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Original article

Predictive performance of obesity indexes for the risk of high blood

pressure in an adult population
Performance prédictive des indices d’obésité pour le risque d’hypertension
artérielle dans une population de sujets adultes
Sanaz Tahmasebi a,b , Leila Nikniaz c,∗ , Reza Mahdavi b
a
Student Research Committee, Tabriz University of Medical Science, Tabriz, Iran
b
Nutrition Research Center, Department of Biochemistry and Diet Therapy, Faculty of Nutrition and Food Science, Tabriz University of Medical Sciences,
Tabriz, Iran
c
Tabriz Health services management research center, Tabriz University of Medical Sciences, Tabriz, Iran

a r t i c l e i n f o a b s t r a c t

Article history: Background and objectives. – Comparisons of predictive performance of various anthropometric measures
Received 10 June 2018 in high blood pressure have not been investigated. This study aimed at evaluating and comparing the
Received in revised form 8 September 2018 predictive power of Body Mass Index (BMI), Body Adiposity index (BAI) and A Body Shape Index (ABSI)
Accepted 12 September 2018
for predicting hypertension in adults.
Available online xxx
Methods. – The data of 277 subjects (109 men and 168 women) as a part of the major Lifestyle Promotion
Project (LPP) conducted in the districts of Tabriz-East Azerbaijan-Iran were collected for this study. The
Keywords:
weight, height, waist and hip circumferences were measured and BMI, BAI and ABSI were calculated. Blood
Obesity
Blood pressure
pressure was measured twice, after 5 minutes of rest. The ANOVA and Receiver Operating Characteristic
Body Mass Index (ROC) were used for statistical analysis.
A Body Shape Index Results. – In all subjects, BMI (area under the curve (AUC): 0.65) predicted systolic blood pressure equally
Body Adiposity Index (P < 0.05). None of them had a significant prediction for diastolic blood pressure. By gender, considering
P-value (P < 0.05), BMI predicted systolic in men (AUC: 0.71) and women (AUC: 0.61) and diastolic blood
pressure only in men (AUC: 0.79). In addition systolic blood pressure in women was predicted by both
BAI (AUC: 0.66) and ABSI (AUC: 0.67). Furthermore, BAI (AUC: 0.82) predicted diastolic blood pressure in
men.
Conclusion. – Although it was claimed that ABSI and BAI as the indexes of high waist circumference and
body fat percent respectively, express the excess risk, based on our results, they are not better alternative
than BMI in the clinical evaluation for screening for high blood pressure.
© 2018 Published by Elsevier Masson SAS on behalf of Association pour le développement de la
recherche en nutrition (ADREN).

r é s u m é

Mots clés : Introduction et objectifs. – Les performances prédictives de divers index anthropométriques liés à la masse
Obésité grasse concernant l’hypertension n’ont pas été comparées. L’étude avait pour objectif d’évaluer et de
Tension artérielle comparer la capacité de l’indice de masse corporelle (IMC), l’indice d’adiposité corporelle (IAC) et l’indice
Indice de masse corporelle de forme du corps (IFC) à prédire la présence d’une hypertension chez l’adulte.
Un indice de forme corporelle
Méthodes. – Les données de 277 sujets (109 hommes et 168 femmes) ont été collectées. Les sujets ont
L’indice de l’adiposité
été recrutés dans le cadre du Projet Majeur de Promotion du Mode de Vie mené dans les districts de
Tabriz-est (Azerbaïdjan-Iran). Le poids, la taille, le tour de taille et le tour de hanche ont été mesurés,
et l’IMC, l’IAC et l’IFC ont été calculés. La pression artérielle a été mesurée deux fois, après 5 minutes de
repos. Le test ANOVA et les courbes ROC ont été utilisés du point de vue statistique.

∗ Corresponding author. Tabriz Health Services Management Research Center, Tabriz University of Medical sciences, 0098 Tabriz, Iran.
E-mail addresses: nu sa tahmasebi@yahoo.com (S. Tahmasebi), nikniazleila@gmail.com (L. Nikniaz), mahdavir@tbzmed.ac.ir (R. Mahdavi).

https://doi.org/10.1016/j.nupar.2018.09.003
0985-0562/© 2018 Published by Elsevier Masson SAS on behalf of Association pour le développement de la recherche en nutrition (ADREN).

Please cite this article in press as: Tahmasebi S, et al. Predictive performance of obesity indexes for the risk of high blood pressure in an
adult population. Nutr clin métab (2018), https://doi.org/10.1016/j.nupar.2018.09.003
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Résultats. – L’IMC (Aire sous la courbe (ASC) : 0,65), l’IAC (ASC : 0,68) et l’IFC (ASC : 0,65) ont prédit de
manière très proche la pression artérielle systolique (p < 0,05 dans tous les cas). Aucun des index n’a prédit
la pression artérielle diastolique de manière significative. L’IMC a prédit la pression artérielle systolique
chez les hommes (ASC : 0,71) et les femmes (ASC : 0,61) et la pression artérielle diastolique uniquement
chez les hommes (ASC : 0,79). En outre, la pression artérielle systolique chez les femmes a été prédite à
la fois par l’IAC (ASC : 0,66) et l’IFC (ASC : 0,67), et l’IAC a prédit la pression artérielle diastolique chez les
hommes (AUC : 0,82).
Conclusion. – L’IAC et l’IFC ne semblent pas être des index de dépistage de l’hypertension artérielle
supérieurs à l’IMC.
© 2018 Publié par Elsevier Masson SAS au nom de Association pour le développement de la recherche en
nutrition (ADREN).

1. Introduction 2. Methods

The prevalence of hypertension, as one of the main causes of
cardiovascular disease, is increasing worldwide and it is expected
that about 30% of people will have high blood pressure in 2025.
Hence, the health economic burden will be inevitable in both devel-
oped and developing countries [1]. In previous studies, overweight
and obesity, especially with increased visceral adiposity, has been
introduced as a main cause of high blood pressure, which account-
ing for 65% to 75% of the risk [2]. Since, consideration of the first
level of health care and screening techniques is very valuable,
there is a special focus on methods that can identify people at
risk [3].
To screen metabolic disease, Body Mass Index (BMI) is widely
used as a measure of obesity in studies and clinical settings;
however, its validity remains questionable [4]. As an important
limitation, BMI cannot differentiate between fat mass and fat free
mass, and cannot indicate body fat distribution [5]. Furthermore,
its accuracy in categorizing overweight and obesity has not been
confirmed in different gender, race, and ages [5,6].
Considering the limitation of BMI, many studies have been
conducted to improve anthropometric measurements for the diag-
nosis of obesity and adipose tissue distribution, with the aim of
exploring better screening indexes for chronic disease such as
hypertension. In 2011, Body Adiposity Index (BAI) was suggested
by Bergman et al. as an index for estimating the percentage of
body fat [7]. It has been reported that BAI provides an acceptable
estimate of body fat percentage in comparison with dual-energy
X-ray absorption (DXA), as the standard fat estimation method
[7].
In addition, A Body Shape Index (ABSI), was proposed in 2012 by
Krakauer and Krakauer for predicting of morbidity [8]. It is claimed
that ABSI, which is obtained through improving the waist circum-
ference (WC) scale using allometric analysis, represents central
body fat. So, it can perform better in predicting metabolic diseases
[8].
Several studies have examined BAI and ABSI as indexes of obe-
sity and risk factors for diseases [9–13]. However, to date, the
exact relationship between obesity, abdominal obesity and their
indicators with the risk of metabolic diseases is uncertain. Finding
this relationship can be helpful in developing health policy for the
screening of metabolic diseases for those at risk.
To the best of our knowledge, the comparison of predictive
power of BAI, and ABSI as indicators of obesity and abdominal
obesity has not been reported in identifying the risk of metabolic
diseases, including high blood pressure. Therefore, the purpose of
this study was to compare the prediction performance of various
anthropometric measures (BMI, ABSI, and BAI) in predicting hyper-
tension, in order to find out appropriate screening index at the first
level of community health care in an adult population in Tabriz-
Iran.
From the previous study entitled “Lifestyle survey of East Azer-
baijanis” 277 participants including 109 men and 168 women aged
18 to 50 were eligible according our inclusion criteria. Details of the
study design and characteristics of the study have been previously
reported [14]. (IR.TBZMED.REC.1396.614) Subjects were relatively
educated with middle-to-upper socioeconomic status and from
Tabriz city. Adults with severe chronic illness requiring bed rest,
physical disability, mental disability and the presence of commu-
nication barriers, pregnant or postmenopausal women, smokers,
professional athletes, and people taking routine medications were
excluded from this study.
Weight of the subjects with the minimum of clothing was mea-
sured using the Seca calibrated scale (made in Germany) with a
precision of 100 grams. Height was measured using a standard sta-
diometer with a precision of 2 millimeter in a non-shoe standing
position, with legs sticking and the heels, buttocks, shoulders, and
posters with tangent to the wall. The waist circumference (WC) was
measured twice from the midpoint of the thoracic lowest point and
the iliac ridge with a precision of 0.5 centimeters. To determine the
hip circumference, the most prominent posterior part at the level
of the greater trochanter was measured in duplicate. BMI, BAI, and
ABSI were then calculated using the appropriate formulas [7,8,15].
Weight (kg)
BMI =
Height 2 (m)
Hip (cm)
BAI = − 18
Height(m)1.5
WC (kg)
ABSI =  
BMI 2/3 ∗ height 1/2(m)
Subjects were classified using BMI as normal weight (18.5–24.9),
overweight (25.0–29.9), and obese (> 30.0) (26). BAI and ABSI were
divided to the equal tertile groups.
Blood pressure was measured by trained staff using a mer-
cury sphygmomanometer (Richter, Germany) after 5 minutes of
rest, twice in the same day with a 3 minute interval. If the dias-
tolic blood pressure difference was greater than 5 mm Hg or the
difference in systolic blood pressure was greater than 10 mmHg,
the blood pressure was measured for the third time and the two
readings with minimal difference were recorded and the mean of
measurements was taken as a person’s blood pressure [16]. Systolic
blood pressure ≥ 140 and/or diastolic blood pressure ≥ 90 mmHg
was considered as high blood pressure [17].

Please cite this article in press as: Tahmasebi S, et al. Predictive performance of obesity indexes for the risk of high blood pressure in an
adult population. Nutr clin métab (2018), https://doi.org/10.1016/j.nupar.2018.09.003
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Table 1
Anthropometric characteristics and blood pressure status of the participants in the study (n = 277).

Variables Total (n = 277)Mean ± SD Men (n = 109)Mean ± SD Women (n = 168)Mean ± SD P*

Weight (kg) 73.7 ± 13.8 78.5 ± 12.8 70.3 ± 13.4 0.001

Height (cm) 163 ± 12 170 ± 16 158 ± 5 0.001
Waist (cm) 92.1 ± 0.1 94.2 ± 14.2 90.6 ± 12.6 0.03
Hip circumference (cm) 104.7 ± 11.1 102.5 ± 9.7 106.2 ± 11.7 0.007
BMI (kg/m2 ) 27.3 ± 4.6 26.5 ± 4.5 27.8 ± 4.7 0.02
ABSI 0.079 ± 0.006 0.08 ± 0.006 0.07 ± 0.007 0.006
BAI 32.3 ± 6.6 28.3 ± 5.8 34.9 ± 5.7 0.001
Systolic BP (mmHg) 117.3 ± 16.8 116.6 ± 17.3 116.6 ± 15.9 0.86
Diastolic BP (mmHg) 77.5 ± 11.8 77.4 ± 12.1 77.4 ± 11.7 0.78

BMI: Body Mass Index; ABSI: A Body Shape Index; BAI: Body Adiposity Index; BP: Blood pressure.
*
Independent sample t-test.

3. Statistical analysis
All statistical analyses were carried out using the SPSS version
18. The data was tested by Kolmogorov Smirnov test for their nor-
mal distribution. Results were expressed in terms of mean and
standard deviation and, if needed, expressed as a percentage. The
one-way analysis of variance (ANOVA) with Tukey post hoc com-
parisons was used for between group analyses. The comparison
between men and women was performed using the Independent
T-test. Receiver operating characteristic (ROC) were used to calcu-
late the area under the curve (AUC) between blood pressure and
obesity indexes. The area under the ROC curve demonstrated the
discriminatory power of a diagnostic test and can be used statisti-
cally to compare the discriminating ability between two diagnostic
tests, with value between 0 and 1.
4. Results
Table 1 shows anthropometric characteristics and blood pres-
sure status in participant. As shown, men had higher ABSI, while
BMI and BAI were higher in women. There was a statistically sig-
nificant difference between men and women in weight, height,
waist and hip circumference, BMI, BAI and ABSI. According to
BMI category, 40.0%, 39.0% and 18.5% of men were in the normal
weight range, overweight and obese respectively, whereas, 28.0% of
women were in the normal weight range, 42.3% were overweight,
and 27.4% were obese. On the base of ABSI results, in men and
women, 4.2% and 1.3% were in the first, 9.3% and 5.4% were in
the second, and 7.8% and 4.3% in the third tertile respectively. As
well, 52.0%, 31.0% and 14.0% of men and 5.1%, 7.3% and 50.0% of
women were in the first, second and third tertile of BAI respec-
tively. Systolic and diastolic blood pressure were high in 12.7%
(10.1% in men and 14.9% in women) and 8.6% (4.6% in men and
7.9% in women) of participants respectively. There were no signif-
icant differences in systolic and diastolic blood pressure between
men and women.
Table 2 shows the mean systolic and diastolic blood pressures
in different BMIs and tertiles of BAI and ABSI. Results indicated that
overall there is a correlation between BMI and hypertension. Those
who were in the obese group, in men and women, had higher blood
pressure. This association was not observed in diastolic blood pres-
sure in women. Furthermore, subjects who categorized in the third
tertile of BAI had significantly higher systolic blood pressure than
the first tertile. In addition, in all individuals and men, diastolic
blood pressure of subjects in the second tertile of BAI was signif-
icantly higher than first tertile. Only the women who were in the
third tertile of ABSI had a higher systolic blood pressure than the
first tertile. No other significant difference was observed in blood
pressure in different groups of each index.
The predictive validity was analyzed by Receiver Operating
Characteristic (ROC) curves. Table 3 presents the results of the
statistical analysis and the comparison of the predictive power of
obesity indexes for systolic and diastolic hypertension. Generally in
the participants, all three prediction indexes significantly predicted
systolic blood pressure with AUCs values of 0.65, 0.65, and 0.68 for
BMI, ABSI and BAI respectively (P < 0.05). With gender point of view,
only BMI was a significant predictor in men (P = 0.020; AUC = 0.71)
while ABSI and BAI (P = 0.006; AUC = 0.67 and P = 0.009; AUC = 0.66

Table 2
Mean blood pressure in different group of BMI, BAI, and ABSI.

Variables Blood pressure (mmHg)

Total (n = 277) Men (n = 109) Women (n = 168)

Systolic Diastolic Systolic Diastolic Systolic Diastolic

BMI
18.5–24.9 112.6A 75.2A 112.0A 73.8A 113.6A 76.5
25–29.9 115.6B 77.3 115.3 78.0 115.8B 76.9
≥ 30 125.2AB 81.1A 129.0A 84.0A 123.5AB 79.8
P* 0.01 0.01 0.01 0.01 0.01 0.30
BAI
First tertile (20.0–28.7) 113.8A 74.6A 113.9 74.2A 113.9 75.7
Second tertile (28.7–34.8) 117.7 77.7A 119.3 81.6A 116.9 78.7
Third tertile (34.9–47.0) 120.1A 80.6 121.9 82.1 119.6 79.9
*
P 0.04 0.01 0.10 0.01 0.20 0.20
ABSI
First tertile (0.063–0.076) 115.6 75.4 118.5 76.5 114.5A 75.0
Second tertile (0.077–0.081) 116.4 78.0 114.5 77.2 117.6 78.5
Third tertile (0.82–0.095) 119.7 79.0 117.3 78.2 122.0A 79.9
P* 0.20 0.10 0.60 0.80 0.04 0.06

BMI: Body Mass Index; ABSI: A Body Shape Index; BAI: Body Adiposity Index; BP: Blood pressure.
*
One-way ANOVA; same capital letters are statistically different among the each tertile groups by the Tukey test (P < 0.05).

Please cite this article in press as: Tahmasebi S, et al. Predictive performance of obesity indexes for the risk of high blood pressure in an
adult population. Nutr clin métab (2018), https://doi.org/10.1016/j.nupar.2018.09.003
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Table 3
Comparison of BMI, BAI and ABSI as blood pressure predictor.
Variables Total (n = 277)
AUC (95%CI) P value
BMI
Systolic BP 0.65 (0.55–0.75) 0.004
Diastolic BP 0.61 (0.48–0.75) 0.100
BAI
Systolic BP 0.68 (0.59–0.77) 0.001
Diastolic BP 0.63 (0.52–0.75) 0.600
ABSI
Systolic BP 0.65 (0.54–0.76) 0.004
Diastolic BP 0.55 (0.41–0.70) 0.400
BMI: Body Mass Index; ABSI: A Body Shape Index; BAI: Body Adiposity Index; AUC: area under curve; BP: Blood pressure.
respectively) were significantly predicted systolic blood pressure
in women. In the evaluation of indicators as a predictor of diastolic
blood pressure, no significant correlation was observed in all sub-
jects and women. Only BMI and BAI had significant AUC in men
(P = 0.020; AUC = 0.79 and P = 0.010; AUC = 0.82 respectively).
5. Discussion
Obesity is considered to be one of the hypertension risk fac-
tors [3]. Many studies have shown the association between body
adiposity and the risk of high blood pressure [18]. However, the
association of whole body fat and the distribution of body fat as a
risk factor for hypertension have not been clearly reported [19].
BAI and ABSI have recently been introduced as the estimation
of the body fat percent and abdominal fat respectively [7,8]. In this
study, for the first time, we examined and compared the power of
these indexes, as well as BMI, in predicting high blood pressure.
According to our results, similar to other studies, there were cor-
relations between obesity indexes and high blood pressure. This
correlation in BMI was better than the other two indicators. In
addition, BAI had a better correlation than ABSI in all individuals
and men, while ABSI was better in women. These results highlight
the importance of overweight and obesity as a risk for high blood
pressure, and confirm the results of previous studies which have
showed this correlation, and express the importance of focusing
on weight loss to reduce risk [20]. However, to predict the risk of
developing hypertension according obesity, in this study, different
indicators of obesity were examined more closely.
Based on ROC analysis results, in general, all three indicators
predicted the high blood pressure. The results of this study indi-
cated that both systolic and diastolic pressures are related to BMI,
BAI and ABSI in the participants, however, all predictions were
relatively weak and nearly identical.
BMI predicted systolic blood pressure which was relatively
strong in men while its prediction performance in all participants
and women were negligible. As well, diastolic blood pressure was
strongly predicted by BMI in men. BAI could predict systolic blood
pressure in all participants and women, as well diastolic blood pres-
sure in men. It is noteworthy that all of them were not strong and
could be ignored. ABSI had a poor predictor of systolic blood pres-
sure of all participants and women, with no significant prediction
of diastolic blood.
The results couldn’t determine any anthropometric measure as
the strong predictor of hypertension risks. Similar to the previous
studies in Iran, BMI did not completely succeed in predicting blood
pressure in our study [21,22]. This could refer to the fact that the
central distribution of fat plays a more important role in the devel-
opment of diseases [23]. As BMI cannot reveal the fat distribution, it
has a weak performance in predicting blood pressure [24]. This is in
contrast to studies that have identified BMI as an acceptable indica-
tor of blood pressure diagnosis [25]. From this perspective, genetic
Please cite this article in press as: Tahmasebi S, et al. Predictive performance of obesity indexes for the risk of high blood pressure in an
adult population. Nutr clin métab (2018), https://doi.org/10.1016/j.nupar.2018.09.003
Men (n = 109) Women (n = 168)
AUC (95%CI) P value AUC (95%CI) P value
0.71 (0.55–0.87) 0.020 0.61 (0.48–0.74) 0.070
0.79 (0.66–0.93) 0.020 0.52 (0.35–0.70) 0.700
0.69 (0.53–0.84) 0.400 0.66 (0.56–0.77) 0.009
0.82 (0.72–0.93) 0.010 0.55 (0.35–0.68) 0.800
0.67 (0.47–0.87) 0.600 0.67 (0.55–0.79) 0.006
0.52 (0.24–0.80) 0.400 0.60 (0.44–0.76) 0.200
variations which affect weight and height, and consequently BMI,
can be one of the causes which have led to different results. Local-
ization of BMIs cut Offs may have advantageous to develop its
performance [26].
Interestingly, our results showed that the new indicators did
not have any advantage over BMI. Although it is claimed that these
indexes were able to predict mortality and morbidity regardless of
gender [7,8], similar to previous study [27], they had a different
function for predicting blood pressure in men and women in our
study. This may be due to the difference in height, waist circum-
ference and hip circumference in women and men which suggests
the need for using different indicators. Women usually have lower
height and waist circumference, and higher hip circumference,
and this directly affects the index if did not consider these dif-
ferences. Further investigations can be made to apply a correction
value.
Moreover, considering that the means of ABSI and BAI in our
study were less than that of Krakauer and Krakauer, and Bergman
et al. [7,8], it seems that the genetic differences between the study
populations could affect results. As well, since previous studies in
Iran have found good correlation between WC and hip circum-
ference with metabolic risk factors [21,22], absence of WC in BAI
and hip in ABSI could consider as a limitation for comparing the
predictive value of different formulas.
Although we tried to control factors that affect blood pressure,
such as exercise, menopause, and smoking, nevertheless, it should
be noted that metabolic diseases are a multifactorial, and individ-
ual’s life condition during years can affect them [28]. So, attention to
a single condition such as obesity may not be sufficient. Therefore,
it seems that paying attention to a life conditions such as subject’s
nutritional and medical history and personalizing evaluations will
be more beneficial than using an obesity factors.
This study has some strength. None of the measurements were
self-reporting and confounding factors such as smoking, alcoholic
beverages, physical activity, and menopause were considered to
make the results more reliable. The main limitation of this study
was the low sample size. In addition, it should be noted that,
metabolic diseases are multifactorial and effects of genetic and
epigenetic alterations on obesity and the chronic diseases is very
significant [29]. So, the result of studies that consider these factors
will be more credible.
6. Conclusion
In the base of our finding, BAI and ABSI are not better alternative
than BMI in clinical assessment for better screening of hypertension
in adult population in Iran. They may function as a measure of over-
all obesity; however, their applications in predicting the metabolic
disease are questionable and require further investigations.
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Disclosure of interest
The authors declare that they have no competing interest.
Acknowledgment
The authors wish to thank the East Azarbaijan Provincial Health
Center, Tabriz Health Services Management Research Center at
Tabriz University of Medical Sciences and Eastern Azarbaijan Gov-
ernor General for financial supportments.
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