To study the comparison between Hip Circumference (HC), Waist Circumference (WC) and Waist to Hip Ratio (WHR) as predictors of Type 2 Diabetes

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2 To study the comparison between Hip Circumference (HC), Waist Circumference (WC) and Waist to Hip Ratio (WHR) as predictors of Type 2 Diabetes Submitted by: Namrata Nasit (Enrolment no.:12sptpt11053) Heena Pandya (Enrolment no.:12sptpt11054) 6 th Semester, July, 2015 Guided by: Dr. Nivedita Chopra (MSPT) Lecturer, SOPT, RKU I

3 CERTIFICATE This is to certify that the project work entitled To study the comparison between Hip Circumference (HC), Waist Circumference (WC) and Waist to Hip Ratio (WHR) as predictors of Type 2 Diabetes has been undertaken and written under my supervision and it describes the original research work carried out by Ms. Namrata Nasit and Heena Pandya egistered at RK University under 6 th semester, Degree of Bachelors of Physiotherapy. Signature of Guide Name: Dr. Nivedita Chopra Degree: MSPT Designation: Lecturer II II

4 DECLARATION We hereby certify that we are the authors of this project work. We certify to the best of our knowledge, our project does not infringe upon anyone s copyright nor violate any proprietary rights and that any ideas, techniques, quotations, or any other material from the work of other people included in our project published or otherwise, are fully acknowledged in accordance with the standard referencing practices. We declare that this is a true copy of our project, including any final revisions, as approved by our project review committee. Signature of candidate Signature of candidate Namrata Nasit Heena Pandya Enrolment no.: 12SPTPT11053 Enrolment no.: 12SPTPT11054 Date: 16/07/2015 Date: 16/07/2015 Place: Rajkot Place: Rajkot III

5 ACKNOWLEGEMENT First and foremost we would like to thank our parents who are our living Gods and sister for their valuable support and encouragement, blessing and love which has always been a source of inspiration and strength in accomplishing this academic task. Our heartfelt gratitude to almighty God who has guided us this far and to whom goes all the honor and glory for the successful completion of this study. We wish to express our regards to our Director Dr. Priyanshu Rathod, School of Physiotherapy, R.K.University for his whole hearted guidance and meticulous suggestions in the completion of this work and for all the facilities and support extended to us during this study. We are extremely thankful for his constant encouragement and inspiration during the course of this study. With due respect, We would like to express our sincere thanks to our guide Dr. Nivedita Chopra, Lecturer, School of Physiotherapy, R.K.University, for her judicious information, expert suggestions, valuable guidance, continuous support, incessant reassurance during every stage of this work and interest shown in this dissertation without which this work would not have been possible. Our sincere thanks to Dr. Jagruti Pandya for taking keen interest in our study, guiding us through the path, giving us support and motivation during the course of study. We wish to express our thanks to Mr. Harshal, our librarian for their timely help in lending us books and journals for our reference all the time. IV

6 We shall fail our duties if we don t acknowledge our Colleagues and Friends for their suggestions and criticism while assisting us in this study. Last but not the least we would like to thank all the Individuals in our study, without whom this task would not have been possible. Our sincere thanks to all the contributors whose names we might have missed but who truly deserve our gratitude. We would like to thank once again to all who have helped us all the while. Name: Namrata Nasit Name: Heena Pandya V

7 LIST OF ABBREVIATIONS 1. WC : Waist Circumference 2. HC : Hip Circumference 3. WHR : Waist to hip ratio 4. BMI : Body mass index

8 ABSTRACT Background: Abdominal obesity is increasingly recognized as a major risk factor for type 2 diabetes [1]. Anthropometric measures of abdominal obesity appears to be more strongly associated with metabolic risk factors [1]. WHR is generally taken to indicate an excess of abdominal fat but is a poor measure of visceral mass [4][3]. HC is an aggregate measurement of the actual amount of total and abdominal fat accumulation and is a crucial correlate of the complexities found among obese and over-weight patients [2]. Therefore recent studies have integrated the separate contribution of HC and WHR to the glucose level and type 2 diabetes [3]. The need of this study is to identify the better predictor of Type 2 Diabetes. VI Aim: To determine whether there is strength of association of WC, HC and WHR with type 2 diabetes in both gender. Methodology: Study design: Cross-Sectional Observational study. Inclusion criteria: year old males with Type 2 Diabetes. Sample size: 30 Sampling technique: Convenient sampling. Study setting: Different Clinics of Rajkot. Results and Discussion: Hip circumference is higher in females as compared to waist circumference and waist circumference is higher in males as compared to Hip circumference in individuals with type 2 diabetes. Conclusion: On the basis of result of the present study, it has been concluded that HC is higher in females and WC is higher in males with type 2 diabetes. Keywords : Waist circumference, Hip circumference, waist to hip ratio, type 2 diabetes

9 TABLE OF CONTENTS Sr. No. TITLE Page No. VII 1. INTRODUCTION 1 2. AIMS & OBJECTIVES 7 3. REVIEW OF LITERATURE METHODOLOGY RESULTS DISCUSSION CONCLUSION SUMMARY BIBLIOGRAPHY ANNEXURES 42 VIII

10 Graph. no LIST OF GRAPH Graph title Within group comparison of WC between obtained value and normal value in female. Within group comparison of HC between obtained value and normal value in female. Within group comparison of WC and HC of obtained value in female. Within group comparison of WHR between Obtained Value and Normal value in female Within group comparison of WC between obtained value and normal value in male. Within group comparison of HC between obtained value and normal value in male. Within group comparison of WC and HC of obtained value in male Within group comparison of WHR between Obtained Value and Normal value in male Page no IX

11 LIST OF TABLE Table. no Table title Within group comparison of WC between obtained value and normal value in female. Within group comparison of HC between obtained value and normal value in female. Within group comparison of WC and HC of obtained value in female. Within group comparison of WHR between Obtained Value and Normal value in female Within group comparison of WC between obtained value and normal value in male. Within group comparison of HC between obtained value and normal value in male. Within group comparison of WC and HC of obtained value in male Within group comparison of WHR between Obtained Value and Normal value in male Page no X

12 LIST OF FIGURES Figure. no. Figure title Page no. 4.1 Materials used in the study Measurement of waist circumference Measurement of hip circumference 20 XI

13 INTRODUCTION Ratio (WHR) as predictors of Type 2 Diabetes 1

14 INTRODUCTION Inrecent years, considerable attention hasbeen given to the role of adiposity in the development of chronic diseases, leadingto speculations that some forms of fat distribution may be more important in thecausation of cardiovascular diseases than Others 2. Clinical evidence suggests that the association of diabetes with central obesity is stronger than the association with general fat. Studies using computed tomography and magnetic resonance imaging have provided further evidence to support that central obesity, visceral adipose tissue, and upper-body non visceral fat are the major contributors to the metabolic complications. Central obesity has beenassociated with decreased glucose tolerance, alterations in glucose insulin homeostasis, reduced metabolic clearance of insulin, and decreased insulin stimulated glucose disposal 6. Abdominal obesity is increasingly recognized as a major riskfactor for diabetes type 2. Anthropometric measures of abdominalobesity [e.g. hip circumference (HC), waist circumference (WC), waist-to-hip ratio(whr)] appear to be morestrongly associated with metabolic risk factors 1. Hoorn studied that the waist-to-hip ratio (WHR) and not body mass index (BMI) is an important independent predictor of incident diabetes result indicates that fat distribution may be a better predictor for progression to type 2 diabetes than is BMI, which is also suggested by studies that examined the WHR or the waist-to-thigh ratio (WTR). 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 5. A high WHR is generally taken to indicate an excess ofvisceral or abdominal fat, however, it can also be due to asmaller hip circumference. Therefore, recent Ratio (WHR) as predictors of Type 2 Diabetes 2

15 studieshave investigated the separate contributions of waist andhip circumferences to the glucose levels and type IIdiabetes. 3 As the glucose test is invasive, relativelyexpensive, time consuming and not easy to apply to mass-screening programmes, several other diagnostic tools, including obesity indicators such as waist circumference (WC)and body mass index (BMI), have been proposed and appliedin diabetes prevention programmes 4. Diabetes increases dramatically worldwide as aconsequence of changes in lifestyle, including physical inactivity and unhealthy diet. Physical inactivityand obesity have been well recognized as major lifestylerelated risk factors for diabetes 4. Type 2 diabetes mellitus is characterized by 4 major metabolic abnormalities: obesity, impaired insulin action, insulin secretory dysfunction, and increased endogenous glucose output 9. In this article, studies for comparison betweenhc, WC and WHR in their relation to the incidence andprevalence of type II diabetes in adults were reviewed 4. Lifestyle intervention to prevent non-communicable diseasesincluding diabetes has been included in the Action Plan (World Health Organization, 2008). One of theobjectives of this plan is to develop simple strategies toidentify those at risk and provide them with early lifestyleinterventions 4. Lifestyle changes and treatment with metformin both reduced the incidence of diabetes in persons at high risk. The lifestyle intervention was more effective than metformin 11. WHR measures central fat deposition but is a poormeasure of visceral fat mass, particularly in lean individuals 4. Ratio (WHR) as predictors of Type 2 Diabetes 3

16 Waist circumference isan aggregate measurement of the actualamount of total and abdominal fat accumulationand is a crucial correlate of thecomplexities found among obese and overweight patients. Cutoff values for WCwere 85 and 80 cm for men and women, respectively; the corresponding WHRs were 0.88 and0.81, respectivel 8. Unlike the BMI, waistcircumference is not profoundly influencedby height and is therefore a better predictorof some cardiovascular diseases.waist circumference has also been shown tobe more correlated with levels of abdominal visceral adipose tissue 2. Ratio (WHR) as predictors of Type 2 Diabetes 4

17 NEED OF THE STUDY Ratio (WHR) as predictors of Type 2 Diabetes 5

18 NEED OF THE STUDY 1) Need of this study was to develop simple strategies to identify those at risk of type 2 diabetes mellitus and provide them with early life style interventions 2) To study the magnitude of the association among anthropometric measure and type 2 diabetes mellitus in Rajkot population. Ratio (WHR) as predictors of Type 2 Diabetes 6

19 AIMS AND OBJECTIVES Ratio (WHR) as predictors of Type 2 Diabetes 7

20 AIMS The aim of this study was to investigate the independent associations of waist and hip circumferences and waist to hip ratio with type 2 diabetes in Rajkot population. OBJECTIVES To measure Waist Circumference and find out the strength of association with type 2 diabetes. To measure Hip Circumference and find out the strength of association with type 2 diabetes. To measure Waist Hip ratio and find out the strength of association with type 2 diabetes. To find out better predictor of type 2 diabetes among WC, HC, WHR in both gender. Ratio (WHR) as predictors of Type 2 Diabetes 8

21 HYPOTHESIS Ratio (WHR) as predictors of Type 2 Diabetes 9

22 HYPOTHESIS Null hypothesis: There is no significant difference between HC, WC and WHR as a predictor of type 2 diabetes. Alternative hypothesis: There is significant difference between HC, WC and WHR as a predictor of type 2 diabetes. Ratio (WHR) as predictors of Type 2 Diabetes 10

23 REVIEW OF LITERATURE Ratio (WHR) as predictors of Type 2 Diabetes 11

24 REVIEW OF LITERATURE Jacqueline M Dekker et al. (2015) 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 isassociated with a higher risk 5 Statistical analysis by Qiao and Nyamdorj (2010) showed that WC or WHR discriminate the cases with diabetes in a better way than BMI 4. Lawrence de Koning et al.(2007) have concluded that WHR and WC are significantly associated with the risk of incident CVD events 1. Ford et al. (2007) support the use of waist circumference as a measure of obesity to predict health risk. Among their arguments are that waist circumference has been shown to be a good or better predictor than body mass index of the metabolic syndrome, diabetes, cardiovascular disease, and all-cause mortality; Dr. Clegg (2007) suggested that hormones made by the ovaries may be critical in determining where fat is deposited."given the difference in gene expression profiles, a female fat tissue won't behave anything like a male fat tissue and vice versa," Marieke B Snijder et al. (2003) have concluded that Large hip and thigh circumferences are associated with a lower risk of type 2 diabetes, independently of BMI, age, and waist circumference 3 Chamukuttan Snehalatha et al.(2003) have reviewed the Cutoff values for WC were 85 and 80 cm for men and women, respectively; the corresponding WHRs were 0.88 and 0.81 respectively. The cutoff values for WC and WHR were lower in women than in men Journal List J Clin Invest v.104(6); 1999 suggested that Type 2 diabetes mellitus ischaracterized by 4 major metabolic abnormalities: obesity, impaired insulin action, insulin secretory dysfunction, and increased endogenous glucose output (EGO). Although there is substantial evidence that the first 3 of these abnormalities are present in most individuals before the onset of diabetes. Ratio (WHR) as predictors of Type 2 Diabetes 12

25 Okosun et al. (1998) have conducted a study on various populations and concluded that waist circumference is positively correlated with fasting blood glucose level and also substantial reduction in glucose level if waist size is decreased. 2 Ratio (WHR) as predictors of Type 2 Diabetes 13

26 METHODOLOGY Ratio (WHR) as predictors of Type 2 Diabetes 14

27 Methodology Study design: Cross-Sectional Observational study. Sample size: 60 Sampling technique: convenient sampling. Study setting: life span hospital, kansagara hospital and tramba village. Ratio (WHR) as predictors of Type 2 Diabetes 15

28 CRITERIA FOR SELECTION INCLUSION CRITERIA 1. Age between 40 to 60 years 2. Established cases of type 2 diabetes 3. Both Males and Females EXCLUSION CRITERIA: 1. Pregnancy 2. Diabetes with hypo or hyper thyroidism. 3. Tuberculosis Ratio (WHR) as predictors of Type 2 Diabetes 16

29 MATERIALS USED IN THE STUDY Pen Paper Non elastic measuring tape Figure no. 4.1: Materials used in the study Ratio (WHR) as predictors of Type 2 Diabetes 17

30 METHOD In this study, the study population was taken from various hospitals of Rajkot viz. life span hospital, kansagara hospital and tramba village. Participants were selected based on inclusion criteria. A detailed procedure was informed to them and ethically proved informed consent form was filled up by the participants. A brief questionnaire regarding health habits, medical history and current medication was administrated. Waist circumference was measured between the midpoint of lower rib and iliac crest. Hip circumference was measured at the higher point of the buttocks. Waist hip ratio were calculated by taking ratio of waist and hip. Mean of 3 readings was recorded for each anthropometric measure. Procedure: Participant s position: Standing with normal base of support For waist circumference the part was exposed Hip circumference was measured with minimal clothing and removing unnecessary items like wallet, mobile etc. Examiner s position: Half kneeling, facing the anterior part of the body. Ratio (WHR) as predictors of Type 2 Diabetes 18

31 Figure no. 4.2: Measurement of Waist Circumferance Ratio (WHR) as predictors of Type 2 Diabetes 19

32 Figure no. 4.3: Measurement of Hip Circumferance Ratio (WHR) as predictors of Type 2 Diabetes 20

33 RESULTS Ratio (WHR) as predictors of Type 2 Diabetes 21

34 RESULTS An observational study was performed in which waist circumference; hip circumference and waist to hip ratio were assessed in established cases of type 2 diabetes in both genders between 40 to 60 years of age. Results were analyzed comparing the mean values within groups. Ratio (WHR) as predictors of Type 2 Diabetes 22

35 Graph no. 5.1: Within group comparison of WC between obtained value and normal value in female. Comparision of WC (cm) in female normal value obtained value After obtaining this result we have found that WC is higher in females having type 2 diabetes. Table no. 5.1: Within group normal value in female. comparison of WC between obtained value and WC Normal value Obtained value To study the comparison between Hip Circumference (HC), Waist Circumference (WC) and Waist to Hip Ratio (WHR) as predictors of Type 2 Diabetes 23

36 Graph no. 5.2: Within group comparison of HC between obtained value and normal value in female. Comparision of HC (in) females Normal value Obtained value This result also shows higher HC in females with type 2 diabetes. Table no. 5.2: Within group value in female. comparison of HC between obtained value and normal HC Normal value Obtained value To study the comparison between Hip Circumference (HC), Waist Circumference (WC) and Waist to Hip Ratio (WHR) as predictors of Type 2 Diabetes 24

37 Graph no. 5.3: Within group comparison of WC and HC of obtained value in female. Comparision between obtain value of WC and HC (cm) in female WC HC After observing this we found that a female with larger hip circumference are more at risk for developing type 2 diabetes. Table no. 5.3: : Within group comparison of WC and HC of obtained value in female. WC & HC Obtained value WC HC To study the comparison between Hip Circumference (HC), Waist Circumference (WC) and Waist to Hip Ratio (WHR) as predictors of Type 2 Diabetes 25

38 Graph no. 5.4: Within group comparison of WHR between obtained value and normal value in female. Comparision between normal value and obtained value of WHR Normal value obtained value After observing this we found WHR. that a female with type 2 diabetes also having increased Table no. 5.4: Within group normal value in female. comparison of WHR between obtained value and WHR Normal value Obtained value To study the comparison between Hip Circumference (HC), Waist Circumference (WC) and Waist to Hip Ratio (WHR) as predictors of Type 2 Diabetes 26

39 Graph no. 5.5: Within group comparison of WC between obtained value and normal value in male. Comparision of WC(cm) in male normal value obtain value Result shows the higher WC in male with type 2 diabetes. Table no. 5.5: Within group normal value in male. comparison of WC between obtained value and WC Normal value Obtained value To study the comparison between Hip Circumference (HC), Waist Circumference (WC) and Waist to Hip Ratio (WHR) as predictors of Type 2 Diabetes 27

40 Graph no. 5.6: Within group comparison of HC between obtained value and normal value in male. Comparision of HC (cm) in male normal value obtain value After observing this we found that HC is also high in male with type 2 diabetes. Table no. 5.6: Within group value in male. comparison of HC between obtained value and normal HC Normal value Obtained value To study the comparison between Hip Circumference (HC), Waist Circumference (WC) and Waist to Hip Ratio (WHR) as predictors of Type 2 Diabetes 28

41 Graph no. 5.7: Within group comparison of WC and HC of obtained value in male. Comparision between WC and HC (cm) in male WC HC The above graph shows comparison of WC and HC by the obtained values from the sample. This graph shows WC is higher than the HC in male. This result shows higher the waist in male are more at risk for developing type 2 diabetes. After obtaining these results, this was found that Hip circumference is higher in females as compared to waist circumference and waist circumference is higher in males as compared to Hip circumference in individuals with type 2 diabetes. Table no. 5.7: : Within group comparison of WC and HC of obtained value in male. WC & HC Obtained value WC HC To study the comparison between Hip Circumference (HC), Waist Circumference (WC) and Waist to Hip Ratio (WHR) as predictors of Type 2 Diabetes 29

42 Graph no. 5.8: Within group comparison of WHR between obtained value and normal value in male. Comparision between normal value and obtained value of WHR Normal Value Obtained Value After observing this we found WHR that a male with type 2 diabetes also having increased Table no. 5.8: Within group normal value in male. comparison of WHR between obtained value and WHR Normal value Obtained value To study the comparison between Hip Circumference (HC), Waist Circumference (WC) and Waist to Hip Ratio (WHR) as predictors of Type 2 Diabetes 30

43 DISCUSSION Ratio (WHR) as predictors of Type 2 Diabetes 31

44 DISCUSSION Fat distribution, apart from overall obesity, is an important risk factor for type II diabetes and cardiovascular diseases. Most studies use the waist-to-hip ratio (WHR) for measuring fat distribution, or simply the waist circumference because the waist circumference alone is more strongly correlated to visceral fat than the WHR. Visceral fat has been shown to be strongly correlated to components of the metabolic syndrome, and is generally assumed to be a causal factor by releasing free fatty acids into the portal vein. A high WHR is generally taken to indicate an excess of visceral or abdominal fat, however, it can also be due to a smaller hip circumference. Therefore, recent studies have investigated the separate contributions of waist and hip circumferences to blood glucose levels and type II diabetes. (3) In the present study, we showed that the body circumference ratios are better predictors of future type 2 diabetes 5. We observe that the male with higher the waist are more at risk of developing type 2 diabetes. Marieke B Snijder et al. (2015)have found the same that higher waist circumference is associated with higher risk of type 2 diabetes.5 Gabriela Vazquez et al. (2007)demonstrated consistently strong associations of body mass index, waist circumference, and waist/hip ratio with incident diabetes. 6 Q Qiao et al. (2009) also suggested that the evidence based on the prospective studies equallyfavoured all anthropometric measures of BMI, WC, WHRand the waist-to-stature Ratio (WHR) as predictors of Type 2 Diabetes 32

45 ratio. But most of the cross-sectionalstudies showed that WC or WHR discriminate better thecases with diabetes. 4 IkeS. Okosunet al. (1998) concluded that Substantial reduction in hypertension and diabetes in men and women is achievable if the waist size is decreased in these populations. Lawrence de Koning et al (2007) suggested that WHR and WC are significantly associated with the risk of incident CVD events. After observing the result we have found that Hip circumference is higher in females compared to waist circumference in type 2 diabetes Dr. Clegg (2007)found that hormones made by the ovaries may be critical in determining where fat is deposited. In humans, men are more likely to carry extra weight around their guts while premenopausal women store it in their butts, thighs and hips. For men is that belly, or visceral, fat has been associated with numerous obesity-related diseases including diabetes and heart disease. Women, on the other hand, are generally protected from these obesity-related disorders until menopause, when their ovarian hormone levels drop and fat storage tends to shift from their rear ends to their waists. This is reason that why women in the sample data are shows higher hip circumferences compare to waist circumference. Ratio (WHR) as predictors of Type 2 Diabetes 33

46 LIMITATIONS OF THE STUDY The study sample size is small Age limitation (40-60 year were taken) Correlation with limited investigative measures FURTHER RECOMMENDATION Need to correlate with menstruation time in female and glucose levels to find stronger association. Different population with larger sample size should be assessed. Can be assessed with trial protocol given to the sample population and observe any change in the diabetes level with anthropometric values differ in individual. Ratio (WHR) as predictors of Type 2 Diabetes 34

47 CONCLUSION Ratio (WHR) as predictors of Type 2 Diabetes 35

48 CONCLUSION Large waist circumference are associated with higher risk of type 2 diabetes in male and female because WC is more predictable of visceral fat mass but female with higher hip circumference are also more prone to type 2 diabetes as their hormonal level changes. So, females with higher hip circumference may be at a higher risk for developing type 2 diabetes and males with higher waist circumference may be at a higher risk for developing type 2 diabetes Ratio (WHR) as predictors of Type 2 Diabetes 36

49 SUMMARY Ratio (WHR) as predictors of Type 2 Diabetes 37

50 SUMMARY Abdominal obesity is increasingly recognized as a major riskfactor for type 2 diabetes. Compared with anthropometric measures of abdominalobesity [e.g. waist circumference (WC), waist-to-hip ratio(whr),] appear to be morestrongly associated with metabolic risk factors males and 30 females were included for the study. Outcome measures were WC, HC and WHR. The data was then tabulated and subjected to statistical analysis of the mean for outcome measures. After the analysis the data the following inference were drawn: 1. Hip circumference is higher in females compared to waist circumference due to the role of hormonal level. So, females with higher hip circumference are at a higher risk for developing type 2 diabetes in present and also after changes in hormonal level. 2. Waist circumference is higher in males compared to Hip circumference. So, males with higher waist circumference are at a higher risk for developing type 2 diabetes due to visceral fat mass is better predictable with WC. Ratio (WHR) as predictors of Type 2 Diabetes 38

51 BIBILOGRAPHY Ratio (WHR) as predictors of Type 2 Diabetes 39

52 BIBILOGRAPHY 1. Lawrence de Koning, Anwar T. Merchant, Janice Pogue and Sonia S. Anand. (2007). Waist circumference and waist-to-hip ratio as predictors of cardiovascular events: meta-regression analysis of prospective studies.european Heart Journal 28: Ike S. Okosun, Richard S. Cooper, Charles N. Rotimi, Babatunde Osotlmehin, Terrence forrester. (1998) Association of Waist Circumference With Risk of Hypertension and Type 2 Diabetes in Nigerians, Jamaicans, and African Americans. Diabetes care 21: Number MB Snijder, PZ Zimmet, M Visser, JM Dekker, JC Seidell and JE Shaw.(2004) Independent and opposite association of waist and hip circumferences with diabetes, hypertension and dyslipidemia : the AusDiab Study.International Journal of Obesity 28: Q Qiao and R Nyamdorj. (2010) Is the association of type II diabetes with waist circumference or waist-to-hip ratio stronger than that with body mass index.european Journal of Clinical Nutrition 64: 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. (2003) Associations of hip and thigh circumferences independent of waist circumference with the incidence of type 2 diabetes: the Hoorn Study. American journal for Clinical Nutrition 77: Gabriela Vazquez, Sue Duval David R. Jacobs, and Karri Silventoinen. (2007) Comparison of Body Mass Index, Waist Circumference, and Waist/Hip Ratio in Predicting Incident Diabetes: A Meta-Analysis. Johns Hopkins Bloomberg School of Public Health Dr. Clegg. (2014). Why men store fat in bellies, women on hips. Linkedin Chamukuttan Snehalatha, Vijay Viswanathan, Ambady Ramachandran. (2003) Cutoff Values for Normal Anthropometric Variables in Asian Indian Adults. Diabetes Care 26, Number 5 Ratio (WHR) as predictors of Type 2 Diabetes 40

53 . 9. American Diabetes Association and National Institute of Diabetes.(2002) the prevention or delay of type 2 diabetes. Diabetes care 25, number Diabetes Prevention Program Research Group. (2006) Reduction in the incidence of type 2 diabetes with life style intervention or metformin. Diabetes care 346(6): Ratio (WHR) as predictors of Type 2 Diabetes 41

54 ANNEXURES Ratio (WHR) as predictors of Type 2 Diabetes 42

55 ANNEXURE 10.1 CONSENT FORM Ratio (WHR) as predictors of Type 2 Diabetes 43

56 ANNEXURE 10.2 DATA COLLECTION FORM NAME: AGE: GENDER: ADDRESS: SINCE HOW LONG SUFFERING FROM TYPE II DIABETES MALLITUS: DATE OF ASSESSMENT: OUTCOME MEASURES: Reading 1 Reading 2 Reading 3 Average Waist circumference (cm) Hip circumference (cm) Waist to hip ratio Remarks: Signature of patient Signature of researcher Signature of witness Ratio (WHR) as predictors of Type 2 Diabetes 44

57 MASTER CHART No. Age WC (Cm) HC (Cm) WHR Ratio (WHR) as predictors of Type 2 Diabetes 45

58 Ratio (WHR) as predictors of Type 2 Diabetes 46