Skip to main content


Log in

Abdominal Obesity Is More Strongly Correlated with Obstructive Sleep Apnea than General Obesity in China: Results from Two Separated Observational and Longitudinal Studies

  • Original Contributions
  • Published:
Obesity Surgery Aims and scope Submit manuscript



Previous studies have reported that obesity can result in or worsen obstructive sleep apnea (OSA). However, whether abdominal or general obesity indices or visceral adiposity indicators have a stronger association with OSA remains unclear.


This cross-sectional study included 4344 patients who underwent polysomnography (PSG) due to suspicion of OSA. We also performed a longitudinal study on 86 patients who underwent bariatric surgery to confirm the relationship between OSA and obesity. Data on overnight PSG parameters, biochemical biomarkers, and multiple anthropometric obesity indices were collected.


In the cross-sectional study, waist circumference (WC) and body mass index (BMI) were independently associated with the apnea-hypopnea index (AHI) after adjusting for potential confounding factors (additional R2 = 0.232, standardized beta coefficient [Beta] = 0.210; and additional R2 = 0.015, Beta = 0.183, respectively). Logistic regression analysis showed similar results, as did stratified analysis of adult males aged ≤ 55 years. Restricted cubic spline (RCS) analysis revealed a linear dose-response relationship between OSA and obesity. In the longitudinal study, no significant relationship was found between remission of OSA and improvement in WC and BMI (r = 0.252, p = 0.098; and r = 0.132, p = 0.395, respectively), whereas the change in the visceral adiposity indicator (lipid accumulation calculated according to WC and fasting triglycerides) was significantly correlated with ΔAHI (r = 0.322, p = 0.033).


Abdominal obesity, rather than general obesity, appears to play a more important role in OSA.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1

Similar content being viewed by others


  1. Young T, Palta M, Dempsey J, et al. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med. 1993;328:1230–5.

    Article  CAS  Google Scholar 

  2. Shahar E, Whitney CW, Redline S, et al. Sleep-disordered breathing and cardiovascular disease: cross-sectional results of the Sleep Heart Health Study. Am J Respir Crit Care Med. 2001;163:19–25.

    Article  CAS  Google Scholar 

  3. Ng M, Fleming T, Robinson M, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014;384:766–81.

    Article  Google Scholar 

  4. Pillar G, Shehadeh N. Abdominal fat and sleep apnea: the chicken or the egg? Diabetes Care. 2008;31:S303–9.

    Article  Google Scholar 

  5. Wolk R, Somers VK. Obesity-related cardiovascular disease: implications of obstructive sleep apnea. Diabetes Obes Metab. 2006;8:250–60.

    Article  CAS  Google Scholar 

  6. Wong AM, Barnes HN, Joosten SA, et al. The effect of surgical weight loss on obstructive sleep apnoea: a systematic review and meta-analysis. Sleep Med Rev. 2018;42:85–99.

    Article  Google Scholar 

  7. Onat A, Hergenc G, Yuksel H, et al. Neck circumference as a measure of central obesity: associations with metabolic syndrome and obstructive sleep apnea syndrome beyond waist circumference. Clin Nutr. 2009;28:46–51.

    Article  Google Scholar 

  8. Chen Z, Smith M, Du H, et al. Blood pressure in relation to general and central adiposity among 500 000 adult Chinese men and women. Int J Epidemiol. 2015;44:1305–19.

    Article  Google Scholar 

  9. Ashwell M, Cole TJ, Dixon AK. Ratio of waist circumference to height is strong predictor of intra-abdominal fat. BMJ. 1996;313:559–60.

    Article  CAS  Google Scholar 

  10. Ashwell M, Cole TJ, Dixon AK. Obesity: new insight into the anthropometric classification of fat distribution shown by computed tomography. Br Med J (Clin Res Ed). 1985;290:1692–4.

    Article  CAS  Google Scholar 

  11. Direk K, Cecelja M, Astle W, et al. The relationship between DXA-based and anthropometric measures of visceral fat and morbidity in women. BMC Cardiovasc Disord. 2013;13:25.

    Article  Google Scholar 

  12. Dobbelsteyn CJ, Joffres MR, MacLean DR, et al. A comparative evaluation of waist circumference, waist-to-hip ratio and body mass index as indicators of cardiovascular risk factors. The Canadian Heart Health Surveys. Int J Obes Relat Metab Disord. 2001;25:652–61.

    Article  CAS  Google Scholar 

  13. Zhang C, Rexrode KM, van Dam RM, et al. Abdominal obesity and the risk of all-cause, cardiovascular, and cancer mortality: sixteen years of follow-up in US women. Circulation. 2008;117:1658–67.

    Article  Google Scholar 

  14. Ruiz AJ, Rondon Sepulveda MA, Franco OH, et al. The associations between sleep disorders and anthropometric measures in adults from three Colombian cities at different altitudes. Maturitas. 2016;94:1–10.

    Article  Google Scholar 

  15. Chen X, Pensuksan WC, Lohsoonthorn V, et al. Obstructive sleep apnea and multiple anthropometric indices of general obesity and abdominal obesity among young adults. Int J Soc Sci Stud. 2014;2:89–99.

    PubMed  PubMed Central  Google Scholar 

  16. Degache F, Sforza E, Dauphinot V, et al. Relation of central fat mass to obstructive sleep apnea in the elderly. Sleep. 2013;36:501–7.

    Article  Google Scholar 

  17. Kripke DF, Ancoli-Israel S, Klauber MR, et al. Prevalence of sleep-disordered breathing in ages 40-64 years: a population-based survey. Sleep. 1997;20:65–76.

    Article  CAS  Google Scholar 

  18. Jablonowska-Lietz B, Wrzosek M, Wlodarczyk M, et al. New indexes of body fat distribution, visceral adiposity index, body adiposity index, waist-to-height ratio, and metabolic disturbances in the obese. Kardiol Pol. 2017;75:1185–91.

    Article  Google Scholar 

  19. Schuster J, Vogel P, Eckhardt C, et al. Applicability of the visceral adiposity index (VAI) in predicting components of metabolic syndrome in young adults. Nutr Hosp. 2014;30:806–12.

    PubMed  Google Scholar 

  20. Amato MC, Giordano C, Galia M, et al. Visceral adiposity index: a reliable indicator of visceral fat function associated with cardiometabolic risk. Diabetes Care. 2010;33:920–2.

    Article  Google Scholar 

  21. Guerrero-Romero F, Simental-Mendia LE, Gonzalez-Ortiz M, et al. The product of triglycerides and glucose, a simple measure of insulin sensitivity. Comparison with the euglycemic-hyperinsulinemic clamp. J Clin Endocrinol Metab. 2010;95:3347–51.

    Article  CAS  Google Scholar 

  22. Kahn HS. The “lipid accumulation product” performs better than the body mass index for recognizing cardiovascular risk: a population-based comparison. BMC Cardiovasc Disord. 2005;5:26.

    Article  Google Scholar 

  23. Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. J Am Coll Cardiol. 2014;63:2985–3023.

    Article  Google Scholar 

  24. World Health Organization. Definition, diagnosis and classification of diabetes mellitus and its complications: report of a WHO consultation. Part 1: diagnosis and classification of diabetes mellitus. 1999.

  25. Obesity: preventing and managing the global epidemic. Report of a WHO consultation. World Health Organ Tech Rep Ser. 2000;894:i-xii, 1-253.

  26. Rosendorff C, Lackland DT, Allison M, et al. Treatment of hypertension in patients with coronary artery disease: a scientific statement from the American Heart Association, American College of Cardiology, and American Society of Hypertension. J Am Soc Hypertens. 2015;9:453–98.

    Article  Google Scholar 

  27. Iber C, Ancoli-Israel S, Chesson AL, et al. American Academy of Sleep Medicine The AASM manual for the scoring of sleep and associated events: rules, terminology and technical specifications 1st ed, American Academy of Sleep Medicine.

  28. Du T, Yuan G, Zhang M, et al. Clinical usefulness of lipid ratios, visceral adiposity indicators, and the triglycerides and glucose index as risk markers of insulin resistance. Cardiovasc Diabetol. 2014;13:146.

    Article  Google Scholar 

  29. Simpson L, Mukherjee S, Cooper MN, et al. Sex differences in the association of regional fat distribution with the severity of obstructive sleep apnea. Sleep. 2010;33:467–74.

    Article  Google Scholar 

  30. Okushin K, Takahashi Y, Yamamichi N, et al. Helicobacter pylori infection is not associated with fatty liver disease including non-alcoholic fatty liver disease: a large-scale cross-sectional study in Japan. BMC Gastroenterol. 2015;15:25.

    Article  Google Scholar 

  31. Aune D, Sen A, Prasad M, et al. BMI and all-cause mortality: systematic review and non-linear dose-response meta-analysis of 230 cohort studies with 3.74 million deaths among 30.3 million participants. BMJ. 2016;353:i2156.

    Article  Google Scholar 

  32. Harada Y, Oga T, Chihara Y, et al. Differences in associations between visceral fat accumulation and obstructive sleep apnea by sex. Ann Am Thorac Soc. 2014;11:383–91.

    Article  Google Scholar 

  33. Bruno E, Alessandrini M, Napolitano B, et al. Dual-energy X-ray absorptiometry analysis of body composition in patients affected by OSAS. Eur Arch Otorhinolaryngol. 2009;266:1285–90.

    Article  Google Scholar 

  34. Kim AM, Keenan BT, Jackson N, et al. Tongue fat and its relationship to obstructive sleep apnea. Sleep. 2014;37:1639–48.

    Article  Google Scholar 

  35. Godoy IR, Martinez-Salazar EL, Eajazi A, et al. Fat accumulation in the tongue is associated with male gender, abnormal upper airway patency and whole-body adiposity. Metabolism. 2016;65:1657–63.

    Article  CAS  Google Scholar 

  36. Lee YG, Lee YJ, Jeong DU. Differential effects of obesity on obstructive sleep apnea syndrome according to age. Psychiatry Investig. 2017;14:656–61.

    Article  Google Scholar 

  37. Mauvais-Jarvis F. Epidemiology of gender differences in diabetes and obesity. Adv Exp Med Biol. 2017;1043:3–8.

    Article  CAS  Google Scholar 

  38. Dixon JB, Schachter LM, O'Brien PE, et al. Surgical vs conventional therapy for weight loss treatment of obstructive sleep apnea: a randomized controlled trial. JAMA. 2012;308:1142–9.

    Article  CAS  Google Scholar 

  39. Feigel-Guiller B, Drui D, Dimet J, et al. Laparoscopic gastric banding in obese patients with sleep apnea: a 3-year controlled study and follow-up after 10 years. Obes Surg. 2015;25:1886–92.

    Article  Google Scholar 

  40. Schwartz AR, Patil SP, Laffan AM, et al. Obesity and obstructive sleep apnea: pathogenic mechanisms and therapeutic approaches. Proc Am Thorac Soc. 2008;5:185–92.

    Article  Google Scholar 

  41. Ashrafian H, le Roux CW, Rowland SP, et al. Metabolic surgery and obstructive sleep apnoea: the protective effects of bariatric procedures. Thorax. 2012;67(5):442–9.

    Article  Google Scholar 

Download references


This study was supported by grants-in-aid from National Key R&D Program of China (2017YFC0112500); National Natural Science Foundation of China (81770987, 81700896, 81701306, 81770988); Innovation Program of Shanghai Municipal Education Commission (2017-01-07-00-02-E00047); multi-center clinical research project from school of medicine, Shanghai Jiao Tong University (DLY201502); and Shanghai Shen-Kang Hospital Management Center Project (SHDC12015101).

Author information

Authors and Affiliations



Prof. Shankai Yin, Jian Guan, and Hongliang Yi had full access to all of the data in the study and took responsibility for the integrity of the data and the accuracy of the data analysis. Study design: Xiaolong Zhao, Jian Guan, Hongliang Yi, and Shankai Yin; data collection: Huajun Xu, Yupu Liu, Yingjun Qian; statistical analysis: Huajun Xu; manuscript draft: Xiaolong Zhao, Jian Guan, Hongliang Yi, and Shankai Yin.

Corresponding authors

Correspondence to Jian Guan or Shankai Yin.

Ethics declarations

Conflict of Interest

The authors declare that they have no competing interests.

Ethical Approval

This study was approved by the Internal Review Board of the Institutional Ethics Committee of Shanghai Jiao Tong University Affiliated Sixth Hospital and was conducted in accordance with the Declaration of Helsinki.

Informed Consent

Informed consent was obtained from all participants included in the study

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic Supplementary Material

Supplementary Figure 1

The flow diagram of recruitment of participants in longitudinal study. T2DM, type 2 diabetes mellitus; PSG polysomnography, OSA obstructive sleep apnea, RYGB, Roux-en-Y gastric bypass (TIF 99 kb)

High resolution image (PNG 579 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Zhao, X., Xu, H., Qian, Y. et al. Abdominal Obesity Is More Strongly Correlated with Obstructive Sleep Apnea than General Obesity in China: Results from Two Separated Observational and Longitudinal Studies. OBES SURG 29, 2535–2547 (2019).

Download citation

  • Published:

  • Issue Date:

  • DOI: