New waist-to-height cut-offs to assess fat mass and obesity predicted the risk of hypertension better than body mass index, according to a new study from the University of Eastern Finland and the Robert Wood Johnson Medical School at Rutgers University in the US. The aim of the study was to externally validate new paediatric waist circumference-to-height ratio (WHtR)-estimated fat mass cut-offs for predicting the risk of elevated blood pressure and hypertension among a multiracial population of children and adults in the US.
Obesity is a chronic, complex disease characterised by excess adiposity. The universally available body mass index (BMI) is the current standard for diagnosing obesity, but it has several limitations, with experts urging for more accurate methods. BMI’s inability to distinguish between fat mass and muscle mass is of particular importance because increased muscle mass has been shown to reduce the risk of cardiometabolic diseases, such as type 2 diabetes, as well as bone fractures.
Waist-to-height ratio has attracted interest as an alternative or supplementary measure of body fat and obesity. For instance, a commonly used cut-off of WHtR 0.5 has been recommended to diagnose central obesity by the UK National Institute for Clinical Excellence (NICE) in 2025, and other cut-offs have been proposed for different populations.
The researchers of this study have recently proposed new WHtR cut-offs to assess excess fat mass and have shown that they perform better than BMI in detecting the risk of prediabetes, type 2 diabetes, fatty liver disease and bone fractures. However, how well these WHtR cut-offs predict elevated blood pressure and hypertension has remained unclear.
The researchers used population-representative data from the US National Health and Nutrition Examination Survey (NHANES) 2015–2023, including 19,124 participants aged 12 years or older. The WHtR cut-offs used to define sex-specific normal, high, and excess fat can be found at https://urfit-child.com/waist-height-calculator/. For this study, elevated blood pressure was defined as ≥120/70 mm Hg and hypertension ≥140/90 mm Hg.
In the most recent 2021–2023 NHANES cycle, including 7243 participants with a mean age of 44.8 years, the prevalence of elevated blood pressure was 63.5%, and the prevalence of hypertension was 14.4%. The ability of WHtR to predict the risk of elevated blood pressure and hypertension was determined after controlling for age, sex, ethnic background, educational status, smoking status, physical activity, total cholesterol and inflammation.
The study revealed that participants with WHtR-assessed high fat mass were 50% more likely to have elevated blood pressure and 82% more likely to be hypertensive, and those with excess fat had respective 91% and 161% higher likelihoods of elevated blood pressure and hypertension. Excess adiposity conferred its strongest effect on blood pressure in adults aged 25–65 years.
Meanwhile, among youths under 25 years, WHtR-assessed high and excess fat increased the likelihood of elevated blood pressure by 66% and 98%, respectively. The association with hypertension was not statistically significant in this age group where hypertension was still rare.
On the other hand, unlike WHtR, which showed a stronger association with higher stages of hypertension, BMI-assessed overweight and obesity were strongly associated with elevated blood pressure – carrying 71% and 130% higher likelihoods, respectively – but neither were associated with hypertension across all participants.
Dr Mahidere Ali, a doctoral researcher at the University of Eastern Finland and lead author of the study, noted: “BMI failed to detect the independent effect of adiposity, likely because it does not isolate the confounding influence of muscle mass, which may inflate its association with blood pressure at earlier stages while obscuring its relationship with established hypertension.”
“After demonstrating consistent associations across ethnic backgrounds, age categories and survey cycles, it is safe to conclude that WHtR-based estimates of fat mass provide a more precise and clinically meaningful indicator of hypertension risk. WHtR is a simple, scalable tool that can strengthen early screening and improve detection of adiposity-related cardiovascular risk,” Dr Ali concludes.
Research article:
Ali MW, Corsi DR, Agbaje AO. Novel Waist-to-Height Ratio Estimated Fat Mass Pediatric Cut-offs Predict Hypertension Better than Body Mass Index in Multiracial United States Youths and Adults: The National Health and Nutrition Examination Survey 2015-2023 Cycle. J Nutr. 2026 Feb 18;156(4):101426. https://doi.org/10.1016/j.tjnut.2026.101426
For further information, please contact:
Mahidere Ali, MD, MPH, Doctoral Researcher, urFIT-child research group, Institute of Public Health and Clinical Nutrition, University of Eastern Finland, https://uefconnect.uef.fi/en/mahidere.ali/
Phone: +358402556162
Email: [email protected]
Research group Webpage: urFIT-child
