Key result
Higher adiposity indices are linked to up to ~49% higher risk of incident CVD.
Why the study?
BMI does not capture body-fat distribution, and evidence comparing alternative measured adiposity indices for cardiovascular risk remains fragmented across single indices, single countries, and self-reported measurements. Head-to-head comparisons of anthropometric indices and tests of whether resulting risk signals and prediction models generalise between China and England were needed.
Do seven measured anthropometric indices of adiposity independently predict incident cardiovascular disease and generalise in risk prediction models between older adult populations in China and England?
Cohort (n=15,788)
Yes
Do seven measured anthropometric indices of adiposity independently predict incident cardiovascular disease and generalise in risk prediction models between older adult populations in China and England?
All seven measured adiposity indices independently predict incident CVD across Chinese and English populations, and adding waist circumference and weight-adjusted waist index modestly improves conventional cardiovascular risk discrimination.
Multiple adiposity indices may inform future CVD risk models across populations; extends prior evidence but remains hypothesis-generating and should not yet change practice.
Background Body-mass index (BMI) does not capture body-fat distribution, and evidence comparing alternative measured adiposity indices for cardiovascular risk remains fragmented across single indices, single countries and self-reported measurements. We aimed to compare seven anthropometric indices head-to-head and to test whether the resulting risk signals and prediction models generalise between China and England. Methods Prospective analysis of two nationally representative ageing cohorts with measured anthropometry: CHARLS (China, n = 10,557) and ELSA (England, n = 5,231), yielding 15,788 adults aged ≥ 45 years free of cardiovascular disease (CVD) at baseline and 3,175 incident CVD events. Cox models with a pre-specified adjustment gradient estimated dose–response associations; mediation analysis, quantile g-computation, Fine–Gray competing-risk models and restricted-mean-time-lost analyses characterised mechanisms and absolute effects; and gradient-boosted models trained in one country were externally validated in the other with TreeSHAP interpretation. Results All seven indices showed independent, monotonic associations with incident CVD (fully adjusted top-versus-bottom tertile hazard ratios 1.13–1.49). Blood pressure and cardiometabolic disease jointly mediated 32.4% of the BMI–CVD association (China 40.6%; England 22.7%). A simultaneous one-tertile increase in the adiposity–blood-pressure mixture yielded a joint hazard ratio of 1.59 (95% CI 1.49–1.70). The highest BMI tertile lost 0.132 years of CVD-free time over 7 years. Prediction models transported bidirectionally (C-index 0.623 China→England; 0.618 England→China; combined-model 5-year time-dependent AUC 0.680 in China and 0.739 in England) with preserved discrimination but imperfect calibration. Adding the seven indices to conventional risk factors improved the C-index by 0.010 (95% CI 0.008–0.014). Conclusions Measured waist circumference and the weight-adjusted waist index should complement BMI in cardiovascular risk assessment. Adiposity signals generalise across populations with very different adiposity distributions, but absolute-risk deployment requires country-specific recalibration. Clinical trial registration Clinical trial number: not applicable.
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Mao et al. (2026) conducted a cohort in Cardiovascular disease risk in older adults (n=15,788). Seven anthropometric adiposity indices (BMI, WC, WHtR, ABSI, WWI, BRI, CI) - highest tertile (T3) vs. Lowest tertile (T1) of adiposity indices was evaluated on Incident cardiovascular disease (first self-reported physician diagnosis of stroke or heart disease) (HR 1.49 (for BMI and WC T3 vs T1; range 1.13-1.49 across all 7 indices), 95% CI 1.35-1.65, p=<0.001). Seven adiposity indices were independently associated with incident CVD in China and England (top-vs-bottom tertile HR 1.13–1.49; BMI and WC both HR 1.49, P<0.001).
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