General and abdominal adiposity and hypertension in eight world regions: a pooled analysis of 837 population-based studies with 7·5 million participants

Authors: Bin Zhou, James E Bennett, Aidan Wickham, Rosie Singleton, Anu Mishra, Rodrigo M. Carrillo‐Larco, Nayu Ikeda, Lakshya Jain, Ana Barradas‐Pires, Rachel A Heap, Victor P. F. Lhoste, Kate E. Sheffer, Nowell H Phelps, A. Rayner, Edward W. Gregg, Mark Woodward, Gretchen A Stevens, Maria LC Iurilli, Goodarz Danaei, Mariachiara Di Cesare, Carlos A Aguilar-Salinas, Noor Ani Ahmad, Pascal Bovet, Zhengming Chen, Albertino Damasceno, Sarah Filippi, Imre Janszky, André Pascal Kengne, Young‐Ho Khang, Kamlesh Khunti, Avula Laxmaiah, Lee‐Ling Lim, Lauren Lissner, Paula Margozzini, Jean Claude Mbanya, Stephen T McGarvey, Jonathan E Shaw, Stefan Söderberg, Luis Adrián Soto-Mota, Junyang Wang, Francesco Zaccardi, Leandra Abarca-Gómez, Mohsen Abbasi‐Kangevari, Shynar Abdrakhmanova, Suhaila Abdul Ghaffar, Hanan F Abdul Rahim, Zulfiya Abdurrahmonova, Niveen Abu-Rmeileh, Benjamín Acosta-Cázares, Ishag Adam, Marzena Adamczyk, Wichai Aekplakorn, Imelda Angeles‐Agdeppa, Javad Aghazadeh-Attari, Charles Agyemang, Mohamad Hasnan Ahmad, Ali Ahmadi, Naser Ahmadi, Nastaran Ahmadi, Soheir H. Ahmed, Wolfgang Ahrens, Gulmira Aitmurzaeva, Kamel Ajlouni, Hazzaa M Al-Hazzaa, Halima Al-Hinai, Jawad Al‐Lawati, Rajaa Al‐Raddadi, Deena Alasfoor, Huda Al Hourani, Monira Alarouj, Fadia AlBuhairan, Shahla AlDhukair, Mohamed M Ali, Anna V Alieva, Abdullah Alkandari, Buthaina Alkhatib, Eman Aly, Deepak Amarapurkar, Pilar Amiano Etxezarreta, Norbert Amougou, Lars Bo Andersen, Sigmund A Anderssen, Odysseas Androutsos, Ranjit Mohan Anjana, Alireza Ansari‐Moghaddam, Е. И. Ануфриева, Hajer Aounallah-Skhiri, Tahir Aris, Raphael E. Arku, Nimmathota Arlappa, Krishna Kumar Aryal, Félix Assah, Batyrbek Assembekov, Maria Cecília F Assunção, Juha Auvinen, Mária Avdičová, Kishwar Azad, Ana Azevedo, Mohsen Azimi-Nezhad, Fereidoun Azizi, Flora Bacopoulou, Suhad Bahijri, Izet Bajramović, Nagalla Balakrishna, Mohamed Bamoshmoosh, Maciej Banach, Piotr Bandosz, José R. Banegas, Rafał Baran, Carlo M Barbagallo, Valter Cordeiro Barbosa Filho, Alberto Barceló, Maja Baretić, Joaquín Barnoya, Lena Barrera, Aluísio J. D. Barros, Mauro Virgílio Gomes de Barros, Abdul Basit, João Luiz Bastos, Anwar Batieha, Aline Priscila Batista, Rosângela Fernandes Lucena Batista, Zhamilya Battakova, Louise A. Baur, Pascal Bayauli, Silvia Bel‐Serrat, Belavendra Antonisamy, Habiba Ben Romdhane, Theodora Benedek, Judith Benedics, Mikhail Benet Rodríguez, Gilda Estela Benitez Rolandi, Michaela Benzeval, Elling Bere, Nicolas Berger, Ingunn Holden Bergh, Salim Berkinbayev, Antonio Bernabé‐Ortiz, Heloísa Bettiol, Augustin F Beybey, Jorge Bezerra, Aroor Bhagyalaxmi, Santosh K. Bhargava, Elysée Claude Bika Lele, Mukharram M Bikbov, Bihungum Bista, Dusko J Bjelica, Peter Bjerregaard, Espen Bjertness, Marius B Bjertness, Cecilia Björkelund, Kátia Vergetti Bloch, Anneke Blokstra, Simona Bo, Martin Bobák, Lynne M. Boddy, Bernhard O Boehm, Jose G Boggia, Elena Bogova, Marialaura Bonaccio, Alice Bonilla-Vargas, Herman Borghs, Steve Botomba, Rupert Bourne, Khadichamo Boymatova, Lutgart Braeckman, Tasanee Braithwaite, Imperia Brajkovich, Francesco Branca, Hermann Brenner, Lizzy M. Brewster, Yajaira Briceño, Lăcrămioara Aurelia Brîndușe, Bettina Bringolf‐Isler, Miguel Brito, Johannes Brug, Anna Bugge, Frank Buntinx, Marta Buoncristiano, Con Burns, Antonio Cabrera de León, Roberta B. Caixeta, Tilema Cama, Günay Can, Ana Paula Carlos Cândido, Felicia Cañete, Mario V. Capanzana, Naděžda Čapková, Eduardo Capuano, Rocco Capuano, Vincenzo Capuano, Viviane C Cardoso, Axel C. Carlsson, Felipe F. Casanueva, Maribel Casas, Laura Censi, Marvin Cervantes–Loaiza, Parinya Chamnan, Snehalatha Chamukuttan, Queenie Chan, Nish Chaturvedi, Fangfang Chen, Huashuai Chen, Long‐Sheng Chen, Yiling J. Cheng, Bahman Cheraghian, Angela Chetrit, Ekaterina Chikova‐Iscener, Mai J. M. Chinapaw, Anne Chinnock, Arnaud Chioléro, Adela Chiriță-Emandi, María‐Dolores Chirlaque, Chean Lin Chong, Diego Giulliano Destro Christófaro, Jerzy Chudek, Renata Cifkova, Massimo Círillo, Frank Claessens, Philip Clare, Emmanuel Cohen, Susana Cararo Confortin, Tara Coppinger, Lilia Yadira Cortés, Cosmin Cojocaru, Simona Costanzo, Melanie J Cowan, Chris Cowell, Amelia C. Crampin, Amanda J. Cross, Ana B. Crujeiras, Juan J. de la Cruz, Alexandra M Cucu, Felipe Vogt Cureau, Sarah Cuschieri, Graziella D'Arrigo, Eleonora d’Orsi, Haroldo da Silva-Ferreira, Christina C. Dahm, Jean Dallongeville, Rachel Dankner, Kairat Davletov, Francisco de Assis Guedes de Vasconcelos, Maria Alice Altenburg de Assis, Dirk De Bacquer, Jaco De Bacquer, Jeroen de Bont, Amalia De Curtis, Patrícia de Fragas Hinnig, Giovanni de Gaetano, Stefaan De Henauw, Pilar De Miguel‐Etayo, Paula Duarte de Oliveira, Karina Mary de Paiva, Karin De Ridder, Marco Aurélio de Valois Correia, Mohan Deepa, Vincent Jr DeGennaro, Stefaan Demarest, Elaine Dennison, Valérie Deschamps, Meghnath Dhimal, María Pilar Díez Ripollés, Živka Dika, Shirin Djalalinia, Liria Dominguez, Maria Benedetta Donati, Chiara Donfrancesco, Guang‐Hui Dong, Silvana P Donoso, Maria Dorobanţu, Marcus Dörr, Nico Dragano, Wojciech Drygas, Shufa Du, Charmaine A Duante, Priscilla Duboz, Rosemary B. Duda, Vesselka Duleva, Anar Dushpanova, Дюсупова А.А., Elżbieta Dziankowska–Zaborszczyk, Narges Ebrahimi, Guadalupe Echeverría, Ricky Eddie, Ebrahim Eftekhar, Vasiliki Efthymiou, Eruke E Egbagbe, Sareh Eghtesad, Ulf Ekelund, Mohammad El-Khateeb, Jalila El Ati, Roberto Elosúa, Ofem Enang, Rajiv T Erasmus, Cihangir Erem, Gül Ergör, Louise Eriksen, Johan G Eriksson, Jorge Escobedo-de la Peña, Ali Esmaeili, Roger G. Evans, Ildar Fakhradiyev, Albina A. Fakhretdinova, Caroline H Fall, Elnaz Faramarzi, Mojtaba Farjam, Farshad Farzadfar, Yosef Farzi, Mohammad Reza Fattahi, Asher Fawwad, Francisco Javier Félix-Redondo, Trevor S Ferguson, Romulo A Fernandes, Daniel Fernández‐Bergés, Desha R Fernando, Daniel Ferrante, Gérson Ferrari, Marika Ferrari, Catterina Ferreccio, Eldridge Ferrer, Thamara Hübler Figueiró, Anna Fijałkowska, Günther Fink, Mauro Fisberg, Maria Forsner, Edward Fottrell, Heba Fouad, Damian K Francis, Guillermo Frontera, Flavio D Fuchs, Sandra Cristina Pereira Costa Fuchs, Viktoriya Furdela, T. Furusawa, Stefan Adela Gabriela, Zbigniew Gaciong, Manuel Galán Cuesta, Andrzej Galbarczyk, Sonya Galcheva, Myriam Galfo, Manoli Garcia-de-la-Hera, Pablo García, Sarah P. Garnett, Magda Gasull, Andrea Gazzinelli, Ulrike Gehring, Eva Gerdts, Ebrahim Ghaderi, Seyyed‐Hadi Ghamari, Ali Ghanbari, Erfan Ghasemi, Oana-Florentina Gheorghe-Fronea, Anup Ghimire, Alessandro Gialluisi, Simona Giampaoli, Francesco Gianfagna, Glen Gironella, Aleksander Giwercman, Konstantinos Gkiouras, Natalya Glushkova, Ramesh Godara, Justyna Godos, Marcel Goldberg, Georgina Gómez, Jesús‐Humberto Gómez, Luis Fernando Gómez, Santiago F. Gómez, Aleksandra Gomuła, Bruna Gonçalves Cordeiro da Silva, Helen Gonçalves, Mauer Gonçalves, Ana D González-Alvarez, David Alejandro González‐Chica, Esther M. González‐Gil, Marcela González‐Gross, Juan P. González‐Rivas, Angel R Gonzalez, Frédèric Gottrand, Dušan Grafnetter, Aneta Grajda, Maria G Grammatikopoulou, Tomasz Grodzicki, Else Karin Grøholt, Anders Grøntved, Viviana Guajardo, Pilar Guallar-Castillón, Maëlenn Guerchet, Ramiro Guerrero, André Luiz Sena Guimarães, Unjali P. Gujral, Martin Gulliford, Marc J. Gunter, Rajeev Gupta, Oye Gureje, Mirjana Gurinović, Beata Gurzkowska, Laura Gutiérrez, Xinyi Gwee, Rosa Haghshenas, Hamid Hakimi, Jytte Halkjær, Ian Hambleton, Behrooz Hamzeh, Willem A. Hanekom, Dominique Hange, Abu Abdullah Mohammad Hanif, Sari Hantunen, Jie Hao, Carla Menêses Hardman, Louise L. Hardy, Rachakulla Hari Kumar, Javad Harooni, Seyed Mohammad Hashemi‐Shahri, Maria Hassapidou, Jun Hata, Teresa Haugsgjerd, Mirjam M. Heinen, Marleen Elisabeth Hendriks, Rafael dos Santos Henrique, Ana Henriques, Leticia Hernandez Cadena, Sauli Herrala, Marianella Herrera‐Cuenca, Victor M Herrera, Isabelle Herter‐Aeberli, Karl‐Heinz Herzig, Ramin Heshmat, Allan G. Hill, Sai Yin Ho, Michelle Holdsworth, Reza Homayounfar, Clara Homs, Emiel O. Hoogendijk, Andrea RVR Horimoto, Claudia M Hormiga, Bernardo L Horta, Leila Houti, Christina Howitt, Thein Thein Htay, Aung Soe Htet, Maung Maung Than Htike, José María Huerta, Ilpo Huhtaniemi, Laëtitia Huiart, Constanta Huidumac Petrescu, Martijn Huisman, Abdullatif Husseini, Inge Huybrechts, Nahla Hwalla, Licia Iacoviello, Ellina M. Iakupova, Anna G. 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Katzmarzyk, Jussi Kauhanen, Gyulli M. Kazakbaeva, François Folefack Kaze, Calvin Ke, Sirkka Keinänen-Kiukaanniemi, Roya Kelishadi, Cecily C. Kelleher, Han C. G. Kemper, Maryam Keramati, Mathilde Kersting, Yousef Khader, Arsalan Khaledifar, Davood Khalili, Bahareh Kheiri, Motahareh Kheradmand, Alireza Khosravi, Ursula Kiechl‐Kohlendorfer, Sophia J. Kiechl, Stefan Kiechl, Hyeon Chang Kim, Heidi Klakk, Suntara Klanarong, Jana Klánová, Magdalena Klimek, Michael Knoflach, Susanne Kobel, Bhawesh Koirala, Elin Kolle, Patrick Kolsteren, Jürgen König, Raija Korpelainen, Paul Korrovits, Magdalena Korzycka, Jelena Kos, Seppo Koskinen, Malik Koussoh Simone, Éva Kovács, Irina Kovalskys, Sudhir Kowlessur, Sławomir Kozieł, Jana Kratěnová, Wolfgang Kratzer, Susi Kriemler, Peter Lund Kristensen, Helena Križan, María F Kroker-Lobos, Steinar Krokstad, Herculina Kruger, Ruan Kruger, Łukasz Kryst, Růžena Kubínová, Urho M. Kujala, Enisa Kujundžić, Zbigniew Kułaga, Mukhtar Kulimbet, Meena Kumari, Marie Kunešová, Pawel Kurjata, Catherine Kyobutungi, Quang Dai La, Demetre Labadarios, Carl Lachat, Daphne Teck Ching Lai, Youcef Laid, Lachmie Lall, Maritza Landaeta Jiménez, Edwige Landais, Tiina Lankila, Vera Lanska, Georg Lappas, Bagher Larijani, Mina Lateva, Tint Swe Latt, Martino Laurenzi, Maria Lazo-Porras, Gwenaëlle Le Coroller, Khanh Le Nguyen Bao, Terho Lehtimäki, Daniel Lemogoum, Elvynna Leong, Justyna Leszczak, GM Leung, Yanping Li, Merike Liivak, Charlie Lim, Wei‐Yen Lim, Maria Fernanda Lima‐Costa, Hsien-Ho Lin, Lars Lind, Mieczysław Litwin, Liping Liu, X. Liu, Guadalupe Longo Abril, Oscar Lopes, Esther Lopez-Garcia, José Francisco López-Gil, Tania Lopez, José Eugenio Lozano, Janice Luísa Lukrafka, Dalia Lukšienė, Annamari Lundqvist, Nuno Lunet, Charles Lunogelo, Michala Lustigová, Jean-René M’Buyamba-Kabangu, George LL Machado-Coelho, Aristides M. 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Background Adiposity can be measured using BMI (which is based on weight and height) as well as indices of abdominal adiposity. We examined the association between BMI and waist-to-height ratio (WHtR) within and across populations of different world regions and quantified how well these two metrics discriminate between people with and without hypertension. Methods We used data from studies carried out from 1990 to 2023 on BMI, WHtR and hypertension in people aged 20–64 years in representative samples of the general population in eight world regions. We graphically compared the regional distributions of BMI and WHtR, and calculated Pearson's correlation coefficients between BMI and WHtR within each region. We used mixed-effects linear regression to estimate the extent to which WHtR varies across regions at the same BMI. We graphically examined the prevalence of hypertension and the distribution of people who have hypertension both in relation to BMI and WHtR, and we assessed how closely BMI and WHtR discriminate between participants with and without hypertension using C-statistic and net reclassification improvement (NRI). Findings The correlation between BMI and WHtR ranged from 0·76 to 0·89 within different regions. After adjusting for age and BMI, mean WHtR was highest in south Asia for both sexes, followed by Latin America and the Caribbean and the region of central Asia, Middle East and north Africa. Mean WHtR was lowest in central and eastern Europe for both sexes, in the high-income western region for women, and in Oceania for men. Conversely, to achieve an equivalent WHtR, the BMI of the population of south Asia would need to be, on average, 2·79 kg/m 2 (95% CI 2·31–3·28) lower for women and 1·28 kg/m 2 (1·02–1·54) lower for men than in the high-income western region. In every region, hypertension prevalence increased with both BMI and WHtR. Models with either of these two adiposity metrics had virtually identical C-statistics and NRIs for every region and sex, with C-statistics ranging from 0·72 to 0·81 and NRIs ranging from 0·34 to 0·57 in different region and sex combinations. When both BMI and WHtR were used, performance improved only slightly compared with using either adiposity measure alone. Interpretation BMI can distinguish young and middle-aged adults with higher versus lower amounts of abdominal adiposity with moderate-to-high accuracy, and both BMI and WHtR distinguish people with or without hypertension. However, at the same BMI level, people in south Asia, Latin America and the Caribbean, and the region of central Asia, Middle East and north Africa, have higher WHtR than in the other regions. Funding UK Medical Research Council and UK Research and Innovation (Innovate UK).