Protocol - Waist Circumference - Framingham Heart Study

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Waist circumference is measured at several body sites in the scientific literature. This protocol is from the Framingham Heart Study in which measurement of the participant’s waist circumference is performed at the level of the umbilicus (i.e., navel or "belly button"). Although this protocol is still used in surveys and studies, care should be taken in using it because it does not rely on reliable bony landmarks and is biased by degree of abdominal obesity. On the other hand, unlike the protocols that require palpation for bony landmarks (which may be problematic with some populations), an umbilicus is visualized or can be located through thin clothing. In both children and adults and compared with measurements taken using other protocols, measurements taken at the level of the umbilicus tend to be roughly comparable with those taken midway between the lowest rib and iliac crest (NCFS protocol) if the participants are at a normal weight, but measurements tend to be more comparable with or even larger than those taken over the iliac crest (NHANES protocol) when the participant is obese and the umbilicus has been displaced downward (i.e., pendulous abdomen). The relationship of this measure with cardiometabolic risk factors is, however, comparable with waist circumference measures taken at other sites.

NOTE: Waist circumference can be measured on pregnant women. However, national reference data do not include pregnant women, and waist circumference has different associations with abdominal and total body fat among those who are not pregnant.

Specific Instructions

Several overarching, critical issues for high-quality data collection of anthropometric measures that optimize the data in gene-environment etiologic research include (1) the need for training (and retraining) of study staff in anthropometric data collection; (2) duplicate collection of measurements, especially under field conditions; (3) use of more than one person for proper collection of measurements where required; (4) accurate recording of the protocols and measurement units of data collection; and (5) use of required and properly calibrated equipment.

The notion of recommending replicate measurements comes from the reduction in random errors of measurement and accompanying improved measurement reliability when the mean of multiple measurements is used rather than a single measurement. This improvement in measurement reliability, however, depends on the reliability of a single measurement in the hands of the data collectors in a particular study (Himes, 1989). For example, if a measure such as recumbent length in a given study has a measurement reliability of 0.95 (expressed as an intraclass correlation coefficient), taking a second measurement and using the mean of the two measurements in analyses will improve the reliability to only 0.97, yielding only a 2% reduction in error variance for the additional effort. If, in the same study, the reliability of a single triceps skinfold measurement was 0.85, using the mean, including a replicate measurement, would raise the reliability to 0.92 and yield a 7% reduction in error variance, more than a three-fold improvement compared with recumbent length. The intraclass correlation coefficient is specifically recommended here for assessing reliability because it takes account of both random and systematic errors of measurement, whereas the interclass correlation (e.g., Pearson correlation) takes account of only random errors of measurement.

Because the benefits of taking replicate measurements are so closely linked with the existing measurement reliability, it is recommended that as a part of the training of those who will be collecting anthropometry data, a reliability study be conducted that will yield measurement reliability estimates for the data collectors, protocols, settings and participants involved in that particular study (Himes, 1989). If the measurement reliability for a single measurement is greater than or equal to 0.95, the recommendation is that replicate measurements are not necessary and will yield little practical benefit. If the measurement reliability is less than 0.95, the recommendation is to include replicate measurements as prescribed.

If replicate measurements are indicated because of relatively low reliability, a second measurement should be taken, including repositioning the participant. A third measurement should be taken if the first two measurements differ by more than 1.0 cm in those 12 years or older and more than 0.50 cm in those younger than 12 years. If it is necessary to take a third measurement, the two closest measurements are averaged. Should the third measurement fall equally between the first two measurements, all three should be averaged.




Note: Hospital gown or correct underclothing should be worn by the participant before measurement.

Waist circumference measured at the umbilicus:

The waist circumference is the horizontal plane centered on the umbilicus of the participant (see Exhibit 2). Note that the umbilicus may be embedded in sagging fat in extremely obese participants.

Follow the procedures below to obtain this measure.

1. Participant stands erect, arms hanging loosely at sides, weight equally distributed on both feet, head facing straight ahead.

2. The technician will take the gown from the back and place it over the shoulder of the participant. The technician will ask the participant to bend their arms at the elbow and hold the gown in place.

3. Apply anthropometric tape at the level of the umbilicus.

4. Apply tape snugly but not tightly.

5. Make sure the tape is horizontal and not twisted, checking from both the front and back by using 2 mirrors mounted to the wall.

6. Before recording measurement, ask the participant to fully relax their shoulders.

7. Record measurement to the nearest 0.1 cm. For off-site visits, the waist measurement will be done without using a mirror. A code should be entered to capture this as a protocol modification.

Exhibit 2. Location of Measurement at Umbilicus

Graphic from the Framingham Heart Study. Personal Communication, J. Murabito.

Interpretation of Findings

Waist circumference has become an important indicator of obesity and especially of abdominal obesity, including visceral and subcutaneous fat at the site measured. Often, it is compared with appropriate reference data for populations. The exact site, ages, and protocol used in the reference data need to carefully identified; although several different body sites have been used, the actual measurement may differ considerably based on the site measured. Investigators should be sure to match the specific location of the waist circumference measurement with the reference data used.

Waist circumference is often a measurement criterion for defining metabolic syndrome. Because of the considerable changes in waist circumference with age and variation by gender, attention must be given to these factors when interpreting results.

Several references are provided as follows for discussions of appropriate applications of waist circumference measurements and applications related to waist-to-hip ratio and metabolic syndrome.

Personnel and Training Required

Trained examiner: Individuals need to be trained to identify the waist location on persons of varying body mass; training should include dexterity in wrapping the tape around participants, in ensuring a horizontal plane for measurement, in using one standardized tape measure, in positioning the tape measure; and in knowing how to measure adults and children. A pocket guide detailing the protocol is helpful for personnel to carry for review. Training should include methods for recording (e.g., forms, computer screens). Have all personnel practice on the same people to compare reproducibility of measurements and verify against an expert examiner to assure validity; retrain regularly on the same volunteer to ensure reproducibility.

Equipment Needs

Flexible measuring tape

Requirement CategoryRequired
Major equipment No
Specialized training No
Specialized requirements for biospecimen collection No
Average time of greater than 15 minutes in an unaffected individual No
Mode of Administration

Physical Examination


Infant, Toddler, Child, Adolescent, Adult, Senior


Participant aged 16 years or older, although the protocol can be used at ages 2 years or older

Selection Rationale

The state of the science does not indicate a clear choice of protocol at this time. Therefore, the PhenX Expert Review Panel recommends that one protocol be selected in measuring the waist circumference and that the protocol correspond to the reference data used. Further, the exact protocol used should be recorded and reported.

These recommendations differ from those included in the original PhenX datasheets. Previously, slightly different protocols were recommended for youth and adults; these are now combined into three protocols appropriate for all age groups. Also, it is now recommended that only one protocol be used in a particular study rather than using all three protocols.


English, Other languages available at source

Human Phenotype Ontology Abnormal waist to hip ratio HP:0031818 HPO
caDSR Form PhenX PX021603 - Waist Circumference Framingham Heart Study 5806360 caDSR Form
Derived Variables

Waist-to-Hip Ratio (WHR), Waist-to-Height Ratio (WHtR)

Process and Review

The Expert Review Panel #1 reviewed the measures in the Anthropometrics, Diabetes, Physical Activity and Physical Fitness, and Nutrition and Dietary Supplements domains.

Guidance from the ERP includes:

• Added replicate measure language

• Changed unit of measurement

Back-compatible: no changes to Data Dictionary

Previous version in Toolkit archive (link)

Protocol Name from Source

Framingham Heart Study - Offspring Cohort, Exam 5, 1994


National Heart, Lung, and Blood Institute, & Boston University. (1994). Framingham Heart Study - Offspring Cohort, Exam 5. Retrieved from http://tinyurl.com/6n6wez

General References

Because of the variability in the site of measurement of waist circumference, different cutoffs for metabolic syndrome in adults of various racial/ethnic groups, and variations among different populations of children and adolescents, more references are provided for potential users than for some other anthropometric measurements. Further, publications providing percentile curves (often including the 90th percentile) for children and adolescents have been included in the references as examples that may be suitable reference data for some investigations.

Alberti, K. G., Eckel, R. H., Grundy, S. M., Zimmet, P. Z., Cleeman, J. I., Donato, K. A., . . . Smith, S. C. (2009). Harmonizing the metabolic syndrome: A joint interim statement of the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity. Circulation, 120(16), 1640-1645.

Brannsether, B., Roelants, M., Bjerknes, R., & Júlíusson, P. B. (2011). Waist circumference and waist-to-height ratio in Norwegian children 4-18 years of age: Reference values and cut-off levels. Acta Paediatrica, 100(12), 1576-82.

Bergen Growth Study, 2,945 boys and 2,780 girls, aged 4-18 years

Freedman, D. S., Serdula, M. K., Srinivasan, S. R., & Berenson, G. S. (1999). Relation of circumferences and skinfold thicknesses to lipid and insulin concentrations in children and adolescents: The Bogalusa Heart Study. American Journal of Clinical Nutrition, 69(2), 308-317.

Galcheva, S. V., Iotova, V. M., Yotov, Y. T., Grozdeva, K. P., Stratev, V. K., & Tzaneva, V. I. (2009). Waist circumference percentile curves for Bulgarian children and adolescents aged 6-18 years. International Journal of Pediatric Obesity, 4(4), 381-388.

Bulgarian children, 2,052 boys and 1,758 girls, aged 6-18 years

Harrington, D. M., Staiano, A. E., Broyles, S. T., Gupta, A. K., & Katzmarzyk, P. K. (2012). Waist circumference measurement site does not affect relationships with visceral adiposity and cardiometabolic risk factors in children. Pediatric Obesity, 8(3), 199-206.

Jackson, R. T., Al Hamad, N., Prakash, P., & Al Somaie. M. (2011). Waist circumference percentiles for Kuwaiti children and adolescents. Public Health Nutrition, 14(1), 70-76.

Kuwait Nutrition Surveillance System (KNSS), schoolchildren, 4,843 boys and 4,750 girls, aged 5-18.9 years

Ji, C. Y., Yt Sung, R., Ma, G. S., Ma, J., He, Z. H., & Chen, T. J. (2010). Waist circumference distribution of Chinese school-age children and adolescents. Biomedical and Environmental Sciences, 23(1), 12-20.

Hong Kong and 15 mainland China provinces, 160,225 children and adolescents, aged 7-18 years

Kuriyan, R., Thomas, T., Lokesh, D. P., Sheth, N. R., Mahendra, A., Joy, R., . . . Kurpad, A. V. (2011). Waist circumference and waist for height percentiles in urban South Indian children aged 3-16 years. Indian Pediatrics, 48(10), 765-771.

PEACH (Pediatric Epidemiology and Child Health) Study, Bangalore, urban preschool- and school-age children, 5,172 boys and 3,888 girls, aged 3-16 years

Mancini, M. C. (2009). Metabolic syndrome in children and adolescents: Criteria for diagnosis. Diabetology & Metabolic Syndrome, 1, 20 doi:10.1186/1758-5996-1-20

Mason, C., & Katzmarzyk, P. T. (2009). Variability in waist circumference measurements according to anatomic measurement site. Obesity, 17(9), 1789-1795. doi:10.1038/oby.2009.87

Ross, R., Berentzen, T., Bradshaw, A. J., Janssen, I., Kahn, H. S., Katzmarzyk, P. T., . . . Després, J. P. (2008). Does the relationship between waist circumference, morbidity and mortality depend on measurement protocol for waist circumference? Obesity Reviews, 9(4), 312-325.

Samson, S. L., & Garber, A. J. (2014). Metabolic syndrome. Endocrinology Metabolism Clinics of North America, 43, 1-23.

World Health Organization. (2011). Waist circumference and waist-hip ratio: Report of a WHO expert consultation, Geneva, 8-11 December 2008. World Health Organization: Geneva.

Zannolli, R., & Morgese, G. (1996). Waist percentiles: A simple test for atherogenic disease? Acta Paediatrica, 85(11), 1368-1369.

Pescara, Central Italy (Abruzzo), schoolchildren, 1,440 boys and 1,418 girls, aged 6-14 years

Protocol ID


Export Variables
Variable Name Variable IDVariable DescriptiondbGaP Mapping
PX021603020400 What was the average waist measurement? N/A
PX021603020100 What was the waist measurement? Variable Mapping
PX021603020200 What was the waist measurement? N/A
PX021603020300 What was the waist measurement? N/A
PX021603010000 With the subject standing upright with feet more
together, arms hanging loosely at sides, and weight evenly distributed, did the examiner take the subject's hospital gown from the back, place it over the shoulder, place the anthropometric tape at the leve show less
Measure Name

Waist Circumference

Release Date

March 27, 2009


Waist circumference is a measurement to estimate the abdominal circumference.


The measure of waist circumference is an indirect measure of abdominal fatness (central obesity), and a large waist circumference is associated with increased risk for diseases such as types 1 and 2 diabetes, dyslipidemia, hypertension, and cardiovascular disease. It is often used in conjunction with hip circumference to calculate the waist-to-hip ratio.


Anthropometrics, abdominal obesity, obesity, weight, girth, Waist-To-Hip Ratio, WHR, Waist-to-Height Ratio, WtHR, metabolic syndrome, NHANES, NCFS

Measure Protocols
Protocol ID Protocol Name
21601 Waist Circumference - Waist Circumference NHANES
21602 Waist Circumference - Waist Circumference NCFS
21603 Waist Circumference - Framingham Heart Study

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