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Association between sagittal abdominal diameter-to-height ratio and all-cause mortality among adults in the United States: a longitudinal study

Archives of Public Health volume 82, Article number: 213 (2024) Cite this article

Abstract

Background

The global health crisis of obesity has prompted a need for better indicators of abdominal obesity than body mass index, with sagittal abdominal diameter emerging as a potential candidate. Nonetheless, the association between sagittal abdominal diameter-to-height ratio (SADHtR) and mortality remains inadequately established. Our objective was to contribute novel evidence to this association.

Methods

This study encompassed 12,572 participants aged 18–80 years from the National Health and Nutrition Examination Survey 2011–2016. Mortality data were tracked until December 31, 2019. Weighted multivariable Cox proportional hazard models were employed to evaluate the association between SADHtR and all-cause mortality, with subgroup analyses conducted for result robustness.

Results

Following a median follow-up period of 69 months, each standard deviation (SD) increase in SADHtR was consistently associated with a higher risk of all-cause mortality across three models, yielding a hazard ratio (HR) and 95% confidence interval (CI) of 1.51(1.29,1.76) in model 3. Additionally, compared to the first tertile of SADHtR, the third tertile exhibited a higher risk for all-cause mortality, with HRs(95%CIs) of 1.58(1.25,2.01) in model 1, 2.01(1.33,3.02) in model 2, and 1.74(1.19,2.57) in model 3. Notably, subgroup analysis revealed persistent positive associations between SADHtR and all-cause mortality among subgroups based on age-at-risk (< 65, ≥ 65 years), sex, diabetes, hypertension, and hyperlipidemia.

Conclusions

Elevated SADHtR was consistently associated with a higher risk of all-cause mortality in American adults. Regular SADHtR measurement should be considered to be integrated into clinical practice and healthcare examinations.

Peer Review reports

Text box 1. Contributions to the literature

• This study introduces the sagittal abdominal diameter-to-height ratio (SADHtR) as a promising and easily obtainable measure for assessing abdominal obesity, which may outperform conventional indicators like body mass index in predicting mortality.

• By employing a large, nationally representative sample of U.S. adults and robust analytical methods, this research provides generalizable evidence of the association between SADHtR and all-cause mortality.

• Findings underscore the potential of integrating SADHtR into routine clinical assessments to enhance risk stratification and guide preventive health strategies for obesity-related mortality.

Introduction

Obesity has emerged as a pervasive global epidemic. Previous studies indicate that approximately 2.1 billion individuals, roughly one-third of the global population, suffer from overweight or obesity, resulting in substantial health crises and economic burdens [1, 2]. To date, obesity has been primarily characterized by the body mass index (BMI) [3]. Nevertheless, an increasing body of evidence suggests that the primary driver of adverse health outcomes lies in abdominal obesity, specifically the surplus accumulation of visceral adipose tissue (VAT) [4,5,6]. BMI falls short in capturing the distribution of adipose tissue, highlighting the need for a more precise method of measuring body composition [7, 8].

Supine sagittal abdominal diameter (SAD) is a superior metric to waist circumference (WC) or BMI in reflecting the accumulation of VAT [9, 10]. Its association with various cardiometabolic risk factors, including Framingham risk score [11], glucose metabolism [12], metabolic syndrome [13], insulin resistance, and low-grade inflammation [14], suggests that heightened SAD may contribute to mortality through these factors. Unfortunately, research on the direct association between SAD and mortality remains limited, particularly in the general population.

Sagittal abdominal diameter-to-height ratio (SADHtR) exhibits a stronger association with certain cardiometabolic risks compared to unadjusted SAD [15]. Given the ease of measuring both SAD and height in clinical and epidemiological settings, it becomes crucial to examine the association between SADHtR and mortality among the general population. To investigate this association, we conducted a longitudinal cohort study involving adult individuals from the National Health and Nutrition Examination Survey (NHANES) dataset in the United States (US). Our hypothesis posited that an increased SADHtR would correspond to a higher risk of all-cause mortality.

Materials and methods

Study population

A total of 68,897 individuals aged 18 years or older participated in the NHANES 2011–2016 study. Initially, we excluded 53,170 individuals with missing SAD data and 11 individuals without height data. Subsequently, 28 individuals without mortality status data were excluded. Additionally, 3,116 individuals without covariate information, including smoking, drinking, poverty-income ratio (PIR), education, weight, and estimated glomerular filtration rate (eGFR) concentrations, were excluded. Ultimately, the final analysis included 12,572 participants aged 18–80 years. Please refer to Fig. 1 for a visual representation of the exclusion process. Written consent was obtained from all participants before the study commenced. The study protocol (Protocols #2011-17) was approved by the Research Ethics Review Board at the National Center for Health Statistics (NCHS) [16]. The study adhered strictly to the reporting guidelines specified in Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) [17].

Fig. 1
figure 1

Flowchart of exclusion and inclusion of participants in NHANES 2011–2016 adults in the USA. Abbreviations: NHANES, National Health and Nutrition Examination Survey; SAD, sagittal abdominal diameter; eGFR, estimated glomerular filtration rate; USA, United States of America

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Assessment of SADHtR

First, SAD was assessed with the participant lying supine on the examination table. An abdominal caliper was employed to measure the external distance between the anterior abdominal wall and the lower back at the iliac level. Second, the mean SAD was derived by averaging up to four SAD readings. For most participants, two SAD readings were available and used to obtain the mean value. However, if four readings were available due to a difference greater than 0.5 cm between the first two measurements, the three closest readings were used to obtain the mean value [18]. In exceptional instances where two outlying measurements were equally distant from the means of the two closest measurements, all four readings were included to obtain the mean SAD value. Third, SADHtR was determined by dividing the average SAD (cm) by the individual’s standing height(cm) [19].

Assessment of all-cause mortality

The linked mortality files were created by integrating NHANES participant data with the National Death Index mortality records. The linkage of these datasets was accomplished by the NCHS. These recently released data were tracked until December 31, 2019. All-cause mortality referred to deaths attributed to any cause [20].

Covariates

Demographic data comprised age (years), age-at-risk (baseline age plus follow-up time, years), sex, ethnicity, education level, and PIR, which were further categorized as low-income (≤ 1.3), middle-income (> 1.3, ≤ 3.5), and high-income (> 3.5) [21]. Participants were classified into non-smokers (≤ 100 lifetime cigarettes), former smokers (> 100 cigarettes in the past but not currently), and current smokers (> 100 cigarettes consumed to date and still smoking). Drinking status was determined by consuming ≥ 2 drinks per day for males or ≥ 1 drink per day for females [22]. Physical activity (PA) status was assessed based on participation in recreational activities. The eGFR was determined by applying the CKD-EPI-sCr formula, which was described in detail by Inker et al. [23] Body weight was measured at the Mobile Examination Center (MEC). The diagnoses of diabetes mellitus, hypertension, and hyperlipidemia relied on medical history, laboratory test results, body measure results, and medication usage, as detailed in our previous study [24].

Statistical analyses

Data analyses were conducted from December 2023 to April 2024, employing weighted methods recommended by NHANES. The sample weights were calculated as 1/3 multiplied by the 2-year MEC weights. Baseline characteristics of participants were presented as mean (standard error) for normally distributed continuous variables and median (interquartile range [IQR]) for skewed distributed continuous variables. Categorical variables were expressed as weighted percentages. Statistical differences among tertiles of SADHtR in baseline characteristics were examined using one-way ANOVA for continuous variables and chi-square tests for categorical variables.

Cox proportional hazard models were utilized to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for all-cause mortality with SADHtR. SADHtR was incorporated into the regression model using two methodologies: per standard deviation (SD) and tertile. Normalizing SADHtR values by expressing them as “per SD” allowed for more intuitive and comparable HR estimates. Model 1 adjusted for age-at-risk, sex, and ethnicity, while Model 2 additionally adjusted for educational level, PIR, smoking status, drinking status, PA, and weight. Furthermore, Model 3 further adjusted for eGFR, diabetes mellitus, hypertension, and hyperlipidemia. Variables considered confounders based on existing literature [25, 26], and clinical judgment were included. It should be noted that the additionally adjusted covariates in Model 3 could be potential effect mediators that lie in the causal pathway between SADHtR and mortality. Tests for trends were conducted using multivariate regression models by treating the median value of each SADHtR tertile as a continuous variable. Stratified Cox proportional hazards models were used for subgroup analyses based on age-at-risk (< 65, ≥ 65 years), sex (male, female), diabetes (yes, no), hypertension (yes, no), and hyperlipidemia (yes, no). Modifications and interactions of subgroups were evaluated using likelihood ratio tests. The Kaplan-Meier curves were employed to compare the cumulative death rates among three groups characterized by different levels of SADHtR. Schoenfeld residuals were employed to assess the proportional hazards assumption, with no observed violations (p > 0.05). Sensitivity analysis was performed to evaluate the association between SADHtR and cardiovascular mortality.

To elucidate the comparative efficacy of SADHtR against alternative measures of adiposity in assessing mortality risk, we examined the associations between BMI, WC, VAT, and all-cause mortality.

No imputation was performed. All analyses were performed using R 4.3.2 (http://www.R-project.org, The R Foundation), package ‘survey’ version 4.2-1, and Free Statistics software version 1.9.2. A two-sided p-value < 0.05 was considered statistically significant.

Results

Baseline characteristics of the participants in NHANES 2011–2016

Among the 12,572 participants, the median (IQR) SADHtR value was 0.13(0.11,0.15), with a median follow-up time of 69 months. A total of 747 all-cause deaths occurred. The mean age of participants was 46.69 (0.36) years, and 49.61% were males. In the highest tertile group of SADHtR, participants tended to be older, have higher weights, and have a higher prevalence of females and non-Hispanic whites.

With an increase in SADHtR, participants showed a decrease in the proportion of individuals with higher education levels, higher income levels, non-smokers, and those engaging in PA. Conversely, there was an increase in the proportion of former smokers, non-drinkers, individuals with lower eGFR levels, and those diagnosed with diabetes mellitus, hypertension, and hyperlipidemia. The results are presented in Table 1.

Table 1 Description of baseline characteristics of NHANES 2011–2016 adult participants (N = 12,572) in the USA according to tertiles of SADHtR
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Association between SADHtR and all-cause mortality among NHANES adults 2011–2016

In the univariable Cox regression analysis, a per SD increase in SADHtR was significantly associated with a higher risk of all-cause mortality (HR: 1.46, 95% CI: 1.36–1.56). Additionally, factors such as increased age, sex of male, smoking, and the presence of comorbidities such as diabetes mellitus, hypertension, and hyperlipidemia were also positively associated with a higher risk of all-cause mortality. The Kaplan-Meier curves revealed statistically significant differences in cumulative death rates among tertiles of SADHtR, with a p-value less than 0.001. For detailed results, please refer to an additional file (see Supplementary Table 1, Supplementary Fig. 1). In the multivariable Cox regression analysis, SADHtR (per SD increase) was consistently associated with a higher risk of all-cause mortality in all models. The HRs (95%CIs) were 1.27(1.16,1.38), 1.67(1.40,1.98), and 1.51(1.29,1.76) in model 1, model 2, and model 3, respectively. Compared to the first tertile of SADHtR, the second and third tertiles were found to be associated with a higher risk of all-cause mortality, as evidenced by the HRs (95%CIs) of 1.12(0.84,1.51) and 1.58(1.25,2.01) in model 1, 1.28(0.90,1.81) and 2.01(1.33,3.02) in model 2, and 1.18(0.85,1.64) and 1.74(1.19,2.57) in model 3. The relevant results are shown in Table 2. Sensitivity analysis found positive associations between SADHtR and cardiovascular mortality (see Supplementary Table 2).

Table 2 Association between SADHtR and all-cause mortality in multivariable Cox regression models among NHANES 2011–2016 adults (N = 12,572) in the USA
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Subgroup analyses of the association between SADHtR and all-cause mortality among NHANES adults 2011–2016

In five subgroups, each SD increase in SADHtR was associated with a higher risk of all-cause mortality. Among individuals younger than 65 years, the HR (95% CI) for all-cause mortality was 1.55(1.12,2.15), while among those aged 65 years or older, it was 1.60(1.30,1.97), p for interaction was 0.01. For male participants, the HR (95% CI) for all-cause mortality was 1.64(1.26,2.12), and for females, it was 1.36(1.09,1.71), p for interaction was 0.38. Among individuals with and without diabetes mellitus, the HRs (95% CIs) for all-cause mortality were 1.24(0.92,1.67) and 1.63(1.33,2.00), respectively, and p for interaction was 0.50. Similarly, among those with and without hypertension, the HRs (95% CIs) for all-cause mortality were 1.62(1.30,2.01) and 1.17(0.84,1.63), respectively, and p for interaction was 0.97. Finally, among individuals with and without hyperlipidemia, the HRs (95% CIs) for all-cause mortality were 1.41(1.17,1.69) and 1.82(1.28,2.61), respectively, and the p for interaction was 0.86. The results can be seen in Fig. 2. The incidence rates for all subgroups and the absolute risk difference for subgroups are presented in Supplementary Table 3.

Fig. 2
figure 2

Subgroup analyses of the association between SADHtR and all-cause mortality in NHANES 2011–2016 adults in the USA. Each subgroup was adjusted for age-at-risk, sex, ethnicity, education, poverty-income ratio, smoking, drinking, physical activity, eGFR, weight, diabetes, hypertension, and hyperlipidemia, except for the stratified variable itself. Abbreviations: NHANES, National Health and Nutrition Examination Survey; SADHtR, sagittal abdominal diameter-to-height ratio; HR, hazard ratio; CI, confidence interval; eGFR, estimated glomerular filtration rate; USA, United States of America

Full size image

Associations between SADHtR, BMI, WC, VAT, and all-cause mortality among NHANES adults 2011–2016

As the results shown in Supplementary Table 4, we found that SADHtR was better associated with all-cause mortality than BMI, WC, and VAT in US adults from NHANES 2011–2016.

Discussion

In this extensive longitudinal cohort study involving a large representative sample of the general US population, we observed a significant positive association between SADHtR and the risk of all-cause mortality. Subgroup analysis revealed that this association remained consistent and appeared to be particularly pronounced among individuals aged 65 years or above.

After reviewing relevant literature, we identified studies that yielded comparable findings to ours. For instance, a cohort study consisted of 635 individuals with type 2 diabetes but no prior history of myocardial infarction or stroke at baseline [27]. Following a mean follow-up period of 7.1 years, their analysis demonstrated that SAD > 25 cm, as opposed to BMI or WC, remained significantly associated with major cardiovascular events, even after adjusting for covariates (HR 2.81, 95% CI 1.37–5.76). The outcome encompassed fatal or non-fatal cardiovascular events. In our investigation, we similarly observed a positive association between SADHtR and overall mortality. However, unlike the previous study limited to diabetes patients, our analysis included a broader population, and our outcome focused on all-cause mortality. Moreover, their study dichotomized SAD using a 25 cm cut-off point. In contrast, our analysis treated SADHtR as both a continuous variable (to evaluate the effect of each SD increase) and a categorical variable (by dividing it into tertiles). This approach enabled a more comprehensive assessment of its association with mortality, capturing both gradual changes and distinct groupings. Similarly, another study enrolled 30 intensive care unit patients diagnosed with severe sepsis [28]. Baseline measurements of both SAD and BMI were obtained, and they found that SAD, rather than BMI, exhibited an association with mortality up to day 60 post-admission. In contrast, our study revealed a similar positive association among participants in an epidemiological survey, rather than solely hospitalized patients. Furthermore, compared to their study, we implemented more rigorous adjustments for covariates in our multivariable regression models, enhancing the stability of our results. In yet another study, researchers included 418 incident peritoneal dialysis patients [29]. Through adjustment for pertinent risk factors, they independently linked SAD measured via lateral abdominal X-ray with all-cause and cardiovascular mortality during a mean follow-up period of 39.4 months. In our study, which involved NHANES participants with varying kidney functions, SAD was assessed using an abdominal caliper rather than X-ray. Even after adjusting for covariates, including eGFR, our analysis demonstrated a persistent positive association between SADHtR and all-cause mortality. Additionally, a study [30] encompassing 403 patients in the intensive care unit revealed that compared to the control group, the abdominally obese group (SAD ≥ 75th percentile) exhibited an increased risk of mortality in the intensive care unit up to day 60 post-admission (adjusted odds ratio 2.12, 95% CI 1.25–3.60). Although our findings were similar, it is important to note that our study was not conducted within a hospital setting, and our surveyed population differed significantly. Furthermore, our study featured a considerably larger sample size.

Our study differed from another study that examined 82 in-hospital patients with acute respiratory distress syndrome [31]. The participants were categorized as abdominally obese patients (SAD ≥ 26 cm) and the control group (SAD < 26 cm). The aforementioned study showed no significant difference in ICU mortality between the two groups from admission to day 7 (p = 1.00), however, it did reveal an elevated risk of mortality specifically among abdominally obese patients subjected to prolonged cumulative prone positioning. In contrast, our study revealed a positive association between higher SADHtR and increased all-cause mortality risk in the general US adult population. This positive association was consistently observed across all subgroups.

In Supplementary Table S4, SADHtR exhibited a stronger association with all-cause mortality compared to BMI, WC, and VAT in US adults. These findings suggest that SADHtR may offer a more accurate reflection of the association between visceral adiposity and mortality than conventional anthropometric and fat measures. Nonetheless, these conclusions warrant further validation in diverse populations and over extended follow-up periods.

We acknowledge that the findings in subgroup analyses might appear intriguing and seemingly contradictory, suggesting that diabetes and hyperlipidemia are protective for mortality. However, we believe these results can be explained through several plausible reasons. Firstly, it is important to distinguish between absolute risk and relative risk. Diabetes and hyperlipidemia are well-established major risk factors for mortality, meaning individuals with these conditions are already at a higher absolute risk of death. In this context, SADHtR might appear to have a smaller relative risk due to this higher baseline risk. This phenomenon, where relative risks are attenuated in high-risk groups, is not uncommon in epidemiology. Secondly, individuals with diabetes and hyperlipidemia typically receive more intensive medical monitoring and treatment, including medications, dietary modifications, and lifestyle interventions. These interventions might mitigate the impact of other risk factors, potentially reducing the observed relative risk in these populations. Thirdly, survival bias could also be a factor. Individuals with diabetes or hyperlipidemia who have survived long enough to be included in our study might represent a subgroup with better overall health management or resilience, which could skew the relative risk calculations. In addition, given that the p for interaction in the subgroups of diabetes and hyperlipidemia are both greater than 0.05, it suggests that the effect of the SADHtR on mortality does not significantly differ by the presence or absence of diabetes and hyperlipidemia. To further elucidate this phenomenon, future research should incorporate additional confounding variables, extend follow-up durations, and ensure sufficient subgroup-specific events to provide robust estimates.

We outlined several potential biological mechanisms that underlie the association between SADHtR and all-cause mortality. First, SADHtR is often linked to metabolic syndrome, including insulin resistance, elevated glucose, insulin levels, hypertension, and high triglycerides [12,13,14]. These metabolic abnormalities can contribute to the development of cardiovascular diseases, diabetes, and other chronic conditions, thereby increasing the risk of mortality. Second, visceral adiposity is associated with increased systemic inflammation. Excessive fat accumulation leads to the release of inflammatory mediators from adipocytes, such as tumor necrosis factor-alpha (TNF-α) and interleukin-6 (IL-6), triggering chronic inflammatory responses [32, 33]. This chronic inflammation may promote the formation of atherosclerosis, increasing the risk of cardiovascular disease and related mortality. Third, visceral adiposity may further increase overall mortality risk by impacting the risk of conditions such as sleep apnea, osteoporosis, and certain cancers [5, 34, 35].

Our study has several notable strengths. Firstly, we employed a large sample size and utilized a weighted analysis method, resulting in our findings being highly representative and applicable to the broader US population. Secondly, the stability and robustness of our results were evident through the implementation of multivariable regression models and subgroup analysis. Thirdly, the measurement of SADHtR is straightforward to implement in clinical practice and epidemiological surveys, and it also offers a cost-effective alternative to more expensive imaging techniques such as computed tomography and magnetic resonance imaging.

Several limitations should be acknowledged in our study. Firstly, it is important to recognize that this study adopts an observational design, which precludes the establishment of causal relationships. Secondly, we identified a positive association between SADHtR and all-cause mortality in US adults. However, the generalizability of these findings to individuals in other countries or regions remains uncertain. Further research is needed to elucidate this association comprehensively. Thirdly, it is worth noting that the incidence of mortality, particularly in relation to cause-specific mortality, appears to be relatively low. However, it is important to mention that data on SAD prior to the year 2011 are unavailable.

Conclusions

This longitudinal study establishes a positive association between elevated SADHtR levels and heightened all-cause mortality risk in US adults, underscoring the significance of incorporating SADHtR measurement into clinical practice and healthcare evaluations. Timely intervention targeting the dietary and lifestyle habits of individuals with elevated SADHtR levels could yield substantial benefits.

Data availability

The datasets generated during and analyzed during the current study are available in the NHANES repository, https://www.cdc.gov/nchs/nhanes/index.htm.

Abbreviations

BMI:

Body mass index

SAD:

Sagittal abdominal diameter

SADHtR:

Sagittal Abdominal Diameter-to-height ratio

WC:

Waist circumference

NHANES:

National Health and Nutrition Examination Survey

NCHS:

National Center for Health Statistics

US:

United States

PIR:

Poverty-income ratio

eGFR:

Estimated glomerular filtration rate

STROBE:

Strengthening the Reporting of Observational Studies in Epidemiology

PA:

Physical activity

MEC:

Mobile Examination Center

IQR:

Interquartile range

HR:

Hazard ratio

CI:

Confidence interval

SD:

Standard deviation

VAT:

Visceral adipose tissue

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Acknowledgements

We gratefully thank Jie Liu of the Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital for his contribution to the statistical support, study design consultations, and comments regarding the manuscript.Thanks to Zhang Jing (Second Department of Infectious Disease, Shanghai Fifth People’s Hospital, Fudan University) for his work on the NHANES database. His outstanding work, the nhanesR package, and webpage, make it easier for us to explore the NHANES database.We thank the funding support for co-author Fanfan Zhu’s study. The funding organization is the Shanghai Municipal Huangpu District Commission (HLQ202205).

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Author notes

  1. Xi Gu, Ping Gao and Fanfan Zhu contributed equally to this work.

Authors and Affiliations

  1. Department of Endocrinology, RuiJin Hospital Lu Wan Branch, Shanghai Jiaotong University School of Medicine, No.149 Chongqing South Road, Shanghai, China

    Xi Gu, Ping Gao, Fanfan Zhu, Ying Shen & Leiqun Lu

Authors
  1. Xi Gu
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  2. Ping Gao
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  3. Fanfan Zhu
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  4. Ying Shen
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Contributions

Study concept and design: Xi Gu. Acquisition of data: Ping Gao and Fanfan Zhu. Analysis and interpretation of data: Xi Gu. Drafting of the manuscript: Xi Gu. Critical revision of the manuscript for important intellectual content: Ying Shen and Leiqun Lu. All authors reviewed the manuscript.

Corresponding authors

Correspondence to Ying Shen or Leiqun Lu.

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Approval was obtained from the NCHS Research Ethics Review Board. The procedures used in this study adhere to the tenets of the Declaration of Helsinki.

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The authors declare no competing interests.

Informed consent

was obtained from all individual participants included in the study.

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Gu, X., Gao, P., Zhu, F. et al. Association between sagittal abdominal diameter-to-height ratio and all-cause mortality among adults in the United States: a longitudinal study. Arch Public Health 82, 213 (2024). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s13690-024-01443-w

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s13690-024-01443-w

Keywords

Archives of Public Health

ISSN: 2049-3258