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    3 Comments for this article
    Underlying cause of normal-weight central "obesity"
    Diane Browning, BBA |
    It would be interesting to know how many of the “normal-weight with central obesity” women had undergone hysterectomy. 45% of U.S. women end up having one although less than 8% are done for a cancer diagnosis.(1)

    Hysterectomy (with or without ovary removal / oophorectomy) alters a woman’s figure such that her midsection becomes shorter and thicker (central “obesity”). This occurs because the uterine ligaments are the pelvis’ support structures that keep the spine, hips and rib cage in their rightful positions. When those support structures are severed to remove the uterus, the torso collapses. The ensuing widening of
    the hip bones and descent of the rib cage leads to, besides the aforementioned figure changes, back, hip and leg problems and reduced mobility.

    Hysterectomy (without ovary removal) has been shown to increase risk of a number of health problems including cardiovascular disease (2,3), some cancers - renal cell (4), rectal (5), thyroid (6,7), and metabolic morbidity (8).

    Therefore, one has to question if “normal-weight with obesity” is the underlying cause of the mortality risk or if it is hysterectomy.

    1 Stewart EA, Shuster LT, Rocca WA. Reassessing hysterectomy. Minn Med. 2012;95(3):36–39.
    2 Centerwall BS. Premenopausal hysterectomy and cardiovascular disease. Am J Obstet Gynecol. 1981 Jan;139(1):58-61.
    3 Laughlin-Tommaso SK, Khan Z, Weaver AL, Smith CY, Rocca WA, Stewart EA. Cardiovascular and metabolic morbidity after hysterectomy with ovarian conservation: a cohort study. Menopause. 2018;25(5):483–492. doi:10.1097/GME.0000000000001043
    4 Altman D, Yin L, Johansson A, Lundholm C, Grönberg H. Risk of Renal Cell Carcinoma After Hysterectomy. Arch Intern Med. 2010;170(22):2011–2016. doi:10.1001/archinternmed.2010.425
    5 Luoto R1, Auvinen A, Pukkala E, Hakama M. Hysterectomy and subsequent risk of cancer. Int J Epidemiol. 1997 Jun;26(3):476-83.
    6 Luoto R1, Auvinen A, Pukkala E, Hakama M. Hysterectomy and subsequent risk of cancer.
    7 Luo J, Hendryx M, Manson JE, Liang X, Margolis KL. Hysterectomy, Oophorectomy, and Risk of Thyroid Cancer. J Clin Endocrinol Metab. 2016;101(10):3812–3819. doi:10.1210/jc.2016-2011
    8 Laughlin-Tommaso SK, Khan Z, Weaver AL, Smith CY, Rocca WA, Stewart EA. Cardiovascular and metabolic morbidity after hysterectomy with ovarian conservation: a cohort study.
    NAFLD/NASH: Another Important Comorbidity of Central Obesity
    Cathleen Dohrn, PhD | Continuum Clinical
    This study showed a relationship between post-menopausal central obesity and CVD, as well as cancer. It concludes that guidelines are needed to prevent and control post-menopausal women with normal weight and central obesity but does not go far enough in addressing other key concerns for this population.

    There are other diseases that are associated with central obesity that could be included in the guidelines. It is well accepted that Type 2 diabetes and metabolic syndrome are more prevalent in patients with central obesity. Central, or visceral, obesity is also implicated in the related disease non-alcoholic fatty liver
    disease (NAFLD), which can progress to non-alcoholic steatohepatitis (NASH). Based on the results in this study, it follows that post-menopausal women are not only at a higher risk for CVD, but also NAFLD/NASH because of the higher rate of central obesity in this population.

    1. Tyrovolas et al., Experimental Gerontology, 2015: 64:70-77
    2. Bellentani, Liver International, 2017:37 (Suppl. 1): 81-84
    3. Farrell and Larter, Hepatology, 2006:43 (No. 2, Suppl. 1: S99-S112
    CONFLICT OF INTEREST: Continuum Clinical employee.
    Waist Hip Ratio as useful risk factor
    Arthur Hartz, PhD, MD and Alfred Rimm, PhD | Case WesternReserve University School of Medicine
    The analysis of Sun et al[1] of Women’s Health Initiative (WHI) data showed that waist circumference (WC) was independent of body mass index (BMI) as a risk factor for mortality from all causes, cardiovascular diseases, and cancer. In 2011 we published a similar analysis of the WHI data[2] that found that waist circumference was independent of BMI as a risk factor for all-cause mortality, diabetes, hypertension, gall bladder disease, and stroke.

    One difference between our study and Sun et al study was that we also included as a risk factor the ratio of waist circumference
    to hip circumference (WHR). Although WHR is a weaker single risk factor than WC, it is less associated with BMI. After adjusting for BMI and many other variables the risks of several conditions were more strongly associated with WHR than with WC as indicated by higher chi-squared values for the same condition in the same sample. These conditions with the chi-squared values for WHR and WC were 1) diabetes at baseline (2364 vs 1788), 2) incident diabetes (2204 vs 1395), 3) hypertension at baseline (1752 vs 1193), 4) systolic blood pressure in those untreated for hypertension (624 vs 395), 5) MI during follow-up (132 vs 112), and 6) stroke during follow-up (45 vs 34).

    A way of showing the clinical importance of WHR is to compare the highest WHR quintile and highest WC quintile for the risk of current diabetes among normal weight women. Since almost all high WC women were overweight or obese, there were 23 times as many normal weight women with high WHR as with high WC (3213 vs 139). The adjusted hazard ratios (compared to women in the lowest quintile) among normal weight women were about 3.9 for high WHR and 2.4 for high WC. Our results suggest that WHR might be a useful risk factor for cardiovascular mortality although we did not test this.

    Neither WC or WHR are new risk factors. We introduced both of them at conferences in 1980[3,4] and since 1983[3]have published many articles in reputable journals. The major conclusions of all of these articles are that WC is a stronger risk factor than BMI for many diseases, and that WHR adds more information than WC to BMI. We don’t know if WHR would have been a useful risk factor in the Sun et al. study. It should have been considered.

    1. 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 Network Open.. 2019;2(7):e197337. doi:10.1001/jamanetworkopen.2019.7337
    2. Hartz AJ, He T, Rimm AR. Comparison of Adiposity Measures as Risk Factors in Post-Menopausal Women. The Journal of Clinical Endocrinology & Metabolism (2012) 97(1): 227–233.
    3. Hartz AJ, Rupley DC Jr, Kalkhoff RD, Rimm AA. Relationship of obesity to diabetes: influence of obesity level and body fat distribution. Prev Med. (1983); 12(2): 351-357.
    4. Hartz AJ, Rupley DC, Kissebah AH, Kalkhoff RK, Rimm AA. Relationship of Obesity to Diabetes: Influence of Obesity Level and Body Fat Distribution. Third International Congress on Obesity, October 10, 1980.
    5. Rimm A, Hartz AJ, Rupley D Jr et al. Body shape overweight as distinct risk factors for diabetes (abstract) Am J Epidemiol 1980; 112(3):446
    Original Investigation
    Nutrition, Obesity, and Exercise
    July 24, 2019

    Association of Normal-Weight Central Obesity With All-Cause and Cause-Specific Mortality Among Postmenopausal Women

    Author Affiliations
    • 1Department of Epidemiology, College of Public Health, University of Iowa, Iowa City
    • 2Division of Research, Kaiser Permanente Northern California, Oakland
    • 3Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York
    • 4Cancer Prevention Program, Fred Hutchinson Cancer Research Center, Seattle, Washington
    • 5Department of Family Medicine and Public Health, School of Medicine, University of California, San Diego, La Jolla
    • 6Department of Medical Oncology and Therapeutics Research, City of Hope National Medical Center Duarte, Duarte, California
    • 7Division of Preventive Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
    • 8Obesity Research and Education Initiative, University of Iowa, Iowa City
    • 9Fraternal Order of Eagles Diabetes Research Center, University of Iowa, Iowa City
    JAMA Netw Open. 2019;2(7):e197337. doi:10.1001/jamanetworkopen.2019.7337
    Key Points español 中文 (chinese)

    Question  How is normal-weight central obesity associated with risk of mortality compared with other anthropometric phenotypes?

    Findings  In this cohort study of 156 624 postmenopausal US women enrolled in the Women’s Health Initiative study, normal-weight central obesity was associated with higher risk of all-cause, cardiovascular disease, and cancer mortality compared with normal weight without central obesity. The magnitude of this association was similar to that of obesity with central obesity and higher than that of other anthropometric phenotypes defined by body mass index and waist circumference.

    Meaning  Normal-weight central obesity is an underrecognized, high-risk phenotype for mortality.


    Importance  Current public health guidelines for obesity prevention and control focus on promoting a normal body mass index (BMI), rarely addressing central obesity, which is reflected by high waist circumference (WC) and common in the general population. Studies of the association of normal-weight central obesity with long-term health outcomes are sparse.

    Objective  To examine associations of normal-weight central obesity with all-cause and cause-specific mortality in postmenopausal women in the United States.

    Design, Setting, and Participants  A nationwide prospective cohort study of 156 624 postmenopausal women enrolled in the Women’s Health Initiative at 40 clinical centers in the United States between 1993 and 1998. These women were observed through February 2017. Data analysis was performed from September 15, 2017, to March 13, 2019.

    Exposures  Different combinations of BMI (calculated as weight in kilograms divided by height in meters squared; normal weight: BMI, 18.5-24.9; overweight: BMI, 25.0-29.9; and obesity: BMI, ≥30) and WC (normal: WC, ≤88 cm and high: WC, >88 cm).

    Main Outcomes and Measures  Mortality from all causes, cardiovascular disease, and cancer.

    Results  Of the 156 624 women (mean [SD] age, 63.2 [7.2] years), during 2 811 187 person-years of follow-up, 43 838 deaths occurred, including 12 965 deaths from cardiovascular disease (29.6%) and 11 828 deaths from cancer (27.0%). Compared with women with normal weight and no central obesity and adjusted for demographic characteristics, socioeconomic status, lifestyle factors, and hormone use, the hazard ratio for all-cause mortality was 1.31 (95% CI, 1.20-1.42) among women with normal weight and central obesity, 0.91 (95% CI, 0.89-0.94) among women with overweight and no central obesity, 1.16 (95% CI, 1.13-1.20) for women with overweight and central obesity, 0.93 (95% CI, 0.89-0.94) for women with obesity and no central obesity, and 1.30 (95% CI, 1.27-1.34) for women with obesity and central obesity. Compared with normal weight without central obesity, normal-weight central obesity was associated with higher risk of cardiovascular disease mortality (hazard ratio, 1.25; 95% CI, 1.05-1.46) and cancer mortality (hazard ratio, 1.20; 95% CI, 1.01-1.43).

    Conclusions and Relevance  Normal-weight central obesity in women was associated with excess risk of mortality, similar to that of women with BMI-defined obesity with central obesity. These findings underscore the need for future public health guidelines to include the prevention and control of central obesity, even in individuals with normal BMI.