Logo Université Laval Logo Université Laval
International Chair on Cardiometabolic Risk
My Healthy Waist

Influence of Ethnicity

Defining CMR - Visceral Adipose Tissue: the Culprit? Causes and Correlates of Visceral Obesity

Key Points

There are clear ethnic differences in BMI and adipose tissue distribution:

  • Asian and Caucasian populations are more likely to accumulate adipose tissue in the visceral cavity than African Americans.
  • Despite a higher BMI, black women are more likely to accumulate fat subcutaneously. Because they are less likely to develop visceral obesity, they may also be less prone than Caucasians to developing the high triglyceride-low-HDL cholesterol dyslipidemic state.
  • Populations characterized by a large amount of visceral adipose tissue generally have a less favourable metabolic risk profile.
  • Caucasian and Asian populations appear to accumulate more visceral adipose tissue and thus seem to be at highest risk of developing type 2 diabetes and CVD for a given BMI value.

The Influence of Ethnicity on Adipose Tissue Distribution

It is well known that there is a marked difference in regional adipose tissue distribution among various populations worldwide. This ethnic difference also applies visceral adipose tissue accumulation. Some populations are more likely to accumulate adipose tissue in the subcutaneous adipose depots whereas other populations are more likely to accumulate adipose tissue in the visceral cavity, placing them at higher risk of developing obesity-related complications. It is therefore crucial that public health authorities around the world identify cases of high-risk obesity associated with excess visceral fat.

The impact of ethnicity on body fat mass in the U.S. population has been studied by McTigue et al. [1] using the National Longitudinal Survey of Youth 1979, a national U.S. study of 9,179 individuals with over sampling of minority ethnic groups. They observed significant ethnic differences in body weight, with black and Hispanic populations at highest risk of obesity when compared to white populations. Obesity onset was 2.1 and 1.5 times faster for black and Hispanic women respectively when compared to white women. The obesity onset pattern for men was slightly different, with Hispanic men being at highest risk.

A World Health Organization (WHO) expert committee has recommended using body mass index (BMI)—the ratio of weight in kilograms divided by height in meters squared—as an index of relative body weight linked to an increased risk of disease.
They proposed a BMI cutoff value of 25 kg/m2 (but below 30 kg/m2) to define overweight. They also reported that a substantial proportion of Asian people were at increased risk of type 2 diabetes and cardiovascular disease (CVD) at BMI values lower than the proposed WHO overweight cutoff point of ≥25 kg/m2 [2].

Furthermore, a meta-analysis of 32 studies has revealed that mean BMI values (kg/m2) were 21.3 for Ethiopians, 22.2 for Chinese, 22.4 for Indonesians, 23.0 for Thais, 24.1 for Caucasians, 25.7 for Blacks, and 29.7 for Polynesians [3]. BMI therefore differs significantly among populations of the same age, sex, and body fatness. Moreover, in Asian populations, a higher body fat content was reported at a lower BMI when compared to Caucasians [4]. These significant ethnic differences in mean BMI may be explained by differences in energy balance as well as intrinsic differences in body composition. In light of this, the general WHO obesity cutoff point of 30 kg/m2 can no longer be applied worldwide without taking into account ethnicity. Revised BMI cutoff points to define obesity have been suggested for South Asians, Chinese and Aboriginals in a publication of Razak et al. [5]. In fact, cutoff BMI values defining obesity in relation to glucose and lipid levels and blood pressure, three significant CVD risk factors, were found to be much lower for these populations than values traditionally used for people of European origin.

Marked differences have also been reported regarding susceptibility to abdominal obesity. Available data suggests that Blacks are more prone to subcutaneous fat accumulation for a given BMI than Whites [6-9], whereas Asians are especially prone to visceral fat accumulation [2,10]. Fujimoto [11] has suggested that genetic predisposition as well as environmental and lifestyle factors may explain differences among various ethnic groups in their susceptibility to abdominal fat accumulation, visceral fat in particular.

For a similar level of total body fat, white subjects have been shown to have more visceral adipose tissue than Blacks [6-9,12]. When white and black men with the same total body fat mass are compared, white men have significantly more visceral fat than black men. Black women generally have higher total body fat mass but less visceral adipose tissue than white women [6,8,9]. This means black women are more prone to subcutaneous obesity than white women. On the other hand, Japanese individuals are more likely to accumulate visceral fat compared to white individuals, despite the fact that they have substantially less total body fat than their American counterparts (Figure 1) [10]. This difference in susceptibility to visceral adiposity may be one factor behind the high rate of type 2 diabetes in Asia.

Ethnic differences on visceral adiposity have also been examined in the large multiethnic INSPIRE ME IAA study [13]. Although having lower overall adiposity levels, East Asian men and women were characterized by a larger relative visceral adipose tissue accumulation than any other ethnic group studied (white, African Caribbean black, Hispanic, Southeast Asian). In addition, such differences in visceral adiposity were even more marked at higher BMI values. The study of ethnic differences in body fat distribution is of particular interest and has generated many publications [14-18].

As a summary, Figure 2 illustrates relative accumulation of visceral vs. subcutaneous depots in Caucasians, Blacks and Asians.

Figure 1:
Evidence for a greater relative accumulation of visceral adipose tissue in Japanese than in Caucasian Americans
Figure 2:
Relative accumulation of visceral vs. subcutaneous depot according to ethnicity

The Influence of Ethnicity on Metabolic Complications

Ethnic differences do seem to influence adipose tissue distribution. It has been suggested that Asian, Hispanic, and Caucasian populations are particularly prone to visceral obesity and its associated health risks.

Compared to Whites, Blacks generally have a better lipoprotein-lipid profile, including lower fasting triglyceride and apolipoprotein B levels as well as higher HDL cholesterol concentrations [6,8,9]. Després et al. [8] have found that visceral adipose tissue accumulation was a critical correlate of plasma triglycerides, apolipoprotein B, and HDL cholesterol, suggesting that the more favourable metabolic profile of black individuals could be due to the fact that they are less prone to visceral fat deposition than white individuals. Black subjects also have significantly higher postheparin hepatic lipase and lower hepatic lipase activity than white subjects, both in men and women [8]. The low hepatic lipase activities in Blacks may have a genetic basis and contribute to their higher plasma HDL cholesterol concentrations when compared to Whites [19].

Though they have less visceral adipose tissue accumulation, black women are especially prone to insulin resistance. This finding holds up even after matching them with white women for age, degree of obesity, and waist-to-hip ratio as a relative index of abdominal obesity [9]. Among women, upper body obesity independent of total body fatness has been shown to be less detrimental to black women than to white women with regard to the risk of developing diabetes and CVD [20]. This could be explained by the fact that black women are more likely than white women to store their excess trunk fat subcutaneously.

Despite lower BMI indices, Asian populations have an increased tendency to accumulate visceral adipose tissue and are more prone to develop type 2 diabetes and CVD [21-23]. Several studies have also shown that Japanese Americans have a greater amount of visceral adipose tissue along with a higher prevalence of type 2 diabetes [24,25]. In fact, among all populations examined, Asians, Hispanics, and North American aboriginals have the highest rates of type 2 diabetes [21].

Adiponectin concentrations—which are inversely associated with the level of obesity— have been shown to be higher in American men (whites 99%) than in Japanese men, despite American men’s higher levels of obesity [26]. It has been suggested that American men’s smaller relative visceral adipose tissue deposition may account for this difference. These results are supported by Côté et al. [27], who have emphasized that adiponectin is more influenced by visceral than subcutaneous adiposity.

Finally, ethnic differences in the prevalence of metabolic syndrome have also been observed. In the United States, Hispanics were characterized by the highest prevalence of the metabolic syndrome while African-Americans had the lowest prevalence [28]. In Canada, the prevalence of the metabolic syndrome was 41.6% in Native Indians, 25.9% in South Asians, 22.0% in Europeans and 11.0% in Chinese [29]. The influence of ethnicity of metabolic syndrome has been reviewed by Lear and Gasevic [30].

There is growing literature on the impact of ethnicity on adipose tissue distribution. It has been proposed that the greater propensity of some populations to accumulate visceral adipose tissue could explain their higher rates of type 2 diabetes and CVD. Further research is needed to establish a clear definition of high-risk abdominal obesity in various populations worldwide. Large epidemiological studies that use computed tomography and metabolic profiling to measure visceral fat directly hold out the greatest potential. These methods will enable researchers to propose ethnicity-specific waist circumference values predictive of excess visceral adiposity and related health risk worldwide.

References

  1. McTigue KM, Garrett JM and Popkin BM. The natural history of the development of obesity in a cohort of young U.S. adults between 1981 and 1998. Ann Intern Med 2002; 136: 857-64.

    PubMed ID: 12069559

  2. WHO Expert Consultation. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet 2004; 363: 157-63.

    PubMed ID: 14726171

  3. Deurenberg P, Yap M and van Staveren WA. Body mass index and percent body fat: a meta analysis among different ethnic groups. Int J Obes Relat Metab Disord 1998; 22: 1164-71.

    PubMed ID: 9877251

  4. Deurenberg P, Deurenberg-Yap M and Guricci S. Asians are different from Caucasians and from each other in their body mass index/body fat per cent relationship. Obes Rev 2002; 3: 141-6.

    PubMed ID: 12164465

  5. Razak F, Anand SS, Shannon H, et al. Defining Obesity Cut Points in a Multiethnic Population. Circulation 2007.

    PubMed ID: 17420343

  6. Albu JB, Murphy L, Frager DH, et al. Visceral fat and race-dependent health risks in obese nondiabetic premenopausal women. Diabetes 1997; 46: 456-62.

    PubMed ID: 9032103

  7. Conway JM, Chanetsa FF and Wang P. Intrabdominal adipose tissue and anthropometric surrogates in African American women with upper- and lower-body obesity. Am J Clin Nutr 1997; 66: 1345-51.

    PubMed ID: 9394685

  8. Després JP, Couillard C, Gagnon J, et al. Race, visceral adipose tissue, plasma lipids, and lipoprotein lipase activity in men and women: the Health, Risk Factors, Exercise Training, and Genetics (HERITAGE) family study. Arterioscler Thromb Vasc Biol 2000; 20: 1932-8.

    PubMed ID: 10938014

  9. Lovejoy JC, de la Bretonne JA, Klemperer M, et al. Abdominal fat distribution and metabolic risk factors: effects of race. Metabolism 1996; 45: 1119-24.

    PubMed ID: 8781299

  10. Kadowaki T, Sekikawa A, Murata K, et al. Japanese men have larger areas of visceral adipose tissue than Caucasian men in the same levels of waist circumference in a population-based study. Int J Obes (Lond) 2006; 30: 1163-5.

    PubMed ID: 16446744

  11. Fujimoto WY. Overview of non-insulin-dependent diabetes mellitus (NIDDM) in different population groups. Diabet Med 1996; 13: S7-10.

    PubMed ID: 8894472

  12. Hoffman DJ, Wang Z, Gallagher D, et al. Comparison of visceral adipose tissue mass in adult African Americans and whites. Obes Res 2005; 13: 66-74.

    PubMed ID: 15761164

  13. Nazare JA, Smith JD, Borel AL, et al. Ethnic influences on the relations between abdominal subcutaneous and visceral adiposity, liver fat, and cardiometabolic risk profile: the International Study of Prediction of Intra-Abdominal Adiposity and Its Relationship With Cardiometabolic Risk/Intra-Abdominal Adiposity. Am J Clin Nutr 2012; 96: 714-26.

    PubMed ID: 22932278

  14. Carroll JF, Fulda KG, Chiapa AL, et al. Impact of race/ethnicity on the relationship between visceral fat and inflammatory biomarkers. Obesity (Silver Spring) 2009; 17: 1420-7.

    PubMed ID: 19197255

  15. Katzmarzyk PT, Bray GA, Greenway FL, et al. Racial differences in abdominal depot-specific adiposity in white and African American adults. Am J Clin Nutr 2010; 91: 7-15.

    PubMed ID: 20448537

  16. Kohli S, Sniderman AD, Tchernof A, et al. Ethnic-specific differences in abdominal subcutaneous adipose tissue compartments. Obesity (Silver Spring) 2010; 18: 2177-83.

    PubMed ID: 20448537

  17. Kohli S and Lear SA. Differences in subcutaneous abdominal adiposity regions in four ethnic groups. Obesity (Silver Spring) 2013; 21: 2288-95.

    PubMed ID: 23703792

  18. Sam S. Differential effect of subcutaneous abdominal and visceral adipose tissue on cardiometabolic risk. Horm Mol Biol Clin Investig 2018; 33:/j/hmbci.2018.33.issue-1/hmbci-2018-0014/hmbci-2018-0014.xml.

    PubMed ID: 29522417

  19. Vega GL, Clark LT, Tang A, et al. Hepatic lipase activity is lower in African American men than in white American men: effects of 5′ flanking polymorphism in the hepatic lipase gene (LIPC). J Lipid Res 1998; 39: 228-32.

    PubMed ID: 9469601

  20. Dowling HJ and Pi-Sunyer FX. Race-dependent health risks of upper body obesity. Diabetes 1993; 42: 537-43.

    PubMed ID: 8454103

  21. Abate N and Chandalia M. The impact of ethnicity on type 2 diabetes. J Diabetes Complications 2003; 17: 39-58.

    PubMed ID: 12505756

  22. Ramachandran A, Snehalatha C, Viswanathan V, et al. Risk of noninsulin dependent diabetes mellitus conferred by obesity and central adiposity in different ethnic groups: a comparative analysis between Asian Indians, Mexican Americans and Whites. Diabetes Res Clin Pract 1997; 36: 121-5.

    PubMed ID: 9229196

  23. McKeigue PM, Shah B and Marmot MG. Relation of central obesity and insulin resistance with high diabetes prevalence and cardiovascular risk in South Asians. Lancet 1991; 337: 382-6.

    PubMed ID: 1671422

  24. Boyko EJ, Leonetti DL, Bergstrom RW, et al. Visceral adiposity, fasting plasma insulin, and blood pressure in Japanese-Americans. Diabetes Care 1995; 18: 174-81.

    PubMed ID: 7729294

  25. Fujimoto WY, Bergstrom RW, Boyko EJ, et al. Visceral adiposity and incident coronary heart disease in Japanese-American men. The 10-year follow-up results of the Seattle Japanese-American Community Diabetes Study. Diabetes Care 1999; 22: 1808-12.

    PubMed ID: 10546012

  26. Kadowaki T, Sekikawa A, Okamura T, et al. Higher levels of adiponectin in American than in Japanese men despite obesity. Metabolism 2006; 55: 1561-3.

    PubMed ID: 17142124

  27. Côté M, Mauriège P, Bergeron J, et al. Adiponectinemia in visceral obesity: impact on glucose tolerance and plasma lipoprotein and lipid levels in men. J Clin Endocrinol Metab 2005; 90: 1434-9.

    PubMed ID: 15598678

  28. Aguilar M, Bhuket T, Torres S, et al. Prevalence of the metabolic syndrome in the United States, 2003-2012. JAMA 2015; 313: 1973-4.

    PubMed ID: 25988468

  29. Anand SS, Yi Q, Gerstein H, et al. Relationship of metabolic syndrome and fibrinolytic dysfunction to cardiovascular disease. Circulation 2003; 108: 420-5.

    PubMed ID: 12860914

  30. Lear SA and Gasevic D. Ethnicity and metabolic syndrome: implications for assessment, management and prevention. Nutrients 2019; 12: 15.

    PubMed ID: 31861719
Reference 1 CLOSECLOSE

McTigue KM, Garrett JM and Popkin BM. The natural history of the development of obesity in a cohort of young U.S. adults between 1981 and 1998. Ann Intern Med 2002; 136: 857-64.

PubMed ID: 12069559
Reference 2 CLOSECLOSE

WHO Expert Consultation. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet 2004; 363: 157-63.

PubMed ID: 14726171
Reference 3 CLOSECLOSE

Deurenberg P, Yap M and van Staveren WA. Body mass index and percent body fat: a meta analysis among different ethnic groups. Int J Obes Relat Metab Disord 1998; 22: 1164-71.

PubMed ID: 9877251
Reference 4 CLOSECLOSE

Deurenberg P, Deurenberg-Yap M and Guricci S. Asians are different from Caucasians and from each other in their body mass index/body fat per cent relationship. Obes Rev 2002; 3: 141-6.

PubMed ID: 12164465
Reference 5 CLOSECLOSE

Razak F, Anand SS, Shannon H, et al. Defining Obesity Cut Points in a Multiethnic Population. Circulation 2007.

PubMed ID: 17420343
Reference 6 CLOSECLOSE

Albu JB, Murphy L, Frager DH, et al. Visceral fat and race-dependent health risks in obese nondiabetic premenopausal women. Diabetes 1997; 46: 456-62.

PubMed ID: 9032103
Reference 7 CLOSECLOSE

Conway JM, Chanetsa FF and Wang P. Intrabdominal adipose tissue and anthropometric surrogates in African American women with upper- and lower-body obesity. Am J Clin Nutr 1997; 66: 1345-51.

PubMed ID: 9394685
Reference 8 CLOSECLOSE

Després JP, Couillard C, Gagnon J, et al. Race, visceral adipose tissue, plasma lipids, and lipoprotein lipase activity in men and women: the Health, Risk Factors, Exercise Training, and Genetics (HERITAGE) family study. Arterioscler Thromb Vasc Biol 2000; 20: 1932-8.

PubMed ID: 10938014
Reference 9 CLOSECLOSE

Lovejoy JC, de la Bretonne JA, Klemperer M, et al. Abdominal fat distribution and metabolic risk factors: effects of race. Metabolism 1996; 45: 1119-24.

PubMed ID: 8781299
Reference 10 CLOSECLOSE

Kadowaki T, Sekikawa A, Murata K, et al. Japanese men have larger areas of visceral adipose tissue than Caucasian men in the same levels of waist circumference in a population-based study. Int J Obes (Lond) 2006; 30: 1163-5.

PubMed ID: 16446744
Reference 11 CLOSECLOSE

Fujimoto WY. Overview of non-insulin-dependent diabetes mellitus (NIDDM) in different population groups. Diabet Med 1996; 13: S7-10.

PubMed ID: 8894472
Reference 12 CLOSECLOSE

Hoffman DJ, Wang Z, Gallagher D, et al. Comparison of visceral adipose tissue mass in adult African Americans and whites. Obes Res 2005; 13: 66-74.

PubMed ID: 15761164
Reference 13 CLOSECLOSE

Nazare JA, Smith JD, Borel AL, et al. Ethnic influences on the relations between abdominal subcutaneous and visceral adiposity, liver fat, and cardiometabolic risk profile: the International Study of Prediction of Intra-Abdominal Adiposity and Its Relationship With Cardiometabolic Risk/Intra-Abdominal Adiposity. Am J Clin Nutr 2012; 96: 714-26.

PubMed ID: 22932278
Reference 14 CLOSECLOSE

Carroll JF, Fulda KG, Chiapa AL, et al. Impact of race/ethnicity on the relationship between visceral fat and inflammatory biomarkers. Obesity (Silver Spring) 2009; 17: 1420-7.

PubMed ID: 19197255
Reference 15 CLOSECLOSE

Katzmarzyk PT, Bray GA, Greenway FL, et al. Racial differences in abdominal depot-specific adiposity in white and African American adults. Am J Clin Nutr 2010; 91: 7-15.

PubMed ID: 20448537
Reference 16 CLOSECLOSE

Kohli S, Sniderman AD, Tchernof A, et al. Ethnic-specific differences in abdominal subcutaneous adipose tissue compartments. Obesity (Silver Spring) 2010; 18: 2177-83.

PubMed ID: 20448537
Reference 17 CLOSECLOSE

Kohli S and Lear SA. Differences in subcutaneous abdominal adiposity regions in four ethnic groups. Obesity (Silver Spring) 2013; 21: 2288-95.

PubMed ID: 23703792
Reference 18 CLOSECLOSE

Sam S. Differential effect of subcutaneous abdominal and visceral adipose tissue on cardiometabolic risk. Horm Mol Biol Clin Investig 2018; 33:/j/hmbci.2018.33.issue-1/hmbci-2018-0014/hmbci-2018-0014.xml.

PubMed ID: 29522417
Reference 19 CLOSECLOSE

Vega GL, Clark LT, Tang A, et al. Hepatic lipase activity is lower in African American men than in white American men: effects of 5′ flanking polymorphism in the hepatic lipase gene (LIPC). J Lipid Res 1998; 39: 228-32.

PubMed ID: 9469601
Reference 20 CLOSECLOSE

Dowling HJ and Pi-Sunyer FX. Race-dependent health risks of upper body obesity. Diabetes 1993; 42: 537-43.

PubMed ID: 8454103
Reference 21 CLOSECLOSE

Abate N and Chandalia M. The impact of ethnicity on type 2 diabetes. J Diabetes Complications 2003; 17: 39-58.

PubMed ID: 12505756
Reference 22 CLOSECLOSE

Ramachandran A, Snehalatha C, Viswanathan V, et al. Risk of noninsulin dependent diabetes mellitus conferred by obesity and central adiposity in different ethnic groups: a comparative analysis between Asian Indians, Mexican Americans and Whites. Diabetes Res Clin Pract 1997; 36: 121-5.

PubMed ID: 9229196
Reference 23 CLOSECLOSE

McKeigue PM, Shah B and Marmot MG. Relation of central obesity and insulin resistance with high diabetes prevalence and cardiovascular risk in South Asians. Lancet 1991; 337: 382-6.

PubMed ID: 1671422
Reference 24 CLOSECLOSE

Boyko EJ, Leonetti DL, Bergstrom RW, et al. Visceral adiposity, fasting plasma insulin, and blood pressure in Japanese-Americans. Diabetes Care 1995; 18: 174-81.

PubMed ID: 7729294
Reference 25 CLOSECLOSE

Fujimoto WY, Bergstrom RW, Boyko EJ, et al. Visceral adiposity and incident coronary heart disease in Japanese-American men. The 10-year follow-up results of the Seattle Japanese-American Community Diabetes Study. Diabetes Care 1999; 22: 1808-12.

PubMed ID: 10546012
Reference 26 CLOSECLOSE

Kadowaki T, Sekikawa A, Okamura T, et al. Higher levels of adiponectin in American than in Japanese men despite obesity. Metabolism 2006; 55: 1561-3.

PubMed ID: 17142124
Reference 27 CLOSECLOSE

Côté M, Mauriège P, Bergeron J, et al. Adiponectinemia in visceral obesity: impact on glucose tolerance and plasma lipoprotein and lipid levels in men. J Clin Endocrinol Metab 2005; 90: 1434-9.

PubMed ID: 15598678
Reference 28 CLOSECLOSE

Aguilar M, Bhuket T, Torres S, et al. Prevalence of the metabolic syndrome in the United States, 2003-2012. JAMA 2015; 313: 1973-4.

PubMed ID: 25988468
Reference 29 CLOSECLOSE

Anand SS, Yi Q, Gerstein H, et al. Relationship of metabolic syndrome and fibrinolytic dysfunction to cardiovascular disease. Circulation 2003; 108: 420-5.

PubMed ID: 12860914
Reference 30 CLOSECLOSE

Lear SA and Gasevic D. Ethnicity and metabolic syndrome: implications for assessment, management and prevention. Nutrients 2019; 12: 15.

PubMed ID: 31861719