A new study published in The Lancet Regional Health suggests that waist-to-height ratio (WHtR) predicts buildup of coronary artery calcium (CAC) and future heart disease risk better than body mass index (BMI). WHtR is calculated by dividing waist circumference by height and reflects abdominal fat relative to body size.
Study overview
Researchers followed 2,721 adults in São Paulo, Brazil, who were free of detectable CAC at baseline. Participants averaged about 48 years old, were roughly two-thirds female, and the cohort was racially diverse. After five years, about 15% had developed CAC. Investigators measured BMI, waist circumference, and WHtR at baseline and reassessed CAC at follow-up.
Key findings
– In unadjusted analyses, BMI, waist circumference, and WHtR all correlated with CAC. After adjusting for traditional cardiovascular risk factors (including blood pressure, cholesterol, and diabetes), only WHtR remained an independent predictor of CAC development.
– Participants with WHtR ≥ 0.5 had CAC in about 18% of cases versus about 10% for those with WHtR < 0.5.
– The study estimated that each moderate increase in waist relative to height was associated with roughly an 18% higher risk of developing coronary artery calcium.
Why WHtR may be superior to BMI
– BMI uses weight and height to estimate body fat but does not capture where fat is distributed. Two people with the same BMI can have very different amounts of harmful abdominal (visceral) fat.
– WHtR better reflects visceral abdominal fat, which is metabolically active and linked to inflammation, insulin resistance, atherosclerosis, and diabetes—pathways involved in CAC and cardiovascular disease.
– The association between larger WHtR and CAC was not fully explained by traditional metabolic measures, suggesting additional harmful effects of abdominal fat that BMI misses.
Expert perspective
Study authors and outside cardiologists noted a shift toward using waist-based measures for cardiovascular risk related to metabolic and atherosclerotic disease. Marcio Sommer Bittencourt, MD, PhD, highlighted the field’s movement from BMI to WHtR for these outcomes. Thiago Bosco Mendes, MD, emphasized that WHtR predicted arterial sclerosis development after five years even after accounting for classic cardiovascular risk factors. Yu-Ming Ni, MD, agreed that waist-based measures are useful markers of metabolic dysfunction and heart risk.
Clinical and public-health implications
WHtR is quick, inexpensive, and easy to measure. It could be used in routine screening to identify people at elevated cardiovascular risk who might be missed by BMI alone—particularly those with BMI in the normal or overweight range (including BMI 25–29.9). Despite the predictive value of WHtR, prevention recommendations remain the same: healthy diet, regular physical activity, weight management when needed, and limiting ultra-processed foods to reduce abdominal fat and overall risk.
How to measure WHtR at home
1. Use a tape measure long enough for your height.
2. Measure height without shoes and record in the same units (inches or centimeters).
3. Measure waist around the bare abdomen at the level of the belly button while breathing out normally.
4. Divide waist by height using the same units (for example, waist 34 in ÷ height 68 in = 0.5).
5. Rule of thumb: keep waist less than half your height; WHtR ≥ 0.5 suggests increased risk.
Bottom line
WHtR provides a simple, low-cost way to better gauge risk for coronary artery calcium and future heart disease beyond BMI or waist circumference alone. It is especially useful for detecting elevated risk in people whose BMI appears healthy, underscoring abdominal fat as an important prevention target.
