Waist-to-height ratio outperforms BMI in predicting heart disease risk, particularly among people who are not classified as obese.
A simple comparison between waist size and height may offer a clearer picture of heart disease risk than the long-used body mass index (BMI), according to new findings from physician-scientists at UPMC and the University of Pittsburgh. Unlike BMI, which relies only on height and weight, this measurement captures where body fat is stored, an important factor in cardiovascular health.
The research, published in The Lancet Regional Health—Americas, suggests that current approaches to evaluating heart risk may overlook many people who do not fall into standard obesity categories. As a result, individuals who appear healthy by conventional measures could still face elevated cardiovascular risk.
Waist-to-height outperforms BMI
To reach these conclusions, the researchers analyzed health data from 2,721 adults participating in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). All participants were free of cardiovascular disease at the beginning of the study and were tracked for more than five years, allowing the team to examine how early body measurements related to later heart outcomes.
“Higher BMI, waist circumference, and waist-to-height ratio at baseline were all associated with higher risk of developing future cardiovascular disease—until we adjusted for other classic risk factors, such as age, sex, smoking, exercise, diabetes, hypertension, and cholesterol,” said lead author Thiago Bosco Mendes, clinical instructor of medicine at Pitt and obesity medicine fellow at UPMC. “When we did that, only waist-to-height ratio held as a predictor.”
The strongest signal came from people with a BMI below 30, which is under the standard cutoff for obesity. Many in this group may not consider themselves at risk, even though their waist-to-height ratio indicates a higher likelihood of developing cardiovascular disease later on.
Fat distribution explains hidden risk
BMI doesn’t account for fat distribution or distinguish between harmful, visceral fat and protective, subcutaneous fat. By contrast, waist-to-height ratio (WHtR), calculated by dividing waist circumference by height, directly reflects central obesity, which is more closely linked to heart disease. That means that people with a BMI lower than 30, but a WHtR over 0.5, may be at higher risk of future coronary artery calcification, a key marker of cardiovascular disease, even in the absence of other risk factors.
“Using waist-to-height ratio as a cardiovascular screening tool could lead to earlier identification and intervention for at-risk patients who might otherwise be missed,” said senior author Marcio Bittencourt, associate professor of medicine at Pitt and cardiologist at UPMC. “It’s a simple and powerful way to spot heart disease risk early, even if a patient’s weight, cholesterol and blood pressure all seem normal.”
Reference: “Waist-to-height ratio and coronary artery calcium incidence: the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil)” by Thiago Bosco Mendes, Giuliano Generoso, Ronaldo C. Fabiano, Bruno Halpern, Carolina Castro Porto Silva Janovsky, Carlos Manuel Romero, Raul D. Santos, Isabela Bensenor, Paulo Andrade Lotufo and Marcio Sommer Bittencourt, 31 October 2025, The Lancet Regional Health – Americas.
DOI: 10.1016/j.lana.2025.101281
ELSA-Brasil received funding from the Brazilian National Council for Scientific and Technological Development.
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