Neck Circumference as a Simple Screening Measure for Identifying Overweight and Obese Patients

Liubov (Louba) Ben-Noun,* Ezra Sohar, and Arie Laor

Abstract BEN-NOUN, LIUBOV (LOUBA), EZRA SOHAR, AND ARIE LAOR. Neck circumference as a simple screening measure for identifying overweight and obesity patients. Obes Res. 2001;9:470 477. Objective: There are numerous methods of assessing overweight and obesity. We undertook an observational study to test a method of identifying overweight or obese patients solely by measuring the circumference of the neck. Research Methods and Procedures: A test sample and a second validation sample included 979 subjects (460 men and 519 women), who visited a family medicine clinic in a southern Israeli urban district for any reason between the randomly chosen months of January and September 1998. Main outcome included neck, waist, and hip circumferences; body mass index (BMI); and waist:hip ratio measures. Results: Pearsons correlation coefficients indicated a significant association between neck circumference (NC) and: BMI (men, r 0.83; women, r 0.71; each, p 0.0001), age (men, r 0.33; women, r 0.36; each, p 0.0001), weight (men, r 0.7; women, r 0.81; each, p 0.0001), waist circumference (men, r 0.86; women, r 0.85; each, p 0.0001), hip circumference (men, r 0.62; women, r 0.56; each, p 0.0001), and waist:hip ratio (men, r 0.66; women, r 0.87; each, p 0.0001). NC 37 cm for men and 34 cm for women were the best cutoff levels for determining the subjects with BMI 25.0 kg/m2 using the receiver output curve analysis. In the validation unrelated group, the test characteristics were excellent with 98% sensitivity, 89% specificity, and 94% accuracy for men, and 100% sensitivity, 98% specificity, and 99% accuracy for women. NC 39.5 cm for men and 36.5 cm for women were the best cutoff levels for determining the subjects with BMI 30 kg/m2 using the receiver output curve analysis. In the validation unrelated group, the test characteristics were excellent with 93% sensitivity, 90% specificity, and 91% accuracy for men, and 93% sensitivity, 98% specificity, and 97% accuracy for women. Discussion: NC measurement is a simple and time-saving screening measure that can be used to identify overweight and obese patients. Men with NC 37 cm and women with NC 34 cm are not to be considered overweight. Patients with NC 37 cm for men and 34 cm for women require additional evaluation of overweight or obesity status. Key words: obesity, obesity indices, anthropometry, neck circumference

Introduction
Overweight is defined as a body mass index (BMI) between 25 and 29.9 kg/m2 and obesity is defined as a BMI of 30 kg/m2 or higher. These conditions pose a major public problem because they are associated with various chronic diseases (1). It is estimated that more than one-half of adults, 35 to 65 years of age, living in Europe are either obese or overweight. The prevalence of obesity in Europe is estimated to be 10% to 20% of adult men and 15% to 25% of adult women. These figures seem to be increasing (2). In the United States, the crude prevalence of overweight and obesity (BMI 25 kg/m2) for age 20 was 59.4% for men, 50.7% for women, and 54.9% overall between 1988 and 1994. The prevalence of obesity (BMI 30 kg/m2) is also on the increase; it was estimated to be 14.5% between 1976 and 1980, and 22.5% between 1988 and 1994 (3). There are numerous methods of assessing overweight and obesity. Some techniques are applicable at primary care facilities, such as measurements of weight, height, abdominal sagittal diameter, abdominal and hip circumferences, and calculations of waist:hip ratio and BMI. It

Submitted for publication November 28, 2000. Accepted for publication in final form May 22, 2001. *Department of Family Medicine, Ben-Gurion University of the Negev, Faculty for Health Sciences, Israel; Tel Aviv University, Heller Institute of Medical Research, Israel; and Medicine A Carmel Medical Center, Technion Institute of Technology Haifa, Israel. Address correspondence to Dr. Liubov (Louba) Ben-Noun, POB 572, Kiryat-Gat 82104, Israel. E-mail: l-bennun@zahav.net.il Copyright 2001 NAASO

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Table 1. Characteristics of subjects in the test and the validation sample

Test sample Variables Age (yr) Weight (kg) Height (cm) Waist circumference (cm) Hip circumference (cm) NC (cm) BMI (kg/m2) Waist:hip ratio Men (n 353) Women (n 371) Men (n Validation sample 107) Women (n 148)

51.1 (17.7) 78.0 (13.7)* 170.5 (8.0) 95.9 (12.5) 97.5 (7.5) 38.8 (3.2) 27.1 (4.8) 0.98 (0.1)

52.0 (16.0) 69.9 (14.4) 158.2 (6.8) 95.9 (16.0) 101.8 (8.4) 35.3 (2.8) 28.1 (5.7) 0.94 (0.1)

48.2 (17.9) 74.9 (12.4) 170.8 (7.8) 92.4 (12.4) 96.7 (8.3) 38.2 (2.7) 26.0 (4.3) 0.96 (1.1)
0.04 for weight; p

53.6 (16.3) 67.7 (13.3) 157.6 (8.6) 93.8 (16.2) 100.6 (8.3) 35.0 (2.6) 27.5 (5.6) 0.93 (1.4)

Values are in means (SD). Test sample men vs. validation sample men: * p 0.03 for BMI, p 0.02 for waist:hip ratio by t test.

0.02 for waist circumference; p

is not always practical to use these techniques, especially in winter, in busy, everyday primary care practice. Other procedures, such as ultrasound, computed tomography, and magnetic resonance imaging, are expensive and are primarily used for research purposes. As a first step to achieve obesity control, it is important to develop a reliable, simple, quick method for the assessment of obesity in primary care clinics. Jean Vague was the first researcher to realize that different body morphology or types of fat distribution are related to the health risks associated with obesity. He used a neck skinfold in his index of masculine differentiation to assess

Table 3. Relationship between NC and various variables, Pearsons correlation coefficients and their statistical significance (bivariate analysis)
NC (cm) Variables Test sample Age (yr) Weight (kg) Height (cm) Waist circumference (cm) Hip circumference (cm) Waist:hip ratio BMI (kg/m2) (n r 0.328 0.7 0.044 0.857 Men 353) p 0.0001 0.0001 0.4108 0.0001 Women (n 371) r 0.360 0.805 0.134 0.845 p 0.0001 0.0001 0.01 0.0001

Table 2. Cross tabulation by different categories of BMI and NC in the test sample*
BMI (kg/m2) Men (n) 25 25 to 30 30 Total Women (n) 25 25 to 30 30 Total 37 80 0 0 80 34 95 2 0 97 NC (cm) 37 to 39.5 23 79 1 103 34 to 36.5 15 120 6 141 39.5 12 66 91 169 36.5 3 11 119 133 Total 115 145 92 352 Total 113 133 125 371

0.616 0.0001 0.657 0.0001 0.828 0.0001 (n Men 107) p 0.0001 0.0001 0.3173 0.0001

0.560 0.0001 0.865 0.0001 0.710 0.0001 Women (n 148) r 0.351 0.795 0.202 0.874 p 0.0001 0.0001 0.01 0.0001

Validation sample Age (yr) Weight (kg) Height (cm) Waist circumference (cm) Hip circumference (cm) Waist:hip ratio BMI (kg/m2)

r 0.405 0.723 0.098 0.859

0.507 0.0001 0.730 0.0001 0.837 0.0001

0.455 0.0001 0.753 0.0001 0.860 0.0001

* Similar results were obtained for validation sample. Frequency missing one.

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Table 4. NC (cm) cutoff levels for determining the subjects with BMI the test group
Men Cutoff level (cm) 29 31 32 33 34 35 36 36.5 37 37.5 38 38.5 39 39.5 40 41 43 45 47 49 52 Sensitivity (%) 100 100 100 100 100 100 100 100 99 99 68 67 48 47 34 24 10 5 2 0 0 1-Specificity (%) 100 96 92 85 72 60 27 25 92 8 6 6 4 4 3 3 1 1 1 1 1 PPV/ NPV 0.71 0.72 0.73 0.76 0.79 0.89 0.90 0.99 0.99 1.72 1.76 2.18 2.20 2.49 2.68 3.00 3.00 2.75 1.67 0.00 Accuracy (%) 70 71 72 75 78 82 92 92 97 97 76 75 63 62 53 46 37 33 31 30 30 Sensitivity (%) 100 100 99 99 99 68 50 49 25 21 13 12 7 7 3 2 1 0 0 0 0

25 kg/m2 using ROC analysis:

Women 1-Specificity (%) 91 59 36 12 100 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 PPV/ NPV 0.75 0.84 0.91 0.98 1.03 1.88 2.35 2.38 3.02 3.14 3.36 3.39 3.52 3.53 3.63 3.66 3.69 3.70 Accuracy (%) 75 84 90 96 99 76 64 63 46 42 36 36 32 32 29 28 27 27 27 27 27

The cutoff level is the NC with the highest accuracy (true-positives is shown bold and underlined.

true-negatives/all), and the closest to 1 PPV/NPV. The cutoff level

upper-body fat distribution (4). Although obesity results in metabolic abnormalities, upper-body obesity is more strongly associated with glucose intolerance, hyperinsulinemia, diabetes, hypertriglyceridemia, gout, and uric calculous disease than is lower-body obesity (4,5). NC, as an index of upper-body subcutaneous adipose tissue distribution, was evaluated in relation to cardiovascular risk factors by Sjostrom et al. (6). In addition, relationships were ex amined between changes in body composition, including the neck girth, and changes in cardiovascular risk factors (7). Furthermore, the free fatty acid release from upperbody subcutaneous fat was found to be larger than that from lower-body subcutaneous fat (8), a fact that further strengthens the relevance of measuring upper-body subcutaneous adipose tissue depots. These observations indicate that NC as an index of upper body fat distribution can be used to identify overweight and obese patients.
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The aim of this study was to determine whether a single measure of NC might be used to identify overweight patients and to define NC cutoff levels for overweight and obesity according to existing BMI cutoff levels.

Research Methods and Procedures

Test Sample Seven hundred thirty-five consecutive patients (355 men and 380 women), who visited a family medicine clinic in a southern Israeli urban district for any reason between the randomly chosen months of January and September 1998, were included in this study. Two subjects who were chairbound, six with a thyroid nodule, and three who refused to participate were excluded, leaving 353 men and 371 women in the test sample. Anthropometric evaluation was performed during the first visit but not during subsequent visits.

Neck Circumference for Identifying Overweight and Obese Patients, Ben-Noun, Sohar, and Laor

Table 5. NC (cm) cutoff levels for determining the subjects with BMI the validation group
Men Cutoff level (cm) 29 31 32 33 34 35 36 36.5 37 37.5 38 38.5 39 39.5 40 41 43 45 47 49 52 Sensitivity (%) 100 100 100 100 100 100 100 100 98 97 71 71 57 57 38 17 6 2 2 2 2 1-Specificity (%) 100 98 95 91 82 70 34 32 89 11 5 5 0 0 0 0 0 0 0 0 0 PPV/ NPV 0.59 0.60 0.61 0.64 0.67 0.81 0.82 0.95 0.97 1.37 1.37 1.61 1.61 1.89 2.18 2.34 2.41 2.41 2.41 2.41 Accuracy (%) 59 60 61 63 66 71 86 87 94 93 81 81 75 75 64 51 45 42 42 42 42 Sensitivity (%) 100 100 100 100 100 64 47 47 27 25 11 11 5 5 2 0 0 0 0 0 0

25 kg/m2 using ROC analysis:

Women 1-Specificity (%) 98 69 44 17 98 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 PPV/ NPV 0.65 0.73 0.81 0.91 0.99 1.67 1.98 1.98 2.35 2.38 2.63 2.63 2.75 2.75 2.81 Accuracy (%) 66 76 84 94 99 76 66 66 53 51 43 43 39 39 36 35 35 35 35 35 35

The cutoff level is the NC with the highest accuracy (true-positives is shown bold and underlined.

true-negatives/all), and the closest to 1 PPV/NPV. The cutoff level

Validation Sample The sample comprised 258 patients (108 men and 150 women), who randomly visited the same family medicine clinic for any reason during the same randomly chosen months of January and September 1998. They were not local residents but came to the town for a visit to their family or on business. They underwent the same anthropometric measurements. Three patients with thyroid nodule were excluded, leaving 107 men and 148 women in the validation group. Anthropometry All measurements were made by L.B.-N. with standard techniques (9): weight by digital scales (HANSON, Watford, Hertforshire, England) to within 100 g, without heavy clothing; height barefoot by portable stadiometer (Holtain, Crymmych, Wales) to within 0.5 cm; waist and

hip circumferences were calibrated weekly to within 1 mm, using plastic tapes. The waist was measured at the end of a gentle expiration midway between the lowest rib and iliac crest, with the patient standing, and the hips were measured at the greater trochanter. NC was measured in the midway of the neck, between midcervical spine and midanterior neck, to within 1 mm, with plastic tape calibrated weekly. In men with a laryngeal prominence (Adams apple), it was measured just below the prominence. All circumferences were taken with the subjects standing upright, with the face directed toward L.B.-N., and shoulders relaxed. Definitions Low BMI was defined as 25 kg/m2 for both men and women. High BMI was defined at two levels as 25 or 30 kg/m2 for both men and women (1). Waist circumference was defined as low: 94 cm for men and 80 cm for
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Table 6. NC (cm) cutoff levels for determining the subjects with BMI the test group
Men Cutoff level (cm) 29 31 32 33 34 35 36 36.5 37 37.5 38 38.5 39 39.5 40 41 43 45 47 49 52 Sensitivity (%) 100 100 100 100 100 100 100 100 100 100 99 99 96 96 72 52 21 11 4 1 0 1-Specificity (%) 100 98 97 93 87 82 68 67 58 58 26 24 6 95 2 2 0 0 0 0 0 PPV/ NPV 0.33 0.33 0.34 0.35 0.37 0.41 0.42 0.45 0.45 0.65 0.66 0.91 0.92 1.07 1.16 1.32 1.32 1.21 0.74 0.00 Accuracy (%) 32 33 35 37 41 44 54 55 61 61 82 83 95 95 90 83 74 71 69 68 67 Sensitivity (%) 100 100 100 100 99 98 97 97 51 42 25 23 14 13 6 4 1 1 0 0 0

30 kg/m2 using ROC analysis:

Women 1-Specificity (%) 96 82 72 62 57 22 3 99 0 0 0 0 0 0 0 0 0 0 0 0 0 PPV/ NPV 0.37 0.41 0.44 0.48 0.50 0.73 0.97 0.99 1.26 1.31 1.38 1.39 1.49 1.49 1.53 1.54 1.56 1.56 Accuracy (%) 39 47 54 60 63 85 97 98 82 79 73 72 69 69 66 65 64 64 64 64 64

The cutoff level is the NC with the highest accuracy (true-positives is shown bold and underlined.

true-negatives/all), and the closest to 1 PPV/NPV. The cutoff level

women (10). High waist circumference was defined at two levels as described previously (10), with slight changes, as 94 to 102 cm for men and 80 to 88 cm for women or 102 cm for men and 88 cm for women. Waist:hip ratio was defined as low 0.95 for men and 0.80 for women and high as 0.95 for men and 0.80 for women (10 13). True-positive subjects were those with high BMI and high NC. True-negative subjects were those with low BMI and low NC. False-positive subjects were those with high NC and low BMI. False-negative subjects were those with low NC and high BMI. Sensitivity was calculated as true-positives/(true-positives false-negatives); specificity as truenegatives/(true-negatives false-positives). Positive predictive value (PPV) was defined as the percentage of subjects with high BMI who had high NC. Negative predictive value (NPV) was defined as the percentage of subjects with low BMI who had low NC.
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Additional Evaluation All patients in the test sample with false-positive and false-negative findings were invited for an additional examination. The records and data from a clinic computer for these patients were reviewed as well. These procedures were aimed at evaluating whether there was any pathological finding that might explain the correlation between NC and overweight or obesity. Statistical Analysis The significance of differences in proportions was tested by using the 2 test; if the predicted size of any cell was five or less, then Fishers exact test was used. The significance of differences between continuous variables was assessed by using the Students t test. Equality of variance was tested by the folded form of F statistics; correction for unequal variances was performed when appropriate. All tests of

Neck Circumference for Identifying Overweight and Obese Patients, Ben-Noun, Sohar, and Laor

Table 7. NC (cm) cutoff levels for determining the subjects with BMI the validation group
Men Cutoff level (cm) 29 31 32 33 34 35 36 36.5 37 37.5 38 38.5 39 39.5 40 41 43 45 47 49 52 Sensitivity (%) 100 100 100 100 100 100 100 100 97 97 97 97 93 93 63 30 13 3 3 3 3 1-Specificity (%) 100 99 97 95 90 83 62 61 49 48 23 23 10 90 6 3 0 0 0 0 0 PPV/ NPV 0.28 0.29 0.29 0.30 0.32 0.38 0.39 0.44 0.45 0.63 0.63 0.80 0.80 0.91 1.05 1.34 1.38 1.38 1.38 1.38 Accuracy (%) 28 29 30 32 36 40 55 56 64 64 82 82 91 91 85 79 76 73 73 73 73 Sensitivity (%) 100 100 100 100 100 98 93 93 52 48 20 20 9 9 4 0 0 0 0 0 0

30 kg/m2 using ROC analysis:

Women 1-Specificity (%) 99 84 72 58 50 16 2 98 2 2 2 2 1 1 0 0 0 0 0 0 0 PPV/ NPV 0.31 0.35 0.39 0.44 0.47 0.75 0.98 0.98 1.13 1.14 1.12 1.12 1.13 1.13 1.43 Accuracy (%) 32 42 51 60 66 89 97 97 84 82 74 74 71 71 70 69 69 69 69 69 69

The cutoff level is the NC with the highest accuracy (true-positives is shown bold and underlined.

true-negatives/all), and the closest to 1 PPV/NPV. The cutoff level

significance were two-tailed. To find the optimal, maximal sensitivity and specificity for NC, the receiver output curve (ROC) analysis of cutoff points at intervals of 0.5, 1, or 2 cm for NC against two levels of BMI was performed. Maximal accuracy and PPV/NPV closest to 1 were used for cutoff level determination. A p value of 0.05 was considered significant. Data were analyzed using SAS statistical software (14).

Results
The mean age, height, NC, and hip circumferences were similar for men and women in both the test and validation samples. Men in the test sample were heavier, had a larger waist circumference, a higher BMI, and a higher waist:hip ratio than men in the validation sample (Table 1). A significant association was found using the 2 test between BMI

and NC categories (men, 2 376.54, 4 df; women, 2 661.90, 4 df; each, p 0.0001) (Table 2). In both sexes, BMI correlated positively with age (r 0.32, p 0.0001), weight (r 0.78, p 0.0001), height (r 0.27, p 0.001), waist circumference (r 0.85, p 0.0001), hip circumference (r 0.65, p 0.0001), and NC and waist: hip ratio (each, r 0.62, p 0.0001). In bivariate analysis, a strong correlation was found between NC and age, weight, waist circumference, waist:hip ratio, and BMI for men and women. A small significant negative correlation was found between height and NC for women (the test group, r 0.13; the validation group, r 0.20; each, p 0.01) (Table 3). In the test group, NC 37 cm for men and 34 cm for women were the best cutoff levels for determining the subjects with BMI 25 kg/m2, using ROC analysis with
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gion or any other disease, for example, hypothyroidism, which might have influenced the correlation between NC and overweight or obesity. In scattergrams (Figure 1) a positive relation is shown between NC and BMI for men and women in the test sample. Similar results were obtained for the validation sample.

Discussion
This study indicates that NC was associated with age, weight, waist and hip circumferences, waist:hip ratio, and BMI for men and women. Thus, a strong association was found between NC and conventional overweight and obesity indexes. BMI is a reasonable index of fatness because it is simple, easy to determine, inexpensive, safe, and practical. It has shown reasonably good correlation with the direct measures of fatness (15). It is age and sex dependent when used as an indicator of body fatness, although it is ethnicity independent in black and white adults (16). BMI should be used to assess overweight and obesity and to monitor changes in body weight (1). Therefore, in this study overweight- and obesity-related variables were compared primarily with BMI values. An evaluation of subjects who were defined as falsepositive or false-negative did not disclose any significant pathology, including soft tissues, bones and muscles in the neck region, or any other disease, for example, hypothyroidism, which may have influenced the association between NC and overweight or obesity. There are various indices that predict specifically intraabdominal fat, cardiovascular risk factors, and disease. These include waist:hip circumference ratio (1719), waist circumference (20,21), abdominal sagittal diameter (2,20), the ratio of waist:thigh circumference, and the ratio of waist:height or the conicity index (2). NC used in combination with other measurements in a three-compartment model of interpretable anthropometry separates the effects of visceral adipose tissue mass, subcutaneous adipose tissue mass, and subcutaneous adipose tissue distribution on metabolic parameters under cross-sectional and longitudinal conditions (7). NC is also related to cardiovascular risk factors in severely obese men and women (6). It seems, therefore, that with an increase in NC, the likelihood of risk factors for cardiovascular disease also increases. A significant negative correlation was found between NC and height among women, but not in men. This finding can be explained by differences in bodily structures between men and women. NC 37 cm for men and 34 cm for women identified subjects with BMI 25.0 kg/m2 with 98% to 99% sensitivity for men and 99% to 100% for women, 89% to 92% specificity for men and 98% to 100% for women, 0.95 to 0.99 PPV/NPV for men and 0.99 to 1.03 for women, and 94% to 97% accuracy for men and 99% for women. NC 39.5 cm for men and 36.5 cm for women identified

Figure 1: NC of 37 cm for men and 34 cm for women identified most of the subjects with BMI 25 kg/m2. NC of 39.5 cm for men and 36.5 cm for women identified most of the subjects with BMI 30 kg/m2. Horizontal lines show two BMI levels. Vertical lines show two neck circumference levels. Falsepositives appear in the lower right quadrant. False-negatives appear in the upper left quadrant.

99% sensitivity, 92% specificity, 0.99 PPV/NPV, and 97% accuracy for men, and 99% sensitivity, 100% specificity, 1.03 PPV/NPV, and 99% accuracy for women (Table 4). In the validation group, using the same cutoff levels of NC for BMI, 98% sensitivity, 89% specificity, 0.95 PPV/NPV, and 94% accuracy were found for men and 100% sensitivity, 98% specificity, 0.99 PPV/NPV, and 99% accuracy for women (Table 5). NC 39.5 cm for men and 36.5 cm for women were the best cutoff levels for determining subjects with BMI 30.0 kg/m2 using ROC analysis. In the test group, 96% sensitivity, 95% specificity, 0.92 PPV/NPV, and 95% accuracy were found for men and 97% sensitivity, 99% specificity, 0.99 PPV/NPT, and 98% accuracy for women (Table 6). In the validation unrelated group, 93% sensitivity, 90% specificity, 0.80 PPV/NPV, and 91% accuracy were found for men and 93% sensitivity, 98% specificity, 0.98 PPV/ NPV, and 97% accuracy for women (Table 7). Additional evaluation of patients and their records did not detect any significant pathological finding in the neck re476 OBESITY RESEARCH Vol. 9 No. 8 August 2001

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subjects with BMI 30 kg/m2 with 93% to 96% sensitivity for men and 93% to 97% for women, 90% to 95% specificity for men and 98% to 99% for women, 0.80 to 0.92 PPV/NPV for men and 0.98 to 0.99 for women, and 91% to 95% accuracy for men and 97% to 98% women. These findings indicate that NC can be used as a simple, easy to perform, quick test that can be used to identify overweight or obese patients. Although NC shows a strong correlation with both overweight and obesity, it is reasonable to consider it as a screening test. Men with NC 37 cm and women with NC 34 cm do not require additional evaluation. Patients above these levels require a more comprehensive evaluation of their overweight or obesity status.

Acknowledgments
No outside funding/support was provided for this study.
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