European Journal of Clinical Nutrition (2010) 64, 2329

& 2010 Macmillan Publishers Limited All rights reserved 0954-3007/10 $32.00
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REVIEW
The optimal cutoff values and their performance of
waist circumference and waist-to-hip ratio for
diagnosing type II diabetes
Q Qiao1,2 and R Nyamdorj1,2

1
Department of Public Health, University of Helsinki, Helsinki, Finland and 2Department of Chronic Disease Prevention, National
Institute for Health and Welfare, Helsinki, Finland

Studies on the theme of optimal cutoff values of waist circumference (WC) and waist-to-hip ratio (WHR) for assessing risk of type
II diabetes were reviewed. Twenty-eight studies of individuals aged 1874 years are eligible for inclusion. Four of these studies
are prospective and the rest are all cross-sectional. Tongans had the highest WC (103 cm for both men and women) cutoff value
(but not for WHR), followed by studies in the USA and U.K. The WC cutoff values were higher for all races in the USA and the UK
studies compared with their counterparts in their original countries. The optimal WC (WHR) cutoff values were 9799 cm (0.95)
for White men and 85 cm (0.830.85) for White women living outside the USA and the UK, whereas they were 85 cm (0.90) for
Asian men and 7580 cm (0.790.85) for Asian women; the values for other ethnic groups were between those for White and
Asians. Men had higher values than women in White, Chinese, Japanese, Indians and Bangladeshis, but not in Thai, Iranians,
Iraqi, Tunisians, Mexicans, Africans and Tongans. At these optimal cutoff points the sensitivities were around 6070%, which
was higher or equal to the specificity. There is no universal cutoff value that can be applied worldwide, and a country-specific
value should be considered taking into account the purposes and resources.
European Journal of Clinical Nutrition (2010) 64, 2329; doi:10.1038/ejcn.2009.92; published online 19 August 2009

Keywords: waist circumference; BMI; type II diabetes; cutoff values; sensitivity and specificity

Introduction
Obesity, as a major risk factor for type II diabetes, has been
very well documented. Clinical trials have unequivocally
shown that reducing weight and increasing physical activity
can prevent or at least delay the onset of type II diabetes in
individuals with impaired glucose tolerance in many ethnic
groups around the world including Swedish (Eriksson and
Lindgarde, 1991), Chinese (Pan et al., 1997), Finnish
(Tuomilehto et al., 2001), American (Diabetes Prevention
Program Research, 2002), Indians (Ramachandran et al.,
2006) and Japanese (Kosaka et al., 2005). The relative risk
reduction ranged from 28% in Indians to 67% in Japanese.
A sustainable long-term effect of lifestyle intervention 20
years after trial in the Chinese Daqing Study (Li et al., 2008)
Correspondence: Dr Q Qiao, Department of Public Health, University of
Helsinki, PL41, Mannerheimintie 172, FIN-00014 Helsinki, Finland.
E-mail: qing.qiao@ktl.fi
Received 3 February 2009; accepted 29 May 2009; published online 19
August 2009
and 7 years after the trial in the Finnish Diabetes Prevention
Study (Lindstrom et al., 2006) have also been reported, with
an effect size of 43% for both the trials.
The most commonly used anthropometric measurements
for obesity are body mass index (BMI) indicating general
obesity, waist circumference (WC) and waist-to-hip ratio
(WHR) as markers for central obesity. Other indicators such
as hip circumference (Lissner et al., 2001; Snijder et al., 2004),
waist-to-height ratio (Hsieh and Muto, 2005) and waist-to-
stature ratio (Ho et al., 2003) have also been suggested to be
useful markers of obesity. The concept of central obesity was
first introduced by Vague in the 1940s (Vague, 1947) and
later in 1956 he pointed out for the first time that central
obesity (android) was more important than peripheral
obesity (gynaecoid) in relation to diabetes, gout, athero-
sclerosis and urate calculus diseases (Vague, 1956). Since the
1990s interest in WC has increased because it correlates more
closely with the abdominal visceral fat than either WHR or
BMI (Pouliot et al., 1994; Han et al., 1995; Lean et al., 1995).
The association of these obesity indicators with type II
 Waist cutoff for diabetes
Q Qiao and R Nyamdorj
24
diabetes has been studied in different ethnic groups in recent
years with regard to the optimal cutoff values for definition
of obesity. Attempts to identify optimal cutoff values to
assess diabetes risk have come out with different findings.
These findings are reviewed and summarized in this article,
with the aim to answer questions of (1) What is the optimal
WC (WHR) cutoff point for assessing the risk of type II
diabetes? (2) How effective is this cutoff point?
Materials and methods
Inclusion criteria
All publications in English that reported optimal cutoff
values for the WC or the WHR in adults, derived at the point
that maximizes the sum of sensitivity and specificity or
applying other valid methods, were included.
Data sources and limitations
Published articles related to these topics have been
searched in PubMed from 1975 onwards or knowing from
conferences and colleagues etc., have been reviewed by two
independent researchers (RN, QQ). Most of the studies
include individuals aged 1874 years, except for one Chinese
study (Woo et al., 2002). Participants in this Chinese study
were older than 70 years and selected from a list of recipients
of Old Age and Disability Allowance. Compared with
other Chinese studies, the WC was obviously higher whereas
the BMI was lower in this elderly Chinese population.
In different studies waist has been measured in different
anatomic locations, and diabetes defined by either a
previous history of diabetes or based on FPG or FPG plus
2hPGT levels. Most of the studies are population-based with
random sampling approaches and a few are hospital-based
with participants coming for the health check-up as
indicated in Table 1. Twenty-eight studies have tried to
identify optimal cutoff values by selecting the point that
maximizes the sum of sensitivity and specificity. Four of the
28 studies were prospective (Stevens et al., 2001; Sargeant
et al., 2002; Woo et al., 2002; Katzmarzyk et al., 2007), and 24
studies cross-sectional.
Results
To easily compare the similarity and difference between
ethnic groups, findings of different studies have been re-
arranged by putting the results of the same ethnic group
side-by-side (Table 2). Studies with more than one ethnicity
were split according to ethnicity, and those with mixed races
who could not be separated were not included in the Table 2.
The main findings are summarized below:
(1) Except for Tongans who had highest cutoff values for the
BMI and the WC (but not for the WHR), the optimal
European Journal of Clinical Nutrition
cutoff values for the WC were higher for all races in the
USA and in the UK studies compared with their counter-
parts in their original countries (Stevens et al., 2001; Diaz
et al., 2007).
(2) When the two studies from the USA and UK were not
counted in, there were fewer variations for both the WC
and the WHR in White men and women, and in Asian
men as well; the optimal cutoff values for the WC was
9799 cm for White men, 85 cm for White women,
whereas they were 85 cm for Asian men and 7580 cm
for Asian women; the optimal cutoff values for the WC
for other ethnic groups were between those of White and
Asians.
(3) If not including studies from the USA and UK, the
optimal WHR cutoff values were 0.95 for White men and
0.90 for Asian men, 0.830.85 for White women and
0.790.85 for Asian women; the values for the other
ethnic groups were between the two.
(4) The optimal cutoff values for the WC and the WHR
were higher in men than in women in White,
Chinese, Japanese, Indians and Bangladesh; but the
WC was similar to or even lower in men than in
women in Pakistani living in the USA and the UK, Thai,
Iranians, Iraqi, Tunisians, Mexicans, Africans and
Tongans.
(5) For men the optimal cutoff values were about 10 cm
higher in White than in Asians for the WC and 0.020.03
higher for the WHR; but the difference for women was
not as striking as that for men.
(6) At the optimal cutoff values the sensitivity was higher
than or equal to the specificity, with the lowest
sensitivity of 47% for the WC and 57% for the WHR in
Mexican men; for most of the studies the sensitivities
were around 6070%.
Conclusions
In the literature almost all studies have applied the
sensitivity and specificity approach to determine the
optimal cutoff values for assessing type II diabetes risk. The
cutoff values selected using such an approach are all
arbitrary, because they are based purely on the analyzing
trade-off between sensitivity and specificity. To increase the
sensitivity, it will reduce the specificity and vice versa. We
may hope to have a high sensitivity for the WC measure-
ment in the health promotion to increase public awareness
of obesity and diabetes, but a high specificity for an
individual diagnosis is expected in clinical practice. How-
ever, whether the WC measurement can be applied, as a first-
step diagnostic tool for assessing an individuals diabetes risk
is still unknown and need to be further investigated based
on the well designed prospective studies with incidence of
diabetes as an outcome. As the majority of the studies in the
literature were cross-sectional, the evidence obtained based
on these studies is less confirmative because they might
 Waist cutoff for diabetes
Q Qiao and R Nyamdorj
25
Table 1 Optimal waist circumference (WC, cm) and WHR cutoff values for assessing risk of type II diabetes (DM)

Ethnicity (country) Optimal cutoffs, sensitivity and specificity (%) Comments

Men Women

BMI WC WHR BMI WC WHR

(kg/m2) (cm) (kg/m2) (cm)

Mixed Canadian 25.6 85.5 0.85 25.6 85.5 0.85 Random household, n 1543, 1869 years;
(Canada) 66 and 66 67 and 67 63 and 63 66 and 66 67 and 67 63 and 63 incidence of diagnosed DM , follow-up
16 years; lowest floating rib
Katzmarzyk et al. (2007)

White (France) 27 97 0.95 25 85 0.83 Random sample, n 3576, 4064 years;

77 and 69 72 and 74 77 and 65 86 and 63 77 and 74 77 and 70 Screened DM (FPGX7.0 mmol/l); WC measure
not available; (DESIR) Balkau et al. (2006)

White (majority) X28.0 X103 X0.97 X27.8 X94.0 X0.87 Primary care-based, n 5377, X18 years;
(Germany) 64 and 64 65 and 64 58 and 60 68 and 68 68 and 67 58 and 63 physicians diagnosis of DM; midway between
the lowest rib and pelvis
Schneider 2007 (DETECT) (Schneider et al., 2007)

Chinese (Mainland 24.0 85 24.0 80 Random sample, n 80 000, meta-analysis;

China and Taiwan) 58 and 59 50 and 66 61 and 58 58 and 66 FPGX7.0 mmol/l; WC measure is NA
Zhou, (2002) (Working Group on Obesity in China)

Chinese (Taiwan) 24.5 84.5 0.88 23.4 74.5 0.79 From four nationwide health screening centers,
66 and 66 97 and 70 71 and 71 75 and 75 78 and 77 79 and 79 n 55 563, mean 37 years; FPG X7.0 mmol/l;
midway between the lowest rib and the
crest of the ilium; Lin et al. (2002)

Chinese 24.3 84.0 0.91 24.3 78.4 0.83 Occupational study n 1513; FPG X7.8/2hPG
(Hong Kong- 67 and 66 67 and 67 76 and 76 67 and 66 70 and 70 71 and 70 X11.1 mmol/l; at minimum circumference
working age) between the umbilicus and xiphoid process;
Ko et al. (1999)

Chinese 22.3 88.2 0.97 18.4 85.3 0.83 From recipients of old age and disability allowance,
(Hong Kong) 89 and 56 78 and 67 39 and 85 100 and 15 58 and 55 96 and 18 n 2032, X70 years; incidence of diagnosed
DM, Fu 3 years; Between umbilicus and
xiphoid process; Woo et al. (2002)

Chinese 24.4 83.9 0.92 23.3 78.0 0.83 Random sample n 2895, 2574 years;
(Hong Kong) 71 and 56 76 and 58 64 and 76 81 and 52 75 and 69 78 and 73 FPG X7.0/2hPGX11.1/self-reported DM;
midway between xiphisternum and umbilicus;
Ho et al. (2003)

Chinese 24 85 24 80 Random sample, n 13 817, X18 years;

(Shanghai) 66 and 50 59 and 58 62 and 54 65 and 62 FPGX7.0 mmol/l/diagnosed DM;
1 cm above navel; Li et al. (2008)

Chinese, Malays, 23.2 79.5 0.82 Employees of a hospital, n 566 females,

Indian (Singapore) 96 and 57 89 and 74 71 and 79 1868 years; FPGX7.0 mmol/l; midway
between the lowest rib and the crest of the
ilium; Pua and Ong (2005)

Indian (India) 23 85 0.92 23 80 0.85 Population-based, n 10 025, X20 years; FPG

67 and 63 64 and 67 61 and 66 67 and 53 70 and 56 66 and 54 X7.0/2hPGX11.1 mmol/l; The smallest girth
between the coastal margin and iliac crests
Snehalatha et al. (2003) (NUDS)

Indian (India) 22 87 23 83 Random sample, n 4950; X20 years; 2hPG

78 and 48 69 and 58 72 and 54 65 and 60 X11.1 mmol/l/self-report of DM under treatment
by the physician; At the smallest girth between
the costal margin and the iliac crests;
Mohan et al. (2007)

European Journal of Clinical Nutrition

 Waist cutoff for diabetes
Q Qiao and R Nyamdorj
26
Table 1 Continued

Ethnicity (country) Optimal cutoffs, sensitivity and specificity (%) Comments

Men Women

BMI WC WHR BMI WC WHR

(kg/m2) (cm) (kg/m2) (cm)

Japanese (Japan) 23.6 85 0.92 23.1 73 0.81 Check-up, n 2728, 2079 years;
59 and 59 62 and 62 71 and 71 67 and 67 70 and 70 78 and 78 FPGX7.0/HbA1c X6.5%/treatment; NA;
Ito et al. (2003)

Thai (Thailand) 23 85 0.91 25 85 0.88 Random sample, n 5305, X35 years;

FPGX7.0 mmol/l/ diagnosed DM; 1 cm above
navel; Aekplakorn et al. (2006) (InterAisa Study)

Iranian (Iran) Random sample, n 10 522, 1874 years;

FPGX7.0 mmol/l; narrowest level;
Mirmiran et al. (2004) (TLGS)
1834 years 25.0 86 0.88 25.5 82.0 0.82
3554 years 27.0 91 0.94 29.0 93.0 0.87
5574 years 26.0 92 0.96 28.0 95.0 0.91

Iranian women (Iran)a Random sample as above, n 5073,

1874 years; FPGX7.0/2hPGX11.1 mmol/l;
narrowest level; Esmaillzadeh et al. (2006) (TLGS)
1839 years X25 X80 X0.80
84 and 51 90 and 58 86 and 53
4074 years X25 X80 X0.80
82 and 25 97 and 33 90 and 18

All participants X25 X80 X0.80

83 and 40 94 and 47 89 and 39

Tongan (Kingdom 31.7 102.9 0.93 35 102.8 0.86 Random sample, n 767; 2hPG X11.1 mmol/l
of Tonga) 66 and 68 63 and 64 69 and 71 62 and 61 65 and 63 69 and 71 with elevated HbA1c/2hPG X11.1 alone;
at midpoint between the ribs and the iliac crest;
Craig et al. (2007)

Iraqi (Iraq) 25.4 90 0.92 26 91 0.91 Community-based, n 12 986, mean 45 years;

66 and 54 80 and 49 77 and 61 66 and 47 80 and 47 72 and 63 FPGX7.0/diagnosed DM; at umbilicus
Mansour and Al-Jazairi (2007)

Turkish (Turkey) X95 X91 Random sample, n 1682 women and n 1638
70 and 53 75 and 55 men, 2879 years; incidence DM, Fu 7.0 years,
FPGX7.0/2 h PG X11.1 mmol/l/self-report; At
midway between the lower rib margin and the
iliac crest; Onat et al. (2007a, b) (TARFS)

Jamaican 24.8 88.0 0.87 29.3 84.5 0.90 Random sample, n 728, 2574 years,
(African ancestry) 71 and 71 71 and 79 Similar 62 and 65 62 and 65 Similar incidence of DM, Fu 4 years, FPGX7.0/2 h PG
(Jamaica) X11.1 mmol/l; at smallest horizontal
circumference between the ribs and
the iliac crest; Sargeant et al. (2002)

Brazilian (Brazil) 88 84 Random family clusters, n 1439, X20 years

69 and 68 67 and 66 (mean 40); FPGX7.0 mmol/l /diagnosed DM;
Barbosa et al. (2006)

Mexican (Mexico) 25.3 90 0.90 25.4 85 0.86 Hospital workers (check-up), n 8365, X20
57 both 47 both 57 both 55 Both 53 both 62 both years (mean 39); FPGX7.0/2 h PG X11.1 mmol/l;
Berber et al. (2001)

Mexican (Mexico) 27 95 28 97 Random sample, n 38 377, 2069 years; random

56 and 56 60 and 60 59 and 59 65 and 65 glucose X11.1 mmol/l symptoms; middle point
between iliac crest and the lowest part of the
costal margin at the mid-axillary line;
Sanchez-Castillo et al. (2003)

European Journal of Clinical Nutrition

 Waist cutoff for diabetes
Q Qiao and R Nyamdorj
27
Table 1 Continued

Ethnicity (country) Optimal cutoffs, sensitivity and specificity (%) Comments

Men Women

BMI WC WHR BMI WC WHR

(kg/m2) (cm) (kg/m2) (cm)

Guadeloupean (Guadeloupe) (African descent) Health center check-ups, n 5149; 1874 years
(mean 40); FPGX7.0/drug use; above the iliac
crests and below the lowest rib margin;
Foucan et al. (2002)
1839 years 26.0 85.0
83 and 69 84 and 78
4074 years 27.0 88.0
62 and 52 70 and 60
1874 years 27.0 89.0
70 and 54 70 and 60

Tunisian 85 85 Random sample (district and household),

(Tunisia) 71 and 63 76 and 67 n 3435, X20 years; FPGX7.0 mmol/l/drug use;
At midway between the lower rib margin and
the iliac crest; Bouguerra et al. (2007)

Biracial n 12 814, 4564 years; incidence of DM,

Cohort (USA) Fu 8.1 years, FPGX7.0/random glucose
X11.1 mmol/l/treated DM; at the umbilicus;
Stevens et al. (2001) (ARIC)
African American 28 99 0.94 30 101 0.92
61 and 68 61 and 71 62 and 60 63 and 60 62 and 68 61 and 66
White American 28 101 0.97 27 95 0.91
60 and 70 61 and 67 69 and 58 65 and 69 67 and 68 69 and 64

Multi-ethnics from 10 countries Random sample, n 155 122; FPGX7.0;

WC measurement is NA; OAC 2007
(Huxley et al., 2007)
Asian 23.7 85 0.92 24.5 82 0.82
61 and 60 65 and 61 69 and 58 55 and 66 60 and 67 58 and 67
Caucasian 27.7 99 0.94 27.9 85 0.85
(Australia) 68 and 62 62 and 60 66 and 62 67 and 66 84 and 64 78 and 69

Multi-ethnics (USA and England) Random sample, n 11 624, X20 years;

self-reported DM/HbA1c46.1%; WC
measurement is not available Diaz et al. (2007)
(NHANES0304 and HSE)
Bangladeshi 61 24 96 27 88
Chinese 104 25 95 24 84
Indian 337 27 97 25 89
Pakistan 134 25 93 30 101
Black English 279 29 100 28 88
Black US 491 32 109 28 105
Mexican American 517 28 100 30 104
White English 4488 28 103 27 91
White US 1486 30 106 28 96

Multi-ethnics from16 countries n 263 000, 3755 years; FPGX

7.0 mmol/l Huxley et al. (2008) (OAC)
Asians 24 85 0.90 25 80 0.82
White (Australia) 28 99 0.94 28 85 0.85
a
Not the optimal cutoff values.

have been confounded by other concurrent condi- universal optimal cutoff value that can be applied world-
tions such as hypertension and dyslipidemia, etc. Never- wide. A country- or region-specific cutoff value should
theless, the literature review shows that the optimal cutoff be considered taking into account the purposes and the
values vary across different ethnicities, and there is no resources.

European Journal of Clinical Nutrition

 Waist cutoff for diabetes
Q Qiao and R Nyamdorj
28
Table 2 Optimal cutoff values of waist circumference (WC, cm) and waist-to-hip ratio (WHR) for assessing risk of type II diabetes, and their
corresponding sensitivity (Sen) and specificity (Spe) by combining the same race of different studies side-by-side (not including those studies with mixed
races)

Ethnicity (country) Men Women

WC (cm) WHR WC (cm) WHR

Cutoff Sen Spe Cutoff Sen Spe Cutoff Sen Spe Cutoff Sen Spe

White (others) 9799 72 74 0.95 77 65 85 77 74 0.830.85 77 70

White (USA, UK) 1016 61 67 0.97 69 58 95 67 68 0.91 69 64
Turkish (Turkey) 95 70 53 91 75 55
Chinese 85 5097 5870 0.880.92 6476 7176 7580 5878 6677 0.790.83 7179 7079
Chinese (USA UK) 95 84
Indian (India) 8587 6469 5867 0.92 61 66 8083 6570 5660 0.85 66 54
Indian (USA UK) 97 89
Bangladeshi (USA UK) 96 88
Pakistani (USA UK) 93 101
Japanese (Japan) 85 62 62 0.92 71 71 73 70 70 0.81 78 78
Thai (Thailand) 85 0.91 85 0.88

Iranian (Iran)
1834 years 86 0.88 82 0.82
3554 years 91 0.94 93 0.87
5574 years 92 0.96 95 0.91

Iraqi (Iraq) 90 80 49 0.92 77 61 91 80 47 0.91 72 63

Tunisian (Tunisia) 85 71 63 85 76 67
Tongan (Tonga) 103 63 64 0.93 69 71 103 65 63 0.86 69 71
Brazilian (Brazil) 88 69 68 84 67 66
Mexican (Mexico) 9095 47 47 0.90 57 57 8597 53 53 0.86 62 62
Mexican (USA UK) 100 104
African (USA) 99 61 71 0.94 62 60 101 62 68 0.92 61 66
African 88 71 79 0.87 8589 62 65 0.90
Black (USA UK) 109100 10588

Conflict of interest Berber A, Gomez-Santos R, Fanghanel G, Sanchez-Reyes L (2001).

The authors declare no conflict of interest.
Acknowledgements
The earlier version of the paper was prepared as a back-
ground paper for the WHO Expert Consultation on waist
circumference and waist-hip-ratio (Geneva, 811 December
2008). We owe our sincere thanks to all experts who gave
comments to improve the paper. The work has been
financially supported by the Academy Finland (118492).
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