Risk Assessment of Dyslipidemias, Hyperglycemia, Hyperuricemia, and Hypertension Utilizing Self-Reported Body Silhouettes

Objective Self-reported body silhouette is an anthropometric instrument that has been utilized as a screening tool for underweight, overweight, obesity, and other abnormal anthropometric variables. Herein, we analyzed the risk associated with the self-reported body silhouette in the scope of dyslipidemias, hyperglycemia, hyperuricemia, and hypertension. Methods Adult participants of the Health Workers Cohort Study enrolled between March 2004 and April 2006 were included. Then, risk analysis was performed considering dyslipidemias as serum triglycerides, high total cholesterol, high LDL-C, low HDL-C, hyperglycemia, hyperuricemia, and hypertension. Results A total of 2,297 males and 5,003 females were analyzed. The median ages of the studied population was 39 (30–49) and 41 (31–50) years for males and females, respectively. Overall, there is a stepwise increase in the risk of presenting dyslipidemias, hyperglycemia, hyperuricemia, and hypertension as the self-reported body silhouette number increases, this tendency was observed in both males and females. Conclusion Self-reported body silhouette is a useful risk assessment tool for dyslipidemias, hyperglycemia, hyperuricemia, and hypertension in Mexican adults. Applications of questioners containing this silhouette might be considered a valuable public health instrument due to their low cost, relative simplicity, and absence of specialized equipment, training, or respondent knowledge.


Introduction
Cardiovascular disease (CVD) is one of the most prevalent public health problems worldwide. Due to the high morbidity and mortality associated with this group of pathologies [1], in recent decades, we have developed a better understanding of the clinical and metabolic factors associated with CVD such as hypertension [2], dyslipidemias [3,4], hyperglycemia, and hyperuricemia [5]. Tus, in order to modify the cardiovascular risk, it has become a common practice that physicians order tests to assess those variables. However, the quantifcation of biochemical and clinical parameters requires special instruments, trained personnel, and resources that are in some clinical settings not always available.
Self-reported body silhouette is an anthropometric tool that was initially postulated by Sorensen et al. [6], and since then it has been validated and modifed by several authors

Clinical Variables and Self-Reported Body Silhouette
Assessment. Te past medical history, clinical, and demographic characteristics were recorded through selfadministered questionnaires [15]. In those, the participants were asked to identify their current body silhouette on a scale from 1 to 9, with 1 being the thinnest silhouette and 9 being the silhouette of someone with morbid obesity. Te body silhouettes are composed of two diferent sets, one for males and the other for females. Te silhouette used in this research were those initially postulated by Sorensen et al. [6] ( Figure 1). Additionally, the participant's civil or marital status and the highest level of educational attendance were assessed. For the analysis of the educational level, patients were classifed as either Primary school (in the Mexican education system: Escuela Primaria), middle school (in the Mexican education system: Escuela Secundaria), high school (in the Mexican education system: Escuela Preparatoria or Normal Superior), or those planning to attend graduate school or postgraduate school.
Bodyweight was measured with a calibrated electronic scale (model BC-533; Tanita, Tokyo, Japan) with participants wearing minimum clothing and without shoes and socks. Height was measured using a conventional stadiometer (SECA brand), with barefoot participants standing with their shoulders in a normal position; the measurements were taken with a measuring tape in a horizontal plane perpendicular to the vertical scale, touching the top of the head at the moment of inspiration. Ten BMI was calculated with the standard formula (weight in kg/(height in m) 2 ).

Biochemical Analysis.
Paraclinical tests were carried out using a venous blood sample taken after 8 hours or longer fasting; approximately 20 ml of venous blood was obtained from each participant. Ten, plasma triglycerides were measured with a colorimetric method following enzymatic hydrolysis performed with the lipase technique. Furthermore, the total cholesterol was measured by the colorimetric method following an enzymatic assay. Additionally, low-density lipoprotein cholesterol (LDL-C) and highdensity lipoprotein cholesterol (HDL-C) were measured with the clearance method. In addition, serum glucose and uric acid concentration were obtained. All biomedical assays were performed using a Selectra XL instrument (Randox), in accordance with the International Federation of Clinical Chemistry and Laboratory Medicine Guidelines [16].

Lipids, Glucose, Uric Acid, and Blood Pressure Profle
Assessment. Dyslipidemias were defned according to the criteria set by the National Cholesterol Education Program ATP-III, which defnes a high lipid profle as high serum triglycerides ≥150 mg/dL, high serum total cholesterol ≥200 mg/dL, high LDL-C ≥100 mg/dL, and low HDL-C <40 mg/dL for males and <50 mg/dL for females [17]. Hyperglycemia was considered as a serum glucose concentration of ≥100 mg/dL, per the American Diabetes Association standards for prediabetes [18]. Additionally, uric acid above ≥7 mg/dl was considered hyperuricemia [19].
During the participants' visit, blood pressure was measured twice by a trained nurse using an automatic monitor. Te frst measurement was performed after the patient rested for 5 minutes, while the participant was sitting with the dominant arm supported at the level of the heart. Te second measurement was taken using the same methodology fve minutes apart from the frst blood pressure measurement, and the mean of both recordings was used as a variable for the statistical analysis. Te nurses who performed all measurements were trained in the use of standardized procedures (reproducibility was evaluated, resulting in concordance coefcients between 0.83 and 0.90) [20]. Furthermore, hypertension was considered to have a diastolic blood pressure ≥90 mmHg and a systolic blood pressure ≥140 mmHg [21]. For the purpose of the statistical analysis, diastolic and systolic blood pressures were analyzed as a single variable each.

Statistical Analysis.
Te statistical analysis was performed with the SPSS version 24 program for Windows. Continue variables were presented with either the mean and standard deviation (±SD) or median and interquartile range (25 th -75 th ), depending on the data distribution. Categorical variables were presented as absolute values and frequencies. Diferences in biochemical markers were compared according to the type of body silhouette, a Spearman's correlation was performed. Additionally, for the risk analysis, the second self-reported body silhouette in both males and females, was considered the reference value (Odds ratio (OR) � 1). Furthermore, the β and standard error values were obtained through the binary logistical regression analysis adjusted for age, then those values were transferred to the RevMan 5.3 program (Cochrane Collaboration) to create the OR plots. For the purpose of this study a p value <0.05 was considered statistically signifcant.
Te medians of the biochemical markers, BMI, and blood pressure in accordance with self-reported body silhouette and sex are shown in Table 2. Correlational analysis was statistically signifcant (p < 0.001) for all variables; the correlation was a positive correlation for all markers, except for HDL, which shows a negative correlation.

Discussion
Our results indicate that the self-reported body silhouette is a useful risk assessment tool for dyslipidemias, hyperglycemia, hyperuricemia, and hypertension in Mexican adults. We fnd that there is a stepwise increase in the risk of presenting these abnormal parameters as the self-reported body silhouette number increased, this tendency was observed in both males and females.
Te underlying pathophysiology that supports our observations might be attributed to the intrinsic correlation of the selfreported body silhouettes and anthropometric parameters (i.e., BMI and body fat percentage). Tis observation is supported by a previous study performed on the Mexican population [22], in which a strong correlation between the BMI and the Stunkard's silhouette (males: r � 0.702, females: r � 0.766) was reported. In addition, using another type of silhouettes, the Pulver's silhouettes, Yepes et al. [23] also found a strong correlation between reported body silhouettes and BMI (males: r � 0.80, females: r � 0.81) and body fat percentage (males: r � 0.71, females: r � 0.73) within an African cohort. Tus, as the BMI increase so does the risk of pathological conditions (i.e., dyslipidemia, diabetes mellitus, hyperuricemia, and hypertension) becomes higher [12,13,24]. Hence, this opens the possibility of using the self-reported body silhouettes as a screening tool to indirectly assess the risk of those pathological states, particularly in rural areas in which special instruments and trained healthcare professionals are not always available. In our cohort, we found that there is a positive correlation between selfreported body silhouettes and biochemical markers, such as BMI and blood pressure, except for a negative correlation between HDL self-reported body silhouettes.
In the present study, the association with dyslipidemias remains strong with the higher self-reported body silhouette (silhouettes: 6, 7, 8, and 9); this association persists after correcting the analysis by age, a variable that strongly infuences the lipid profle in healthy patients [25]. Our fndings might be attributed to the proxy measurement of adiposity performed by the self-reported body silhouette, as it has been reported that excessive body fat percentage is a main metabolic comorbidity associated with dyslipidemia. [26] Although there is no substantial change in the overall risk of dyslipidemias among silhouettes 6 through 9, it is clear that there is a strong tendency for the higher silhouette to have dyslipidemia; nonetheless, in some silhouette, the CI 95% suggests that the association is statistically signifcant (i.e., females with silhouettes 8 and 9 associated with high LDL-C, and males on silhouette 9 with low HDL-C) this is probably due to the small number of participants analyzed within those particular body silhouettes.
Current evidence strongly supports the notion that hyperglycemia is a cardiovascular risk factor [27]. Moreover, it has been reported that an increased visceral abdominal fat is associated with insulin resistance (OR � 1.77, 95% CI: 1.04-3.02) [28]. Hence, with an increase in the visceral abdominal fat with each silhouette's number, there is a higher risk of hyperglycemia (particularly in females) with higher self-reported body silhouettes.
Uric acid seems to have antioxidant activity in the extracellular environment; however, once it enters the intracellular environment (i.e., vascular smooth muscle cells and adipocytes), this molecule has harmful efects, which include the inhibitory efect on nitric oxide production, the   Journal of Obesity induction of platelet aggregation, and pro-infammatory activity. Tus, it has been proposed that hyperuricemia could independently increase the risk of the metabolic syndrome, diabetes mellitus, hypertension, renal disease, gout, and CVD [29], mainly in patients with overweight and obesity [30]. Moreover, anthropometric variables such as the BMI have been signifcantly correlated with serum uric acid levels (male: r � 0.235, female: r � 0.140) [31]. Hence, it is possible that the intrinsic correlation of the BMI and the selfreported body silhouettes is responsible for the stepwise increase in the risk of hyperuricemia observed in both male and female silhouettes. A study performed in the Framingham cohort reported that the interarm systolic blood pressure diference ≥10 mm Hg was signifcantly associated with an increased incidence of cardiovascular events (hazard ratio � 1.38, 95% CI: 1.09-1.75) [32]. Furthermore, it has been shown that a reduction in systolic blood pressure decreases the risk of CVD and all-cause mortality [33]. Tus, from a clinical standpoint, it is of great interest to monitor blood pressure and diagnose those with hypertension. Although self-reported body silhouettes cannot measure blood pressure parameters, in our research, we have shown that self-reported body silhouettes can assess the risk of diastolic and systolic hypertension, mainly in silhouettes 8 and 9. Te strong association seen in this analysis might be adjudicated to the intrinsic relation between the body silhouettes and anthropometric parameters (i.e., BMI and body fat percentage), as Dua et al.'s [34] study indicated that an increase in BMI correlates with increased diastolic (male: r � 0.32; female: r � 0.35) and systolic (male: r � 0.26; female: r � 0.30) blood pressure. Tis correlation is also signifcant when analyzing body fat percentage and diastolic (male: r � 0.51; female: r � 0.42) and systolic (male: r � 0.42; female: r � 0.47) blood pressure.

Journal of Obesity
Tere are several limitations of utilizing self-reported body silhouettes as a clinical instrument, this due to the test-taking ability and body perception that may change according to the socioeconomic status, illiteracy, and educational level of each individual [35]. Additionally, as has been indicated by Osuna-Ramírez et al. [10], a limitation of this study is that our cohort has a high percentage of health-related workers and overall a higher degree of education compared to the average Mexican population; for that reason, our results may not represent the complete picture of the general Mexican population.
Despite the limitations of this study, our fndings provide an important insight into the application of self-reported Sorensen's body silhouette as a simple risk assessment instrument. Given their relative simplicity in the  Figure 3: Risk assessment of triglycerides ≥150 mg/dL, total cholesterol ≥200 mg/dL, LDL-C ≥100 mg/dL, and low HDL-C (males <40 mg/ dL, females <50 mg/dL), for each self-reported body silhouette for both females and males. All models were adjusted by age.
administration of those questioners and the absence of specialized equipment, training, or respondent knowledge, the self-reported body silhouette might be considered a lowcost screening epidemiological instrument [23], useful in the screening of individuals at risk of dyslipidemias, hyperglycemia, hyperuricemia, and hypertension. Additionally, the self-reported body silhouette may also be utilized in public health promotion mediatic campaigns, in which interactive methodological strategies that ask individuals to identify themselves within the body silhouette scale, provide automatic feedback to each participant on the cardiovascular risk factors. Consequently, this public health intervention will indicate participants with a higher risk of CVD to initiate lifestyle changes and will refer them to their primary care physician. Tough the fndings in our research are encouraging, further studies that determine the sensibility, specifcity, and positive likelihood ratio to each self-reported body silhouette in other educational strata, might help clinicians better determine the utility of the self-reported body silhouettes as a screening instrument for dyslipidemias, hyperglycemia, hyperuricemia, and hypertension. It is our opinion that a self-reported body silhouette will not replace the standardized and well-validated anthropometric screening tools but will assist as an additional instrument in the arsenal that medical providers have to improve the detection of cardiovascular risk factors in the overall population.

Conclusion
Self-reported body silhouette is a useful risk assessment tool for dyslipidemias, hyperglycemia, hyperuricemia, and hypertension in Mexican adults. Applications of questioners containing this silhouette might be considered a valuable public health instrument due to their low cost, relative simplicity, and absence of specialized equipment, training, or respondent knowledge.

Data Availability
Data used to support the fndings of this study are available upon reasonable request through a data access committee.

Ethical Approval
Te study was approved by the IRB of the three participating institutions, the Mexican Social Security Institute (12CEI  Figure 4: Risk assessment of glucose ≥100 mg/dL, uric acid ≥7 mg/dL, diastolic blood pressure ≥90 mmHg, and systolic blood pressure ≥140 mmHg, for each self-reported body silhouette for both females and males. All models were adjusted by age.

Conflicts of Interest
Te authors declare that there are no conficts of interest.