Waistline and increased risk of premature death: what’s so new?

A recent European Society of Cardiology Congress in Munich coincided with the last days of a Gallery of the Modern exhibition of caricatures by Munich satirist Karl Arnold:  amongst them a striking 1922 image of a stylish corpulent man said for 20 years not to have been able to see his feet. Then a social observation, it is of course now well recognized that the frankly obese are at high risk of diabetes, heart disease, stroke and other medical conditions.

At first sight surprising, that there should have been major interest from scientists and the press in new US research presented at the Heart Congress linking a larger waistline to premature death; and not just from a beer belly, but for anyone with a body shape with above normal waist to hip circumference.  What’s so unusual? Surely everyone knows that being overweight increases risk of serious medical problems.

What did these American researchers do? They looked at the strength of the link between different measures of obesity and risk of early death. In the research, lead by Professor  Francisco Lopez-Jimenez from the Mayo Clinic, almost 13,000 American men and women were studied for around 14 years, within a cohort study: the Third National Health and Nutrition Examination Survey (NHANESIII). There were around 2500 deaths of which around 1100 were from cardiovascular causes. The researchers measured body-mass index (BMI), a general measure of fatness, and waist-to-hip ratio (WHR), a measure of central obesity. This meant they were able to include people not currently considered obese based on BMI, but who had a relatively large belly, as well as those overweight both based on BMI and abdominal girth. The surprising finding of the study was that, compared to subjects with normal BMI and WHR, the group with normal BMI but relatively high central fat not only had a high death rate (2.8 times for cardiovascular disease and 2.1 times for all causes), but their risk of premature death was much higher than participants who were obese based on BMI (1.4 times normal cardiovascular risk).

It is already well established that abdominal fat is particularly deadly in relation to risk of heart disease. This new NHANESIII research in addition reported that increasing waist-hip ratio is linked to earlier death from all causes, not just for heart disease. It also provided objective data of the graded increase in risk as abdominal fat and waist-hip ratio increases.

What messages to take from this study? Obvious questions include whether it is reliable and if so generalizable from US to European and other international populations. As a prospective observational study, the results are open to bias – i.e. factors co-incidentally present in the larger waisted people may have been responsible e.g. the type of diet causing the central overweight rather than distribution of the fat itself.

However the authors reported that their findings were similar after adjusting for other well-known risk factors for premature heart disease and death, such age, male gender, ethnicity, socio-economic factors, smoking, hypertension, and diabetes.  Furthermore, this new report from Munich supported the previous systematic review by the authors noting similar findings in patients with coronary artery disease: i.e. central obesity a much stronger link  than BMI to premature death.

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Why worry about high blood pressure?

Listen to blood pressure specialist Donald Singer and pharmacist Ejaz Cheema in discussion with Annie Othen on BBC radio about blood pressure, knowing your numbers, tips on blood pressure measurement, why treatment is important, and how doctors, nurses and pharmacists can help to keep people with high blood pressure as healthy as possible.

High blood pressure is a very common preventable cause of stroke, heart attack and other serious diseases. These complications may at best cause disability and are major causes of preventable premature death in the UK and around the world.

For the public in general, the lower the blood pressure the better: most blood pressure-related heart attacks and strokes occur at blood pressure levels within what many still consider to be normal blood pressure.

A healthy lifestyle will help to keep blood pressure and other cardiovascular risk factors in check. Keeping weight in check, regular exercise, minimising salt intake and moderation in alcohol, as well as eating healthy foods rich in fruit and vegetables all help, as does avoiding or stopping smoking.

For people with raised blood pressure, tests are important to rule out underlying causes and to identify other cardiovascular risk factors.

Blood pressure treatment is well-established as effective in helping to prevent or reduce severity of heart attack, stroke and other serious medical problems. However  blood pressure is still poorly controlled in many patients even in the most developed healthcare systems.

One of several reasons for poor blood pressure control is that many patients find it difficult to keep taking their tablets. Surprisingly, in people newly diagnosed with high blood pressure, as many as half may have stopped their tablets by 12 months.

It is as important to understand and address reasons for poor patient adherence with their medicines. These include not being sure of why blood pressure is important, reasons for choice of medicines, and concerns about possible or actual side effects of tablets.

Other contributory factors includes failure of prescribers to follow established national guidelines for choice of tablets and how they should be used singly or in combination. This risks exposing patients to avoidable side effects without achieving effective lowering of blood pressure.

 

An important element in approaches to improving adherence to blood pressure medicines is continuing education of health professionals and patients about high blood pressure and its treatment. Doctors, nurses and pharmacists can all play important roles in this.