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“Making Ends Meet” Multicultural Waist Circumference Ribbons: A health educator’s tool for starting a conversation about risk for type 2 diabetes and cardiovascular disease

Author(s): Dawn Corl, RN, MN, CDE, Diabetes Clinical Nurse Specialist, Harborview Medical Center, Seattle, WA
Reviewer(s): Brent Wisse, MD, Harborview Medical Center

Introduction

Pre-cut waist ribbons are simple to produce, very inexpensive, and provide a strategy to begin a discussion about excess body fat without the stigma of numbers (pounds or waist size in inches). Additional ribbons can be taken home for family/friends. 

Waist circumference has been recommended as a screening tool to evaluate the risk of developing both diabetes and cardiovascular disease since 1995, though exact cut off points for maximum waist circumference have been debated (Lean, Han & Morrison, 1995). 

The risk of developing diabetes (controlled for age, sex, race, and smoking) is 4.12 (2.72–6.24) times higher if waist is larger than International Diabetes Federation (IDF) recommendations (Janiszewski, Janssen & Ross, 2007).

The risk of developing cardiovascular disease is greater for persons with intra-abdominal obesity who have high levels of triglycerides. A recent study conducted in the United Kingdom proposes that screening for increased waist circumference and hypertriglyceridemia (the hypertriglyceridemic-waist phenotype) is an inexpensive approach for identifying patients with excess intra-abdominal adiposity and associated metabolic abnormalities (Arsenault, Lemieux, Després, Wareham, Kastelein, Khaw & Boekholdt, 2010). 

The hypertriglyceridemic-waist phenotype was defined for Caucasians as a waist circumference of 90 cm or more and a triglyceride level of 175 mg/dL (2.0 mmol/L) or more in men, and a waist circumference of 85 cm or more and a triglyceride level of 130 mg/dL (1.5 mmol/L) or more in women (Arsenault, Lemieux, Després, Wareham, Kastelein, Khaw & Boekholdt, 2010). 

The study’s authors suggest that measuring triglycerides and waist circumference is particularly important in patients with normal traditional risk scores. Patients who have hypertension or diabetes or raised cholesterol will be identified with traditional methods. However, patients in the study with hypertriglyceridemic waists and normal values on traditional risk scores had double or triple the risk of developing heart disease (Arsenault, Lemieux, Després, Wareham, Kastelein, Khaw & Boekholdt, 2010).   

Waist Ribbons: A Risk Screening Tool With A Take-home Goal

Waist ribbons, made of non-stretch, multicolored materials such as gift wrap ribbon, pre-cut to measurements for maximum recommended abdominal girth for sex/ethnicity (see IDF table in next section) can be created as an alternative measurement device for screening for risk of developing type 2 diabetes and cardiovascular disease.  

How waist ribbons can be used

  • At health fairs as an opener for discussion about weight/obesity: “Would you like to know if you can make the ends meet?” Followed with information about why it is important and how to lower risk. Additional ribbons can be taken home for friends and family.
  • In clinics to identify those at greater risk of developing type 2 diabetes and cardiovascular disease or for enrollment in weight management clinics.
  • In gyms, community centers, and sporting events as a promotional ad or public service.
  • At home with a small hook and refrigerator magnet listing healthy lifestyle tips.

How to measure waist circumference

Measuring tape position at waist
Measuring tape position for waist (abdominal) circumference in adults. Image courtesy of the National Heart, Lung, and Blood Institute, 2000.

 

Place the pre-cut ribbon or tape measure evenly around the bare abdomen just above the hip bone. Relax abdominal muscles. The ribbon or tape should be snug, but not cinched into the skin. Record the waist circumference as ‘not exceeding’ or ‘exceeding’ maximum recommendation for sex and ethnic background or in inches if using a tape measure.

 

 

 

 

 

 

 

 

 

 

Table: International Diabetes Federation (except when noted otherwise) MAXIMUM waist circumference recommendations differ by ethnic background (IDF, 2005)

Table: Waist Ribbon Measurement

 

 

 

 

 

 

 

 

 

 

 

*From ATP III metabolic syndrome screening guidelines. Some Americans have higher risk when the waist circumference is only marginally increased (e.g., males 94-102 cm; females 80-88 cm) if they have a strong genetic contribution to insulin resistance (National Heart Lung and Blood Institute, 2004).


Response Tested at Harborview Medical Center, Seattle

The response to using the pre-measured waist circumference ribbons was tested  in subjects (n=24) in a clinic waiting room by University of Washington School of Nursing students and supervisors Dr. Joie Whitney and Dawn Corl, RN, MN, CDE, Diabetes Clinical Nurse Specialist. Participants who expressed interest were given information about diabetes and were then invited to try the appropriate ribbon for themselves either in-person at that time or at home. These patient volunteers were asked to take a short Likert scale (1 strongly disagree to 5 strongly agree) survey.

Results

  • 24 total surveys were collected and analyzed.  Most of the respondents were under 65 years of age and two-thirds were female. Of those who filled out the survey, 13% stated they currently had diabetes and 19% had been told by the primary care provider that they were at risk for diabetes.
  • When asked to rate whether or not the information received was valuable, participants responded positively (mean =4.4; Standard Deviation = 0.59).
  • Many participants were receptive to using the ribbon at their primary care offices (mean = 4; SD = 1.2) and planned to share the information with family (mean = 4; SD = 0.98).
  • Among participants who agreed the information would change the way they thought about their health, about the amount of calories eaten and about physical activity, average responses equaled 3.9 (SD=1.4), 3.9 (SD=1.4) and 3.7 (SD=1.2) respectively in those areas.
  • The average response for planning to use the ribbon at home as a method to keep track of progress was 3.5 (SD = 1.4).

The overall consensus was that the ribbons were a non-disparaging tool that provided valuable information (Picol, Escoto, Whitney & Corl, 2009).

Displaying Ribbons

An inexpensive and portable way of displaying ribbons is to use a clothes hanger for each culture group. See example below:

Ribbons on Hanger
Label: Waist ribbons
Color key for different measures of ribbon on hanger.

Discussion with Ribbon Users

Just knowing one’s risk for developing diabetes is rarely enough to motivate the adoption of new long-term lifestyle behaviors. A discussion about how to address barriers to adopting behaviors that decrease risk of obesity, type 2 diabetes, and cardiovascular disease is helpful. Some barriers to be discussed might include:

  • Increased availability of calorie rich, nutrient poor foods
  • Expense of healthier food choices, particularly fresh fruits and vegetables
  • Less physical activity due to extreme weather conditions, safety concerns (getting lost, safe streets and housing), access to public parks and use of cars/busses instead of walking/cycling for transportation.
  • Access to TV/computers at home and computer use at work

It is important to provide accurate and accessible information about choices that have been shown to reduce diabetes risk every day, such as:

  • Get 8 hours of restorative sleep (“Sleep and Diabetes,” 2010).
  • Increase servings of fruits and vegetables to five a day, substitute whole grains, low fat dairy, nuts/seeds for processed meats, refined grains. Avoid sweetened beverages and calorie rich, nutrient poor foods that contribute to weight gain (Nettleton, Steffen, Ni, Liu & Jacobs, 2008).
  • Beware of portion distortion. Use smaller plates, share an entrée, save half for later, measure snacks.
  • Limit recreational screen time (TV and computer) to 2 hours (Oregon Department of Human Services, 2008).
  • Plan for a minimum of 1 hour of physical activity throughout the day, including aerobic, strength, flexibility and household chores (“Sleep and Diabetes,” 2010).
  • Discuss your risk profile with your health care provider and request a test for diabetes (A1c) and heart disease (triglycerides) if your waist ribbon “ends don’t meet.”

References

Arsenault, B.J., Lemieux, I., Després, J.P., Wareham, N.J., Kastelein, J.J., Khaw, J.T., & Boekholdt, S.M. (2010). The hypertriglyceridemic-waist phenotype and the risk of coronary artery disease: results from the EPIC-Norfolk Prospective Population Study. CMAJ 2010, 182(13).doi:10.1503/cmaj.091276. Retrieved from http://www.cmaj.ca/cgi/content/full/182/13/1427

DHS Oregon Department of Human Services. (2008). Reversing the trends of obesity and diabetes: A Report to the 2009 Oregon Legislature from the HB 3486 Advisory Committee. Retrieved from http://www.oregon.gov/DHS/ph/diabetes/docs/hb3486/diabstratgicplnsm.pdf?ga=t

Food and Fitness, Types of Exercise (n.d.) Retrieved July 28, 2010, from http://www.diabetes.org/food-and-fitness/fitness/ideas-for-exercise/types-of-exercise.html

International Diabetes Federation (2007). Backgrounder 1: The IDF consensus worldwide definition of the metabolic syndrome. Retrieved from  http://www.idf.org/webdata/docs/MetSyndrome_FINAL.pdf

Janiszewski, P.M., Janssen, I., & Ross, R. (2007). Does Waist Circumference Predict Diabetes and Cardiovascular Disease Beyond Commonly Evaluated Cardiometabolic Risk Factors? Advance online publication. doi: 10.2337/dc07-0945. Retrieved from http://care.diabetesjournals.org/content/30/12/3105.full

Lean, M.E.J., Han, T.S., & Morrison, C.E. (1995). Waist circumference as a measure for indicating need for weight management. BMJ 1995;311:158-161. Retrieved from http://www.bmj.com/content/311/6998/158.full

Nettleton, J.A., Steffen, L.M., Ni, H., Liu, K., & Jacobs, D.R. (2008) Dietary patterns and risk of incident type 2 diabetes in the multi-ethnic study of atherosclerosis (MESA). Diabetes Care 31(9):1777-1782.

Piol, A., Escoto, C., Whitney, J., & Corl, D. (2009, January). Making ends meet: Central obesity and risk for diabetes. Poster session presented at Seattle Nursing Research Conference, Seattle, WA.

Sleep and Diabetes (n.d.) Retrieved July 28, 2010, from http://www.dlife.com/diabetes/information//daily_living/adults/sleep.html

U.S. Department of Health and Human Services. National Institutes of Health, National Heart, Lung and Blood Institute. (2006). Facts about Healthy Weight (NIH Publication No. 06-5830). Retrieved from http://www.nhlbi.nih.gov/health/prof/heart/obesity/aim_kit/healthy_wt_facts.pdf

U.S. Department of Health and Human Services. National Institutes of Health, National Heart, Lung and Blood Institute. (2000). The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults (NIH Publication No. 00-4084). Retrieved from http://www.nhlbi.nih.gov/guidelines/obesity/prctgd_c.pdf

U.S. Department of Health and Human Services. National Institutes of Health, National Heart, Lung and Blood Institute. (2004). Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Retrieved from http://www.nhlbi.nih.gov/guidelines/cholesterol/

Further Reading

U.S. Department of Health and Human Services. National Institutes of Health. National Institutes of Diabetes and Digestive and Kidney Diseases. National Diabetes Information Clearinghouse. (n.d.). The Pima Indians, Genetic Research. Retrieved from http://diabetes.niddk.nih.gov/dm/pubs/pima/genetic/genetic.htm

Ramaya, R. (n.d.).  Diabetes in sub-Saharan Africa [PowerPoint slides]. University of Pittsburg. Retrieved from www.pitt.edu/~super4/33011-34001/33571.ppt

U.S. Department of Health and Human Services. National Institutes of Health. National Institutes of Diabetes and Digestive and Kidney Diseases. National Diabetes Information Clearinghouse. (2008, June). National Diabetes Statistics, 2007 (NIH Publication No. 08–3892). Retrieved from http://diabetes.niddk.nih.gov/dm/pubs/statistics/#allages

Schulz, L., Bennett, M.B., Ravussin, E., Kidd, J.R., Esparza, M.S., & Valencia, M.E. (2006).  Effects of Traditional and Western Environments on Prevalence of Type 2 Diabetes in Pima Indians in Mexico and the U.S. Diabetes Care, 29(8), 1866-1871. doi: 10.2337/dc06-0138. Retrieved from http://care.diabetesjournals.org/content/29/8/1866.full

Chan, J.C., Malik, V., Jia, W., Kadowaki, T., Yajnik, C.S., Yoon, K.H., & Hu, F.B. (2009). Diabetes in Asia: epidemiology, risk factors, and pathophysiology. JAMA, 301(20), 2129–2140. Retrieved from http://jama.ama-assn.org/cgi/content/abstract/301/20/2129

Mbanya, J.C.N., Motala, A.A., Sobngwi, E., Assah, F.K., & Enoru, S.T. (2010). Diabetes in sub-Saharan Africa. Lancet, 375(9733), 2254–2266. doi:10.1016/S0140-6736(10)60550-8. Retrieved from http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60550-8/fulltext

Hu,  F.B., Li, T.Y., Colditz, G.A., Willett, W.C., & Manson, J.E. (2003). Television watching and other sedentary behaviors in relation to risk of obesity and type 2 diabetes mellitus in women. JAMA ,289(14), 1785-1791. Retrieved from http://jama.ama-assn.org/cgi/content/abstract/289/14/1785)

NHANES Study reported by: Weiss, E.C., Galuska, D.A.,.Kettle Khan, L., Gillespie, C., Serdula, M.K. (2007) Weight regain in U.S. adults who experienced substantial weight loss, 1999-2002. Am J Prev Med 33(1), 2007.

U.S. Department of Health and Human Services. National Institutes of Health, National Heart, Lung and Blood Institute. (1998). Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: Evidence Report. National Heart, Lung, and Blood Institute. Retrieved from http://www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.pdf