Background and aims Simple, low-cost central obesity measures may help identify individuals with increased cardiometabolic disease risk, although it is unclear which measures perform best in African adults. We aimed to: 1) cross-sectionally compare the accuracy of existing waist-to-height ratio (WHtR) and waist circumference (WC) thresholds to identify individuals with hypertension, pre-diabetes, or dyslipidaemia; 2) identify optimal WC and WHtR thresholds to detect CVD risk in this African population; and 3) assess which measure best predicts 5-year CVD risk. Methods and results Black South Africans (577 men, 942 women, aged >30years) were recruited by random household selection from four North West Province communities. Demographic and anthropometric measures were taken. Recommended diagnostic thresholds (WC > 80 cm for women, >94 cm for men; WHtR > 0.5) were evaluated to predict blood pressure, fasting blood glucose, lipids, and glycated haemoglobin measured at baseline and 5 year follow up. Women were significantly more overweight than men at baseline (mean body mass index (BMI) women 27.3 ± 7.4 kg/m2, men 20.9 ± 4.3 kg/m2); median WC women 81.9 cm (interquartile range 61–103), men 74.7 cm (63–87 cm), all P < 0.001). In women, both WC and WHtR significantly predicted all cardiometabolic risk factors after 5 years. In men, even after adjusting WC threshold based on ROC analysis, WHtR better predicted overall 5-year risk. Neither measure predicted hypertension in men. Conclusions The WHtR threshold of >0.5 appears to be more consistently supported and may provide a better predictor of future cardiometabolic risk in sub-Saharan Africa. •Obesity & CVD are increasing rapidly in Africa.•Low cost measures are needed to find those at risk.•Debate continues on the optimum Waist Circumference threshold for African adults.•Waist-to-height ratio predicts current & future CVD risk in South-African adults.•There is greater global agreement on the WHtR threshold (>0.5) for risk. http://www.sciencedirect.com/science?_ob=ArticleListURL&_method=list&_ArticleListID=-921226990&_sort=r&_st=13&view=c&md5=dce0821726f5c1f0e72702d33bcd99dd&searchtype=aTesthttp://dx.doi.org/10.1016/j.numecd.2014.02.005Test
