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1192 Am J Clin Nutr 2003;77:1192–7. Printed in USA. © 2003 American Society for Clinical Nutrition
Associations of hip and thigh circumferences independent of waist
circumference with the incidence of type 2 diabetes: the Hoorn Study
1–3
Marieke B Snijder, Jacqueline M Dekker, Marjolein Visser, Lex M Bouter, Coen DA Stehouwer, Piet J Kostense, John S Yudkin,
Robert J Heine, Giel Nijpels, and Jacob C Seidell
ABSTRACT
Background: The higher risk of type 2 diabetes in persons with
a high waist-to-hip ratio (WHR) or waist-to-thigh ratio (WTR) has
mostly been attributed to increased visceral fat accumulation.
However, smaller hip or thigh circumference may also explain the
predictive value of the WHR or WTR for type 2 diabetes.
Objective: This study considered prospectively the association of
hip and thigh circumferences, independent of waist circumference,
with the incidence of type 2 diabetes.
Design: The Hoorn Study is a population-based cohort study of
diabetes. A total of 1357 men and women aged 50–75 y and non-
diabetic at baseline participated in the 6-y follow-up examination.
Glucose tolerance was assessed by use of a 75-g oral-glucose-
tolerance test. Baseline anthropometric measurements included
body mass index (BMI) and waist, hip, and thigh circumferences.
Results: Logistic regression analyses showed that a 1-SD larger
hip circumference gave an odds ratio (OR) for developing diabetes
of 0.55 (95% CI: 0.36, 0.85) in men and 0.63 (0.42, 0.94) in
women, after adjustment for age, BMI, and waist circumference.
The adjusted ORs for a 1-SD larger thigh circumference were 0.79
(0.53, 1.19) in men and 0.64 (0.46, 0.93) in women. In contrast
with hip and thigh circumferences, waist circumference was pos-
itively associated with the incidence of type 2 diabetes in these
models (ORs ranging from 1.60 to 2.66).
Conclusion: Large hip and thigh circumferences are associated
with a lower risk of type 2 diabetes, independently of BMI, age,
and waist circumference, whereas a larger waist circumference is
associated with a higher risk. Am J Clin Nutr 2003;77:1192–7.
KEY WORDS Hip circumference, thigh circumference,
waist-to-hip ratio, waist circumference, BMI, body composition,
fat distribution, type 2 diabetes, insulin resistance, the Hoorn
Study
INTRODUCTION
Although the dramatic worldwide increase in the incidence of
obesity, and consequently in the incidence of type 2 diabetes, has
been recognized, the exact etiologic link between these remains
unclear. It was observed in the Hoorn Study that the waist-to-hip
ratio (WHR) and not body mass index (BMI) is an important inde-
pendent predictor of incident diabetes in 50–75-y-olds (1). This
result indicates that fat distribution may be a better predictor for
progression to type 2 diabetes than is BMI, which is also sug-
gested by studies that examined the WHR or the waist-to-thigh
1
From the Institute for Research in Extramural Medicine, VU University
Medical Center, Amsterdam (MBS, JMD, MV, LMB, CDAS, PJK, JSY, RJH,
GN, and JCS); the Department of Medicine, Diabetes and Cardiovascular Dis-
ease Academic Unit, University College London Medical School, London
(JSY); and the Department of Nutrition and Health, Faculty of Earth and Life
Sciences, Vrije Universiteit, Amsterdam (JCS).
2
Supported by the Dutch Diabetes Research Foundation, project number
96.111.
3
Reprints not available. Address correspondence to MB Snijder, Institute
for Research in Extramural Medicine, VU University Medical Center, Van der
Boechorststraat 7, 1081 BT Amsterdam, Netherlands. E-mail: mb.snijder.
emgo@med.vu.nl.
Received July 29, 2002.
Accepted for publication November 4, 2002.
ratio (WTR) (2–6). In particular, the accumulation of visceral fat
is assumed to play an important role in the etiology of diabetes by
overexposing the liver to free fatty acids, resulting in insulin
resistance and hyperinsulinemia (7–9).
Evidence, however, that the strong predictive value of the WHR
or WTR for type 2 diabetes is not solely due to abdominal fat
accumulation (as indicated by waist circumference) is growing.
Cross-sectional studies showed that a larger hip circumference is
associated with a lower prevalence of self-reported type 2 diabetes
and lower fasting glucose concentrations, independently of BMI
and waist circumference (10, 11). We obtained similar results in
the Hoorn Study for both hip and thigh circumferences (12).
In one prospective study of Chinese men and women, hip cir-
cumference was positively associated with the incidence of
type 2 diabetes (13). In that study, however, neither waist cir-
cumference nor BMI was taken into account. To our knowledge,
only one prospective study of the specific association of hip cir-
cumference with the incidence of diabetes has been carried out
in whites. That study found a larger hip circumference to be
associated with a lower incidence of several cardiovascular end-
points and diabetes, independently of waist circumference (14).
However, the latter study was limited to women and in both
prospective studies the presence of diabetes was not examined
on the basis of an oral-glucose-tolerance test (OGTT).
In the Hoorn Study, a population-based cohort study of glucose
tolerance, both men and women were included and a 75-g OGTT
was performed. The aim of the present study was to investigate
the associations of hip and thigh circumferences independent of
waist circumference with the incidence of type 2 diabetes and with
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HIP AND THIGH CIRCUMFERENCES AND TYPE 2 DIABETES 1193
TABLE 1
Baseline characteristics of the men and women
1
Men (n = 619) Women (n = 738)
Age (y) 60.2 ± 6.9 60.4 ± 6.9
BMI (kg/m
2
) 25.9 ± 2.7
2
26.5 ± 3.5
WHR 0.94 ± 0.06
2
0.83 ± 0.07
WTR 1.68 ± 0.15
2
1.46 ± 0.16
Waist circumference (cm) 94.2 ± 8.4
2
85.8 ± 9.9
Hip circumference (cm) 100.2 ± 5.1
2
102.9 ± 6.9
Thigh circumference (cm) 56.6 ± 4.6
2
59.6 ± 5.2
Fasting glucose (mmol/L) 5.46 ± 0.49
2
5.31 ± 0.53
Postload glucose (mmol/L) 5.22 ± 1.65
2
5.54 ± 1.59
1
x
–
± SD. WHR, waist-to-hip ratio; WTR, waist-to-thigh ratio.
2
Significantly different from women, P < 0.05 (Student’s t test).
changes in fasting and postload glucose concentrations during
6 y of follow-up.
SUBJECTS AND METHODS
Subjects
The Hoorn Study is a population-based cohort study of glucose
tolerance among 2484 white men and women aged 50–75 y that
started in 1989 and has been described elsewhere (15). In
1996–1998 a follow-up examination was carried out. Of the 2484
subjects, 150 subjects had died and 108 subjects had moved out of
Hoorn. Another 140 subjects were not invited because of logistic
reasons. Of the remaining 2086 subjects who were invited to the
follow-up examination, 1513 subjects (72.5%) participated. After
the exclusion of subjects with type 2 diabetes at baseline (49 men
and 44 women) and subjects with missing anthropometric data,
prospective analyses were performed in 1357 subjects (619 men
and 738 women). Informed consent was obtained from all partic-
ipants, and ethical approval for the study was obtained from the
local ethics committee.
Measurements
Fasting glucose concentrations and postload glucose concentra-
tions 2 h after a 75-g OGTT were measured in plasma (mmol/L)
with the glucose dehydrogenase method (Merck, Darmstadt, Ger-
many) at baseline (15) and with the hexokinase method (Boehringer
Mannheim, Mannheim, Germany) at follow-up, except in subjects
who were already known to have diabetes. Fasting and postload
glucose concentrations were used to classify subjects according to
the 1999 World Health Organization criteria (16).
Weight and height were measured while subjects were barefoot
and wearing light clothes only, and BMI was calculated as weight
divided by height squared (kg/m
2
). Waist circumference was
measured at the level midway between the lowest rib margin and
the iliac crest, and hip circumference was measured at the widest
level over the greater trochanters. Thigh circumference was meas-
ured on the left leg directly below the gluteal fold. The mean value
of 2 measurements was used in the analyses. Waist-to-hip ratio
(WHR) was calculated as waist circumference divided by hip cir-
cumference, and waist-to-thigh ratio (WTR) was calculated as
waist circumference divided by thigh circumference.
Information on lifestyle factors was obtained by questionnaire.
Smoking was expressed in cigarette-years (number of cigarettes
smoked per day times the number of years smoked) for smokers
or former smokers. Alcohol intake was categorized in 4 groups:
nondrinkers and drinkers of ≤ 10, 10–30, and > 30 g/d. Habitual
physical activity was expressed as hours per day. The activities
included sports, bicycling, gardening, walking, odd jobs, and
housekeeping.
Statistical analysis
Differences in baseline characteristics between men and women
were tested by Student’s t test for normally distributed variables
and by Mann-Whitney’s test for variables with a skewed distribu-
tion. Differences in proportions were tested by the chi-square test.
Logistic regression analyses were performed to study the asso-
ciation of baseline anthropometric measures (BMI, WHR, WTR,
and waist, hip, and thigh circumferences) with the incidence of
type 2 diabetes. Associations are expressed as odds ratios (ORs)
with their 95% CIs per (sex-specific) 1-SD increase in the anthro-
pometric variable involved. An OR can be interpreted as a relative
risk. All models were adjusted for age and then additionally for
baseline glucose concentrations. The influence of possible con-
founding by lifestyle factors was studied by adding these factors
to the regression model. Possible interaction (effect modification)
by sex, age, and anthropometric characteristics was studied by
adding product terms to the model. Because the follow-up dura-
tion was not the same for each individual, we repeated the analy-
ses with additional adjustment for follow-up duration.
To use cutoffs for fasting and postload glucose concentrations
and combine them for the definition of type 2 diabetes (16) impli-
cates a loss of quantitative information. To examine whether the
results of the logistic regression analyses for hip, thigh, and waist
circumferences were influenced by the use of these criteria, linear
regression analyses were performed with continuous fasting and
continuous postload glucose concentrations at follow-up as the
outcome variables. These regression models were adjusted for age
and BMI and then additionally for baseline fasting or postload glu-
cose concentrations. Standardized coefficients are reported to
make the regression coefficients directly comparable between the
different anthropometric measures. A standardized of 0.1 indi-
cates that if the independent variable changes 1 SD, the depend-
ent variable changes 0.1 SD. The stability of the models was con-
sidered to be disturbed by multicolinearity if tolerance was < 0.1.
Tolerance is a statistic used to determine how much the inde-
pendent variables are linearly related to one another. It is calcu-
lated as 1 R
2
for an independent variable when it is predicted by
the other independent variables already included in the analyses.
All analyses were performed by using SPSS for WINDOWS (ver-
sion 10.1.0; SPSS Inc, Chicago).
RESULTS
Baseline characteristics by sex are shown in Table 1. The men
and women were of the same age, but differed significantly in all
anthropometric measures: the women had higher BMI and thigh
and hip circumferences, but lower waist circumference, WHR, and
WTR. The men had higher fasting glucose concentrations,
whereas the women had higher postload glucose concentrations,
although the differences in glucose concentrations were relatively
small. Follow-up duration did not differ significantly between the
men and women (6.4 ± 0.5 y in both sexes), and ranged from 4.4
to 8.1 y in men and from 4.5 to 7.9 y in women. The women were
more physically active, smoked less, and had a lower alcohol
intake than did the men (data not shown).
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1194 SNIJDER ET AL
FIGURE 1. Odds ratios (ORs) for developing type 2 diabetes per
1-SD larger waist () and hip () circumferences. Waist circumference
was adjusted for hip circumference, BMI, and age; hip circumference was
adjusted for waist circumference, BMI, and age.
During follow-up, 64 men (10.3%) and 68 women (9.2%)
developed type 2 diabetes. Type 2 diabetes was diagnosed by a
general practitioner in only 6 men and 12 women before the fol-
low-up examination took place; the remaining patients were diag-
nosed at this examination. Because sex was a significant effect
modifier in the relation between anthropometry and incident dia-
betes, we performed all analyses for men and women separately.
The results in Table 2 show that after adjustment for age, WHR
was a strong predictor for type 2 diabetes in both sexes (model
2), whereas BMI was a significant predictor in women only
(model 1). After mutual adjustment (model 3), only WHR seemed
to be important in predicting diabetes. Waist circumference
(model 4) was less strongly associated with incident diabetes after
adjustment for age than was the WHR, suggesting a predictive role
for hip circumference.
To examine whether the association of WHR was largely due
to waist circumference or to hip circumference, we added these
variables separately into one regression model (model 6). After
adjustment for BMI also, both circumferences appeared to be
significantly associated in opposite directions with the risk of dia-
betes in both sexes (Figure 1). BMI was not significantly associ-
ated with the incidence of type 2 diabetes in this model. No inter-
actions were observed between anthropometric variables or
between age and anthropometric variables. Similar analyses were
performed for the WTR and thigh circumference (Table 3 ). The
results were similar, except that in men, thigh circumference was
not significantly associated with a lower risk of diabetes (model
6). Adjustment for BMI did not change this result (Figure 2).
Adjustment for lifestyle factors (smoking, alcohol intake, and
physical activity) also did not change the results (data not shown).
TABLE 3
Relative risk [odds ratio (OR)] for the development of type 2 diabetes per
1-SD increase in risk factor: logistic regression analyses
1
Men (n = 619) Women (n = 738)
Risk factors in model
2
OR (95% CI) OR (95% CI)
Model 1: BMI 1.03 (0.79, 1.34) 1.53 (1.21, 1.95)
3
Model 2: WTR 1.41 (1.05, 1.89)
4
2.08 (1.59, 2.72)
3
Model 3: BMI 0.97 (0.73, 1.27) 1.31 (1.02, 1.69)
4
WTR 1.42 (1.05, 1.92)
4
1.92 (1.45, 2.54)
3
Model 4: Waist circumference 1.23 (0.95, 2.64) 1.98 (1.54, 2.55)
3
Model 5: Thigh circumference 0.90 (0.68, 1.19) 1.00 (0.79, 1.28)
Model 6: Waist circumference 1.44 (1.05, 1.96)
4
2.37 (1.78, 3.17)
3
Thigh circumference 0.73 (0.52, 1.04) 0.68 (0.50, 0.92)
4
1
WTR, waist-to-thigh ratio.
2
All models were adjusted for age.
3
P < 0.01.
4
P < 0.05.
TABLE 2
Relative risk [odds ratio (OR)] for the development of type 2 diabetes per
1-SD increase in risk factor: logistic regression analyses
1
Men (n = 619) Women (n = 738)
Risk factors in model
2
OR (95% CI) OR (95% CI)
Model 1: BMI 1.03 (0.79, 1.34) 1.53 (1.21, 1.95)
3
Model 2: WHR 1.55 (1.17, 2.06)
3
2.15 (1.63, 2.83)
3
Model 3: BMI 0.79 (0.57, 1.08) 1.20 (0.91, 1.58)
WHR 1.75 (1.27, 2.41)
3
1.98 (1.47, 2.67)
3
Model 4: Waist circumference 1.23 (0.95, 2.64) 1.98 (1.54, 2.55)
3
Model 5: Hip circumference 0.87 (0.66, 1.14) 1.27 (1.00, 1.62)
4
Model 6: Waist circumference 1.94 (1.31, 2.88)
3
2.75 (1.90, 3.97)
3
Hip circumference 0.54 (0.36, 0.79)
3
0.65 (0.45, 0.92)
4
1
WHR, waist-to-hip ratio.
2
All models were adjusted for age.
3
P < 0.01.
4
P < 0.05.
FIGURE 2. Odds ratios (ORs) for developing type 2 diabetes per
1-SD larger waist () and thigh () circumferences. Waist circumference
was adjusted for thigh circumference, BMI, and age; thigh circumference
was adjusted for waist circumference, BMI, and age.
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HIP AND THIGH CIRCUMFERENCES AND TYPE 2 DIABETES 1195
TABLE 5
Associations (standardized coefficients) of baseline body
circumferences with continuous postload glucose concentrations at
follow-up: multiple linear regression analyses
Men (n = 619) Women (n = 738)
Independent variables P P
Model 1
1
Waist circumference 0.203 0.003 0.253 0.000
Hip circumference 0.180 0.005 0.203 0.000
Model 2
1
Waist circumference 0.137 0.036 0.182 0.003
Thigh circumference 0.037 0.517 0.148 0.002
Model 3
2
Waist circumference 0.083 0.162 0.119 0.021
Hip circumference 0.074 0.180 0.057 0.240
Model 4
2
Waist circumference 0.056 0.322 0.093 0.072
Thigh circumference 0.007 0.889 0.066 0.097
1
Adjusted for age and BMI.
2
Adjusted for age, BMI, and baseline postload glucose concentration.
The ORs for a 1-SD larger hip circumference after adjustment
for waist circumference and all lifestyle factors were 0.52 (95%
CI: 0.33, 0.80) for men and 0.65 (95% CI: 0.43, 0.98) for women.
A 1-SD larger thigh circumference after adjustment for waist cir-
cumference and all lifestyle factors resulted in ORs of 0.80 (95%
CI: 0.53, 1.20) for men and 0.64 (95% CI: 0.44, 0.93) for women.
Adjustment for follow-up duration did not change any of the
observed associations (data not shown). After adjustment for base-
line fasting and postload glucose concentrations, only waist cir-
cumference in women remained significantly associated with the
incidence of type 2 diabetes (data not shown).
The results of the multiple linear regression models for the asso-
ciations of baseline body circumferences with follow-up fasting and
postload glucose concentrations are shown in Tables 4 and 5, respec-
tively. We adjusted for age and BMI (models 1 and 2) and then addi-
tionally for baseline fasting or postload glucose concentrations
(model 3 and 4). In accordance with the results of the logistic regres-
sion analyses, glucose concentrations (fasting and postload) were
positively associated with baseline waist circumference and nega-
tively associated with baseline hip or thigh circumference, although
the results were not significant for thigh circumference in men
(models 1 and 2). After adjustment for baseline glucose concentra-
tions (models 3 and 4), most associations became nonsignificant: in
men, waist circumference was still significantly and positively asso-
ciated with fasting glucose, whereas in women only thigh circum-
ference was significantly associated (negatively). None of the cir-
cumferences was significantly associated with postload glucose
concentrations in men, whereas in women waist circumference was
positively associated and thigh circumference was negatively asso-
ciated after adjustment for baseline postload glucose concentrations.
The correlation between waist and hip circumferences was 0.71
in men and 0.69 in women, and the correlation between waist and
thigh circumferences was 0.46 in men and 0.42 in women. The
regression models were not disturbed by multicolinearity.
DISCUSSION
In the present study, we showed that the body circumference
ratios (WHR and WTR) are better predictors of future type 2
diabetes than is overall obesity measured by BMI. Both waist and
hip circumference have important, but opposite, associations with
the risk of diabetes after adjustment for age and BMI. A larger waist
circumference is associated with a higher risk of diabetes, whereas
a larger hip circumference is associated with a lower risk of dia-
betes. A larger thigh circumference was also associated with a lower
risk of diabetes, although the protective effect was statistically signi-
ficant only in women. The measurements of continuous glucose con-
centrations showed that fasting and postload concentrations were
positively associated with baseline waist circumference and nega-
tively associated with baseline hip and thigh circumferences.
Of the 2086 persons who were invited for the follow-up exam-
ination, 72.5% participated. These participants were healthier at
baseline than were the nonparticipants (1). Therefore, it is possi-
ble that we underestimated the true incidence of diabetes and con-
sequently underestimated the associations with waist, hip, and
thigh circumferences.
When incident diabetes or continuous glucose concentrations
after follow-up are used as the study outcome, there is often dis-
cussion of whether to adjust for baseline glucose concentrations.
Adjustment for baseline glucose answers the question of whether
knowledge about the thigh or hip circumference contributes to the
prediction of incident diabetes once baseline glucose is taken into
account. In our study, thigh or hip circumference did not inde-
pendently contribute to incident diabetes or continuous glucose
concentrations after adjustment for baseline glucose. However, if
baseline glucose concentrations and baseline thigh or hip circum-
ferences result from the same etiologic process, adjustment for
glucose concentrations would be inappropriate. Alternatively, if
we assume that there is a causal association of thigh or hip cir-
cumference with impaired glucose metabolism, it is possible that
persons with narrow hips or small thighs had increased glucose
concentrations already at baseline. If we then adjust for these
baseline glucose concentrations, the effects of thigh or hip cir-
cumference disappear. The observed cross-sectional association
between body circumferences and glucose concentrations (12)
reinforce these suggestions. Waist circumference is more likely to
remain a significant predictor of type 2 diabetes after adjustment
for baseline glucose concentrations.
TABLE 4
Associations (standardized coefficients) of baseline body
circumferences with continuous fasting glucose concentrations at follow-
up: multiple linear regression analyses
Men (n = 619) Women (n = 738)
Independent variables P P
Model 1
1
Waist circumference 0.284 0.000 0.216 0.000
Hip circumference 0.178 0.005 0.154 0.008
Model 2
1
Waist circumference 0.219 0.001 0.157 0.011
Thigh circumference 0.036 0.528 0.134 0.005
Model 3
2
Waist circumference 0.159 0.008 0.094 0.082
Hip circumference 0.102 0.064 0.076 0.134
Model 4
2
Waist circumference 0.120 0.036 0.060 0.267
Thigh circumference 0.024 0.633 0.084 0.043
1
Adjusted for age and BMI.
2
Adjusted for age, BMI, and baseline fasting glucose concentration.
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1196 SNIJDER ET AL
Our observation that central obesity, independent of overall
obesity, is an important determinant of type 2 diabetes is not new
(3–6). The abdominal visceral fat is considered to be possibly eti-
ologically important through increased fatty acid release into the
portal system (7–9). Our results extend these findings by showing
an independent association of waist and hip circumferences with
the development of diabetes. Our results agree with the results of
the scarce cross-sectional studies (10, 11). One previous prospec-
tive study, showing an independent protective effect of hip cir-
cumference on the development of diabetes, was limited to women
(14). Furthermore, the presence of diabetes was examined on the
basis of an OGTT. In the present prospective study, an OGTT was
performed in both men and women. In addition, we included
measurements of thigh as well as hip circumference.
The negative association of hip circumference with glucose
metabolism was proposed to be caused by a greater muscle mass
at the gluteal region (10). Muscle mass is one of the sites of insulin
resistance as well as the main target of insulin. WHR has been
related to both larger visceral fat and smaller leg muscle areas in
men (17). Also, the higher prevalence of glucose tolerance in
Indian men than in Swedish men was related to lower muscle mass
(18). Thigh circumference might better reflect muscle mass than
hip circumference, because it is less likely to be influenced by
frame size (pelvic width). Our results, however, show that hip cir-
cumference has a stronger negative association with glucose con-
centrations than does thigh circumference, especially in men.
Larger thigh and hip circumferences could also reflect
increased femoral and gluteal subcutaneous fat mass. Particu-
larly in women, these depots have relatively high lipoprotein
lipase activity and relatively low rates of basal and stimulated
lipolysis (19). These depots may protect the liver and muscle
from high exposure to free fatty acids through uptake and stor-
age. Recently, Van Pelt et al (20) showed that larger leg fat mass
measured by dual-energy X-ray absorptiometry was associated
with better insulin sensitivity and a better lipid profile after
adjustment for trunk fat.
Regional differences in adipocyte metabolism (lipoprotein
lipase activity and lipolysis) are more pronounced in women than
in men (19). This may explain why the observed protective role
of larger thighs was stronger in the women than in the men in the
present study. Furthermore, the interpretation of hip circumfer-
ence may differ between men and women. Gluteal fat mass and
pelvic width may be the main determinants of hip circumference
in women, whereas pelvic width and muscle mass may be the
main determinants in men.
Adrenal and sex steroid concentrations and growth hormone
concentrations may influence visceral fat accumulation as well as
the development of insulin resistance (21–24). For example,
hyperandrogenicity in women and hypoandrogenicity in men has
been associated with insulin sensitivity and the development of
type 2 diabetes (25, 26) and with fat distribution (27–29). These
steroids may influence adipose tissue by changing lipoprotein
lipase activity (7, 22, 25, 30). In the present study, no information
on hormones was available.
Although the exact mechanisms need to be further explored,
the results of the present study show that body tissue distribution
is an important factor in the development of type 2 diabetes in
older persons, even more than is BMI. Therefore, lifestyle inter-
ventions aimed at the prevention of type 2 diabetes not only should
focus on weight loss but should preferably combine
approaches that decrease waist circumference and increase hip
or thigh circumference. Increased physical activity, less heavy
drinking, and smoking cessation have been shown to do both (31).
Energy restriction tends to decrease both waist and hip or thigh
circumference. Increased physical activity results in a better body
composition, by an increase of the muscle mass in the legs and a
decrease in visceral fat accumulation. The better body composi-
tion achieved by smoking cessation and less heavy drinking is sug-
gested to be caused by the influence these have on hormones, as
discussed above. Further research on prevention strategies, how-
ever, is needed.
In summary, larger hip or thigh circumference is associated
with a lower risk of type 2 diabetes in both men and women, inde-
pendently of BMI, age, and waist circumference, whereas larger
waist circumference is associated with higher risk. Further
research should be aimed at determining the underlying etiologic
mechanisms of this association and whether our results can be
extrapolated to other ethnic groups.
MBS performed the data analyses and wrote the drafts and the final article;
JMD, MV, LMB, CDAS, JSY, RJH, GN, and JCS provided advice in the pres-
entation or interpretation of the results; JMD, LMB, CDAS, RJH, and GN were
responsible for the design and data collection of the Hoorn Study; and PJK pro-
vided statistical advice. All authors declare that they had no duality or conflicts
of interest.
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