Waist and hip circumferences are useful in epidemiologic research because they are stronger predictors of total body fat than body mass index (BMI).1 Additionally, waist and hip measurement reflect intra-abdominal fat accumulation, which is an important risk factor for a number of diseases.2–4 It has been hypothesized that clothing size is related to physique,5 and it was recently reported that clothing size appears to be a strong surrogate for obesity and intra-abdominal fat.6
In the Netherlands Cohort Study on diet and cancer, clothing size as well as weight and height were self-reported by all persons at baseline. Waist and hip circumferences were reported by only a small subcohort of this population, and therefore, BMI has been used to assess the association between anthropometric indices and cancer risk. The present study had 2 objectives. One, among the subcohort of persons for whom both clothing size and waist and hip circumferences are available, we estimated the correlation of self-reported clothing size and self-reported waist circumference, hip circumference, and BMI. Two, we explored the predictive power of clothing size in cancer risk, and the degree to which the addition of clothing size added to the predictive power of a more complex measure such as BMI.
The design of the Netherlands Cohort Study has been described in detail elsewhere.7–9 This prospective cohort study of diet and cancer was initiated in the Netherlands in 1986. The cohort includes 58,279 men and 62,573 women who were aged 55–69 years at baseline. It was designed as a case-cohort, using all cases and a random sample of 5000 persons randomly selected from the main cohort at baseline. The subcohort has been followed-up biennially from baseline in 1986 for vital status to estimate person-time at risk for the cohort, and to accumulate prospective data regarding dietary and lifestyle factors. Collection of anthropometric information is depicted in the Figure and described in detail in the eAppendix (http://links.lww.com/A1046).
The correlation study was conducted using only subcohort members. Participants were selected if they reported their body weight both at baseline in 1986 and follow-up in 1992 (n = 4009), and if their reported weights did not differ more than 5 kg between these 2 time points (n = 3392). Individuals missing one or more body measurement (height [n = 159], hip circumference [n = 1246], waist circumference [n = 1252], and trouser or skirt size [n = 258]) were dropped, leaving 1158 men and 1334 women in the correlation analysis. We used Spearman rank correlation to assess the sex-specific association between trouser or skirt size and the other anthropometric variables.
We next aimed to establish whether clothing size can predict cancers known to be associated with intra-abdominal fat or a large waist circumference.2,3,10–13 The associations between BMI and endometrial cancer in women and renal cancer in men were investigated previously in this cohort.3,13 We hypothesized that clothing size as a proxy measure for waist circumference would predict risk of these cancers and that adding BMI to this model would not improve the prediction.
Cancer incidence during follow-up was assessed by record linkage of the full cohort with the Netherlands cancer registry and a nationwide pathology database. Multivariate Cox regression using the case-cohort approach was performed on the whole cohort to obtain hazard rate ratios (RRs) and 95% confidence intervals (CIs) after 13.3 years of follow-up. We created models to assess the association between trouser or skirt size and the incidence of endometrial cancer (women) and renal cell carcinoma (men). To evaluate whether clothing size was predicting cancer risk independently of BMI, we compared models with and without BMI.
Cases and subcohort members were excluded from the endometrial cancer analyses if they reported hysterectomy or cancer other than nonmelanoma skin cancer at baseline (n = 77), or if they had incomplete data for BMI, trouser or skirt size, or confounders (n = 350). We adjusted models for age, age at menarche, use of oral contraceptives, age at menopause, parity, cigarette smoking, and physical activity.3 A total of 1708 subcohort members and 297 endometrial case patients were included.
Cases and subcohort members were excluded from the renal cell carcinoma analyses if they were women (n = 2575), if they had reported cancer other than nonmelanoma skin cancer at baseline, or were missing variables for BMI, trouser size, or confounders (n = 523). We adjusted models for age, cigarette smoking, total energy intake, and physical activity.13 A total of 1841 subcohort members and 195 renal cell carcinoma cases were included.
Baseline characteristics for the subcohort members used in the correlation analysis are presented in Table 1. In men, trouser size correlated slightly better with waist circumference (0.64) and hip circumference (0.63) than with BMI (0.53). In women, the correlations between skirt size and hip circumference, waist circumference, and BMI were similar (0.71–0.78). Correlations in women were generally higher than in the men (Table 2). Stratifying correlations by age and BMI did not charge these findings.
Skirt size predicted endometrial cancer risk for women in the 2 largest size categories (for size 46–48, RR = 1.6 [95% CI = 1.1–2.3] and for size 50+, RR = 5.4 [3.0–9.7]), and when size was entered as a continuous variable (RR = 1.35 [1.22–1.51]). When BMI was added to the model, all associations were attenuated (Table 3). In men, RRs for the association between trouser size and renal cell carcinoma for each size category were similar regardless of whether BMI was in the model. This was also true when size was considered as a continuous variable (for pant size alone, RR = 1.05 [CI = 0.99–1.11]; for pant size plus BMI, 1.05 [0.98–1.13]) (Table 3).
Although the idea of using clothing sizes in epidemiologic studies is not new,5,6,14,15 few studies have focused on establishing the potential of this measurement as a predictor of diseases such as cancer that are associated with body weight.2,10–12
Clothing size correlated relatively well with waist and hip circumferences in both men and women, consistent with past findings.6 With respect to cancer risk, mutual adjustment of clothing size and BMI did not improve the prediction of renal cell carcinoma in men compared with clothing size alone. Although the association was not entirely removed in women when BMI was added to the endometrial cancer model, the strength of the association was attenuated. When we repeated the analyses using shirt size, similar associations were observed (eTables 1 and 2, http://links.lww.com/A1046), suggesting that both upper- and lower-clothing-size reflect the same fat distribution.
The differences observed between men and women may be explained in part by the fact that men tend to have a greater percentage of abdominal fat.16 Etiologically, abdominal fat may be more relevant than peripheral fat for many types of cancer.10 Clothing size may be more reflective of the fat distribution associated with cancer risk, at least in men.
Measurement bias may have influenced our findings. All body measurements were obtained by self-report. While self-reported weight, height, waist circumference, and hip circumference correlate highly with technician-measured values,17–24 study participants (especially women with a high BMI) are more likely to under-estimate their waist circumference than over-estimate.24,25 This might lead to an underestimation of actual disease risk.20,24 Secondly, clothing sizes and waist and hip circumferences were reported 2 years apart. We attempted to control for potential bias by limiting our correlation analyses to individuals who did not report an extreme weight change over 6 years; however, misclassification is still possible.
Misclassification on the basis of clothing size may have occurred for additional reasons. Some people may prefer clothes with a very loose or a very tight fit. It could be that men have a large waist circumference yet wear a smaller size trouser that sits below the waist. Similarly, women may wear dresses with an elastic waist, which would also underestimate their size.6 Despite these shortcomings, a recent British study reported that in a study of 362 people, only 3% of subjects reported a clothing size different from the clothing labels.6
In recent years, clothing sizes have drifted from the original standards; differences among manufacturers have been reported in Europe and the United States, and numerical sizing systems differ globally.6,26 Researchers interested in assessing the association between clothing size measurements and disease risk should consider that with international travel, Internet shopping, and the concept of vanity sizing,6,26 some people may report sizes that are not standard in their population.
Clothing size appears to predict cancer risk independently of BMI, suggesting that clothing size reflects a fat distribution different from that indicated by weight and height. Therefore, it may be useful for future epidemiologic studies to collect clothing sizes in addition to weight and height, especially in populations where obtaining waist circumference is culturally problematic or challenging because of extreme obesity.6 There is evidence to suggest clothing size indicates adiposity,6 but more studies are needed to validate this association.
In conclusion, self-reported clothing sizes correlate well with self-reported waist circumference and hip circumference in weight-stable men and women in a Dutch cohort. Furthermore, clothing size can be used in addition to BMI to predict cancer risk.
We are indebted to the participants of this study and further wish to thank the cancer registries (IKA, IKL, IKMN, IKN, IKO, IKR, IKST, IKW, IKZ, and VIKC), and the Netherlands nationwide registry of pathology (PALGA). We also thank A. Volovics and A. Kester for statistical advice; S. van de Crommert, H. Brants, J. Nelissen, C. de Zwart, M. Moll, W. van Dijk, M. Jansen, and A. Pisters for assistance; and H. van Montfort, T. van Moergastel, L. van den Bosch, R. Schmeitz for programming assistance.
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