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International Chair on Cardiometabolic Risk
My Healthy Waist

Sagittal Diameter

Evaluating CMR - Clinical Tools

Key Points

  • Sagittal diameter is the distance between the back and the highest point of the abdomen.
  • Increased sagittal diameter is linked to increased visceral adiposity and related cardiometabolic risk.
  • Sagittal diameter has suggested to be slightly superior to waist circumference as an index of abdominal adiposity although its relevance to clinical practice as opposed to waist remains debated.

Sagittal Diameter, Health Risk, and Visceral Fat

The abdominal sagittal diameter is associated with cardiovascular disease [1,2] and mortality [3,4]. There is evidence that the sagittal diameter is better than the body mass index to identify individuals at increased cardiometabolic risk [5,6]. Additional data suggest that abdominal sagittal diameter is slightly better than the waist circumference for the discrimination of assessing health risk [6-11], although inconsistent findings have been reported [12-16]. In general, most studies show that sagittal diameter and waist circumference are linked to health risk at any BMI value. Many imaging studies have also revealed that both waist circumference and abdominal sagittal diameter are related to visceral adiposity (Figure 1) [16-22]. To date, there are no universally recommended sagittal diameter categories to classify health risk and/or abdominal adiposity although cut-off values have been proposed by some investigators [10,16,23]. However, using a representative survey of Finnish adults, normative reference values for sagittal diameter have been proposed [24]. Currently, waist circumference is a more frequently used measure of abdominal adiposity in clinical settings, perhaps due to its easiness of use. Moreover, it is unclear whether measuring the abdominal sagittal diameter provides any clear advantage over the assessment of waist circumference. Nevertheless, abdominal sagittal diameter is also a simple, inexpensive tool that can be used to assess abdominal obesity and related health risk.

Figure 1:
Relationship between visceral fat with waist circumference (A) and sagittal diameter (B)

Measuring Sagittal Diameter

Abdominal sagittal diameter is commonly assessed using a sagittometer (i.e., a sliding beam caliper with a ruler). As for waist circumference, sagittal diameter is typically measured between the top of the iliac crest and the minimal waist. There is no consensus as to optimal landmarking or methodology. Sagittal diameter should be measured at the end of a normal expiration while the individual is relaxed and in a standing or supine position (Figure 2). To measure sagittal diameter, one of the calipers should be positioned on the individual’s back at the level of the landmark and close the other caliper until it touches the individual’s abdomen. The calipers should be parallel to the ground if the individual is standing and perpendicular to the ground if the individual is supine. The calipers should be snug without indenting the individual’s skin.

There is no firm evidence to prove whether measuring sagittal diameter in the standing or supine position provides a better indicator of visceral adiposity or health risk. Sagittal diameter measured in the standing position will generally be larger than measures in the supine position. The measurement difference will depend on the individual’s degree of obesity and abdominal fat distribution. However, as measures of standing and supine sagittal diameters are related, both may provide comparable estimates of visceral adiposity and related health risk.

Because measuring waist circumference only requires a tape as opposed to a specific tool (caliper) for the sagittal diameter, this may explain why clinical guidelines have recommended waist circumference as a simple measure of abdominal adiposity. However, the sagittal diameter is a good measure of visceral adiposity and related health risk

Figure 2:
Measurement of sagittal diameter in the standing and supine positions

References

  1. Empana JP, Ducimetiere P, Charles MA, et al. Sagittal abdominal diameter and risk of sudden death in asymptomatic middle-aged men: the Paris Prospective Study I. Circulation 2004; 110: 2781-5.

    PubMed ID: 15492315

  2. Radholm K, Tengblad A, Dahlen E, et al. The impact of using sagittal abdominal diameter to predict major cardiovascular events in European patients with type 2 diabetes. Nutr Metab Cardiovasc Dis 2017; 27: 418-22.

    PubMed ID: 28390663

  3. Ohrvall M, Berglund L and Vessby B. Sagittal abdominal diameter compared with other anthropometric measurements in relation to cardiovascular risk. Int J Obes Relat Metab Disord 2000; 24: 497-501.

    PubMed ID: 10805508

  4. Seidell JC, Andres R, Sorkin JD, et al. The sagittal waist diameter and mortality in men: the Baltimore Longitudinal Study on Aging. Int J Obes Relat Metab Disord 1994; 18: 61-7.

    PubMed ID: 8130817

  5. Kahn HS and Bullard KM. Beyond body mass index: advantages of abdominal measurements for recognizing cardiometabolic disorders. Am J Med 2016; 129: 74-81.

    PubMed ID: 26302146

  6. Kahn HS, Gu Q, Bullard KM, et al. Population distribution of the sagittal abdominal diameter (SAD) from a representative sample of US adults: comparison of SAD, waist circumference and body mass index for identifying dysglycemia. PLoS One 2014; 9: e108707.

    PubMed ID: 25272003

  7. Petersson H, Daryani A and Riserus U. Sagittal abdominal diameter as a marker of inflammation and insulin resistance among immigrant women from the Middle East and native Swedish women: a cross-sectional study. Cardiovasc Diabetol 2007; 6: 10.

    PubMed ID: 17391519

  8. Riserus U, Arnlov J, Brismar K, et al. Sagittal abdominal diameter is a strong anthropometric marker of insulin resistance and hyperproinsulinemia in obese men. Diabetes Care 2004; 27: 2041-6.

    PubMed ID: 15277437

  9. Smith DA, Ness EM, Herbert R, et al. Abdominal diameter index: a more powerful anthropometric measure for prevalent coronary heart disease risk in adult males. Diabetes Obes Metab 2005; 7: 370-80.

    PubMed ID: 15955123

  10. Madden AM and Smith S. Body composition and morphological assessment of nutritional status in adults: a review of anthropometric variables. J Hum Nutr Diet 2016; 29: 7-25.

    PubMed ID: 25420774

  11. Gletsu-Miller N, Kahn HS, Gasevic D, et al. Sagittal abdominal diameter and visceral adiposity: correlates of beta-cell function and dysglycemia in severely obese women. Obes Surg 2013; 23: 874-81.

    PubMed ID: 23408092

  12. Vasques AC, Cassani RS, Forti AC, et al. Sagittal abdominal diameter as a surrogate marker of insulin resistance in an admixtured population–Brazilian Metabolic Syndrome Study (BRAMS). PLoS One 2015; 10: e0125365.

    PubMed ID: 25951458

  13. Turcato E, Bosello O, Di Francesco V, et al. Waist circumference and abdominal sagittal diameter as surrogates of body fat distribution in the elderly: their relation with cardiovascular risk factors. Int J Obes Relat Metab Disord 2000; 24: 1005-10.

    PubMed ID: 10951539

  14. Mukuddem-Petersen J, Snijder MB, van Dam RM, et al. Sagittal abdominal diameter: no advantage compared with other anthropometric measures as a correlate of components of the metabolic syndrome in elderly from the Hoorn Study. Am J Clin Nutr 2006; 84: 995-1002.

    PubMed ID: 17093149

  15. Afghani A, Abbott AV, Wiswell RA, et al. Central adiposity, aerobic fitness, and blood pressure in premenopausal Hispanic women. Int J Sports Med 2004; 25: 599-606.

    PubMed ID: 15532003

  16. Pouliot MC, Després JP, Lemieux S, et al. Waist circumference and abdominal sagittal diameter: best simple anthropometric indexes of abdominal visceral adipose tissue accumulation and related cardiovascular risk in men and women. Am J Cardiol 1994; 73: 460-8.

    PubMed ID: 8141087

  17. Han TS, McNeill G, Seidell JC, et al. Predicting intra-abdominal fatness from anthropometric measures: the influence of stature. Int J Obes Relat Metab Disord 1997; 21: 587-93.

    PubMed ID: 9226490

  18. Després JP, Prud’homme D, Pouliot MC, et al. Estimation of deep abdominal adipose-tissue accumulation from simple anthropometric measurements in men. Am J Clin Nutr 1991; 54: 471-7.

    PubMed ID: 1877502

  19. Seidell JC, Björntorp P, Sjöström L, et al. Regional distribution of muscle and fat mass in men–new insight into the risk of abdominal obesity using computed tomography. Int J Obes 1989; 13: 289-303.

    PubMed ID: 2767882

  20. Ross R, Shaw KD, Rissanen J, et al. Sex differences in lean and adipose tissue distribution by magnetic resonance imaging: anthropometric relationships. Am J Clin Nutr 1994; 59: 1277-85.

    PubMed ID: 8198051

  21. Onat A, Avci GS, Barlan MM, et al. Measures of abdominal obesity assessed for visceral adiposity and relation to coronary risk. Int J Obes Relat Metab Disord 2004; 28: 1018-25.

    PubMed ID: 15197408

  22. Neeland IJ, Ross R, Després JP, et al. Visceral and ectopic fat, atherosclerosis, and cardiometabolic disease: a position statement. Lancet Diabetes Endocrinol 2019; 7: 715-25.

    PubMed ID: 31301983

  23. Riserus U, de Faire U, Berglund L, et al. Sagittal abdominal diameter as a screening tool in clinical research: cutoffs for cardiometabolic risk. J Obes 2010; 2010: 757939.

    PubMed ID: 20798888

  24. Kahn HS, Rissanen H, Bullard KM, et al. The population distribution of the sagittal abdominal diameter (SAD) and SAD/height ratio among Finnish adults. Clin Obes 2014; 4: 333-41.

    PubMed ID: 25826163
Reference 1 CLOSECLOSE

Empana JP, Ducimetiere P, Charles MA, et al. Sagittal abdominal diameter and risk of sudden death in asymptomatic middle-aged men: the Paris Prospective Study I. Circulation 2004; 110: 2781-5.

PubMed ID: 15492315
Reference 2 CLOSECLOSE

Radholm K, Tengblad A, Dahlen E, et al. The impact of using sagittal abdominal diameter to predict major cardiovascular events in European patients with type 2 diabetes. Nutr Metab Cardiovasc Dis 2017; 27: 418-22.

PubMed ID: 28390663
Reference 3 CLOSECLOSE

Ohrvall M, Berglund L and Vessby B. Sagittal abdominal diameter compared with other anthropometric measurements in relation to cardiovascular risk. Int J Obes Relat Metab Disord 2000; 24: 497-501.

PubMed ID: 10805508
Reference 4 CLOSECLOSE

Seidell JC, Andres R, Sorkin JD, et al. The sagittal waist diameter and mortality in men: the Baltimore Longitudinal Study on Aging. Int J Obes Relat Metab Disord 1994; 18: 61-7.

PubMed ID: 8130817
Reference 5 CLOSECLOSE

Kahn HS and Bullard KM. Beyond body mass index: advantages of abdominal measurements for recognizing cardiometabolic disorders. Am J Med 2016; 129: 74-81.

PubMed ID: 26302146
Reference 6 CLOSECLOSE

Kahn HS, Gu Q, Bullard KM, et al. Population distribution of the sagittal abdominal diameter (SAD) from a representative sample of US adults: comparison of SAD, waist circumference and body mass index for identifying dysglycemia. PLoS One 2014; 9: e108707.

PubMed ID: 25272003
Reference 7 CLOSECLOSE

Petersson H, Daryani A and Riserus U. Sagittal abdominal diameter as a marker of inflammation and insulin resistance among immigrant women from the Middle East and native Swedish women: a cross-sectional study. Cardiovasc Diabetol 2007; 6: 10.

PubMed ID: 17391519
Reference 8 CLOSECLOSE

Riserus U, Arnlov J, Brismar K, et al. Sagittal abdominal diameter is a strong anthropometric marker of insulin resistance and hyperproinsulinemia in obese men. Diabetes Care 2004; 27: 2041-6.

PubMed ID: 15277437
Reference 9 CLOSECLOSE

Smith DA, Ness EM, Herbert R, et al. Abdominal diameter index: a more powerful anthropometric measure for prevalent coronary heart disease risk in adult males. Diabetes Obes Metab 2005; 7: 370-80.

PubMed ID: 15955123
Reference 10 CLOSECLOSE

Madden AM and Smith S. Body composition and morphological assessment of nutritional status in adults: a review of anthropometric variables. J Hum Nutr Diet 2016; 29: 7-25.

PubMed ID: 25420774
Reference 11 CLOSECLOSE

Gletsu-Miller N, Kahn HS, Gasevic D, et al. Sagittal abdominal diameter and visceral adiposity: correlates of beta-cell function and dysglycemia in severely obese women. Obes Surg 2013; 23: 874-81.

PubMed ID: 23408092
Reference 12 CLOSECLOSE

Vasques AC, Cassani RS, Forti AC, et al. Sagittal abdominal diameter as a surrogate marker of insulin resistance in an admixtured population–Brazilian Metabolic Syndrome Study (BRAMS). PLoS One 2015; 10: e0125365.

PubMed ID: 25951458
Reference 13 CLOSECLOSE

Turcato E, Bosello O, Di Francesco V, et al. Waist circumference and abdominal sagittal diameter as surrogates of body fat distribution in the elderly: their relation with cardiovascular risk factors. Int J Obes Relat Metab Disord 2000; 24: 1005-10.

PubMed ID: 10951539
Reference 14 CLOSECLOSE

Mukuddem-Petersen J, Snijder MB, van Dam RM, et al. Sagittal abdominal diameter: no advantage compared with other anthropometric measures as a correlate of components of the metabolic syndrome in elderly from the Hoorn Study. Am J Clin Nutr 2006; 84: 995-1002.

PubMed ID: 17093149
Reference 15 CLOSECLOSE

Afghani A, Abbott AV, Wiswell RA, et al. Central adiposity, aerobic fitness, and blood pressure in premenopausal Hispanic women. Int J Sports Med 2004; 25: 599-606.

PubMed ID: 15532003
Reference 16 CLOSECLOSE

Pouliot MC, Després JP, Lemieux S, et al. Waist circumference and abdominal sagittal diameter: best simple anthropometric indexes of abdominal visceral adipose tissue accumulation and related cardiovascular risk in men and women. Am J Cardiol 1994; 73: 460-8.

PubMed ID: 8141087
Reference 17 CLOSECLOSE

Han TS, McNeill G, Seidell JC, et al. Predicting intra-abdominal fatness from anthropometric measures: the influence of stature. Int J Obes Relat Metab Disord 1997; 21: 587-93.

PubMed ID: 9226490
Reference 18 CLOSECLOSE

Després JP, Prud’homme D, Pouliot MC, et al. Estimation of deep abdominal adipose-tissue accumulation from simple anthropometric measurements in men. Am J Clin Nutr 1991; 54: 471-7.

PubMed ID: 1877502
Reference 19 CLOSECLOSE

Seidell JC, Björntorp P, Sjöström L, et al. Regional distribution of muscle and fat mass in men–new insight into the risk of abdominal obesity using computed tomography. Int J Obes 1989; 13: 289-303.

PubMed ID: 2767882
Reference 20 CLOSECLOSE

Ross R, Shaw KD, Rissanen J, et al. Sex differences in lean and adipose tissue distribution by magnetic resonance imaging: anthropometric relationships. Am J Clin Nutr 1994; 59: 1277-85.

PubMed ID: 8198051
Reference 21 CLOSECLOSE

Onat A, Avci GS, Barlan MM, et al. Measures of abdominal obesity assessed for visceral adiposity and relation to coronary risk. Int J Obes Relat Metab Disord 2004; 28: 1018-25.

PubMed ID: 15197408
Reference 22 CLOSECLOSE

Neeland IJ, Ross R, Després JP, et al. Visceral and ectopic fat, atherosclerosis, and cardiometabolic disease: a position statement. Lancet Diabetes Endocrinol 2019; 7: 715-25.

PubMed ID: 31301983
Reference 23 CLOSECLOSE

Riserus U, de Faire U, Berglund L, et al. Sagittal abdominal diameter as a screening tool in clinical research: cutoffs for cardiometabolic risk. J Obes 2010; 2010: 757939.

PubMed ID: 20798888
Reference 24 CLOSECLOSE

Kahn HS, Rissanen H, Bullard KM, et al. The population distribution of the sagittal abdominal diameter (SAD) and SAD/height ratio among Finnish adults. Clin Obes 2014; 4: 333-41.

PubMed ID: 25826163