 2 test for categorical variables (age, areas, education levels, smoking status, drinking status, metabolic equivalent, and family history). Spearman correlation coefficient was used to estimate the correlations between variables and BP levels.
The anthropometric and bioelectrical indices were divided into two groups by age‐ and gender‐specific optimal cutoff points preformed in subsequent receiver operating characteristics (ROC) analyses. Logistic regression model was used to calculate odds ratios (ORs) and 95% confidence interval (CI) for adiposity indices. The difference from the elderly (≥65 years) group or men within each corresponding age group was compared by Breslow‐Day test. Multivariate logistic regression model stratified by age and gender was used to evaluate the association of adiposity indices with prehypertension adjusting for areas, education levels, smoking, and drinking status, metabolic equivalent, sedentary behavior, and family history. Goodness of fit of the multivariate logistic regression model was assessed with the Hosmer‐Lemeshow test.
ROC analyses were generated to obtained sensitivity, specificity, Youden's index, and corresponding optimal cutoff points of each adiposity index with regard to prehypertension. Furthermore, the area under the curve (AUC) was conducted by ROC to assess the association strength of adiposity indices and prehypertension. Statistical difference between AUCs were tested with the method of DeLong test (1988) using MedCalc version 11.4.2.0 (MedCalc Software, Ostend, Belgium).
Statistical analyses were completed using SAS 9.1 (SAS Institute, Cary, North Carolina) and SPSS 21.0 software package (SPSS Inc., Chicago, Illinois). P‐values were two‐tailed, and less than 0.05 was considered as statistical significance.
3. RESULTS
3.1. Baseline characteristic of the study subjects
The baseline characteristics of 11 175 eligible participants aged ≥18 years old included in this study, as stratified by gender, are presented in Table 1. There were significant differences between areas, education levels, smoking status, metabolic equivalent, family history sedentary behavior, and prehypertension in both genders. We found that prehypertension was prevalent with higher values of weight, basal metabolic rate, and adiposity indices (WC, BMI, PBF, VFI, WHtR, and ABSI) in both men and women. Furthermore, each adiposity index tended to increase as the BP levels increased for both genders (all P < 0.05). In addition, according to the correlation coefficients, there were positive correlation of age, weight, basal metabolic rate, and adiposity indices with BP levels in men and women.
Table 1.
Baseline characteristics of study participants by blood pressure status
| Men (n = 4738) | Women (n = 6437) | |||||||
|---|---|---|---|---|---|---|---|---|
| Normotension | Stage 1 Prehypertension | Stage 2 Prehypertension | r | Normotension | Stage 1 Prehypertension | Stage 2 Prehypertension | r | |
| Age | 45.67 ± 17.19 | 45.08 ± 17.00 | 50.43 ± 16.58* | 0.15* | 41.48 ± 16.15 | 53.43 ± 14.50* | 57.97 ± 11.98* | 0.41* |
| ∼40 | 709 (39.74) | 627 (39.26) | 362 (27.61) | 1712 (45.87) | 264 (17.18) | 68 (5.82) | ||
| 40‐64 | 859 (46.94) | 736 (46.09) | 666 (50.80) | 1709 (45.79) | 980 (63.76) | 772 (66.10) | ||
| ∼65 | 262 (14.32) | 234 (14.65) | 283 (21.59) | 311 (8.33) | 293 (19.06) | 328 (28.080 | ||
| Areas, n (%) | 1830 (38.62) | 1597 (33.71)* | 1311 (27.67)** | 0.02*** | 3732 (57.97) | 1537 (23.88)* | 1168 (18.15)* | −0.16* |
| Rural | 1305 (71.29) | 1012 (63.37) | 868 (66.21) | 2397 (64.23) | 1096 (71.30) | 866 (74.14) | ||
| Urban | 525 (28.71) | 585 (36.63) | 443 (33.79) | 1335 (35.77) | 441 (28.70) | 302 (25.86) | ||
| Education levels, n (%) | 1830 (38.62) | 1597 (33.71)* | 1311 (27.67)** | −0.04* | 3732 (57.97) | 1537 (23.88)* | 1168 (18.15)* | −0.31* |
| <6 years | 471 (25.74) | 385 (24.21) | 407 (31.04) | 1186 (31.78) | 748 (48.67) | 734 (62.84) | ||
| 6‐12 years | 1008 (55.08) | 736 (54.85) | 697 (53.17) | 1517 (40.65) | 644 (41.90) | 403 (34.50) | ||
| ≥12 years | 351 (19.18) | 476 (20.04) | 207 (15.79) | 1029 (27.57) | 145 (9.43) | 31 (2.66) | ||
| Smoking status, n (%) | 1830 (38.62) | 1597 (33.71)* | 1311 (27.67)*** | −0.03*** | 3732 (57.97) | 1537 (23.88)* | 1168 (18.15)* | 0.02*** |
| Never | 633 (34.59) | 322 (20.16) | 453 (34.55) | 3681 (98.63) | 1492 (97.07) | 1125 (96.32) | ||
| Former | 269 (14.70) | 507 (31.75) | 248 (18.92) | 11 (0.29) | 20 (1.30) | 28 (2.43) | ||
| Current | 928 (50.71) | 768 (48.09) | 610 (45.53) | 40 (1.07) | 25 (1.63) | 15 (1.30) | ||
| Drinking status, n (%) | 1830 (38.62) | 1597 (33.71)* | 1311 (27.67)*** | 0.04* | 3732 (57.97) | 1537 (23.88) | 1168 (18.15) | −0.13* |
| Never | 1035 (56.56) | 815 (51.04) | 634 (48.36) | 3553 (95.20) | 1465 (95.32) | 1118 (95.72) | ||
| Daily | 151 (8.25) | 178 (11.15) | 178 (13.58) | 35 (0.94) | 15 (0.98) | 12 (1.02) | ||
| Weekly | 265 (14.49) | 238 (14.90) | 234 (17.85) | 29 (0.78) | 18 (1.17) | 15 (1.28) | ||
| Monthly | 379 (20.71) | 366 (22.91) | 265 (20.21) | 121 (3.24) | 39 (2.53) | 23 (1.97) | ||
| MET‐min/week, n (%) | 1830 (38.62) | 1597 (33.71) | 1311 (27.67)*** | 0.02 | 3732 (57.97) | 1465 (95.32)** | 1168 (18.15)* | 0.07* |
| Low | 470 (25.68) | 442 (27.68) | 286 (21.82) | 618 (16.56) | 226 (14.70) | 162 (13.87) | ||
| Moderate | 583 (31.86) | 532 (33.31) | 453 (34.55) | 1386 (37.14) | 509 (33.12) | 383 (32.79) | ||
| High | 777 (42.46) | 623 (39.01) | 572 (43.63) | 1728 (46.30) | 802 (52.18) | 623 (53.34) | ||
| Sedentary behavior (min/day) | 250.15 ± 157.89 | 254.60 ± 163.01 | 245.64 ± 165.13* | −0.02*** | 292.67 ± 183.53 | 238.57 ± 152.80* | 219.77 ± 133.22* | −0.18* |
| Family history | 1830 (38.62) | 1597 (33.71)* | 1311 (27.67)* | 0.10* | 3732 (57.97) | 1465 (95.32)** | 1168 (18.15)*** | 0.03*** |
| No | 1349 (73.71) | 1117 (69.95) | 874 (66.67) | 2541 (68.09) | 971 (63.18) | 744 (63.70) | ||
| Yes | 459 (25.09) | 463 (28.99) | 426 (32.49) | 1135 (30.41) | 551 (35.85) | 409 (35.01) | ||
| Unknown | 22 (1.20) | 17 (1.06) | 11 (0.84) | 56 (1.50) | 14 (0.92) | 15 (1.29) | ||
| Height (cm) | 167.90 ± 6.88 | 168.17 ± 6.91 | 167.31 ± 6.50** | −0.04*** | 157.19 ± 6.13 | 155.39 ± 6.21* | 154.70 ± 6.10* | −0.17* |
| Weight (kg) | 65.07 ± 9.84 | 69.04 ± 10.49* | 70.45 ± 10.66* | 0.22* | 57.71 ± 8.90 | 61.12 ± 9.93* | 61.97 ± 10.39* | 0.21* |
| Heart rate (bpm) | 75.84 ± 11.21 | 77.00 ± 11.34* | 77.58 ± 11.83* | 0.07* | 77.44 ± 10.12 | 78.17 ± 10.73*** | 74.14 ± 10.81 | 0.03*** |
| Basal metabolism rate (kcal) | 1526.04 ± 157.22 | 1581 ± 166.81* | 1589.15 ± 172.27* | 0.18* | 1236.62 ± 129.45 | 1272.13 ± 155.46* | 1278.25 ± 152.99* | 0.14* |
| PP (mm Hg) | 43.68 ± 6.69 | 49.60 ± 7.28* | 53.09 ± 8.77* | 0.47* | 42.71 ± 6.89 | 50.80 ± 7.90* | 57.30 ± 9.31* | 0.61* |
| WC (cm) | 82.68 ± 9.03 | 86.07 ± 9.38* | 88.70 ± 9.09* | 0.28* | 78.84 ± 10.21 | 84.97 ± 10.09* | 87.51 ± 9.89* | 0.35* |
| BMI (kg/m2) | 23.06 ± 3.04 | 24.39 ± 3.29* | 25.13 ± 3.25* | 0.27* | 23.38 ± 3.55 | 24.30 ± 3.64* | 25.84 ± 3.71* | 0.30* |
| PBF | 20.74 ± 6.37 | 22.72 ± 6.88* | 24.61 ± 6.06* | 0.25* | 30.14 ± 5.86 | 33.81 ± 5.16* | 35.17 ± 5.01* | 0.38* |
| VFI | 8.44 ± 4.64 | 9.94 ± 4.55* | 11.43 ± 4.57* | 0.29* | 5.77 ± 4.02 | 8.25 ± 4.23* | 9.12 ± 4.06* | 0.37* |
| WHtR | 0.49 ± 0.56 | 0.51 ± 0.06* | 0.53 ± 0.56* | 0.26* | 0.50 ± 0.07 | 0.55 ± 0.07* | 0.57 ± 0.07* | 0.37* |
| ABSI (m11/6 kg−2/3) | 0.0789 ± 0.0050 | 0.0791 ± 0.0049 | 0.0801 ± 0.0048* | 0.10* | 0.0771 ± 0.0058 | 0.0793 ± 0.0054* | 0.0808 ± 0.0057* | 0.27* |
Abbreviations: ABSI, a body shape index; BMI, body mass index; MET, metabolic equivalent; PBF, percentage body fat; PP, pulse pressure; WC, waist circumference; WHtR, waist‐to‐height ratio; VFI, visceral fat index.
Symbols denote significant differences from optimal BP (* P<0.0001 ** P<0.01 *** P<0.05) with independent sample t test or Wilcoxon test (for continuous variables) or Chi‐square test (for categorical variables). Values are given as frequency (percentage) or mean with SD (SD) for each variable.
As presented in Figure 1, in men and women, adiposity indices were found to rise with age. However, for each age‐specific group, men tended to have higher WC, VFI, and ABSI than women (all P < 0.01), as for women, they tend to have greater PBF and WHtR than men (all P < 0.01).
Figure 1.
Levels of adiposity indices by age and gender. *P < 0.01, **P < 0.001
3.2. Comparison of ORs for prehypertension associated with adiposity indices stratified by age and gender
Supplementary file Table 1S presented comparison of crude and adjusted ORs of adiposity indices for prehypertension determined by age‐ and gender‐specific cutoff points proposed in subsequent ROC analyses. The multivariate logistic regression model showed a good fit (Hosmer‐Lemeshow test P > 0.05). Crude and adjusted ORs except ABSI in elderly (~65 years) group for prehypertension were significantly higher than a reference level of 1.00 (all P < 0.05) and tended to lower with elevated age in each age groups. The crude ORs of adiposity indices for stage 2 prehypertension were significantly higher in young (~40 years) women than in elderly women, but ABSI was not considered the difference between two age groups because of the overlapping 95%CI. Moreover, crude ORs of adiposity indices except ABSI for stage 2 prehypertension tended to be higher in young women than in young men (all P < 0.05).
Comparison of crude and adjusted ORs for prehypertension associated with high levels of adiposity indices based on z‐scores standardization by age and gender were shown in Table 2. Each SD increase of adiposity indices except ABSI was associated with greater risk of prehypertension by age and gender (all P < 0.05). In young (~40 years) men and women, we found that individuals with higher VFI had greater risk for prehypertension before and after adjusting for other explanatory variables. In middle‐age (40‐64 years) men, WHtR exhibited closer association with prehypertension than other indices. In elderly (~65 years) men, BMI showed the best performance in identifying prehypertension. Whereas, PBF had the highest OR for prehypertension in women aged over 40 years.
Table 2.
Standardized odds ratios (ORs) and 95% confidence interval (CI) for prehypertension with vs without higher adiposity indices by age and gender
| Stage 1 prehypertension | Stage 2 prehypertension | |||||||
|---|---|---|---|---|---|---|---|---|
| ~40 | 40‐64 | ~65 | ~40 | 40‐64 | ~65 | |||
| Men | ||||||||
| WC z‐score | Crude OR | 1.59 (1.20,1.80) | 1.52 (1.19,1.94) | 1.47 (1.19,1.80) | 2.32 (1.99,2.72) | 2.07 (1.81,2.37) | 1.59 (1.20,1.80) | |
| Adjust ORa | 1.71 (1.46,1.99) | 1.54 (1.31,1.81) | 1.40 (1.13,1.74) | 2.46 (2.06,2.92) | 2.11 (1.83,2.44) | 1.71 (1.46,1.99) | ||
| BMI z‐score | Crude OR | 1.61 (1.40,1.84) | 1.42 (1.91,1.69) | 1.56 (1.24,1.96) | 2.39 (2.05,2.78) | 1.98 (1.74,2.54) | 1.61 (1.40,1.84) | |
| Adjust ORa | 1.77 (1.54,2.05) | 1.43 (1.27,1.62) | 1.52 (1.20,1.94) | 2.52 (2.13,2.97) | 1.94 (1.69,2.21) | 1.77 (1.54,2.05) | ||
| PBF z‐score | Crude OR | 1.63 (1.42,1.87) | 1.61 (1.41,1.84) | 1.41 (1.27,1.60) | 2.65 (2.12,3.19) | 2.27 (1.93,2.67) | 1.63 (1.42,1.87) | |
| Adjust ORa | 1.82 (1.55,2.14) | 1.64 (1.42,1.89) | 1.39 (1.16,1.66) | 2.80 (2.29,3.42) | 2.33 (1.97,2.76) | 1.82 (1.55,2.14) | ||
| VFI z‐score | Crude OR | 1.83 (1.59,2.10) | 1.56 (1.37,1.75) | 1.46 (1.26,1.69) | 2.67 (2.22,3.15) | 2.34 (2.02,2.73) | 1.83 (1.59,2.10) | |
| Adjust ORa | 2.02 (1.70,2.39) | 1.57 (1.39,1.78) | 1.50 (1.19,1.99) | 3.05 (2.49,3.74) | 2.31 (1.92,2.79) | 2.02 (1.70,2.39) | ||
| WHtR z‐score | Crude OR | 1.69 (1.49,1.91) | 1.67 (1.47,1.90) | 1.51 (1.22,1.87) | 2.34 (1.96,2.79) | 2.14 (1.86,2.45) | 1.69 (1.49,1.91) | |
| Adjust ORa | 1.72 (1.50,1.97) | 1.71 (1.49,1.95) | 1.45 (1.16,1.82) | 2.70 (1.80,4.04) | 2.35 (2.00,2.75) | 1.72 (1.50,1.97) | ||
| ABSI z‐score | Crude OR | 1.10 (0.90,1.34) | 1.08 (0.96,1.22) | 1.01 (0.88,1.15) | 1.19 (1.01,1.41) | 1.28 (1.12,1.45) | 1.10 (0.90,1.34) | |
| Adjust ORa | 1.15 (0.93,1.42) | 1.02 (0.86,1.17) | 1.09 (0.97,1.23) | 1.26 (1.10,1.44) | 1.79 (1.50,2.14) | 1.15 (0.93,1.42) | ||
| Women | ||||||||
| WC z‐score | Crude OR | 1.68 (1.47,1.92) | 1.48 (1.36,1.62) | 1.33 (1.11,1.60) | 2.45 (1.97,3.06) | 1.80 (1.63,1.99) | 1.68 (1.47,1.92) | |
| Adjust ORa | 1.60 (1.36,1.89) | 1.45 (1.32,1.59) | 1.30 (1.08,1.57) | 2.11 (1.61,2.76) | 1.68 (1.51,1.87) | 1.60 (1.36,1.89) | ||
| BMI z‐score | Crude OR | 1.62 (1.44,1.83) | 1.42 (1.30,1.54) | 1.30 (1.09,1.56) | 2.19 (1.82,2.64) | 1.59 (1.45,1.75) | 1.62 (1.44,1.83) | |
| Adjust OR a | 1.54 (1.34,1.78) | 1.44 (1.32,1.57) | 1.27 (1.06,1.55) | 1.96 (1.57,2.44) | 1.58 (1.44,1.75) | 1.54 (1.34,1.78) | ||
| PBF z‐score | Crude OR | 1.94 (1.59,2.36) | 1.55 (1.40,1.71) | 1.79 (1.55,2.08) | 2.38 (1.84,3.07) | 2.12 (1.81,2.49) | 1.94 (1.59,2.36) | |
| Adjust ORa | 1.70 (1.36,2.13) | 1.49 (1.35,1.66) | 1.62 (1.39,1.90) | 2.29 (1.59,3.31) | 1.97 (1.44,2.03) | 1.70 (1.36,2.13) | ||
| VFI z‐score | Crude OR | 2.07 (1.52,2.82) | 1.51 (1.38,1.65) | 1.47 (1.21,1.80) | 3.11 (2.32,4.16) | 1.79 (1.60,2.01) | 2.07 (1.52,2.82) | |
| Adjust ORa | 1.90 (1.38,2.62) | 1.46 (1.34,1.62) | 1.44 (1.18,1.78) | 2.58 (1.89,3.56) | 1.62 (1.44,1.83) | 1.90 (1.38,2.62) | ||
| WHtR z‐score | Crude OR | 1.72 (1.51,1.97) | 1.73 (1.44,2.05) | 1.36 (1.15,1.63) | 2.32 (1.87,2.87 | 1.80 (1.62,1.99 | 1.72 (1.51,1.97 | |
| Adjust OR | 1.63 (1.39,1.92) | 1.48 (1.19,1.83 | 1.37 (1.15,1.64 | 1.98 (1.52,2.59 | 1.64 (1.47,1.82 | 1.63 (1.39,1.92) | ||
| ABSI z‐score | Crude OR | 1.22 (1.06,1.40) | 1.21 (1.10,1.32) | 0.98 (0.84,1.16) | 1.28 (1.03,1.65) | 1.38 (1.25,1.53) | 1.22 (1.06,1.40) | |
| Adjust OR | 1.11 (1.01,1.28) | 1.12 (1.02,1.24) | 0.95 (0.79,1.13) | 1.21 (1.01,1.36) | 1.20 (1.08,1.34) | 1.11 (1.01,1.28 | ||
Abbreviations: BMI, body mass index; WC, waist circumference; WHtR, waist‐to‐height ratio; PBF, percentage body fat; VFI, visceral fat index; ABSI, a body shape index.
Adjusted for areas, education levels, smoking status, drinking status, metabolic equivalent, sedentary behavior, family history.
3.3. Comparison of ROC curves for the relationships between adiposity indices and BP levels in men and women of each age group
Table 3 showed the optimal cutoff points, sensitivity, specificity, Youden's index, and AUC of adiposity indices for identifying prehypertension by gender. Compared with men, women consistently had higher AUCs for each adiposity index (all P < 0.05). These AUCs (WC, BMI, PBF, VFI, and WHtR) for the relationships with stage 2 prehypertension were significantly larger than those for the relationships with stage 1 prehypertension in men and women (all P < 0.05). P‐values for pairwise comparison of ROC curves for adiposity indices in men and women were depicted in Supplementary file Table 2S. PBF, VFI, and WHtR consistently tended to have significantly larger AUCs than other indices for prehypertension in both genders (all P < 0.05). Comparison of ROC curves analysis of adiposity indices as indicators for prehypertension by age were shown in Supplementary file Table 3S. Table 4 presented adiposity indices of the discriminatory power to prehypertension by age and gender. We found that the AUCs of adiposity indices tended to decrease with age in both genders.
Table 3.
Comparison of ROC curves analyses of adiposity indices as indicators for prehypertension by gender
| Stage 1 prehypertension | Stage 2 prehypertension | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Cutoff | SE (%) | Sp (%) | Youden index | AUC (95%CI) | Cutoff | SE (%) | Sp (%) | Youden index | AUC (95%CI) | |
| Men | (1597/1830)a | (1311/1830)b | ||||||||
| WC | 84.75 | 56.87 | 59.02 | 0.16 | 0.594 (0.579,0.619) | 83.55 | 71.70 | 54.64 | 0.26 | 0.679 (0.658,0.695)*** |
| BMI | 24.05 | 56.87 | 58.58 | 0.12 | 0.583 (0.564,0.602) | 24.49 | 56.31 | 67.18 | 0.23 | 0.658 (0.644,0.673) *** |
| PBF | 22.55 | 55.56 | 64.81 | 0.19 | 0.608 (0.580,0.617) | 23.45 | 61.56 | 67.64 | 0.29 | 0.689 (0.667,0.705)*** |
| VFI | 8.90 | 61.00 | 57.77 | 0.20 | 0.618 (0.600,0,637) | 8.05 | 72.85 | 58.72 | 0.32 | 0.698 (0.670,0.707)*** |
| WHtR | 0.50 | 61.25 | 53.06 | 0.14 | 0.597 (0.577,0.615) | 0.52 | 62.32 | 64.48 | 0.27 | 0.685 (0.666,0.704) *** |
| ABSI | 0.07604 | 70.31 | 42.75 | 0.16 | 0.516 (0.575,0.600) | 0.07803 | 67.35 | 44.43 | 0.12 | 0.575 (0.555,0.595) |
| Women | (1537/3732)a | (1168/3732)b | ||||||||
| WC | 80.35 | 66.49 | 58.44 | 0.25 | 0.667 (0.649,0.681)** | 82.75 | 70.46 | 61.89 | 0.32 | 0.732 (0.716,0.748)*, *** |
| BMI | 23.89 | 62.57 | 59.38 | 0.22 | 0.649 (0.633,0.666)** | 24.05 | 68.15 | 60.89 | 0.29 | 0.691 (0.674,0.708)**,*** |
| PBF | 30.85 | 76.75 | 53.81 | 0.31 | 0.693 (0.688,0.699)* | 32.85 | 71.63 | 63.92 | 0.39 | 0.752 (0.737,0.768)*,*** |
| VFI | 5.15 | 72.61 | 55.89 | 0.29 | 0.685 (0.665,0.696)* | 5.75 | 80.25 | 57.90 | 0.38 | 0.748 (0.733,0.763)*,*** |
| WHtR | 0.52 | 66.30 | 61.93 | 0.28 | 0.680 (0.664,0.694)* | 0.53 | 72.46 | 64.20 | 0.37 | 0.743 (0.727,0.758)*,*** |
| ABSI | 0.07667 | 70.77 | 49.63 | 0.20 | 0.621 (0.604,0.637)* | 0.07785 | 70.29 | 57.80 | 0.28 | 0.683 (0.666,0.700)*, *** |
Abbreviations: BMI, body mass index; WC, waist circumference; WHtR, waist‐to‐height ratio; PBF, percentage body fat; VFI, visceral fat index; ABSI, a body shape index; Se, sensitivity; Sp, specificity.
Significant differences of the AUCs for adiposity indices compared with men (* P<0.0001, ** P<0.05). Significant differences of the AUCs for adiposity indices between PHT1 and PHT2 (*** P<0.0001).
Denotes the number of stage 1 prehypertension/normotension for each group.
Denotes the number of stage 2 prehypertension/normotension for each group.
Table 4.
Area under the curve (AUC) and 95% confidence interval (CI) of adiposity indices to identify prehypertension by age and gender
| Stage 1 prehypertension | Stage 2 prehypertension | |||||
|---|---|---|---|---|---|---|
| ~40 | 40‐64 | ~65 | ~40 | 40‐64 | ~65 | |
| Men | (627/709)a | (736/859)a | (234/262)a | (362/709)b | (666/859)b | (283/262)b |
| WC | 0.614 (0.584,0.644) | 0.603 (0.551,0.655) | 0.596 (0.568,0.624) | 0.706 (0.673,0.738) | 0.663 (0.635,0.690) | 0.659 (0.627,0.716) |
| BMI | 0.620 (0.590,0.650) | 0.613 (0.585,0.640) | 0.596 (0.543,0.694) | 0.697 (0.665,0.730) | 0.655 (0.622,0.682) | 0.664 (0.616,0.711) |
| PBF | 0.623 (0.594,0.653) | 0.610 (0.558,0.663) | 0.570 (0.542,0.598) | 0.716 (0.683,0.734) | 0.672 (0.645,0.699) | 0.657 (0.610,0.705) |
| VFI | 0.637 (0.607,0.666) | 0.604 (0.552,0.656) | 0.602 (0.574,0.629) | 0.726 (0.694,0.758) | 0.673 (0.645,0.700) | 0.611 (0.561,0.660) |
| WHtR | 0.611 (0.581,0.641) | 0.615 (0.563,0.667) | 0.601 (0.573,0.629) | 0.702 (0.669,0.734) | 0.674 (0.645,0.700) | 0.654 (0.606,0.702) |
| ABSI | 0.531 (0.503,0.560) | 0.526 (0.472,0.580) | 0.516 (0.485,0.547) | 0.564 (0.535,0.592) | 0.546 (0.510,0.582) | 0.533 (0.482,0.584) |
| Women | (264/1712)a | (980/1709)a | (293/311)a | (68/1712)b | (772/1709)b | (328/311)b |
| WC | 0.637 (0.600,0.674) | 0.590 (0.568,0.612) | 0.566 (0.517,0.615) | 0.726 (0.658,0.794) | 0.646 (0.622,0.669) | 0.606 (0.560,0.652) |
| BMI | 0.624 (0.586,0.661) | 0.591 (0.569,0.614) | 0.572 (0.523,0.621) | 0.732 (0.660,0.803) | 0.625 (0.601,0.649) | 0.608 (0.561,0.654) |
| PBF | 0.652 (0.616,0.688) | 0.616 (0.568,0.664) | 0.604 (0.582,0.626) | 0.742 (0.674,0.811) | 0.647 (0.623,0.670) | 0.626 (0.602,0.650) |
| VFI | 0.654 (0.308,0.681) | 0.599 (0.577,0.621) | 0.592 (0.543,0.641) | 0.753 (0.671,0.814) | 0.636 (0.612,0.660) | 0.593 (0.546,0.640) |
| WHtR | 0.650 (0.615,0.686) | 0.601 (0.597,0.624) | 0.583 (0.541,0.639) | 0.728 (0.659,0.796) | 0.632 (0.586,0.677) | 0.603 (0.557,0.650) |
| ABSI | 0.562 (0.524,0.599) | 0.551 (0.529,0.574) | 0.496 (0.446,0.546) | 0.580 (0.556,0.604) | 0.565 (0.493,0.638) | 0.543 (0.496,0.591) |
Abbreviations: BMI, body mass index; WC, waist circumference; WHtR, waist‐to‐height ratio; PBF, percentage body fat; VFI, visceral fat index; ABSI, a body shape index.
Denotes the number of stage 1 prehypertension/normotension for each group.
Denotes the number of stage 2 prehypertension/normotension for each group.
4. DISCUSSION
Notably, we found significantly stronger association of higher adiposity indices with stage 2 prehypertension in young (~40 years) women than in elderly (~65 years) women. We first speculated that low exposure of excess adiposity accumulation in young adults may partly account for the age difference. As reported by a cohort study, 50% of individuals aged>65 years with stage 2 prehypertension progressed to hypertension compared with 37% individuals aged<65 years.27 Similarly, Wakabayashi reported that the association of obesity with prehypertension or hypertension are greater in women than men.28 Moreover, another study showed that the effect of obesity (BMI > 27 kg/m2) on the incidence of hypertension is stronger in women than in men.29 The underlying mechanisms of the age‐related difference have been proposed from previous studies as follows: genetic variation within the angiotensin II receptor type‐1 influenced BP, fatty acid metabolism, secretion of angiotensinogen, and activation of the sympathetic nervous system.30, 31 However, non‐significantly differences between men and women aged over 40 years may be owing to confounding effects of age or fat deposit or interaction between estrogen and confounding factors.
Young (~40 years) group showed the strongest association of higher adiposity indices with the prevalence of prehypertension. Moreover, stronger association of adiposity indices with stage 2 prehypertension in young women than in young men, which was consistent with the findings of previous studies that explored the relation of obesity to multiple cardiometabolic risk factors including prehypertension.28, 32 Sex hormone, especially estrogen, might provide evidence for the existence of such a gender‐related difference.33 Moreover, sympathetic nerve activity plays an important role in regulating BP, whereas increased activity of the sympathetic nervous system was associated with obesity‐related hypertension.30, 34 Muscle sympathetic nerve activity has been reported to mainly associate with WHtR in men but not in women, and this finding may explain gender‐related difference in the regulation of the sympathetic nervous system activity.35 Among young men and women, compared to other indices, VFI had higher strength of association with prehypertension or hypertension. In middle‐aged (40‐64 years) and old‐aged (~65 years) men, WHtR and BMI had highest ORs for prehypertension among adiposity indices, which is consistent with the results in another study.36 In addition, PBF showed the closest association to prehypertension in women aged 40 over years. However, the effects of PBF on prehypertension in age‐ and gender‐related difference needs to be further determined.
The AUCs of adiposity indices tended to decrease with age for prehypertension in both genders, as well as were considerably larger in women than in men. Less modifiable risk factors (ie, metabolic equivalent, smoking, drinking, and so on) in young adults than in older ones may be important contributors in the progression of prehypertension. Moreover, WHtR performed better than WC and BMI in identifying prehypertension. This similar observation has been suggested in other studies.37, 38 According to Youden's index, VFI and PBF reveled the highest discriminatory capacities for prehypertension in men and women, respectively. As indicated in this study, VFI and PBF tended to increase with age in men and women. It is remarkable that, for each age‐specific group, men consistently have greater proportion of visceral fat compared to women whereas women consistently have higher total body fat than men, which may suggest that there was stronger association of VFI and PBF with prehypertension in men than in women, respectively. However, these interesting findings need to be further confirmed in prospective cohort studies. ABSI was not satisfied in discriminating for prehypertension among both genders. Several population‐based cross‐sectional studies reported that ABSI could not be a good predictor for cardiovascular disease and diabetes.39 Another study also found that ABSI showed lowest discriminatory power and had no relation to cardiovascular disease risk compared to BMI and WC after adjusting age, sex, and smoking.40
Given obesity as a modifiable risk factor for hypertension or prehypertension as well as age‐dependent attenuation in the relationship of adiposity with prehypertension. It does not suggest that PBF and VFI would be a way to replace BP measurement in identifying people with prehypertension. We would like to prevention of achieving high visceral body fat and weight may be more beneficial to prevent prehypertension in young individuals than in elderly ones. The growing body of evidence about obesity paradox showed that overweight and at least mildly obese patients with cardiovascular diseases seemed to have a favorable prognosis and decrease the risk of all‐cause mortality when compared to leaner ones.41, 42 A large national cohort study suggested that not only prevention of obesity but aerobic physical fitness should begin early in life to prevent hypertension, even among individuals with normal BMI.43
Since obesity still cannot be neglected for the risk of prehypertension. There is a question of whether we need adiposity indices to identify prehypertension while we can simply measure BP by sphygmomanometer in all overweight/obese individuals? At individual levels, no adiposity indices could not replace BP measures in distinguishing prehypertension. However, we assumed that there were different time intervals between adiposity accumulation and prehypertension in different age and gender groups.44 The cross‐sectional survey addressed the value of adiposity indices not in the diagnosis of prehypertension at individual level but the predicting, early warning and prevention of prehypertension at population level.
4.1. Strengths and limitations
To our knowledge, this is the first study to comparatively evaluate different adiposity indices (PBF, VFI, BMI, WC, WHtR, and ABSI) with respect to their association strength and discriminating power for prehypertension by age and gender in Chinese population. Furthermore, all procedures were performed under the supervisors, which ensure the authenticity and reliability of data. Another strength of the study is that by samples, the participants were from community‐based general population, which may increase the representativeness of results.
Several potential limitations of this study should also be considered. First, it is a cross‐sectional study, which precluded establishing causality between adiposity indices and prehypertension by age and gender. Randomized controlled trials or prospective studies are needed to provide stronger evidence of these associations. Second, this study lacks of data on laboratory measurements (eg, blood lipids and blood glucose). Third, because all the subjects are from Chinese Han in Henan province, caution should be taken in extrapolating our results to other ethnic groups.
5. CONCLUSION
In conclusion, young (~40 years) women with high levels of adiposity indices had greater risk of prehypertension than do those young men. The discriminatory power of each adiposity index for prehypertension consistently declined with age in both genders. In summary, there was stronger association of VFI and PBF with prehypertension in men than in women, respectively, especially for young adults.
CONFLICTS OF INTERESTS
The authors declare no potential conflict of interests.
Supporting information
TABLE S1 Odds ratios (ORs) and 95% confidence interval (CI) for prehypertension with vs without high levels of adiposity indices by age and gender.
TABLE S2 P‐values for pairwise comparison of receiver operating characteristic curves for adiposity indices in men and women.
TABLE S3 Comparison of receiver operating characteristic curves analyses of adiposity indices as indictor for prehypertension by age.
ACKNOWLEDGMENTS
The authors acknowledge all the local officers at each sample site for calling the selected participants in the field studies, and all the team members for their contribution in this epidemiology investigation. The authors would like to sincerely thank Prof. Wang ZW from Fuwai Hospital and Chinese Academy of Medical Sciences for supervision in this survey. This work was supported by grants from the National Key R&D Program in the Twelfth Five‐year Plan (No. 2011BAI11B01), Medical Science and technology key projects of Henan Province (No. 201501016, No. 201602295), Henan University Science and Technology Innovation Talents Support Program (No. 19HASTIT005) and the National Natural Science Foundation of China (No. 81372371, No. U1604168).
Wang S, Peng R, Liang S, et al. Comparison of adiposity indices in relation to prehypertension by age and gender: A community‐based survey in Henan, China. Clin Cardiol. 2018;41:1583–1592. 10.1002/clc.23086
Funding information General Program of National Natural Science Foundation of China, Grant/Award Number: 81372371; Henan university science and technology innovation talents support program, Grant/Award Number: 19HASTIT005; Medical Science and technology key projects of Henan Province, Grant/Award Number: 201501016201602295; the National Key R&D Program in the Twelfth Five‐year Plan, Grant/Award Number: 2011BAI11B01
Contributor Information
Kaijuan Wang, Email: kjwang@163.com.
Chunhua Song, Email: sch16@zzu.edu.cn.
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Associated Data
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Supplementary Materials
TABLE S1 Odds ratios (ORs) and 95% confidence interval (CI) for prehypertension with vs without high levels of adiposity indices by age and gender.
TABLE S2 P‐values for pairwise comparison of receiver operating characteristic curves for adiposity indices in men and women.
TABLE S3 Comparison of receiver operating characteristic curves analyses of adiposity indices as indictor for prehypertension by age.