Original Article
The Ratio of Waist-to-Hip Circumference, Plasma Insulin Level, and Glucose Intolerance as Independent Predictors of the HDL2 Cholesterol Level in Older Adults
N Engl J Med 1990; 322:229-234January 25, 1990
- Abstract
- Abstract
High plasma levels of HDL2, a subfraction of high-density lipoprotein (HDL) cholesterol, are associated with a reduced risk of coronary heart disease. To investigate the characteristics related to HDL2 cholesterol levels, we measured lipoprotein levels and several metabolic and anthropometric variables in 146 healthy subjects (77 men and 69 women) in the seventh decade of life.
The level of HDL2 cholesterol was inversely correlated with the ratio of the waist-to-hip circumference (r = −0.335 for men; r = −0.370 for women; P<0.01) and the plasma insulin level (r = −0.400 for men; r = −0.398 for women; P<0.001). In a multiple regression model including both sexes, 41 percent of the variance in the HDL2 level was explained by the combined effect of the waist-to-hip ratio (P<0.0001), the plasma insulin level (P = 0.0003), and the degree of glucose tolerance indicated by the integrated area under the plasma glucose curve after an oral glucose-tolerance test (P = 0.05). The body-mass index, total percentage of body fat, maximal oxygen uptake, diet, and sex were not significant predictors of the HDL2 level when added to this model, whereas the original variables remained significant predictors. The HDL2 cholesterol level in subjects at the 25th percentile for waist-to-hip ratio was 153 percent of that in subjects at the 75th percentile.
We conclude that HDL2 levels are inversely correlated with truncal fat, plasma insulin levels, and the presence of glucose intolerance and are not independently associated with sex or total body fat. (N Engl J Med 1990; 322: 229–34.)
Media in This Article
Figure 1
HDL2 Cholesterol Level and Waist-to-Hip Ratio in Men (Open Circles) and Women (Solid Circles).Table 1
Characteristics of the Study Population.*Article Activity
- Article
THE level of high-density lipoprotein (HDL) cholesterol has been shown in large prospective studies to be inversely associated with the risk of coronary heart disease.1 , 2 In humans, HDL cholesterol is composed of two principal fractions, HDL2 and HDL3; of the two, HDL2 has been most consistently linked with protection from cardiovascular disease.3 The determinants of the HDL2 cholesterol level are therefore of potential importance to public health.
The present study focused on a group of men and women between 60 and 70 years of age who were healthy but nevertheless at increased risk for coronary disease because of their age. Our purpose was to identify the most important independent predictors of the HDL2 cholesterol levels in this population. Along with HDL2, we measured several related covariates reflecting body weight, fatness, regional distribution of fat, glucose tolerance, plasma insulin level, diet, and fitness. The independent relations between these covariates and the HDL2 level were then determined in a mathematical model. In this study, the waist-to-hip ratio was the variable found to be most closely associated with the level of HDL2 cholesterol; the plasma insulin level and the degree of glucose tolerance were also significant independent predictors of the HDL2 concentration.
Methods
Patients
Healthy, sedentary subjects between the ages of 60 and 70 years were recruited from the community to participate in the study of fitness and health at Washington University. Smokers and those with illnesses requiring active medical or surgical treatment were excluded. Participants were required to have normal hemoglobin levels and normal results on tests of plasma chemistry, urinalysis, chest radiography, and treadmill exercise tests according to the Bruce protocol.4 Written informed consent was obtained from the 146 participants. Five of the subjects were black, and 141 were white. The subjects' mean values for the indexes measured are shown in Table 1Table 1
Characteristics of the Study Population.*.Measurements
The circumferences of the waist, hips, abdomen, and chest were measured as described by Ashwell and collaborators,5 , 6 with the subject in the standing position. The waist measurement recorded was the smallest girth between the rib cage and the iliac crest (and was located craniad to the umbilicus). The hip measurement was the largest horizontal girth between waist and thigh. The abdominal circumference was the girth at the level of the umbilicus and was larger than that measured at the waist in both sexes (Table 1). The chest circumference was measured at the nipple line at mid-tidal volume in men and just above the breast tissue in women. A treadmill test4 was performed in which speed or grade was increased every two minutes until exhaustion, with maximal oxygen consumption recorded as the average of the two highest 30-second values for oxygen consumption. An oral glucose-tolerance test with a 75-g glucose load was performed after three days at an intake of at least 150 g of carbohydrate, with blood samples taken for the measurement of glucose and insulin at 30, 60, 90, 120, and 180 minutes. The insulin concentration was determined by a radioimmunoassay as described by Morgan and Lazarow.7 Energy intake and the percentages of energy intake made up by dietary fat, carbohydrate, protein, and alcohol were calculated from measured seven-day food records with use of the Datadiet program (IPC Datadiet, Camarillo, Calif.). Subscapular, triceps, pectoral, suprailiac, abdominal, and anterior-thigh skinfold thicknesses were measured with a Lange caliper, and the percentage of body fat was calculated separately for women8 and men.9 HDL and HDL3 were measured in the Washington University Lipid Research Clinic Core Laboratory, which participates in the lipid-standardization program of the Centers for Disease Control. Total HDL was measured in the supernatant after precipitation of apolipoprotein B—containing lipoproteins with heparin and manganese.10 HDL3 was then measured after further precipitation of HDL2 with dextran sulfate, and the quantity of HDL2 was calculated as the difference between the amounts of total HDL and HDL3.11
Statistical Analysis
Results were calculated with the general linear model of the Statistical Analysis System.12 With this method, a model is constructed in which HDL2 cholesterol, the dependent variable, is explained by independent variables such as the waist-to-hip ratio, metabolic covariates, and sex. The statistical significance of the independent variables is computed from Type III sums of squares and is independent of the presence and order of consideration of other independent variables in the model. Values for HDL2 were transformed to their natural logarithms before analysis (except in Fig. 1Figure 1
HDL2 Cholesterol Level and Waist-to-Hip Ratio in Men (Open Circles) and Women (Solid Circles).).Results
Table 2Table 2
Correlations between HDL2, HDL3, or Total HDL Cholesterol and the Metabolic Variables.* gives the correlation coefficients for the relation of the study variables to subfractions of HDL cholesterol. The HDL2 cholesterol level correlated inversely with the waist-to-hip ratio, the abdomen-to-hip ratio, the plasma insulin level, the integrated glucose area under the plasma glucose curve after an oral glucose-tolerance test, and the percentage of body fat in both men and women. In contrast, the HDL3 cholesterol level was not related to any of the variables except the percentage of calories derived from alcohol in women. Significant correlations observed between study variables and the total HDL cholesterol level reflected primarily the HDL2 subfraction.The data were analyzed in a multiple regression model to determine the significance and independence of the variables in predicting the HDL2 cholesterol level. Because men and women differ in body-fat distribution, sex was also included in the initial calculations. As Table 3Table 3
Usefulness of Sex and Measures of Fat Distribution to Predict the HDL2 Cholesterol Level When Used Singly and in Combination in a Mathematical Model.* shows, both sex and the waist-to-hip ratio were highly significant predictors of the HDL2 cholesterol level when they were entered separately into the model; when they were entered simultaneously, however, the waist-to-hip ratio remained highly significant (P<0.0001) but sex was no longer significant (P = 0.81). This observation suggested that the HDL2 level was more closely related to the waist-to-hip ratio than it was to sex. Similar results were obtained with a secondary indicator of the degree of truncal obesity, the chest-to-hip ratio. However, the sex of the subjects remained a statistically significant predictor of the HDL2 cholesterol level when analyzed simultaneously with the abdomen-to-hip ratio. The abdominal circumference was measured at the umbilicus, whereas the waist circumference was measured higher, at the narrowest girth between the rib cage and the iliac crest. These results indicate that the degree of regional obesity in the middle or upper trunk, above the level of the umbilicus, measured as either the waist-to-hip ratio or the chest-to-hip ratio, provided much of the same information as the sex of the subjects with respect to the prediction of HDL2 cholesterol levels.Figure 1 shows a plot of the HDL2 cholesterol level as a function of the waist-to-hip ratio. An inverse relation between the two variables was observed, and a single regression line fitted the data on both men and women. This finding is confirmed in Table 4Table 4
Mathematical Models for the Prediction of the HDL2 Cholesterol Level.* (column 4), which presents the regression coefficients for HDL2 versus waist-to-hip ratio according to sex. The unadjusted regression coefficients were −2.67 in men and −3.12 in women, with values of −1.89 in men and −2.07 in women after adjustment for all significant covariates. Thus, the relation between the HDL2 level and the waist-to-hip ratio was very similar in men and women.Combinations of the waist-to-hip ratio and the variables shown in Table 1 were then assessed for their capacity to predict the HDL2 cholesterol level in a linear mathematical model. Only three variables were found to be significantly and independently related to HDL2 in the group as a whole: the waist-to-hip ratio, the fasting plasma insulin level, and the area under the glucose curve (Table 4). The relative importance of these variables can be judged by R2, the square of the multiple (or single) correlation coefficient, which is also equal to the fraction of the total variance in the HDL2 level that can be explained by the predictors considered. Of the total variance in the HDL2 cholesterol level in the study population (including variance due to analytic error and biologic variation), 41 percent could be explained by the combination of the waist-to-hip ratio, the fasting insulin level, and the area under the glucose curve. Of this 41 percent, 77.6 percent was explained by the waist-to-hip ratio alone, an additional 18.8 percent was explained by adding the fasting insulin level, and a final 3.6 percent was contributed by the area under the glucose curve.
When the sexes were analyzed separately, similar results were found (Table 4). For men, a model containing the waist-to-hip ratio, the area under the insulin curve, and the area under the glucose curve was found to account for 24.9 percent of the variance in HDL2 cholesterol levels. For women, a model consisting of the waist-to-hip ratio, the fasting insulin level, and the percentage of calories derived from alcohol in the diet accounted for 31.1 percent of the variance in HDL2 cholesterol levels. For both men and women separately, just as for the entire population analyzed together, the strongest predictors were chosen from those shown in Table 1.
The potential clinical importance of the variables is indicated in Table 5Table 5
HDL2 Cholesterol Levels at the 25th and 75th Percentiles for Selected Variables.*, in which HDL2 cholesterol values are shown for different levels of waist-to-hip ratio, fasting insulin level, or area under the glucose curve after adjustment for variables other than the one being considered. The HDL2 level in subjects at the 25th percentile for waist-to-hip ratio was 153 percent of that in those at the 75th percentile. The HDL2 level in subjects at the 25th percentile for fasting insulin level was 114 percent of that in those at the 75th percentile. The HDL2 level in subjects at the 25th percentile for glucose area was 107 percent of that in those at the 75th percentile. These results suggest that the largest clinical effect might be predicted to result from changes in the waist-to-hip ratio.It is noteworthy that generalized obesity, as measured by the body-mass index or the percentage of body fat, was not found to be related to the HDL2 level after adjustment for the waist-to-hip ratio in men, women, or the total population (P>0.51 for body-mass index; P>0.16 for percentage of body fat). The coefficient for the regression of the HDL2 level on the waist-to-hip ratio in the entire population was −3.03±0.37; after adjustment for body-mass index and percentage of body fat, the regression coefficients were −2.93±0.40 and −3.29±0.44, respectively (the changes were not significant). The unadjusted coefficients for the regression of the HDL2 level on the waist-to-hip ratio were −2.67±0.87 for men and −3.12±0.95 for women. After adjustment for body-mass index, the regression coefficients were −2.56±1.00 for men and −2.90±1.01 for women; after adjustment for percentage of body fat, they were −2.24±0.93 for men and −2.76±0.98 for women (the changes were not significant). Thus, the relation between the HDL2 level and the waist-to-hip ratio was not altered by the covariate body-mass index or percentage of body fat. Similarly, the dietary variables listed in Table 1 and cardiovascular fitness as measured by maximal oxygen uptake during a treadmill exercise test were not independently related to the HDL2 level. The one exception was that the percentage of calories derived from alcohol in the diet was a statistically significant (but relatively minor) predictor of the HDL2 level in women (Table 4).
Discussion
We measured the HDL2 cholesterol level and its metabolic covariates in a population of healthy older men and women. The subjects were between 60 and 70 years of age, were nonsmokers, and were not taking drugs that might affect lipid metabolism; therefore, age, smoking habits, and drug treatment were not important variables in our analysis. The major variables considered in the relation to the HDL2 level in this population were obesity,13 , 14 the degree of glucose tolerance, indicated by the area under the glucose curve,15 plasma insulin level,16 distribution of body fat,17 18 19 fitness level,20 and diet.21 These covariates were measured together with the HDL2 level and analyzed in a mathematical model. In this study, we extended previous data by measuring the HDL2 cholesterol subfraction instead of total HDL, using an optimal measure of truncal obesity (discussed below), and including all the covariates mentioned above. A substantial increase in the power of these variables to predict the level of HDL2, as compared with earlier studies, was observed.
The waist-to-hip ratio was the most powerful predictor of the HDL2 level among those we evaluated, accounting for 31.8 percent of the total observed variance in the HDL2 level. This finding was not unexpected, since the entire group consisted of men with low HDL2 levels and high waist-to-hip ratios and women with high HDL2 levels and low waist-to-hip ratios. Thus, the waist-to-hip ratio may simply have reflected the differences in HDL2 cholesterol levels observed between the sexes. What was not anticipated was that the waist-to-hip ratio would predict the HDL2 level independently of sex and that the effect of sex would become statistically insignificant when the waist-to-hip ratio was considered simultaneously with sex. This finding means that the waist-to-hip ratio is more closely related statistically to the HDL2 level than is sex.
Differences in the waist-to-hip ratio (or unmeasured covariates more closely related to it than were the other variables we considered) appear to account for much of the difference in HDL2 cholesterol levels observed between men and women in this age group. This hypothesis is further supported by two types of evidence. First, the waist-to-hip ratio was a significant predictor of the HDL2 level when each sex was analyzed separately. Second, the regression coefficients that measured the slope of the plot of the HDL2 level in relation to the waist-to-hip ratio were the same for men, women, and all subjects combined. Although large differences in the HDL cholesterol level are observed between the sexes in Western cultures, Gods-land and colleagues have pointed out that in more primitive societies with fewer coronary risk factors and less obesity, the HDL levels of men and women are similar.22 If acquired factors cause part of the sexual difference in the HDL2 cholesterol level seen in our subjects, then the fact that a larger increase in truncal fat accompanies weight gain during adult life in men may be one such factor.
The method used to measure waist girth is important and differs from those used in some previous studies. We measured the narrowest circumference between the chest wall and the iliac crest. The value most frequently reported in the literature is the circumference at the level of the umbilicus (which we have called the abdominal circumference). The waist-to-hip ratio was smaller than the abdomen-to-hip ratio in both men and women, with the waist measurement located at a more craniad position.6 The waist-to-hip ratio was more useful than the abdomen-to-hip ratio in predicting the HDL2 cholesterol level, as indicated by the fact that including the waist-to-hip ratio in a regression model reduced to insignificance the contribution of sex, whereas sex remained a significant predictor of the HDL2 level when the abdominal circumference was used. The chest-to-hip ratio gave results similar to those for the waist-to-hip ratio and different from those for the abdomen-to-hip ratio. These data suggest that the upper truncal circumferences at the waist and chest — rather than the circumference at the umbilicus — are most closely related to the HDL2 cholesterol level. This finding is consistent with the observations that the waist-to-hip ratio correlates highly with the accumulation of intraabdominal but not subcutaneous fat23 and that intraabdominal fat increases while subcutaneous fat decreases as CT scanning is performed at increasingly craniad levels of the abdomen.24 Thus, perhaps the waist-to-hip ratio as currently measured is a more suitable predictor of the HDL2 cholesterol level because it better reflects the amount of intraabdominal fat.
Conclusions from our study must be limited for two reasons. First, the lack of relation of fitness level and diet to the HDL2 level may reflect, in part, the inherent difficulty of measuring those variables, the somewhat low level of maximal oxygen consumption observed in our subjects, and the relative uniformity of the diet they consumed. Second, the results were obtained from cross-sectional data confined to sedentary older adults and were computed in linear models. Nevertheless, the models summarized in Table 4 are consistent wth current ideas about metabolic regulation. The degree of truncal obesity and the plasma insulin level accounted for most of the variance in the HDL2 level explained by our mathematical model. These factors are also important components of "syndrome X," a constellation of findings seen commonly by practicing physicians, which includes hyperinsulinemia and insulin resistance, decreased glucose tolerance or Type II diabetes mellitus, a decreased HDL cholesterol level, hypertriglyceridemia, and truncal obesity.16 , 25 26 27 28 29 It has been proposed that excessive, metabolically active intraabdominal fat causes syndrome X.28 A large amount of intraabdominal fat with a high turnover rate would be expected to result in increased portal free fatty acids and possibly other mediators, with consequent alterations in hepatic metabolism that could, in turn, adversely affect HDL2 metabolism.
The present recommendations for reducing the risk of coronary heart disease justifiably focus on plasma LDL cholesterol levels. Although low levels of HDL cholesterol are a risk factor for coronary disease —independent of the level of LDL cholesterol1 , 2 —much less is known about the determinants of plasma HDL levels. Our results show that the level of HDL3 is not closely related to metabolic or anthropometric variables. However, both the waist-to-hip ratio and the plasma insulin level were strong predictors of the HDL2 cholesterol level in this older population — a finding that raises the possibility that they may be related causally to plasma HDL2 levels as well. If so, more work is needed to understand the mechanisms by which the waist-to-hip ratio and the plasma insulin level alter the HDL2 cholesterol level, since these indexes are difficult to alter in patients. Both may be related, in part, to overweight and may reflect particularly pathogenic aspects of obesity that are not evident in such measures as the body-mass index. In any event, future studies of HDL cholesterol regulation should include these salient components of syndrome X.
Supported by grants from the National Institutes of Health (AG 05562 and HL 29229) and the Washington University General Clinical Research Center.
Source Information
From the Divisions of Metabolism (R.E.O.) and Applied Physiology (M.S., W.M.K., J.S., M.M.), Department of Medicine, Washington University School of Medicine, 660 South Euclid Ave., St. Louis, MO 63110, where reprint requests should be addressed to Dr. Ostlund.
- References
References
1
Kannel
Web of Science | Medline2
Yaari
CrossRef | Web of Science | Medline3
Musliner
Web of Science | Medline4
Bruce
CrossRef | Medline5
Ashwell
Web of Science | Medline6
Ashwell
Web of Science | Medline7
Morgan
Web of Science8
Wilmore
Web of Science | Medline9
Yuhasz MS. The effects of sports training on body fat in man with prediction of optimal body weight. Urbana. Ill.: University of Illinois Press, 1962.
10
Warnick
Web of Science | Medline11
Gidez
Web of Science | Medline12
SAS Institute Inc. SAS user's guide: statistics, 1982 edition. Cary, N.C.: SAS Institute, 1982.
13
Glueck
Web of Science14
Albrink
CrossRef | Web of Science | Medline15
Barrett-Connor
Web of Science | Medline16
Zavaroni
Full Text | Web of Science | Medline17
Despres
Web of Science | Medline18
Terry
CrossRef | Web of Science | Medline19
Haffner
CrossRef | Web of Science | Medline20
Haskell
CrossRef | Web of Science | Medline21
Schonfeld
CrossRef | Web of Science | Medline22
Godsland
CrossRef | Web of Science | Medline23
Ashwell
CrossRef | Web of Science | Medline24
Borkan
Web of Science | Medline25
Kissebah
CrossRef | Web of Science | Medline26
Reaven
CrossRef | Web of Science | Medline27
Krotkiewski
CrossRef | Web of Science | Medline28
Bjorntorp
Medline29
Williams
CrossRef | Web of Science | Medline
- Citing Articles (59)
Citing Articles
1
Dariush Elahi, Marianne McAloon Dyke, Reubin Andres. 2011. Aging, Fat Metabolism, and Adiposity. .
CrossRef2
André Lemay, Lucile Turcot, Francine Déchêne, Sylvie Dodin, Jean-Claude Forest. (2010) Hyperinsulinemia in nonobese women reporting a moderate weight gain at the beginning of menopause. Menopause 17:2, 321-325
CrossRef3
Sérgio Lamego Rodrigues, Marcelo Perim Baldo, Roberto Sá Cunha, Lílian CS Angelo, Alexandre C Pereira, José Eduardo Krieger, José Geraldo Mill. (2010) Anthropometric measures of increased central and overall adiposity in association with echocardiographic left ventricular hypertrophy. Hypertension Research 33:1, 83-87
CrossRef4
B. Singh, S. Arora, B. Goswami, V. Mallika. (2009) Metabolic syndrome: A review of emerging markers and management. Diabetes and Metabolic Syndrome: Clinical Research and Reviews 3:4, 240-254
CrossRef5
Shirya Rashid, Jacques Genest. (2007) Effect of Obesity on High-density Lipoprotein Metabolism**. Obesity 15:12, 2875-2888
CrossRef6
Wing Chuen Chan, Tim Koelmeyer. (2007) Polysarcia Adiposa. The American Journal of Forensic Medicine and Pathology 28:3, 249-254
CrossRef7
F. Xavier Pi-Sunyer. (2004) The Epidemiology of Central Fat Distribution in Relation to Disease. Nutrition Reviews 62, S120-S126
CrossRef8
Peter Kokkinos, George Moutsatsos. (2004) Obesity and Cardiovascular Disease. Journal of Cardiopulmonary Rehabilitation 24:3, 197-203
CrossRef9
Nina Lochner, Christina Lobmaier, Michael Wirth, Alfred Leitner, Fritz Pittner, Franz Gabor. (2003) Silver nanoparticle enhanced immunoassays: one step real time kinetic assay for insulin in serum. European Journal of Pharmaceutics and Biopharmaceutics 56:3, 469-477
CrossRef10
Anders Thelin, Eva-lena Stiernstrom, Sara Holmberg. (2001) Journal of Cardiovascular Risk 8:3, 165-174
CrossRef11
Gérald Luc, Jean-Marie Bard, Alun Evans, Dominique Arveiler, Jean-Bernard Ruidavets, Philippe Amouyel, Pierre Ducimetiere. (2000) The relationship between apolipoprotein AI-containing lipoprotein fractions and environmental factors: the prospective epidemiological study of myocardial infarction (PRIME study). Atherosclerosis 152:2, 399-405
CrossRef12
Christopher D. Gardner, Diane L. Tribble, Deborah Rohm Young, David Ahn, Stephen P. Fortmann. (2000) Associations of HDL, HDL2, and HDL3 Cholesterol and Apolipoproteins A-I and B with Lifestyle Factors in Healthy Women and Men: The Stanford Five City Project. Preventive Medicine 31:4, 346-356
CrossRef13
Dongsheng Hu, Judy Hannah, R. Stuart Gray, Kathleen A. Jablonski, Jeffrey A. Henderson, David C. Robbins, Elisa T. Lee, Thomas K. Welty, Barbara V. Howard. (2000) Effects of Obesity and Body Fat Distribution on Lipids and Lipoproteins in Nondiabetic American Indians: The Strong Heart Study. Obesity 8:6, 411-421
CrossRef14
A. P. Goldberg, M. J. Busby-Whitehead, L. I. Katzel, R. M. Krauss, M. Lumpkin, J. M. Hagberg. (2000) Cardiovascular Fitness, Body Composition, and Lipoprotein Lipid Metabolism in Older Men. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 55:6, M342-M349
CrossRef15
ELIZABETH MANSFIELD, RUTH McPHERSON, KRISTINE G KOSKI. (1999) Diet and Waist-to-Hip Ratio. Journal of the American Dietetic Association 99:11, 1373-1379
CrossRef16
F. XAVIER PI-SUNYER. (1999) Comorbidities of overweight and obesity: current evidence and research issues. Medicine & Science in Sports & Exercise 31:Supplement 1, S602
CrossRef17
Florence A. Trémollières, Jean-Michel Pouilles, Colette Cauneille, Claude Ribot. (1999) Coronary heart disease risk factors and menopause: a study in 1684 French women. Atherosclerosis 142:2, 415-423
CrossRef18
Eiji Manabe, Kiyoshi Aoyagi, Hiroki Tachibana, Tai-ichiro Takemoto. (1999) Relationship of Intra-Abdominal Adiposity and Peripheral Fat Distribution to Lipid Metabolism in an Island Population in Western Japan. Gender Differences and Effect of Menopause.. The Tohoku Journal of Experimental Medicine 188:3, 189-202
CrossRef19
Stephen Riemens, Arie van Tol, Wim Sluiter, Robin Dullaart. (1998) Elevated plasma cholesteryl ester transfer in NIDDM: relationships with apolipoprotein B-containing lipoproteins and phospholipid transfer protein. Atherosclerosis 140:1, 71-79
CrossRef20
Willy Hänggi, Kurt Lippuner, Philippe Jaeger, Martin H. Birkhäuser, Fritz F. Horber. (1998) Differential impact of conventional oral or transdermal hormone replacement therapy or tibolone on body composition in postmenopausal women. Clinical Endocrinology 48:6, 691-699
CrossRef21
Diane E Bild, Phyliss D Sholinsky, Pamela J Schreiner, Joan E Hilner, Christine A Swanson. (1998) Validity of Self-Reported Fat Distribution in Young Adults: The CARDIA Study. Journal of Clinical Epidemiology 51:5, 407-413
CrossRef22
William T. Cefalu, Sandra Werbel, Audrey D. Bell-Farrow, James G. Terry, Zhong O. Wang, Emmanuel C. Opara, Timothy Morgan, William H. Hinson, John R. Crouse. (1998) Insulin resistance and fat patterning with aging: Relationship to metabolic risk factors for cardiovascular disease. Metabolism 47:4, 401-408
CrossRef23
Robert A Wild. (1997) Metabolic aspects of polycystic ovary syndrome. Reproductive Medicine Review 6:02, 69
CrossRef24
Y. Van Der Graaf, M. J. J de Kleijn, Y. T. van der Schouw. (1997) Menopause and cardiovascular disease. Journal of Psychosomatic Obstetrics & Gynecology 18:2, 113-120
CrossRef25
William T. Cefalu, Janice D. Wagner. (1997) Aging and atherosclerosis in human and nonhuman primates. AGE 20:1, 15-28
CrossRef26
Florence A. Trémollieres, Jean-Michel Pouilles, Claude A. Ribot. (1996) Relative influence of age and menopause on total and regional body composition changes in postmenopausal women. American Journal of Obstetrics and Gynecology 175:6, 1594-1600
CrossRef27
Tsutomu Douchi, Hirofumi Ijuin, Sachiko Nakamura, Toshimichi Oki, Shinichi Yamamoto, Mari Katanozaka, Yukihiro Nagata. (1996) The Relation between Body-Fat Distribution and Lipid Metabolism in Postmenopausal Women. Asia-Oceania Journal of Obstetrics and Gynaecology 22:4, 353-358
CrossRef28
Bruce A. Reeder, Liyan Liu, Louis Horlick. (1996) Selective screening for dyslipidemia in a Canadian population. Journal of Clinical Epidemiology 49:2, 217-222
CrossRef29
David L. Rainwater, John Blangero, Perry H. Moore, Wendy R. Shelledy, Thomas D. Dyer. (1995) Genetic control of apolipoprotein A-I distribution among HDL subclasses. Atherosclerosis 118:2, 307-317
CrossRef30
Arne Oshaug, Kari H. Bugge, Christine Helle Bj
nnes, Morten Ryg. (1995) Use of anthropometric measurements in assessing risk for coronary heart disease: a useful tool in worksite health screening?. International Archives of Occupational and Environmental Health 67:6, 359-366
CrossRef31
Paul T. Williams, William L. Haskell, Karen M. Vranizan, Ronald M. Krauss. (1995) The associations of high-density lipoprotein subclasses with insulin and glucose levels, physical activity, resting heart rate, and regional adiposity in men with coronary artery disease: The stanford coronary risk intervention project baseline survey. Metabolism 44:1, 106-114
CrossRef32
Josef R. Patsch. (1994) Triglyceride-rich lipoproteins and atherosclerosis. Atherosclerosis 110, S23-S26
CrossRef33
Kenneth D. Ward, David Sparrow, Lewis Landsberg, James B. Young, Pantel S. Vokonas, Scott T. Weiss. (1994) The relationship of epinephrine excretion to serum lipid levels: The normative aging study. Metabolism 43:4, 509-513
CrossRef34
Marion C. Blonk, Maarten A.J.M. Jacobs, Cylla E. Friedberg, Jos J.P. Nauta, Ton Teerlink, Corrie Popp-Snijders, Robert J. Heine. (1994) Determinants of insulin sensitivity and consequences for lipoproteins and blood pressure in subjects with non-insulin-dependent diabetes mellitus. Metabolism 43:4, 501-508
CrossRef35
R. P. F. DULLAART, W. J. SLUITER, L. D. DIKKESCHEI, K. HOOGENBERG, A. VAN TOL. (1994) Effect of adiposity on plasma lipid transfer protein activities: a possible link between insulin resistance and high density lipoprotein metabolism. European Journal of Clinical Investigation 24:3, 188-194
CrossRef36
Christopher J. Ley, Jonathan Swan, Ian F. Godsland, Christopher Walton, David Crook, John C. Stevenson. (1994) Insuline resistance, lipoproteins, body fat and hemostasis in nonobese men with angina and a normal or abnormal coronary angiogram. Journal of the American College of Cardiology 23:2, 377-383
CrossRef37
Gerard S. Conway, Howard S. Jacobs. (1993) Clinical implications of hyperinsulinaemia in women. Clinical Endocrinology 39:6, 623-632
CrossRef38
E.John Harris, Lloyd M. Taylor, Gregory L. Moneta, John M. Porter. (1993) Outcome of infrainguinal arterial reconstruction in women. Journal of Vascular Surgery 18:4, 627-636
CrossRef39
Leslie I. Katzel, M.Janette Busby-Whitehead, Andrew P. Goldberg. (1993) Adverse effects of abdominal obesity on lipoprotein lipids in healthy older men. Experimental Gerontology 28:4-5, 411-420
CrossRef40
John G. Kral, Fenton Schaffner, Richard N. Pierson, Jack Wang. (1993) Body fat topography as an independent predictor of fatty liver. Metabolism 42:5, 548-551
CrossRef41
Alexandra Kautzky-Willer, Giovanni Pacini, Bernhard Ludvik, Guntram Schernthaner, Rudolf Prager. (1992) β-Cell hypersecretion and not reduced hepatic insulin extraction is the main cause of hyperinsulinemia in obese nondiabetic subjects. Metabolism 41:12, 1304-1312
CrossRef42
Arie Roth, Michael Koffler, Sami Viskin, Boris Shargorotzki, Dora Bernfeld, Shlomo Laniado. (1992) Does adequate control of diabetes in the preinfarction period improve the short-term postinfarction course?. Journal of Diabetes and its Complications 6:4, 218-222
CrossRef43
Andreas C. So¨nnichsen, Werner O. Richter, Peter Schwandt. (1992) Benefit from hypocaloric diet in obese men depends on the extent of weight-loss regarding cholesterol, and on a simultaneous change in body fat distribution regarding insulin sensitivity and glucose tolerance. Metabolism 41:9, 1035-1039
CrossRef44
Gerard S. Conway, R. Agrawal, D. J. Betteridge, H. S. Jacobs. (1992) Risk factors for coronary artery disease in lean and obese women with the polycystic ovary syndrome. Clinical Endocrinology 37:2, 119-125
CrossRef45
Jean Ginsburg, Stanley Okolo, Paul Hardiman, JacobC. Seidell. (1992) Coronary heart disease in women. The Lancet 339:8799, 986-987
CrossRef46
Per Björntorp. (1992) Abdominal Fat Distribution and Disease: An Overview of Epidemiological Data. Annals of Medicine 24:1, 15-18
CrossRef47
A.C. Sönnichsen, W.O. Richter, P. Schwandt. (1991) Body fat distribution and serum lipoproteins in relation to age and body weight. Clinica Chimica Acta 202:3, 133-140
CrossRef48
Joseph A. Houmard, William S. Wheeler, Michael R. McCammon, Don Holbert, Richard G. Israel, Hisham A. Barakat. (1991) Effects of fitness level and the regional distribution of fat on carbohydrate metabolism and plasma lipids in middle- to older-aged men. Metabolism 40:7, 714-719
CrossRef49
Roland T. Jung, Patrick Chong. (1991) The management of obesity. Clinical Endocrinology 35:1, 11-20
CrossRef50
C. Baynes, A. D. Henderson, V. Anyaoku, W. Richmond, D. G. Johnston, R. S. Elkeles. (1991) The Influence of Regional Adiposity on Atherogenic Risk Factors in Men and Women with Type 2 Diabetes. Diabetic Medicine 8:5, 458-463
CrossRef51
Jacob C. Seidell, Massimo Cigolini, Jadviga Charzewska, Britt-Marie Ellsinger, Per Björntorp, Joseph G.A.J. Hautvast, Wictor Szostak. (1991) Fat distribution and gender differences in serum lipids in men and women from four European communities. Atherosclerosis 87:2-3, 203-210
CrossRef52
Matti Mänttäri, Pekka Koskinen, Vesa Manninen, Leena Tenkanen, Jussi K. Huttunen. (1991) Lifestyle determinants of HDL2- and HDL3-cholesterol levels in a hypercholesterolemic male population. Atherosclerosis 87:1, 1-8
CrossRef53
Jacob C. Seidell, Massimo Cigolini, Jean-Paul Deslypere, Jadviga Charzewska, Britt-Marie Ellsinger, Amorim Cruz. (1991) Body fat distribution in relation to serum lipids and blood pressure in 38-year-old European men: the European fat distribution study. Atherosclerosis 86:2-3, 251-260
CrossRef54
Michel Pugeat, Jean Charles Crave, Mohamed Elmidani, Marie Héléne Nicolas, Monique Garoscio-Cholet, Hervé Lejeune, Henri Déchaud, Jacques Tourniaire. (1991) Pathophysiology of sex hormone binding globulin (SHBG): Relation to insulin. The Journal of Steroid Biochemistry and Molecular Biology 40:4-6, 841-849
CrossRef55
(1990) Obesity and Risk of Coronary Heart Disease in Women. New England Journal of Medicine 323:16, 1143-1146
Full Text56
Jens Haarbo, Christian Hassager, Annette Schlemmer, Claus Christiansen. (1990) Influence of smoking, body fat distribution, and alcohol consumption on serum lipids, lipoproteins, and apolipoproteins in early postmenopausal women. Atherosclerosis 84:2-3, 239-244
CrossRef57
Marc L'Hermite. (1990) Risks of estrogens and progestogens. Maturitas 12:3, 215-246
CrossRef58
(1990) Predictors of HDL2 Cholesterol Levels in Older Adults. New England Journal of Medicine 323:5, 348-349
Full Text59
VanItallie, Theodore B., . (1990) The Perils of Obesity in Middle-Aged Women. New England Journal of Medicine 322:13, 928-929
Full Text
- Letters
