Waist-to-height ratio

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The waist-to-height ratio (WHtR,[a] or WSR: waist-to-stature ratio) is the waist circumference divided by body height, both measured in the same units.

WHtR is a measure of the distribution of body fat. Higher values of WHtR indicate higher risk of obesity-related cardiovascular diseases, which are correlated with both total fat mass (adiposity) and abdominal obesity.[1]

History

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In 1996, WHtR was first suggested by Ashwell and Cole as a simple health risk assessment tool because "it is was identified as a proxy for harmful central adiposity since WHtR was correlated with abdominal CT scan".[2] A boundary value of 0.5 was proposed to indicate increased risk.[3][4] A WHtR of over 0.5 signifies an increased risk; a 2010 systematic review of published studies concluded that "WHtR may be advantageous because it avoids the need for age-, sex- and ethnic-specific boundary values".[5]

According to World Health Organization guidance, the waist circumference is usually measured midway between the lower rib and the iliac crest.[6]

Guidelines

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Calculation

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e.g. 1: ⁠72 cm/160 cm ⁠ = 0.45

e.g. 2: ⁠28 in/5 ft 3 in ⁠ = ⁠28 in/63 in ⁠ = 0.44

Any measuring unit will do, as long as the waist and height share the same unit.

United Kingdom

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The UK's National Institute for Health and Care Excellence (NICE): All adults "ensure their waist size is less than half their height in order to help stave off serious health problems".[7][8]

Consensus statement on redefining obesity

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As of 2024, the Lancet Commission on obesity and the European Association for the Study of Obesity recommended that obesity should no longer be diagnosed with BMI alone due to its several limitations, but confirmed by other surrogate measures such as WHtR of greater than 0.5. A strategic paradigm shift in obesity diagnosis,[9][10] NICE provided this guideline in a 2025 advisory (graphs).[11]

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The October 2022 NICE guidelines recommend boundary values for WHtR (defining the degree of "central adiposity" (abdominal obesity) as follows:

WHtR central adiposity health risks action?
0.6 or more high further increased Take action
0.5 to 0.59 increased increased Take care
0.4 to 0.49 healthy not increased none, OK

The NICE statement is that these classifications can be used for people with a body mass index of under 35, for both sexes and all ethnicities, including adults with high muscle mass. The health risks associated with higher levels of central adiposity include type 2 diabetes, hypertension and cardiovascular disease. NICE have proposed the same boundary values for children of 5 years and over.[12]

Boundary values were first suggested for WHtR in 1996 to reflect health implications and were portrayed on a simple chart of waist circumference against height. The boundary value of WHtR = 0.4 was suggested to indicate the start of the 'OK' range. The 0.5 boundary value was suggested to indicate the start of the 'Take Care' range, with the 0.6 boundary value indicated the start of the 'Take Action' range.[13]

The NICE guideline cutpoint is based on ease of memorization, but may be misleading, especially in the pediatric population, which usually does not have 0.6 WHtR values.[14] Rigorous statistical methods have identifed 0.50 to less than 0.53 in males as a risk level for high fat mass, and 0.53 and above as risk level for excess fat mass in the pediatric population.[14] Among females, 0.51 to less than 0.54 is the risk level for high fat mass and 0.54 and above is the risk level for excess fat mass. [14] These pediatric estimates have been validated as predictors of risk of type 2 diabetes, fatty liver diseases, and bone fractures in Blacks, Asians, Hispanics and Whites.[15]

Simplified guidelines

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The first boundary value for increased risk of WHtR 0.5 translates into the simple message "Keep your waist to less than half your height".[16][17] The updated NICE guideline says "When talking to a person about their waist-to-height ratio, explain that they should try and keep their waist to half their height (so a waist-to height ratio of under 0.5)".[8]

Public health tool

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WHtR is a proxy for total body and central (visceral or abdominal) adiposity: values of WHtR are significantly correlated with direct measures of total body and central (visceral or abdominal) adiposity using techniques such as CT, MRI or DEXA.[4][18][19][20]

WHtR is an indicator of 'early health risk': several systematic reviews and meta-analyses of data in adults of all ages, have supported the superiority of WHtR over the use of BMI and waist circumference in predicting early health risk.[21][22][23][24] Among children and adolescents, WHtR is an indicator of 'early health risk'.[14][25][26]

Cross-sectional studies in many different global populations have supported the premise that WHtR is a simple and effective anthropometric index to identify health risks in adults of all ages,[22][23][27][28] and in children and adolescents.[29][30][31]

In a comprehensive narrative review, Yoo concluded that "additional use of WHtR with BMI or WC may be helpful because WHtR considers both height and central obesity. WHtR may be preferred because of its simplicity and because it does not require sex- and age-dependent cut-offs".[32]

Not only does WHtR have a close relationship with morbidity, it also has a clearer relationship with mortality than BMI.[33][34][35]

As an indicator of both total body and central adiposity

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Many cross-sectional studies have shown that, even within the normal BMI range, many adults have WHtR which is above 0.5.[36][37][28] Many children show the same phenomenon.[38][39] Risk factors for metabolic diseases[37][40] and mortality are raised in these subjects.[41][42][43]

See also

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> vertical axis: height
> horizontal axis: waist circumference
> colours: NICE risk level
> lines: Waist-to-height-ratio

Notes

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  1. ^ The abbreviation WHR is more commonly used for Waist–hip ratio, although WHpR is preferred.

References

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  1. ^ Lee CM, Huxley RR, Wildman RP, et al. (July 2008). "Indices of abdominal obesity are better discriminators of cardiovascular risk factors than BMI: a meta-analysis". Journal of Clinical Epidemiology. 61 (7): 646–653. doi:10.1016/j.jclinepi.2007.08.012. PMID 18359190.
  2. ^ Vague J (1956). "The degree of masculine differentiation of obesities: a factor determining predisposition to diabetes, atherosclerosis, gout, and uric calculous disease". The American Journal of Clinical Nutrition. 4 (1): 20–34. doi:10.1093/ajcn/4.1.20. PMID 13282851.
  3. ^ Hsieh SD, Yoshinaga H (December 1995). "Waist/height ratio as a simple and useful predictor of coronary heart disease risk factors in women". Internal Medicine. 34 (12): 1147–1152. doi:10.2169/internalmedicine.34.1147. PMID 8929639.
  4. ^ a b Ashwell M, Lejeune S, McPherson K (February 1996). "Ratio of waist circumference to height may be better indicator of need for weight management". BMJ. 312 (7027): 377. doi:10.1136/bmj.312.7027.377. PMC 2350287. PMID 8611847.
  5. ^ Browning LM, Hsieh SD, Ashwell M (December 2010). "A systematic review of waist-to-height ratio as a screening tool for the prediction of cardiovascular disease and diabetes: 0·5 could be a suitable global boundary value". Nutrition Research Reviews. 23 (2): 247–269. doi:10.1017/S0954422410000144. PMID 20819243.
  6. ^ Waist circumference and waist-hip ratio: report of a WHO expert consultation 2008 (Report). Geneva: World Health Organization. 2011.
  7. ^ "Obesity: identification and classification of overweight and obesity (update)". National Institute for Health and Care Excellence (NICE). 2022.
  8. ^ a b "Obesity: identification and classification of overweight and obesity (update) | Recommendations 1.2.11 and 1.2.12". National Institute for Health and Care Excellence (NICE). 2022.
  9. ^ Busetto L (September 2024). "A new framework for the diagnosis, staging and management of obesity in adults". Nature Medicine. 30 (9): 2395–2399. doi:10.1038/s41591-024-03095-3. PMID 38969880.
  10. ^ Rubino F (March 2025). "Definition and diagnostic criteria of clinical obesity". Lancet Diabetes and Endocrinology. 13 (3): 221–262. doi:10.1016/S2213-8587(24)00316-4. PMID 38969880.
  11. ^ "Overweight and obesity management; Clinical guideline, NG246; Recommendations 1.9.5 and 1.9.6". UK National Institute for Health and Care Excellence. January 14, 2025. Retrieved September 2, 2025.
  12. ^ "Obesity: identification and classification of overweight and obesity (update) Recommendations 1.2.25 and 1.2.26". National Institute for Health and Care Excellence (NICE). 2022.
  13. ^ Antwi F, Fazylova N, Garcon MC, et al. (2012). "The effectiveness of web-based programs on the reduction of childhood obesity in school-aged children: A systematic review". JBI Library of Systematic Reviews. 10 (42 Suppl): 1–14. doi:10.11124/jbisrir-2012-248. PMID 27820152.
  14. ^ a b c d Agbaje AO (October 2024). "Waist-circumference-to-height-ratio had better longitudinal agreement with DEXA-measured fat mass than BMI in 7237 children". Pediatric Research. 96 (5) 1369–1380. doi:10.1038/s41390-024-03112-8. PMC 11522001. PMID 38443520.
  15. ^ Agbaje AO (July 2025). "Novel Pediatric Waist-to-height Ratio Fat Mass Cutoff Predicts Liver Steatosis and Fibrosis Better than Body Mass Index: The NHANES". Journal of the Endocrine Society. 9 (7) bvaf079. doi:10.1210/jendso/bvaf079. PMC 12104973. PMID 40421430.
  16. ^ Ashwell M, Hsieh SD (August 2005). "Six reasons why the waist-to-height ratio is a rapid and effective global indicator for health risks of obesity and how its use could simplify the international public health message on obesity". International Journal of Food Sciences and Nutrition. 56 (5) 303–7. doi:10.1080/09637480500195066. PMID 16236591. S2CID 24420745.
  17. ^ McCarthy HD, Ashwell M (June 2006). "A study of central fatness using waist-to-height ratios in UK children and adolescents over two decades supports the simple message--'keep your waist circumference to less than half your height'". International Journal of Obesity. 30 (6): 988–992. doi:10.1038/sj.ijo.0803226. PMID 16432546. S2CID 26576960.
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  19. ^ Martin-Calvo N, Moreno-Galarraga L, Martinez-Gonzalez MA (August 2016). "Association between Body Mass Index, Waist-to-Height Ratio and Adiposity in Children: A Systematic Review and Meta-Analysis". Nutrients. 8 (8): E512. doi:10.3390/nu8080512. PMC 4997425. PMID 27556485.
  20. ^ Swainson MG, Batterham AM, Tsakirides C, et al. (2017). "Prediction of whole-body fat percentage and visceral adipose tissue mass from five anthropometric variables". PLOS ONE. 12 (5) e0177175. Bibcode:2017PLoSO..1277175S. doi:10.1371/journal.pone.0177175. PMC 5426673. PMID 28493988.
  21. ^ Lee CM, Huxley RR, Wildman RP, et al. (July 2008). "Indices of abdominal obesity are better discriminators of cardiovascular risk factors than BMI: a meta-analysis". Journal of Clinical Epidemiology. 61 (7): 646–653. doi:10.1016/j.jclinepi.2007.08.012. PMID 18359190.
  22. ^ a b Ashwell M, Gunn P, Gibson S (March 2012). "Waist-to-height ratio is a better screening tool than waist circumference and BMI for adult cardiometabolic risk factors: systematic review and meta-analysis". Obesity Reviews. 13 (3): 275–86. doi:10.1111/j.1467-789X.2011.00952.x. PMID 22106927. S2CID 7290185.
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