Amato, M.

Giordano, C.

AMATO, Marco Calogero

GIORDANO, Carla

Archivio istituzionale della ricerca - Università di Palermo

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Authors requiring further informationregarding Elsevier’s archiving and manuscript policies areencouraged to visit:http://www.elsevier.com/authorsrightsAuthor's personal copyLETTERS TO THE EDITORClinical indications and proper use ofVisceral Adiposity IndexVisceral Adiposity Index (VAI), a gender-specific mathe-matical index, based on simple anthropometric [BMI andWaist Circumference (WC)] and metabolic parameters[Triglycerides (TG) and HDL Cholesterol (HDL)], is a sur-rogate marker of adipose tissue function and distribution,independently correlated with insulin sensitivity and car-diometabolic risk in the general population [1]. So far, VAIis an empirical mathematical model that does not origi-nate from theoretical assumptions, but from the obser-vation in a healthy normal/overweight population of alinear relationship between BMI and CV, from which alinear equation has been extrapolated [1]. A Model ofAdipose Distribution (MOAD) was created based on thislinear equation and then it was corrected for TG and HDL,determining the VAI.In the last three years, it has been reported inmore than20publications, in which there was evaluated the capability ofthe VAI to express the cardiometabolic risk and a possible“adipose tissue dysfunction”. The most important resultswereobtained inpopulations atmetabolic riskwithoutalwayshaving an overt Metabolic Syndrome (MetS) (general popula-tion [1e4], women with PCOS [5,6], patients with NAFLD[7e12], patients with HCV [13], patients with acromegaly[14,15], patients with prolactinoma [16], patients with dia-betes [17,18]). In some populations a specific cut-off was alsoidentified as able to facilitate the early recognition of car-diometabolic risk in patients before they develop overt MetS.Three of the variables making up the VAI (WC, TG, HDL)being dichotomically expressed in the criteria of MetS, it isalso obvious that it is futile to apply the index in patientswith overt MetS.However, certain studies in the same type of patientshave yielded conflicting results, and in some cases theFigure 1 Legend: Distribution of the Visceral Adiposity Index (VAI) (A) and its component variables [BMI (B), Waist Circumfer-ences (C), Triglycerides (D), HDL Cholesterol (E)] in a population of 1764 Primary Care patients.Available online at www.sciencedirect.comjournal homepage: www.elsevier .com/locate /nmcdNutrition, Metabolism & Cardiovascular Diseases (2013) 23, e31ee320939-4753/$ - see front matter ª 2013 Elsevier B.V. All rights reserved.http://dx.doi.org/10.1016/j.numecd.2013.04.006Author's personal copypredictive power of the VAI has been ascribed to the indi-vidual variables in the model (BMI, WC, TG, HDL). We thinkthese discrepancies can be attributed to the extreme vari-ability of some variables in the model (e.g. TG) and to thedifficulties of WC assessment in morbid obesity and/orpendulous abdomen. In order to investigate the variability ofthe VAI and that of its components (BMI, WC, TG, HDL), inthe 1764 Primary Care patients studied in a previous study,we retrospectively and cross-sectionally re-examined alldata [2]. Although among all the variables examined noneshowed normal distribution (KolmogoroveSmirnov test:p < 0.001 for all variables), VAI and TG show a greaterskewness (VAI: 3.00  0.05; BMI: 1.53  0.05; WC:1.15  0.05; HDL: 0.58  0.05; TG: 2.57  0.05) and kurtosis(VAI: 15.50  0.11; BMI: 2.90  0.11; WC: 2.03  0.11; HDL:1.43  0.11; TG: 11.30  0.11) (Fig. 1): the two statisticalmeasures describe the lack of symmetry and the “peaked-ness” of the curve of distribution, respectively. Therefore,particularly high values of TG [values > 3.15 mmol/l or279 mg/dl (values equal to the meanþ3SD in the 1764Primary care patients studied)] could affect the validity ofVAI. In conclusion, for proper application in an individualpatient or in small sample size studies, the application ofthe VAI is not recommended, in the presence of morbidobesity, pendulous abdomen, severe hypertriglyceridemiaand/or or use of fibrates.References[1] Amato MC, Giordano C, Galia M, Criscimanna A, Vitabile S,Midiri M, et al. Visceral adiposity index: a reliable indicator ofvisceral fat function associated with cardiometabolic risk.Diabetes Care 2010;33:920e2. http://dx.doi.org/10.2337/dc09-1825.[2] Amato MC, Giordano C, Pitrone M, Galluzzo A. Cut-off pointsof the visceral adiposity index (VAI) identifying a visceral ad-ipose dysfunction associated with cardiometabolic risk in aCaucasian Sicilian population. Lipids Health Dis 2011;10:183.http://dx.doi.org/10.1186/1476-511X-10-183.[3] Knowles KM, Paiva LL, Sanchez SE, Revilla L, Lopez T,Yasuda MB, et al. Waist circumference, body mass index, andother measures of adiposity in predicting cardiovascular dis-ease risk factors among Peruvian adults. Int J Hypertens 2011:931402. http://dx.doi.org/10.4061/2011/931402.[4] Zhang X, Shu XO, Li H, Yang G, Xiang YB, Cai Q, et al. Visceraladiposity and risk of coronary heart disease in relatively leanChinese adults. Int J Cardiol 2013. http://dx.doi.org/10.1016/j.ijcard.2013.01.275. in press.[5] Amato MC, Verghi M, Galluzzo A, Giordano C. The oligome-norrhoic phenotypes of polycystic ovary syndrome are char-acterized by a high visceral adiposity index: a likely conditionof cardiometabolic risk. Hum Reprod 2011;26:1486e94.http://dx.doi.org/10.1093/humrep/der088.[6] Oh JY, Sung YA, Lee HJ. The visceral adiposity index as apredictor of insulin resistance in young women with polycysticovary syndrome. Obesity 2012. http://dx.doi.org/10.1002/oby.20096. in press.[7] Petta S, Amato MC, Di Marco V, Camma` C, Pizzolanti G,Barcellona MR, et al. Visceral adiposity index is associatedwith significant fibrosis in patients with non-alcoholic fattyliver disease. Aliment Pharmacol Ther 2012;35:238e47.http://dx.doi.org/10.1111/j.1365-2036.2011.04929.x.[8] Filik L. Visceral adiposity index and exercise in non-alcoholicfatty liver disease. Aliment Pharmacol Ther 2012;35:489.http://dx.doi.org/10.1111/j.1365-2036.2011.04963.x.[9] Musso G, Cassader M, Gambino R. Diagnostic accuracy of ad-ipose insulin resistance index and visceral adiposity index forprogressive liver histology and cardiovascular risk in nonal-coholic fatty liver disease. Hepatology 2012;56:788e9.http://dx.doi.org/10.1002/hep.25677.[10] Vongsuvanh R, George J, McLeod D, van der Poorten D. Visceraladiposity index is not a predictor of liver histology in patientswith non-alcoholic fatty liver disease. J Hepatol 2012;57:392e8. http://dx.doi.org/10.1016/j.jhep.2012.03.013.[11] Musso G, Cassader M, De Michieli F, Rosina F, Orlandi F,Gambino R. Nonalcoholic steatohepatitis versus steatosis:adipose tissue insulin resistance and dysfunctional responseto fat ingestion predict liver injury and altered glucoseand lipoprotein metabolism. Hepatology 2012;56:933e42.http://dx.doi.org/10.1002/hep.25739.[12] Li Y, Liu L, Wang B, Chen D. Letter: is visceral adiposity indexa predictor of liver histology in patients with non-alcoholicfatty liver disease? Aliment Pharmacol Ther 2013;37:583.http://dx.doi.org/10.1111/apt.12210.[13] Petta S, Amato M, Cabibi D, Camma` C, Di Marco V,Giordano C, et al. Visceral adiposity index is associated withhistological findings and high viral load in patients withchronic hepatitis C due to genotype 1. Hepatology 2010;52:1543e52. http://dx.doi.org/10.1002/hep.23859.[14] Ciresi A, Amato MC, Pivonello R, Nazzari E, Grasso LF,Minuto F, et al. The metabolic profile in active acromegaly isgender-specific. J Clin Endocrinol Metab 2013;98:E51e9.http://dx.doi.org/10.1210/jc.2012-2896.[15] Ciresi A, Amato MC, Pizzolanti G, Giordano Galluzzo C.Visceral adiposity index is associated with insulin sensitivityand adipocytokine levels in newly diagnosed acromegalicpatients. J Clin Endocrinol Metab 2012;97:2907e15. http://dx.doi.org/10.1210/jc.2012-1518.[16] Ciresi A, Amato MC, Guarnotta V, Lo Castro F, Giordano C.Higher doses of cabergoline further improve metabolic pa-rameters in patients with prolactinoma regardless of the de-gree of reduction in prolactin levels. Clin Endocrinol 2013.http://dx.doi.org/10.1111/cen.12204. in press.[17] Al-Daghri NM, Al-Attas OS, Alokail MS, Alkharfy KM,Charalampidis P, Livadas S, et al. Visceral adiposity index ishighly associated with adiponectin values and glycaemic dis-turbances. Eur J Clin Invest 2013;43:183e9. http://dx.doi.org/10.1111/eci.12030.[18] Bozorgmanesh M, Hadaegh F, Azizi F. Predictive performanceof the visceral adiposity index for a visceral adiposity-related risk: type 2 diabetes. Lipids Health Dis 2011;10:88.http://dx.doi.org/10.1186/1476-511X-10-88.M.C. Amato, MDC. Giordano, MD *Dipartimento Biomedico di Medicina interna e specialistica(Dibimis), Section of Endocrinology, Diabetology andMetabolism, University of Palermo, Piazza delle Cliniche 2,90127 Palermo, Italy*Corresponding author. Tel.: þ39 091 6552110;fax: þ39 091 6552123.E-mail address: carla.giordano@unipa.it (C. Giordano)4 April 2013e32 Letters to the Editor

Clinical indications and proper use of Visceral Adiposity Index.

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