European Journal of Clinical Nutrition (2004) 58, 11591165

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ORIGINAL COMMUNICATION
Waist circumference as a measurement of obesity in
the Netherlands Antilles; associations with
hypertension and diabetes mellitus
L Grievink1,2, JF Alberts2*, J ONiel2 and I Gerstenbluth2
1
Northern Centre for Health Care Research, University of Groningen, the Netherlands; and 2Epidemiology and Research Unit, Medical
and Public Health Service of Curacao, Netherlands Antilles

Objectives: To evaluate waist circumference (WC) as a screening tool for obesity in a Caribbean population. To identify risk
groups with a high prevalence of (central) obesity in a Caribbean population, and to evaluate associations between (central)
obesity and self-reported hypertension and diabetes mellitus.
Design: Cross-sectional.
Setting: Population-based study.
Subjects: A random sample of adults (18 y or older) was selected from the Population Registries of three islands of the
Netherlands Antilles. Response was over 80%. Complete data were available for 2025 subjects.
Intervention: A questionnaire and measurements of weight, height, waist and hip.
Main outcome measurement: Central obesity indicator (WC Z102 cm men, Z88 cm women).
Results: WC was positively associated with age (6574 y vs 1824 y) in men (OR 7.7, 95% CI 3.417.4) and women (OR 6.4,
95% CI 3.212.7). Women with a low education had a higher prevalence of central obesity than women with a high education
(OR 0.5, 95% CI 0.30.7). However, men with a high income had a higher prevalence of a central obesity than men with a low
income (OR 1.7, 95% CI 1.12.6). WC was the strongest independent obesity indicator associated with self-reported
hypertension (OR 1.7, 95% CI 1.42.0) and diabetes mellitus (OR 1.6, 95% CI 1.31.9).
Conclusions: The identified risk groups were women aged 5574 y, women with a low educational level and men with a high
income. WC appears to be the major obesity indicator associated with hypertension and diabetes mellitus.
Sponsorship: Island Governments of Saba, St Eustatius and Bonaire, the Federal Government of the Netherlands Antilles, Dutch
Directorate for Kingdom relationships.

European Journal of Clinical Nutrition (2004) 58, 11591165. doi:10.1038/sj.ejcn.1601944

Published online 31 March 2004
Keywords: BMI; waist-to-hip ratio; waist circumference; Caribbean

Introduction
In the Caribbean island of Curacao (Netherlands Antilles), a
very high prevalence of obesity (BMI Z30 kg/m2) was
observed, that is: 36% in women and 19% in men (Grol

*Correspondence: JF Alberts, Epidemiology and Research Unit, Medical

and Public Health Service (GGD), Piscaderaweg 49, Curacao, Netherlands
Antilles.
E-mail: ggdepi.cur@attglobal.net
Guarantor: JF Alberts.
Contributors: L Grievink was involved in the study design and
analysed the data. JF Alberts coordinated the study, J ONiel and I
Gerstenbluth were involved in the study design. All authors contributed to the writing of the article.
Received 29 April 2003; revised 10 November 2003; accepted 22
December 2003; published online 31 March 2004

et al, 1997). In addition, hypertension (2030%) and diabetes

mellitus (10%) were estimated to be highly prevalent in
Curacao (Gerstenbluth et al, 1995; Alberts et al, 1996). From a
number of epidemiological studies it is clear that obesity, and
in particular central obesity, is related to an increased risk of
these and other chronic diseases (Seidell et al, 1997; Okosun
et al, 2001; Visscher & Seidell, 2001).
Some reports have suggested that waist circumference
(WC) might be a better predictor of cardiovascular disease
risk and diabetes mellitus (NIDDM) than waist-to-hip (WHR)
ratio (Han et al, 1995; Wei et al, 1997). WC was introduced as
a simple measurement of (central) obesity (Lean et al, 1995).
So far, the applicability of the cut-offs of WC have mainly
been demonstrated among Caucasian populations (Molarius
& Seidell, 1998). Grol et al (1997) were the first to explore

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1160
WC cut-off points in an ethnically mixed population
(predominantly of west African/European descent), through
the Curacao Health Study.
During 1999 and 2000 data were collected on other islands
of the Netherlands Antilles (Bonaire, St Eustatius and Saba).
One objective was to identify risk groups with a high
prevalence of obesity. We also evaluated whether the
associations between obesity indicators (WC, BMI and
WHR ratio), and hypertension and diabetes mellitus hold
true for the population in this study. Finally, we examined
whether WC as indicator of central obesity was associated
with these disorders independent of overall obesity (BMI).

Methods and procedures

Subjects
Data on three islands of the Netherlands Antilles (Bonaire,
St Eustatius, Saba) are included in this paper; the data
were collected during 1999/2000. Geographically, Bonaire
and Curacao pertain to the Leeward islands close to
Venezuela; Saba and St Eustatius pertain to the Windward
islands.
In Bonaire and St Eustatius, study samples were randomly
drawn from the Population Registries and consisted of
registered inhabitants of 18 y or older, not living in
institutions. In Saba, we included all permanent adult
inhabitants to obtain representative study results because
of the small overall number of residents. The response rates
for the three islands were above 80% (82.1% in Bonaire,
87.9% in St Eustatius and 80.6% in Saba) with the following
number of participants: 1003 for Bonaire, 572 for St
Eustatius, and 562 for Saba. On all islands, the age
distribution of the study sample was representative of the
age distribution of the entire population. In Bonaire and
Saba, women were slightly over-represented in the study
sample.
Weight and height measurements were missing for 110
individuals and data on waist and hip circumferences were
not available for 101 individuals. Overall 2025 persons (1019
men and 1006 women) with complete anthropometric
measures were included in the analyses.

Questionnaire
The study design consisted of an interview survey with
internationally validated instruments and some additional
instruments that had been adapted to local culture (Alberts
et al, 1996). The four main topics of the questionnaire were
health status, use of health care, lifestyle and knowledge/
attitudes towards health and health care. The questionnaire
included a list of 33 chronic conditions or diseases and the
respondent was asked whether he/she had these conditions
currently or had them in the 12 months preceding the
interview. The list was an adapted version of the continuous
household survey of the Statistics Netherlands (Mootz & van
den Berg, 1989). For evaluating possible associations
European Journal of Clinical Nutrition

between obesity and obesity-related diseases in this Dutch

Caribbean population, we selected hypertension and diabetes mellitus because these are known to be highly
prevalent among the Caribbean population, in particular
among individuals of African or Indian subcontinent origin
(Gulliford, 1994).
The following variables were used among others for
defining risk groups: level of education, occupational
prestige and net household income; these were chosen as
indicators of socio-economic status (SES). The highest level
of education completed was coded according to the International Standard Classifications of Education (ISCED),
developed by UNESCO in Paris (1976). For the analyses,
the scores were reduced to three categories of about equal
size, defined as low, middle and high educational level.
Respondents indicated their current or past occupation and,
if applicable, that of their (deceased) spouses. The highest
occupation of either the respondent or partner was used for
calculation of occupational prestige. Occupations were
classified according to the International Standard Classification of Occupations (ISCO-88). The ISCO-88 was coded into
Treimans International Prestige Scale (Ganzeboom et al,
1992). Finally, the scale was divided into three categories
varying from low to high occupational prestige, each
containing approximately equal percentages of respondents.
Respondents indicated their net household income category
out of 11 possibilities, which were reduced into three
categories of about equal sizes, defined as low, intermediate
and high income with the cut-off points at 825 USD and
1650 USD per month.

Anthropometry
In addition to the interview, some anthropometric measurements were taken. The interviewers were trained to measure
weight and height according to the World Health Organisation (WHO, 1987) standards. The participants were asked
beforehand to wear light clothing and to remove jewellery,
shoes and socks. The scales used were calibrated by the
Government Calibration Office, allowing for a margin of
error of 0.5%. To determine the obese proportion of the
study population, the body mass index (BMI) was calculated
(weight [kg]/height [m] squared). Obesity was classified
according to the WHO definition (WHO, 1998) as a BMI
Z30 kg/m2, and we will refer to this in the text as overall
obesity. With the subject standing, hip circumference was
measured with a flexible tape to the nearest 0.5 cm at the
widest point of the hip area. WC was measured to the nearest
0.5 cm at the mid-point between the lower rib and the iliac
crest at the end of a normal expiration. As a measure of both
overall obesity and central obesity, we determined the
optimal cut-off points for WC. These cut-off points were in
agreement with internationally used cut-off points as
determined by Lean et al (1995): 102 cm for men and
88 cm for women.

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Results

As an additional measure of central obesity, we

calculated the WHR. For international comparison, we used
the cut-off values proposed by Lean et al (1995), that is, a
WHR equal to or greater than 0.95 for men and 0.80 for
women.

The study sample consisted of about equal proportions of

men (50.3%) and women (49.7%). Most of the respondents
(about 71%) were born in the Netherlands Antilles or Aruba
(formerly part of the Netherlands Antilles). The mean age
was 44.4 y in general (men: 44.0, and women: 44.7 y)
(Table 1). The mean BMI was higher in women, whereas
the mean WC and WHR were higher in men. The prevalence
of obesity (BMI Z30 kg/m2) was about 34% in women and
22% in men. About 54 and 66% of the women, respectively,
had a high WHR and a high WC. In men these were 24 and
25%, respectively (Table 1).
The overall sensitivity of the cut-offs points of WC was
58.1% in men and 73.5% in women. The overall specificity
was 95.6% in men and 95.4% in women.
The highest correlation between obesity indicators was
observed for BMI and WC, with a Pearson correlation
coefficient of 0.79. WC and WHR were second highest
correlated (Pearson r 0.65) and the correlation coefficient
between BMI and WHR was lowest (Pearson r 0.27).
Table 2 presents the association of each of the obesity
indicators (BMI, WC and WHR), with age and socioeconomic variables in men. A high BMI was associated with
age; the prevalence of obesity started to increase at 25 y and
decreased after 75 y and older. A similar age-related pattern
was observed for WC and WHR (Table 2).
Men with an intermediate or high income (OR and 95% CI
were 1.5 and 1.02.2; and 1.7 and 1.12.6, respectively) had a
higher prevalence of central obesity defined by WC than
men with a low income. WC was not associated with
educational level or occupational prestige. BMI and WHR
were not associated with either a high education, occupational prestige or income in men (Table 2).
Table 3 presents the association between the three obesity
indicators, age, and socio-economic status in women.
Although BMI as obesity indicator was not clearly associated
with age when evaluating the odds ratios (OR of one was
included in the 95% CI), the prevalence of obesity (determined by BMI) increased from 29.7% in the age group of
1824 y to 40.8% in the age group of 6574 y and decreased

Statistical methods
To test the appropriateness of using WC cut-off points as a
screening method for obesity, we determined the sensitivity
and specificity of these cut-off points. Sensitivity and
specificity were calculated according to the method used
by Molarius et al (1999).
To identify possible risk groups in the population,
we studied the associations between the three obesity
indicators (BMI, WC and WHR) and some socio-demographic variables (age, sex, educational level, occupational
prestige and net household income). To calculate the
associations, we used logistic regression models; the estimate
was given as an odds ratio (OR) with a 95% confidence
interval (95% CI). The OR and 95% CI for the three SESindicators were adjusted for age. All analyses were performed
separately by gender.
Furthermore, using logistic regression we analysed
associations between each of the obesity indicators and
hypertension and diabetes mellitus. In these analyses,
each obesity indicator was entered into the regression model
as a continuous variable. Odds ratios are presented for
an increase of one standard deviation in the indicators, so
the magnitude of the odds ratios for each of the obesity
indicators can be compared. The odds ratios were
adjusted for sex, age, educational level (three levels),
smoking cigarettes (yes/no), physical exercise (yes/no),
alcohol consumption (yes/no) and island of residence.
Finally, to evaluate whether the obesity indicators were
independently associated with having hypertension and
diabetes mellitus, we adjusted each obesity indicator for
the other two.
SPSS software (version 9.0) was used for all statistical
analyses (SPSS Inc., 1999).

Table 1 Mean age, BMI, waist circumference and waist-to-hip ratio and the prevalence estimates of the three obesity indicators, overall and by sex
Men (N 1019)

Mean age (y)

Mean BMI (kg/m2)
Mean waist circumference (cm)
Mean waist-to-hip ratio
Prevalence of obesity (%)
BMI Z30.0 kg/m2
WC Z102 cm for men, Z88 cm for women
WHR Z0.95 for men, Z0.80 for women

Women (N 1006)

Overall (N 2025)

Mean

s.d.

Mean

s.d.

Mean

s.d.

44.0
26.6
93.2
0.90

15.8
4.8
12.6
0.07

44.7
28.1
90.0
0.83

16.1
6.4
14.1
0.08

44.4
27.3
91.6
0.87

15.9
5.7
13.5
0.08

21.8%
23.7%
24.6%

33.8%
54.1%
65.9%

27.8%
38.8%
45.1%

s.d. standard deviation; WHR waist-to-hip ratio; WC waist circumference; BMI body mass index.

European Journal of Clinical Nutrition

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1162
Table 2 Prevalence (%) of obesity indicators by age and SES among men
BMI Z30 kg/m2
Socio-demographic variables

Categories

Age groups (y)

1824
2534
3544
4554
5564
6574
75
Low
Intermediate
High
Low
Intermediate
High
o825 USD
8251650 USD
Z1650 USD

Educational level*

Occupational prestige*

Net household income*

WC Z102 cm

WHR Z0.95

Prevalence (%)

OR (95% CI)

Prevalence (%)

OR (95% CI)

Prevalence (%)

11.3
21.0
21.5
24.7
25.2
28.6
18.9
23.3
20.2
22.6
21.7
22.2
22.1
19.5
21.2
22.8

1.0w
2.1 (1.04.1)
2.1 (1.14.2)
2.6 (1.35.1)
2.6 (1.35.4)
3.1 (1.46.8)
1.8 (0.74.5)
1.0w
1.0 (0.71.6)
1.1 (0.81.8)
1.0w
1.1 (0.71.5)
1.0 (0.71.5)
1.0w
1.2 (0.81.9)
1.3 (0.92.1)

8.5
17.3
19.5
31.1
30.1
41.6
32.1
31.4
18.1
25.3
22.4
22.7
26.5
21.8
23.7
26.4

1.0w
2.3 (1.04.9)
2.6 (1.25.5)
4.9 (2.310.3)
4.6 (2.110.2)
7.7 (3.417.4)
5.1 (2.112.4)
1.0w
0.8 (0.51.2)
1.1 (0.71.7)
1.0w
1.1 (0.81.6)
1.2 (0.81.8)
1.0w
1.5 (1.02.2)
1.7 (1.12.6)

5.7
10.7
19.5
33.7
36.6
51.9
43.4
36.3
21.7
21.0
22.4
25.9
25.3
25.7
25.1
20.3

OR (95% CI)
1.0w
2.0
4.0
8.5
9.6
18.0
12.8
1.0w
1.1
0.9
1.0w
1.5
1.1
1.0w
1.6
1.2

(0.85.1)
(1.79.7)
(3.520.3)
(3.923.7)
(7.146.0)
(4.834.2)
(0.71.6)
(0.61.3)
(1.02.2)
(0.81.7)
(1.12.4)
(0.71.8)

*Odds ratios of SES were adjusted for age;

w
Reference group.
BMI body mass index; WC waist circumference; OR odds ratio; 95% CI 95% confidence interval.

Table 3 Prevalence of obesity indicators by age and SES among women

BMI Z30 kg/m2
Socio-demographic variables
Age groups (y)

Educational level*

Occupational prestige*

Net household income*

Categories
1824
2534
3544
4554
5564
6574
75
Low
Intermediate
High
Low
Intermediate
High
o825 USD
8251650 USD
Z1650 USD

Prevalence (%)
29.7
33.2
35.0
35.0
37.1
40.8
17.2
36.8
36.7
27.2
36.8
37.5
27.9
34.9
33.9
33.3

WC Z88 cm

OR (95% CI)
w

1.0
1.2 (0.72.0)
1.3 (0.82.1)
1.3 (0.72.2)
1.4 (0.82.5)
1.6 (0.93.1)
0.5 (0.21.1)
1.0w
0.9 (0.61.3)
0.6 (0.40.9)
1.0w
1.0 (0.81.4)
0.7 (0.50.9)
1.0w
1.0 (0.71.4)
0.9 (0.61.4)

Prevalence (%)
28.6
41.7
55.1
60.0
68.9
71.8
60.3
69.4
50.8
44.0
57.1
54.8
50.8
58.3
54.3
51.2

OR (95% CI)
w

1.0
1.8 (1.13.0)
3.1 (1.85.1)
3.8 (2.26.5)
5.5 (3.110.0)
6.4 (3.212.7)
3.8 (1.97.6)
1.0w
0.7 (0.50.9)
0.5 (0.30.7)
1.0w
1.0 (0.71.4)
0.8 (0.61.1)
1.0w
1.0 (0.71.5)
1.0 (0.71.4)

WHR Z0.80
Prevalence (%)
34.1
50.2
69.2
73.3
77.3
87.3
82.8
78.4
65.3
55.1
67.6
66.4
63.8
70.7
65.0
56.8

OR (95% CI)
1.0w
2.0
4.3
5.3
6.6
13.3
9.3
1.0w
1.0
0.6
1.0w
1.0
0.8
1.0w
1.0
0.7

(1.23.3)
(2.67.2)
(3.19.2)
(3.611.9)
(5.930.3)
(4.120.8)
(0.71.6)
(0.40.9)
(0.71.5)
(0.61.2)
(0.71.4)
(0.51.1)

*Odds ratio of SES were adjusted for age;

w
Reference group.
BMI body mass index; WC waist circumference; OR odds ratio; 95% CI 95% confidence interval.

after 75 y of age to 17.2%. The central obesity indicators WC

and WHR showed the same age-related pattern as in men, be
it that women in the age groups between 55 and 74 y had a
particularly high prevalence of central obesity compared to
women below the age of 34 y. Women with an intermediate
or high education (OR and 95% CI were 0.7 and 0.50.9; and
0.5 and 0.30.7, respectively) had a lower prevalence of
central obesity (WC) than women with a low education. In
addition, women with a high education had a lower
prevalence of overall obesity and central obesity (WHR).
European Journal of Clinical Nutrition

Women with a higher occupational prestige had a lower

prevalence of overall obesity (BMI Z30 kg/m2) than women
with a lower occupational prestige. The prevalence of central
obesity (WC and WHR) tended to decrease with a higher
occupational prestige and income compared to a low status
but this was not statistically significant after adjustment for
age.
Overall, the prevalence of self-reported hypertension was
16.1% and that of diabetes mellitus 7.9%. In Table 4, we
present the odds ratios (OR) of hypertension and diabetes

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Table 4 Association between hypertension, diabetes mellitus and each of the continuous obesity indicators (body mass index, waist circumference,
waist-to-hip ratio), presented as odds ratios (95% confidence intervals) for a s.d. difference of each obesity indicator
Crude

Multi*-adjusted

Multi BMI adjusted

Multi WC adjusted

Multi WHR adjusted

Hypertension
BMI (s.d. 5.7 kg/m2)
WC (s.d. 13.5 cm)
WHR (s.d. 0.08)

1.6 (1.41.8)
2.0 (1.82.3)
1.7 (1.51.9)

1.6 (1.41.8)
1.9 (1.62.1)
1.8 (1.52.0)

2.0 (1.52.5)
1.5 (1.31.8)

0.9 (0.81.2)

1.2 (1.01.5)

1.4 (1.31.6)
1.7 (1.42.0)

Diabetes mellitus
BMI (s.d. 5.7 kg/m2)
WC (s.d. 13.5 cm)
WHR (s.d. 0.08)

1.6 (1.41.8)
2.0 (1.72.4)
1.9 (1.62.2)

1.6 (1.41.9)
1.9 (1.62.2)
1.9 (1.62.3)

1.8 (1.32.5)
1.7 (1.42.0)

1.0 (0.81.4)

1.4 (1.11.8)

1.5 (1.21.7)
1.6 (1.31.9)

s.d. standard deviation.

*Multi-adjusted: age, sex, education, smoking, use of alcohol, sports activities and island of domicile.

mellitus for the obesity indicators as continuous variables.

We analysed the unique contributions of the obesity
indicators to evaluate whether they were independently
associated with hypertension or diabetes mellitus. Since the
associations (odds ratios) of hypertension and diabetes
mellitus with the obesity indicators did not deviate between
men and women after adjustment for possible confounding
factors (data not shown), we did not present these associations separately for each sex. All three obesity indicators were
positively associated with hypertension and diabetes mellitus after adjustment for all possible confounders. However,
the positive association between BMI and hypertension did
not remain after adjustment for WC, whereas the association
between WC and hypertension did remain after adjustment
for BMI. The association between WHR and hypertension
decreased slightly but remained statistically significant after
adjustment for either BMI or WC. The OR of WC for
hypertension decreased slightly after adjustment for WHR
but was higher than the OR of WHR for hypertension after
adjustment for WC.
A similar pattern was observed for the associations
between the obesity indicators and diabetes mellitus
(Table 4).

Discussion
The cut-off points of WC had very high specificity (495%)
in this population, for both men and women. This indicates
that very few subjects would be recommended weight
management unnecessarily if this cut-off point was applied
in this study population. The sensitivity was low for men
(58%) and somewhat higher for women (74%). Molarius et al
(1999) demonstrated that a high prevalence of obesity was
related to a high sensitivity. Men in our study had a
prevalence of obesity comparable to what was found in
Australia and the Czech Republic; the sensitivity of the WC
cut-offs was also comparable. The women in our study had a
higher prevalence of obesity and accordingly the corre-

sponding sensitivity was also higher. The low sensitivity

observed among men in our study, reflects relatively large
proportions of men who had a low BMI and a high waist-tohip ratio. These men would be missed if the cut-off for WC
were to be adopted as screening method for necessary weight
management. However, it is debatable whether subjects with
only a high WHR would really need weight reduction and
would benefit from it (Molarius et al, 1999).
In the present study, the prevalence of obesity determined
by BMI was high (22% among men and 34% among
women). This high prevalence was similar to the prevalence
observed in Curacao in 1993/1994, where 19% of the men
and 36% of the women were obese (Grol et al, 1997). The
prevalence of obesity among women in this ethnically
mixed population of which the majority are of west African
descent was also similar to that observed among black
women in the USA (37%). Men in the current study had a
higher prevalence than black men in the USA (15%) (Flegal
et al, 1998). In Jamaica, women had a similarly high
prevalence of obesity (32%), but again men had a lower
prevalence (7%) than the men in the current study (Wilks
et al, 1998). It appears that compared to some other
(predominantly) black populations the prevalence of obesity
in the Netherlands Antilles is high, in particular, among
men.
In the present study, an age of 25 y or older was associated
with higher prevalence of overall and central obesity among
men and with central obesity (WC and WHR) among
women. Among women, the prevalence of central obesity
further increased after the age of 55 y. The prevalence of all
obesity indicators was highest in the 6574 y age group
among both men and women, while overall obesity (as
determined by BMI) decreased again after the age of 75 y.
Similar results were observed in the Curacao Health Study,
except that among men the decrease of mean BMI, WHR and
WC already set in after the age of 65 y (Grol et al, 1997).
Studies among westernised populations show that the
prevalence of both overall and central obesity increases with
age to about 6065 y and then declines (Lackland et al, 1992;
European Journal of Clinical Nutrition

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1164
Seidell & Visscher, 2000). Compared to Western populations,
men as well as women in these three islands of the
Netherlands Antilles remain obese until an older age. It is
alarming that young women (below the age of 25 y) in this
study had a prevalence of 30% for overall obesity.
We observed a higher prevalence of (central) obesity
among women with a lower socio-economic status (SES) as
was also found in Curacao (Grol et al, 1997). Similar inverse
associations between SES and obesitas have been demonstrated for women in most developed societies (Sobal &
Stunkard, 1989; Gutierrez-Fisac et al, 1995; Visscher &
Seidell, 2001). In our study, the association was most clear
for educational level and not as clear for the other SESindicators occupational prestige and income. Higher educated women may have a more favourable attitude towards
being slim. This hypothesis is supported by the fact that
almost half of the women in the highest educational group
participated in regular physical exercise vs 9% of the lower
educational group (data not shown).
For men, we found that those with a high income had
higher prevalence estimates of central obesity (WC). A
positive association between overall obesity and income
was observed in Brazil (Monteiro, 2000). Positive associations
between SES and obesity have been mostly observed in
developing countries (Sobal & Stunkard, 1989). A possible
explanation might be that a high central obesity (ie a big
belly) among men with high prestige is generally accepted in
society, thus showing their affluence. Further research is
needed to identify possible factors, such as social and
cultural perception and the acceptance of obesity, that
explain the observed associations between socio-economic
status and obesity among men and women. A better
understanding of these underlying factors on these islands
is needed to prevent or treat obesity.
In the present study, WC was the strongest independent
obesity indicator associated with self-reported hypertension
and diabetes mellitus. WHR was also positively associated
with these conditions but the strength of the association
with hypertension decreased after adjustment for WC. BMI
was not independently associated with hypertension and
diabetes mellitus. A study by Han et al (1995) showed clear
associations between WC and hypertension and other
cardiovascular risk factors but did not adjust for the overall
body fatness. WC was a better predictor of diabetes mellitus
(NIDDM) compared to BMI and WHR in Mexican Americans
in a prospective study (Wei et al, 1997). A high WC was
associated with a higher prevalence of hypertension among
populations of West African descent in Jamaica, Barbados
and the United States but not in St Lucia. After adjustment
for BMI, the association only remained significant among
women (Okosun et al, 2000). In a large survey (NHANES III)
the same author found that, independently of BMI, a high
WC was associated with hypertension among black Americans (Okosun et al, 2001).
The use of prevalence estimates for hypertension and
diabetes mellitus based on self-report can introduce a bias.
European Journal of Clinical Nutrition

However, these two conditions showed good correlations

when comparing self-report and doctors lists in the Curacao
Health Study (Gerstenbluth et al, 1996). The true prevalence
is probably up to twice as high for diabetes mellitus and
hypertension because a large proportion of these individuals
have not (yet) been diagnosed with this disorder (Gerstenbluth et al, 1995). If differential misclassification may exist,
that is, if obese individuals would be more likely to be
screened for diabetes or hypertension because the GP or
specialist is aware of the existing association with obesity,
the true estimate of the association (odds ratios) would be
slightly weaker.
It is clear that from a practical point of view in large
epidemiological settings, WC compared to BMI and WHR is
the most simple measurement to use as obesity indicator. In
large-scale health studies where limited resources are involved, the WC appears to reveal sufficient information
about overall and central obesity in both this population and
European populations (Lean et al, 1995).
Traditionally, WHR was used as an indicator for abdominal
obesity. Although this indicator reflects central fat distribution, it is not as strongly correlated to visceral fat accumulation among Caucasians and African Americans as is WC
(Conway et al, 1997; Hill et al, 1999; Rankinen et al, 1999). As
a ratio, waist to hip is difficult to interpret biologically
because a change in body adiposity or weight does not
necessarily result in a change of WHR. In addition, ratios
have limitations in statistical modelling since their use can
introduce spurious correlations between the ratios and other
variables (Allison et al, 1995). WC might be used for
screening the population for necessary weight management,
but additional information is needed on the relation
between WC and (total and visceral) body fat in the
Caribbean population under study (Luke et al, 1997;
Deurenberg et al, 1998). Also, further knowledge is needed
about the distribution of risk factors and health outcomes in
subjects who were classified in the false negative group,
that is, those with a high WHR but normal to low BMI or
WC.
In conclusion, the risk groups identified in the population
were women aged 5574 y, women with a low educational
level and men with an intermediate or high income.
Independent of BMI, a high WC was the strongest obesity
indicator associated with a higher prevalence of hypertension and diabetes mellitus. Although further knowledge is
needed before WC can be used as single screening method
for weight management, weight management is definitely
recommended in a population with such high prevalence
estimates of obesity (WHO, 1998).

Acknowledgements
This study is a joint project of the Epidemiology & Research
Unit of the Medical and Public Health Service of Curacao,
the Northern Centre for Health Care Research of the
University of Groningen in the Netherlands, the Foundation

Obesity in the Netherlands Antilles

L Grievink et al

1165
for Promotion of Research and International Cooperation in
Health Care (ISOG) in Curacao, the Island Governments of
Saba, St Eustatius and Bonaire and the Federal Government
of the Netherlands Antilles. The study was co-financed by
the Dutch Directorate for Kingdom relationships. The
authors wish to thank Gabi Fuchs, Wim van den Heuvel
and Eric van Sonderen and for their valuable contributions.

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