obesity is associated with diabetes mellitus and cardiovascular diseases ( cvd ) such as ischemic heart disease and stroke , as well as major risk factors for metabolic disorders ( 1 ) . the most popular index of obesity is the body mass index ( bmi ) or waist circumference ( wc ) , and most epidemiologic studies on obesity have also used bmi or wc for the measurement of body fatness . however , there are conflicting data as to whether the general obesity assessed by bmi or the central obesity assessed by wc is more closely associated with cardiovascular risk ( 2 ) . previous studies have reported that both bmi and wc values can identify cardiovascular risk equally effectively ( 3 , 4 ) . on the other hand , some studies have demonstrated that the wc is a superior marker for predicting cardiovascular risk than bmi ( 5 - 7 ) . in addition , several studies have shown that even among people with normal bmi , wide ranges were observed for adiposity or metabolic variables . the issue remained whether this variability was associated with cardiovascular risk factors ( 8 - 10 ) . however , little is known about the independent effects of bmi and wc , and the results remain controversial ( 2 , 11 ) . the findings of a high wc in some individuals with normal bmi or a high bmi in others with normal wc have been frequently encountered . when clinicians meet such patients , there is some difficulty in assessing the cardiovascular risk according to the obesity phenotype . the present study was conducted to evaluate the obesity phenotype presented by bmi and wc and to assess their association with coronary heart diseases ( chd ) risk among various cvd outcomes as estimated by the framingham risk score in korean adults . the present study is based on data acquired in the fourth korea national health and nutrition examination survey ( knhanes iv-2 ) conducted in 2008 . the knhanes has been conducted periodically since 1998 to assess the health and nutritional status of the non - institutionalized civilian population of korea . the knhanes iv was a cross - sectional and nationally representative survey conducted by the korea centers for disease control and prevention from 2007 to 2009 . the sampling frame was based on the population census survey conducted by the statistics korea in 2005 . a stratified , multistage probability sampling design was used for the selection of household units . in the knhanes iv-2 , there were 264,186 primary sampling units by proportional allocation , each of which contained about 60 households . two hundred sampling frames from primary sampling units were randomly sampled and 23 households from each sampling frame were sampled using a systemic sampling method . finally , 12,528 individuals in 4,600 households were sampled and 9,744 of them participated in the surveys ( overall participation rate 77.8% ) . of the 5,711 subjects aged 30 to 74 yr , participants with previous diagnoses of stroke , ischemic heart disease , or chronic renal failure ( n = 255 ) and current treatment for cirrhotic liver disease or any cancer ( n = 68 ) , as well as women who were pregnant ( n = 25 ) , were excluded . individuals with low bmi ( < 18.5 kg / m ) and incomplete data on anthropometric measurements or test results were also excluded ( n = 790 ) . the survey collected data via face - to - face interviews inside the households and by direct standardized physical examinations conducted in specially equipped mobile examination centers . the sequence of the health survey administration involved intake , receipt of informed consent , blood pressure ( bp ) measurement , anthropometric measurement , blood sampling , and completion of the questionnaire . a standardized questionnaire regarding age , gender , socioeconomic characteristics , medical history , current drug use , smoking habit , alcohol consumption , and other lifestyle risk factors was prepared . monthly income was defined as the individual 's share of the total household income per month . household equivalent income was calculated by summing up the monthly income of all household members and later dividing this sum by the square root of the household size . the participants were classified as current smokers if they smoked currently and nonsmokers if they had never smoked or had smoked previously but had quit . likewise , alcohol consumption was categorized as those who ingested alcohol  1 time or < 1 time per month according to public health index . physical activity , as assessed by the international physical activity questionnaire ( ipaq ) ( 12 ) , was classified into quartiles . bp was measured 3 times with 5-min intervals using a standard mercury sphygmomanometer ( baumanometer , wa baum co. inc . , anthropometric data , including height , body weight , and wc , were measured according to standardized guidelines . height was measured in the erect position in centimeters with the head and hip touching the wall by mobile anthropometer ( seca 225 , seca deutchland , hamburg , germany ) . body weight was measured in kilograms by mobile scale ( gl-6000 - 20 , caskorea , seoul , korea ) while the patient was dressed in a light gown without shoes . using a fiberglass tape measure ( seca 200 , seca deutchland ) , wc was measured in tenths of a centimeter without compression of the soft tissue along the middle horizontal line between the inferior margin of the last rib and the iliac crest . the feet were 25 - 30 cm apart in a stable standing position for this measurement . bmi was calculated by dividing the body weight by the height squared ( kg / m ) . fasting plasma glucose ( fpg ) , total cholesterol ( t - c ) , triglyceride ( tg ) , and high density lipoprotein cholesterol ( hdl - c ) were measured after a fasting period of at least 8 hr by using the autoanalyzer ( advia 1650 , bayer , tarrytown , ny , usa ) . the obesity phenotype was classified by bmi and wc : with bmi ,  18.5 and < 25.0 kg / m was normal and  25.0 kg / m was obese and with wc , < 90 cm in men or < 80 cm in women was normal and  90 cm in men or  80 cm in women was obese . subsequently , the data were categorized into 4 groups such as normal bmi / normal wc ( group a ) , normal bmi / obese wc ( group b ) , obese bmi / normal wc ( group c ) , and obese bmi / obese wc ( group d ) . to determine individuals ' 10-yr risk of chd , we used the framingham risk model . with the framingham algorithm as outlined by wilson et al . ( 13 ) , a global risk score was calculated based on categorical values of age , gender , t - c , hdl - c , bp , smoking , and diabetes . diabetes was defined as a fpg level of  126 mg / dl or currently being treated with insulin or oral hypoglycemic agents . statistical analyses were performed using spss version 18.0 ( spss inc . , chicago , il , usa ) software packages . all estimates were calculated based on sample weights , which were evaluated by taking into consideration the sampling rate , response rate , and age and gender proportions of the reference population . continuous data were presented as means and standard errors ( se ) , and categorical data as frequencies and se or 95% confidence intervals ( cis ) , as appropriate . comparisons across obesity phenotype groups were made using the student 's t - test for continuous data and the chi - squared test for categorical data . the distribution of the framingham risk score ( low < 6% , moderate 6%- < 10% , moderately high 10%- < 20% and high  20% ) by obesity phenotype groups was also presented . multiple logistic regression analyses were used to analyze relations between moderately high or high 10-yr chd risk and obesity phenotype groups . all tests were two - sided and p values of < 0.05 were considered statistically significant . the present study protocol was reviewed and approved by the institutional review board of busan paik hospital ( irb no . the present study is based on data acquired in the fourth korea national health and nutrition examination survey ( knhanes iv-2 ) conducted in 2008 . the knhanes has been conducted periodically since 1998 to assess the health and nutritional status of the non - institutionalized civilian population of korea . the knhanes iv was a cross - sectional and nationally representative survey conducted by the korea centers for disease control and prevention from 2007 to 2009 . the sampling frame was based on the population census survey conducted by the statistics korea in 2005 . a stratified , multistage probability sampling design was used for the selection of household units . in the knhanes iv-2 , there were 264,186 primary sampling units by proportional allocation , each of which contained about 60 households . two hundred sampling frames from primary sampling units were randomly sampled and 23 households from each sampling frame were sampled using a systemic sampling method . finally , 12,528 individuals in 4,600 households were sampled and 9,744 of them participated in the surveys ( overall participation rate 77.8% ) . of the 5,711 subjects aged 30 to 74 yr , participants with previous diagnoses of stroke , ischemic heart disease , or chronic renal failure ( n = 255 ) and current treatment for cirrhotic liver disease or any cancer ( n = 68 ) , as well as women who were pregnant ( n = 25 ) , were excluded . individuals with low bmi ( < 18.5 kg / m ) and incomplete data on anthropometric measurements or test results were also excluded ( n = 790 ) . the survey collected data via face - to - face interviews inside the households and by direct standardized physical examinations conducted in specially equipped mobile examination centers . the sequence of the health survey administration involved intake , receipt of informed consent , blood pressure ( bp ) measurement , anthropometric measurement , blood sampling , and completion of the questionnaire . a standardized questionnaire regarding age , gender , socioeconomic characteristics , medical history , current drug use , smoking habit , alcohol consumption , and other lifestyle risk factors was prepared . monthly income was defined as the individual 's share of the total household income per month . household equivalent income was calculated by summing up the monthly income of all household members and later dividing this sum by the square root of the household size . the participants were classified as current smokers if they smoked currently and nonsmokers if they had never smoked or had smoked previously but had quit . likewise , alcohol consumption was categorized as those who ingested alcohol  1 time or < 1 time per month according to public health index . physical activity , as assessed by the international physical activity questionnaire ( ipaq ) ( 12 ) , bp was measured 3 times with 5-min intervals using a standard mercury sphygmomanometer ( baumanometer , wa baum co. inc . , anthropometric data , including height , body weight , and wc , were measured according to standardized guidelines . height was measured in the erect position in centimeters with the head and hip touching the wall by mobile anthropometer ( seca 225 , seca deutchland , hamburg , germany ) . body weight was measured in kilograms by mobile scale ( gl-6000 - 20 , caskorea , seoul , korea ) while the patient was dressed in a light gown without shoes . using a fiberglass tape measure ( seca 200 , seca deutchland ) , wc was measured in tenths of a centimeter without compression of the soft tissue along the middle horizontal line between the inferior margin of the last rib and the iliac crest . the feet were 25 - 30 cm apart in a stable standing position for this measurement . bmi was calculated by dividing the body weight by the height squared ( kg / m ) . fasting plasma glucose ( fpg ) , total cholesterol ( t - c ) , triglyceride ( tg ) , and high density lipoprotein cholesterol ( hdl - c ) were measured after a fasting period of at least 8 hr by using the autoanalyzer ( advia 1650 , bayer , tarrytown , ny , usa ) . the obesity phenotype was classified by bmi and wc : with bmi ,  18.5 and < 25.0 kg / m was normal and  25.0 kg / m was obese and with wc , < 90 cm in men or < 80 cm in women was normal and  90 cm in men or  80 cm in women was obese . subsequently , the data were categorized into 4 groups such as normal bmi / normal wc ( group a ) , normal bmi / obese wc ( group b ) , obese bmi / normal wc ( group c ) , and obese bmi / obese wc ( group d ) . to determine individuals ' 10-yr risk of chd , we used the framingham risk model . with the framingham algorithm as outlined by wilson et al . ( 13 ) , a global risk score was calculated based on categorical values of age , gender , t - c , hdl - c , bp , smoking , and diabetes . diabetes was defined as a fpg level of  126 mg / dl or currently being treated with insulin or oral hypoglycemic agents . all estimates were calculated based on sample weights , which were evaluated by taking into consideration the sampling rate , response rate , and age and gender proportions of the reference population . continuous data were presented as means and standard errors ( se ) , and categorical data as frequencies and se or 95% confidence intervals ( cis ) , as appropriate . comparisons across obesity phenotype groups were made using the student 's t - test for continuous data and the chi - squared test for categorical data . the distribution of the framingham risk score ( low < 6% , moderate 6%- < 10% , moderately high 10%- < 20% and high  20% ) by obesity phenotype groups was also presented . multiple logistic regression analyses were used to analyze relations between moderately high or high 10-yr chd risk and obesity phenotype groups . all tests were two - sided and p values of < 0.05 were considered statistically significant . the present study protocol was reviewed and approved by the institutional review board of busan paik hospital ( irb no . the means of age , bmi , and wc of the subjects were 49.1 yr ( se 0.3 yr ) , 24.1 kg / m ( se 0.1 kg / m ) , and 82.8 cm ( se 0.2 cm ) , respectively , and 57.2% ( n = 2,615 ) of the sample was female . the number of subjects with obese bmi was 1,572 ( 34.7% ) and the number of subjects with obese wc was 1,890 ( 37.3% ) . the number of subjects in obesity phenotype groups according to bmi and wc were 2,361 ( 54.0% , group a ) , 640 ( 11.3% , group b ) , 322 ( 8.7% , group c ) , and 1,250 ( 26.0% , group d ) , respectively . subjects with obese wc were older ( p < 0.001 ) and had higher frequencies of being female and having a lower education level ( < 12 yr ) than normal wc subjects in both bmi groups . subjects with normal wc were more likely to be smokers and more frequently reported alcohol consumption than the obese wc group regardless of bmi category . the frequencies of current treatment for hypertension , diabetes , and dyslipidemia were higher in subjects with obese wc than with normal wc in both bmi categories . for individuals with normal bmi , the mean levels of bp , fpg , t - c , tg , and 10-yr chd risk score were higher and that of hdl - c were lower in subjects with obese wc than those in the normal wc group . for individuals with obese bmi , subjects with obese wc had higher systolic bp , fpg , t - c , and 10-yr chd risk scores than those in the normal wc group , although there were no differences in diastolic bp , tg , hdl - c between both wc categories . the frequency of the components used in the framingham risk model for each of the obesity phenotype groups by gender are presented in table 2 . in this study population , categorical values of age (  40 yr in men or  45 yr in women ) , t - c (  200 mg / dl ) , hdl - c ( < 45 mg / dl in men or < 50 mg / dl in women ) , bp (  130/85 mmhg in men or  140/90 mmhg in women ) , smoking , and diabetes were found in 63.8% ( n = 3,018 ) , 35.8% ( n = 1,670 ) , 55.5% ( n = 2,589 ) , 20.9% ( n = 919 ) , 26.6% ( n = 1,014 ) , and 8.1% ( n = 404 ) , respectively . for men and women , the prevalence of high t - c , low hdl - c , and high bp was lowest in group a ( normal bmi / normal wc ) and highest in group d ( obese bmi / obese wc ) . subjects with ages of  40 yr in men or  45 yr in women were higher in the obese wc groups than were those in normal wc groups . the prevalence of diabetes was higher in the obese wc groups than in normal wc groups regardless of gender . group a ( normal bmi / normal wc ) in men and group b ( normal bmi / obese wc ) in women had high frequencies of smokers compared to other groups ; however , there were no significant differences between the obesity phenotype groups . the means of 10-yr chd risk were 9.37% ( se 0.27% ) in men and 4.48% ( se 0.15% ) in women , and there were no significant differences only between group a ( normal bmi / normal wc ) and group c ( obese bmi / normal wc ) in men and women ( not shown in the figure ) . men and women in group a ( normal bmi / normal wc ) had the lowest risk for chd with 50.2% and 89.2% in the < 6% risk category , respectively . men in group b ( normal bmi / obese wc ) had the highest risk over the next 10 yr ( 21.3% with  20% chd risk ) , whereas women in group d ( obese bmi / obese wc ) had the highest risk ( 5.0% with  20% 10-yr chd risk ) . subjects with obese wc had a lower proportion of low risk and a higher proportion of high risk for chd compared to the normal wc group , regardless of bmi category . in both men and women , the proportions with high chd risk status increased more than six - fold from the lowest group to the highest group ( 3.1%-21.3% , in group c vs group b and 0.7%-5.0% , in group a vs group d , respectively , each p < 0.001 across obesity phenotype groups ) . the adjusted odds ratios ( ors ) for the  10% or  20% 10-yr chd risk were calculated by multiple logistic regression analysis ( table 3 ) . education level , equivalent income , alcohol consumption , physical activity , antihypertensive drug use , and antidyslipidemic drug use for the 4 obesity phenotype groups as classified by bmi and wc were included as independent variables in this model . relative to those in group a ( normal bmi / normal wc ) , significantly higher ors of  10% or  20% 10-yr chd risk were observed for subjects in group b ( normal bmi / obese wc ) or group d ( obese bmi / obese wc ) . the adjusted ors of male subjects in group b ( normal bmi / obese wc ) were higher than those in group d ( obese bmi / obese wc ) , whereas the adjusted ors of female subjects in group d ( obese bmi / obese wc ) were higher than in the other obesity phenotype groups . the adjusted ors of the subjects in group c ( obese bmi / normal wc ) for the  10% or  20% 10-yr chd risk were not significantly higher compared to those in group a ( normal bmi / normal wc ) . the purpose of this study was to evaluate the independent association of obesity phenotypes represented by bmi and wc with chd risk as estimated by the framingham risk model . bmi and wc have been widely used as diagnostic indexes of obesity in clinical practice . some have a normal bmi but an obese wc , whereas others have an obese bmi but a normal wc . it is controversial whether individuals whose bmi and wc are conflicting are associated with cardiovascular risk . in this study involving hypothesis testing , the null hypothesis was that the obesity phenotype groups presented by bmi and wc are similarly predictive of chd risk , while the alternative was that there are heterogeneities among the obesity phenotype groups , particularly in normal bmi / obese wc or obese bmi / normal wc group . the percentage of central obesity assessed by wc was 37.3% , which was higher than the percentage of obesity based on bmi ( 34.7% ) . in this study , the prevalence of central obesity in women was obviously higher than that in men . subjects with central obesity were older and had a higher frequency of being females than the normal wc group , regardless of general obesity assessed by bmi . it is well known that when comparing subjects who have similar bmis , older persons would have more body fat than do younger persons and that women have more body fat than do men ( 14 , 15 ) . hauner et al . ( 16 ) has also reported that the prevalence of obesity increased notably with age while women had an increased wc more often than men . in our study , the obese wc in both men and women was associated with chd risk without reference to the level of bmi . the superiority between bmi and wc in estimating cardiovascular risk has been controversial among some previous reports . ( 3 ) reported that both bmi and wc could equally effectively predict the presence of multiple cardiovascular risk factors in a japanese population . lear et al . ( 17 ) suggested that the distribution of body fat in asians differed from that of caucasians and that bmi might be superior in assessing visceral obesity in asians than in caucasians . on the other hand , wc is considered to be a better predictor of cardiovascular risk than bmi ( 18 - 20 ) . wc is related with abdominal fat , which is a strong indicator of cardiovascular risk independent of total body fat ( 21 , 22 ) . bmi is associated with body fat content but has several limitations in estimating obesity for some individuals . some muscular men without excess body fat could be overestimated as obese , whereas some elderly or women with decreased lean body mass could be underestimated as normal ( 23 , 24 ) . findings of many studies are consistent in that wc is a better predictor of obesity - related diseases in the elderly than in younger individuals and also in women than in men ( 25 - 27 ) . the predictability of anthropometric indexes on obesity - related diseases could be a function of age- and gender - related differences in body fat distribution . in addition , we found that there was a small but significant proportion of the korean population whose bmi and wc presented conflicting information . one - fifth of the subjects were categorized into the conflicting obesity groups ( group b or c ) . the proportion of female subjects with normal bmi and obese wc was higher than that with obese bmi and normal wc , while the reverse trend was true for men . subjects with only central obesity but normal bmi ( group b ) were significantly associated with increased chd risk , whereas those with only obese bmi without central obesity ( group c ) were not associated with chd risk . two previous reports have clearly shown that patients with a high wc and low bmi are at high risk of cardiovascular death . zeller et al . ( 28 ) demonstrated that neither bmi nor wc independently predicted death after acute myocardial infarction and that the group of patients with high wc but low bmi had an increased 1-yr death rate . in a large european cohort study , the positive association between abdominal fat distribution and the high risk of mortality over 9.7 yr tended to be stronger among participants with a lower bmi than among those with a higher bmi ( 29 ) . interestingly , chd risk in men with only central obesity but normal bmi ( group b ) was higher than that of subjects with obese bmi and obese wc . our study showed that males in group b ( normal bmi / obese wc ) had the highest frequency of the age component (  40 yr ) and diabetes prevalence among the subjects in the 4 obesity phenotype groups . one of the possible reasons for the sex difference may be the effect of estrogen on the cardiovascular risk factors ( i.e. , the protective effects of estrogen on plasma lipids may be stronger than the variability in adiposity ) . it has been shown that thigh fat is associated with higher plasma hdl - cholesterol levels and a lower incidence of diabetes only in females . most women have a gynoid profile of fat deposition with more adiposity in the lower body segment . however , the present study examined the association between the presence of risk factors and total adiposity but not body fat distribution . variations in abdominal fat may explain the fact there was almost no difference across adiposity quintiles among females with normal weight , as ruderman et al . first , imperfections of the cross - sectional design include the fact that the survey was accomplished on a single visit , which can not account for inherent variability in some laboratory tests and measurements . further , the cardiovascular risk estimated by the framingham risk score is not the actual chd event . therefore , the associations with cardiovascular risk and other anthropometric measurements such as waist - hip ratio or waist - to - height ratio , or more objective surrogates of body fat distribution , can not be discussed . finally , the framingham risk model used to determine individuals ' global risk of experiencing a future cardiovascular event may be overestimated in koreans with significantly different genetic profiles or social and environmental backgrounds . in this study , however , the distribution of the framingham risk score was used as a stratification tool of chd risk , and not in calculating the absolute risk scores of chd . despite these limitations , our study has an advantage in measuring the obesity phenotype via a simple and inexpensive manner to predict chd risk in a relatively large number of subjects . the survey was recently performed in a nationwide , population - based , and representative sample of koreans , and all analyses in this study were completely based on sample weights and adjusted for the complex sample design of the survey . thus , these results can be generalized for the entire korean adult population . in conclusion , central obesity assessed by wc was related to increased chd risk regardless of the level of bmi in korean adults . the chd risk in subjects with only obese bmi without central obesity , in addition , men with only central obesity but normal bmi tended to be associated with moderately higher or higher risk of chd than those with obese bmi and obese wc . the results of this study suggest that the obesity phenotype related with both general obesity and central obesity should be considered in estimating chd risk by anthropometric measures of obesity . considering obesity phenotype by gender differences may also result in an improved approach for the assessment of obesity - related cardiovascular risk .
there are conflicting data as to whether general or abdominal obesity is a better predictor of cardiovascular risk . 
 this cross - sectional study involved 4,573 subjects aged 30 to 74 yr who participated in the fourth korea national health and nutrition examination survey conducted in 2008 . 
 obesity phenotype was classified by means of body mass index ( bmi ) and waist circumference ( wc ) , and participants were categorized into 4 groups . 
 individuals ' 10-yr risk of coronary heart diseases ( chd ) was determined from the framingham risk score . 
 subjects with obese wc had a higher proportion of high risk for chd compared to the normal wc group , irrespective of bmi level . 
 relative to subjects with normal bmi / normal wc , the adjusted odds ratios ( ors ) of normal bmi / obese wc group ( or 2.93 [ 1.70 , 5.04 ] and or 3.10 [ 1.49 , 6.46 ] ) for chd risk in male were higher than obese bmi / obese wc group ( or 1.91 [ 1.40 , 2.61 ] and or 1.70 [ 1.16 , 2.47 ] ) , whereas the adjusted ors of obese bmi / obese wc group ( or 1.94 [ 1.24 , 3.04 ] and or 3.92 [ 1.75 , 8.78 ] ) were higher than the others in female . 
 subjects with obese bmi / normal wc were not significantly associated with 10-yr chd risk in men ( p = 0.449 and p = 0.067 ) and women ( p = 0.702 and p = 0.658 ) . 
 wc is associated with increased chd risk regardless of the level of bmi . 
 men with normal bmi and obese wc tend to be associated with chd risk than those with obese bmi and obese wc .