General and abdominal adiposity and risk of death in Europe

Body mass index, waist circumference and mortality in kidney transplant recipients

Higher body mass index (BMI) appears paradoxically associated with better outcomes in patients with chronic kidney disease. Whereas higher BMI reflects both increased visceral and subcutaneous fat and/or muscle mass, a combined assessment of BMI and waist circumference may enable differentiation of visceral adiposity from muscle and/or nonvisceral fat mass. We examined the association of BMI and waist circumference with all-cause mortality in a prospective cohort of 993 kidney transplant recipients. Associations were examined in Cox models with adjustment for demographic and comorbid conditions and for inflammatory markers. Unadjusted death hazard ratios (95%CI) associated with one standard deviation higher BMI and waist circumference were 0.94 (0.78, 1.13), p = 0.5 and 1.20 (1.00, 1.45), p = 0.05, respectively. Higher BMI was associated with lower mortality after adjustment for waist circumference (0.48 [0.34, 0.69], p < 0.001), and higher waist circumference was more strongly associated with higher mortality after adjustment for BMI (2.18 [1.55-3.08], p < 0.001). The associations of waist circumference with mortality remained significant after additional multivariable adjustments. Higher BMI and waist circumference display opposite associations with mortality in kidney transplant recipients. Waist circumference appears to be a better prognostic marker for obesity than BMI.

Effects of aerobic and resistance training on hemoglobin A1c levels in patients with type 2 diabetes: a randomized controlled trial

CONTEXT

Exercise guidelines for individuals with diabetes include both aerobic and resistance training although few studies have directly examined this exercise combination.

OBJECTIVE

To examine the benefits of aerobic training alone, resistance training alone, and a combination of both on hemoglobin A(1c) (HbA(1c)) in individuals with type 2 diabetes.

DESIGN, SETTING, AND PARTICIPANTS

A randomized controlled trial in which 262 sedentary men and women in Louisiana with type 2 diabetes and HbA(1c) levels of 6.5% or higher were enrolled in the 9-month exercise program between April 2007 and August 2009.

INTERVENTION

Forty-one participants were assigned to the nonexercise control group, 73 to resistance training 3 days a week, 72 to aerobic exercise in which they expended 12 kcal/kg per week; and 76 to combined aerobic and resistance training in which they expended 10 kcal/kg per week and engaged in resistance training twice a week. Main Outcome Change in HbA(1c) level. Secondary outcomes included measures of anthropometry and fitness.

RESULTS

The study included 63.0% women and 47.3% nonwhite participants who were a mean (SD) age of 55.8 years (8.7 years) with a baseline HbA(1c) level of 7.7% (1.0%). Compared with the control group, the absolute mean change in HbA(1c) in the combination training exercise group was -0.34% (95% confidence interval [CI], -0.64% to -0.03%; P = .03). The mean changes in HbA(1c) were not statistically significant in either the resistance training (-0.16%; 95% CI, -0.46% to 0.15%; P = .32) or the aerobic (-0.24%; 95% CI, -0.55% to 0.07%; P = .14) groups compared with the control group. Only the combination exercise group improved maximum oxygen consumption (mean, 1.0 mL/kg per min; 95% CI, 0.5-1.5, P < .05) compared with the control group. All exercise groups reduced waist circumference from -1.9 to -2.8 cm compared with the control group. The resistance training group lost a mean of -1.4 kg fat mass (95% CI, -2.0 to -0.7 kg; P < .05) and combination training group lost a mean of -1.7 (-2.3 to -1.1 kg; P < .05) compared with the control group.

CONCLUSIONS

Among patients with type 2 diabetes mellitus, a combination of aerobic and resistance training compared with the nonexercise control group improved HbA(1c) levels. This was not achieved by aerobic or resistance training alone.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00458133.

Adiposity, fitness and metabolic risk in children: a cross-sectional and longitudinal study

OBJECTIVE

To better understand the early development of cardiovascular disease, we examined the association of adiposity measures and cardiorespiratory fitness (CRF) with baseline values and changes in low-grade chronic inflammation and insulin resistance (IR) in school children.

METHODS

Eighty-three 1(st) and 5(th) grade children from a randomly selected control group of a physical activity intervention study (KISS) were prospectively studied during one academic year. Outcome variables included highly sensitive C-reactive protein (hs-CRP) and homeostasis assessment of IR (HOMA-IR). Adiposity measures included body mass index (BMI), waist circumference and the sum of skinfold thickness at four sites. CRF was assessed by the 20 m shuttle run test. All models were adjusted for age group, sex and pubertal group and included children who had a complete valid dataset for all variables.

RESULTS

Baseline metabolic markers correlated positively with measures of adiposity and inversely with CRF (all p ≤ 0.02). On average, longitudinal changes in hs-CRP concentration increased with high baseline BMI in boys and skinfold thickness in both genders (both p < 0.01). Increases in adiposity had an additional effect on these changes (adjusted R(2) of the models including baseline and change in adiposity 0.49-0.53, p < 0.001). On the other hand, longitudinal changes in HOMA-IR were positively related to changes in BMI and waist circumference (p ≤ 0.03). Increases in HOMA-IR, but not in hs-CRP concentrations, were associated with low baseline CRF (p = 0.01).

CONCLUSION

The relationship of baseline adiposity and CRF with increases in metabolic risk markers may have relevant implications for long-term cardiovascular risk. International Standard Randomised Controlled Trial Number (ISRCTN):

TRIAL REGISTRATION

isrctn.org 15360785.

Trends in low-risk lifestyle factors among adults in the United States: findings from the Behavioral Risk Factor Surveillance System 1996-2007

OBJECTIVE

Our objective was to examine recent trends in low-risk lifestyle factors for chronic diseases (not currently smoking, any exercise during the past 30 days, consuming fruits and vegetables ≥5 times per day, and body mass index <25kg/m(2)) among U.S. adults.

METHODS

We used data from 1,580,220 adults aged ≥18 years who participated in one of seven Behavioral Risk Factor Surveillance System surveys conducted from 1996 to 2007.

RESULTS

The age-adjusted percentage of adults meeting all four low-risk lifestyle factors was 8.5% in 1996 and 7.7% in 2007 (p for linear trend <0.001). Significant decreasing trends were noted for men, women, whites, Hispanics, and most age groups. The percentages of participants who were not currently smoking, who had done any exercise during the past 30 days, who reported consuming fruits and vegetables ≥5 times per day, and who had a body mass index <25kg/m(2) were 70.9%, 76.2%, 47.9% and 24.3%, respectively, in 1996 and 77.1%, 80.0%, 37.8%, and 24.5%, respectively, in 2007. Women and whites were more likely than their counterparts to meet all four criteria.

CONCLUSIONS

From 1996 to 2007, the percentage of U.S. adults meeting all four low-risk lifestyle factors decreased slightly.

Meta-analysis identifies 13 new loci associated with waist-hip ratio and reveals sexual dimorphism in the genetic basis of fat distribution

Waist-hip ratio (WHR) is a measure of body fat distribution and a predictor of metabolic consequences independent of overall adiposity. WHR is heritable, but few genetic variants influencing this trait have been identified. We conducted a meta-analysis of 32 genome-wide association studies for WHR adjusted for body mass index (comprising up to 77,167 participants), following up 16 loci in an additional 29 studies (comprising up to 113,636 subjects). We identified 13 new loci in or near RSPO3, VEGFA, TBX15-WARS2, NFE2L3, GRB14, DNM3-PIGC, ITPR2-SSPN, LY86, HOXC13, ADAMTS9, ZNRF3-KREMEN1, NISCH-STAB1 and CPEB4 (P = 1.9 × 10⁻⁹ to P = 1.8 × 10⁻⁴⁰) and the known signal at LYPLAL1. Seven of these loci exhibited marked sexual dimorphism, all with a stronger effect on WHR in women than men (P for sex difference = 1.9 × 10⁻³ to P = 1.2 × 10⁻¹³). These findings provide evidence for multiple loci that modulate body fat distribution independent of overall adiposity and reveal strong gene-by-sex interactions.

Waist circumference predicts increased complications in rectal cancer surgery

BACKGROUND

The impact of obesity on development of postoperative complications after gastrointestinal surgery remains controversial. This may be due to the fact that obesity has been calculated by body mass index, a measure that does not account for fat distribution. We hypothesized that waist circumference, a measure of central obesity, would better predict complications after high-risk gastrointestinal procedures.

METHODS

Retrospective review of an institutional cancer database identified consecutive cases of men undergoing elective rectal resections. Waist circumference was calculated from preoperative imaging.

RESULTS

From 2002 to 2009, 152 patients with mean age 65.2 ± 0.75 years and body mass index 28.0 ± 0.43 kg/m(2) underwent elective resection of rectal adenoma or carcinoma. Increasing body mass index was not significantly associated with risk of postoperative complications including infection, dehiscence, and reoperation. Greater waist circumference independently predicted increased risk of superficial infections (OR 1.98, 95% CI 1.19-3.30, p < 0.008) and a significantly greater risk of having one or more postoperative complications (OR 1.56, 95% CI 1.04-2.34, p < 0.034).

CONCLUSIONS

Waist circumference, a measure of central obesity, is a better predictor of short-term complications than body mass index and can be used to identify patients who may benefit from more aggressive infection control and prevention.

Genetic susceptibility to obesity and related traits in childhood and adolescence: influence of loci identified by genome-wide association studies

OBJECTIVE

Large-scale genome-wide association (GWA) studies have thus far identified 16 loci incontrovertibly associated with obesity-related traits in adults. We examined associations of variants in these loci with anthropometric traits in children and adolescents.

RESEARCH DESIGN AND METHODS

Seventeen variants representing 16 obesity susceptibility loci were genotyped in 1,252 children (mean ± SD age 9.7 ± 0.4 years) and 790 adolescents (15.5 ± 0.5 years) from the European Youth Heart Study (EYHS). We tested for association of individual variants and a genetic predisposition score (GPS-17), calculated by summing the number of effect alleles, with anthropometric traits. For 13 variants, summary statistics for associations with BMI were meta-analyzed with previously reported data (N(total) = 13,071 children and adolescents).

RESULTS

In EYHS, 15 variants showed associations or trends with anthropometric traits that were directionally consistent with earlier reports in adults. The meta-analysis showed directionally consistent associations with BMI for all 13 variants, of which 9 were significant (0.033-0.098 SD/allele; P < 0.05). The near-TMEM18 variant had the strongest effect (0.098 SD/allele P = 8.5 × 10(-11)). Effect sizes for BMI tended to be more pronounced in children and adolescents than reported earlier in adults for variants in or near SEC16B, TMEM18, and KCTD15, (0.028-0.035 SD/allele higher) and less pronounced for rs925946 in BDNF (0.028 SD/allele lower). Each additional effect allele in the GPS-17 was associated with an increase of 0.034 SD in BMI (P = 3.6 × 10(-5)), 0.039 SD, in sum of skinfolds (P = 1.7 × 10(-7)), and 0.022 SD in waist circumference (P = 1.7 × 10(-4)), which is comparable with reported results in adults (0.039 SD/allele for BMI and 0.033 SD/allele for waist circumference).

CONCLUSIONS

Most obesity susceptibility loci identified by GWA studies in adults are already associated with anthropometric traits in children/adolescents. Whereas the association of some variants may differ with age, the cumulative effect size is similar.

How is the risk of undernutrition associated with cardiovascular disease among individuals of advanced age?

BACKGROUND

The oldest old (85+) are the fastest growing population segment in New Zealand. Cardiovascular disease (CVD) is the main cause of death and is associated with various risk factors including risk of undernutrition.

OBJECTIVES

To determine if there is an association between CVD and nutrition risk in advanced age.

SETTING

Three North Island locations (rural and urban areas) in New Zealand.

PARTICIPANTS

108 participants aged 85 years (75-79 for Maori).

MEASUREMENTS

Comprehensive health assessments were undertaken. Clinically manifest CVD was pre-defined and ascertained from interviews and hospitalisation records. Nutrition risk was assessed using a validated questionnaire-Seniors in the Community: Risk evaluation for eating and nutrition, Version II (SCREEN II).

RESULTS

72 participants (67%) had CVD (49% men); 52% of participants had a SCREEN II score < 50. Those with CVD had lower HDL level [median(IQR)] [1.4(0.7) vs. 1.6(0.6)] (p=0.041), and higher waist circumference [97.5(19.1) vs. 89.3(20.6)] (p=0.043) compared to those without CVD. Those with CVD were at no greater nutrition risk than those without CVD (SCREEN II score: [49(7) vs. 51(10)] (p=0.365). Using logistic regression controlling for confounders, SCREEN II scores trended towards an inverse association with CVD (p=0.10).

CONCLUSION

Two thirds of the study participants had CVD and half were at risk of undernutrition. Nutrition risk was mildly associated with CVD. This study provides further evidence that those in advanced age are at risk of undernutrition. Further research is needed to establish how the causes and consequences of CVD are related to nutrition risk.

Coronary heart disease and body fat distribution

Larger waist circumference or waist-hip ratio, as crude indicators of visceral fat mass, are associated with adverse metabolic profile, but their role in predicting future coronary heart disease (CHD) events has been less investigated. Recent epidemiologic findings suggest that these simple and inexpensive measures of abdominal fat distribution predict CHD independently of body mass index, and, to a certain extent, cardiovascular disease risk factors. The magnitude and shape of the association between abdominal adiposity and CHD have been shown to vary with age, gender, and ethnicity. Studies have also suggested that lower body fat is associated with reduced CHD risk, although the clinical relevance for this finding needs further elucidation. Assessing body fat distribution may be useful for improving CHD risk assessment, although more studies are needed to assess consistency in CHD risk predictions across populations. A consensus is also needed to define the clinically relevant cut-off points for waist circumference or waist-hip ratio.

Cut-points for waist circumference in Europids and South Asians

There is little strong evidence that currently recommended higher waist circumference cut-points for Europids compared with South Asians are associated with similar risk for type 2 diabetes. This study was designed to provide such evidence. Longitudinal studies over 5 years were conducted among 5,515 Europid and 2,214 ethnically South Asian participants. Age-standardized diabetes incidence at different levels of waist circumference and incidence difference relative to a reference value were calculated. The Youden Index was used to determine waist circumference cut-points. At currently recommended cut-points, estimated annual diabetes incidence for a 50-year-old Europid was <0.6% for both sexes, and for a 50-year-old South Asian, 5.8% for men and 2.1% for women. Annual diabetes incidence of 1% was observed for a 50 year old at a waist circumference 35-40 cm greater in Europid compared to South Asian men and women. Incidence difference between recommended cut-points and a reference value (80 cm in men, 70 cm in women) was 0.3 and 4.4% per year for Europid and South Asian men, and 0.2 and 0.8% per year for Europid and South Asian women, respectively. Waist circumference cut-points chosen using the Youden Index were shown to be dependent on obesity levels in the population. The much higher observed risk of diabetes in South Asians compared to Europids at the respective recommended waist circumference cut-points suggests that differences between them should be greater. Approaches that use the Youden Index to select waist circumference cut-points are inappropriate and should not be used for this purpose.

Análise de diferentes medidas antropométricas na identificação de síndrome metabólica, com ou sem alteração do metabolismo glicídico

OBJETIVO: Este estudo comparou parâmetros antropométricos e de resistência à insulina de indivíduos sem e com síndrome metabólica (SM), subestratificados pela presença de anormalidades glicêmicas. SUJEITOS E MÉTODOS: Foram incluídos 454 indivíduos (66% mulheres, 54% brancos), sendo 155 alocados para o grupo 1 (sem SM, sem anormalidade glicêmica), 32 para o grupo 2 (sem SM, com anormalidade glicêmica), 104 no grupo 3 (com SM, sem anormalidade glicêmica) e 163 no grupo 4 (com SM e anormalidade glicêmica). Os grupos foram comparados por ANOVA. RESULTADOS: Os grupos com SM (3 e 4) apresentaram os piores perfis antropométrico e lipídico; no grupo 2, apesar de glicemias significantemente mais elevadas, as médias das variáveis antropométricas e lipídicas não diferiram do grupo 1. Os maiores valores médios de HOMA-IR foram encontrados nos grupos com SM, enquanto o grupo 2 apresentou o menor HOMA-β. A trigliceridemia foi a variável metabólica com coeficientes de correlação mais elevados com a antropometria. Porém, as correlações mais fortes foram da circunferência da cintura (r = 0,503) e da razão cintura-altura (r = 0,513) com o HOMA-IR (p < 0,01). CONCLUSÃO: Nossos achados revelam que, em amostra da população brasileira, qualquer das medidas antropométricas identifica indivíduos com SM, mas não parece capaz de diferenciar aqueles com distúrbio glicêmico. Reforçamos a relação mais forte das medidas de adiposidade central com resistência à insulina, sugerindo utilidade da razão cintura-altura. É possível que componente autoimune contribua para o comprometimento do metabolismo glicídico dos indivíduos do grupo 2.

Role of adipokines in obesity-associated hypertension

It has been well documented that obesity is a major risk factor for the development of the hypertensive state. The correlation between body mass index and blood pressure level is well established. Nevertheless, the exact mechanisms which contribute to obesity-related hypertension remain poorly understood. In the last years, we have realized that the white adipose tissue is not just an inert organ for nutrient storage and isolation but rather depending on the body mass index the biggest endocrinological organ. Thus, the possible contribution of adipokines to the blood pressure elevation becomes an attractive hypothesis to explain the hypertensive state that often occurs in obesity. In this review, we consider direct and indirect effects of main adipokines on structural and functional changes in the cardiovascular system.

Fat tissue, aging, and cellular senescence

Fat tissue, frequently the largest organ in humans, is at the nexus of mechanisms involved in longevity and age-related metabolic dysfunction. Fat distribution and function change dramatically throughout life. Obesity is associated with accelerated onset of diseases common in old age, while fat ablation and certain mutations affecting fat increase life span. Fat cells turn over throughout the life span. Fat cell progenitors, preadipocytes, are abundant, closely related to macrophages, and dysdifferentiate in old age, switching into a pro-inflammatory, tissue-remodeling, senescent-like state. Other mesenchymal progenitors also can acquire a pro-inflammatory, adipocyte-like phenotype with aging. We propose a hypothetical model in which cellular stress and preadipocyte overutilization with aging induce cellular senescence, leading to impaired adipogenesis, failure to sequester lipotoxic fatty acids, inflammatory cytokine and chemokine generation, and innate and adaptive immune response activation. These pro-inflammatory processes may amplify each other and have systemic consequences. This model is consistent with recent concepts about cellular senescence as a stress-responsive, adaptive phenotype that develops through multiple stages, including major metabolic and secretory readjustments, which can spread from cell to cell and can occur at any point during life. Senescence could be an alternative cell fate that develops in response to injury or metabolic dysfunction and might occur in nondividing as well as dividing cells. Consistent with this, a senescent-like state can develop in preadipocytes and fat cells from young obese individuals. Senescent, pro-inflammatory cells in fat could have profound clinical consequences because of the large size of the fat organ and its central metabolic role.

Clinical profile and management of patients with hypertension and chronic ischemic heart disease according to BMI

Obesity is associated with numerous risk factors and comorbidities such as hypertension, metabolic syndrome, type 2 diabetes, and cardiovascular diseases. However, numerous studies have reported an obesity paradox; the overweight and obese patients with established cardiovascular disease have better prognosis than those with a BMI <25 kg/m(2). This study was designed to assess potential differences in the clinical profile and management of hypertensive outpatients with chronic ischemic heart disease in obese and lean patients that could explain these two apparently contradictory points. Overweight and obesity were defined as a BMI 25-29.9 kg/m(2) and ≥30 kg/m(2), respectively. Cardiovascular risk factors goals were considered according to European Society of Hypertension-European Society of Cardiology 2003, National Cholesterol Education Program Adult Treatment Panel III and American Diabetes Association 2005 guidelines. A sample of 2,024 patients (66.8 ± 10.1 years; 31.7% women) was included. Of these, 0.1% had a BMI <20 kg/m(2); 17.1% BMI 20-24.9 kg/m(2); 53.7% BMI 25-29.9 kg/m(2); 23.7% BMI 30-34.9 kg/m(2); 4.3% BMI 35-39.9 kg/m(2); and 1.1% BMI ≥40 kg/m(2). The subgroup of patients with BMI ≥30 kg/m(2) had a higher proportion of women, diastolic dysfunction, diabetes, dyslipidemia, left ventricular hypertrophy, and heart failure. There was an inverse relationship between risk factors control rates and BMI (all comparisons BMI 20-24.9 kg/m(2) vs. 25-29.9 kg/m(2) vs. ≥30 kg/m(2)): blood pressure (BP) control (51.7% vs. 42.4% vs. 29.2%, P < 0.001); low-density lipoprotein cholesterol (LDL-C) control (35.2% vs. 30.5% vs. 27.9%, P = 0.03) and diabetes control (38.6% vs. 27.6% vs. 22.2%, P = 0.023). In conclusion, in patients with hypertension and chronic ischemic heart disease, as BMI increases, the clinical profile worsens as well as risk factors control rates.

Femoral adipose tissue may accumulate the fat that has been recycled as VLDL and nonesterified fatty acids

OBJECTIVE

Gluteo-femoral, in contrast to abdominal, fat accumulation appears protective against diabetes and cardiovascular disease. Our objective was to test the hypothesis that this reflects differences in the ability of the two depots to sequester fatty acids, with gluteo-femoral fat acting as a longer-term "sink."

RESEARCH DESIGN AND METHODS

A total of 12 healthy volunteers were studied after an overnight fast and after ingestion of a mixed meal. Blood samples were taken from veins draining subcutaneous femoral and abdominal fat and compared with arterialized blood samples. Stable isotope-labeled fatty acids were used to trace specific lipid fractions. In 36 subjects, adipose tissue blood flow in the two depots was monitored with (133)Xe.

RESULTS

Blood flow increased in response to the meal in both depots, and these responses were correlated (r(s) = 0.44, P < 0.01). Nonesterified fatty acid (NEFA) release was suppressed after the meal in both depots; it was lower in femoral fat than in abdominal fat (P < 0.01). Plasma triacylglycerol (TG) extraction by femoral fat was also lower than that by abdominal fat (P = 0.05). Isotopic tracers showed that the difference was in chylomicron-TG extraction. VLDL-TG extraction and direct NEFA uptake were similar in the two depots.

CONCLUSIONS

Femoral fat shows lower metabolic fluxes than subcutaneous abdominal fat, but differs in its relative preference for extracting fatty acids directly from the plasma NEFA and VLDL-TG pools compared with chylomicron-TG.

Swedish clinical guidelines--prevention and management of metabolic risk in patients with severe psychiatric disorders

Individuals with severe psychiatric disorders are more likely than the population at large to develop metabolic derangements such as overweight and diabetes. Cardiovascular disease is also more frequently seen in this group. Contributing factors may include inappropriate diet or lack of physical activity, but antipsychotic medication may also play a role. Seven Swedish specialist medical societies have collaborated in formulating a set of concise clinically applicable guidelines-reproduced here in modified form-for the prevention and management of metabolic risk in this patient group. The importance of implementation is emphasized.

Changes in waist circumference and mortality in middle-aged men and women

Background

Waist circumference (WC) adjusted for body mass index (BMI) is positively associated with mortality, but the association with changes in WC is less clear. We investigated the association between changes in WC and mortality in middle-aged men and women, and evaluated the influence from concurrent changes in BMI.

Methodology/Principal Findings

Data on 26,625 healthy men and women from the Danish Diet, Cancer and Health study was analyzed. WC and BMI were assessed in 1993–97 and in 1999–02. Information on mortality was obtained by linkage to the Danish central Person Register. Hazard ratios (HR) were estimated with Cox regression models. During 6.7 years of follow-up, 568 and 361 deaths occurred among men and women, respectively. Changes in WC were positively associated with mortality (HR per 5 cm for the sexes combined  = 1.09 (1.02∶1.16) with adjustment for covariates, baseline WC, BMI and changes in BMI), whereas changes in BMI were inversely associated with mortality (HR per kg/m2 for the sexes combined  = 0.91 (0.86, 0.97) with adjustment for covariates, baseline WC, BMI and changes in WC). Associations between changes in WC and mortality were not notably different in sub-groups stratified according to changes in BMI, baseline WC or when smokers or deaths occurring within the first years of follow-up were excluded.

Conclusions/Significance

Changes in WC were positively associated with mortality in healthy middle-aged men and women throughout the range of concurrent changes in BMI. These findings suggest a need for development of prevention and treatment strategies targeted against redistribution of fat mass towards the abdominal region.

[Body mass index in the prognosis of first myocardial infarction]

BACKGROUND AND OBJECTIVES

The value of body mass index in the prognosis of patients with ischemic heart disease is not well defined. The objective of our study was to determine the association of body mass index with classic and emergent cardiovascular risk factors and with intra-hospital and 6-months mortality.

PATIENTS AND METHODS

We conducted a prospective, multicenter study with a 6-months follow-up. We included 1063 patients between the ages of 25-75 years old who were consecutively admitted to the hospital within the first 24 hours of the onset of symptoms between years 2001 and 2003. We determined demographic and anthropometric variables, as well as classic and emergent factors of risk, clinical variables and the treatment administered. We carried out a univariate and multivariate analysis.

RESULTS

The percentage of patients with overweight or obesity in this population was 73.56%. Overweight and obesity were associated with classical risk factors, except for smoking, and emergent risk factors. Body mass index was not associated with short-or mid-term prognosis.

CONCLUSIONS

Body mass index is not a useful anthropometric measure to determine the prognosis of patients after a first myocardial infarction.

The hypertriglyceridemic-waist phenotype and the risk of coronary artery disease: results from the EPIC-Norfolk prospective population study

BACKGROUND

Screening for increased waist circumference and hypertriglyceridemia (the hypertriglyceridemic-waist phenotype) has been proposed as an inexpensive approach to identify patients with excess intra-abdominal adiposity and associated metabolic abnormalities. We examined the relationship between the hypertriglyceridemic-waist phenotype to the risk of coronary artery disease in apparently healthy individuals.

METHODS

A total of 21,787 participants aged 45-79 years were followed for a mean of 9.8 (standard deviation 1.7) years. Coronary artery disease developed in 2109 of them during follow-up. The hypertriglyceridemic-waist phenotype was defined as a waist circumference of 90 cm or more and a triglyceride level of 2.0 mmol/L or more in men, and a waist circumference of 85 cm or more and a triglyceride level of 1.5 mmol/L or more in women.

RESULTS

Compared with participants who had a waist circumference and triglyceride level below the threshold, those with the hypertriglyceridemic-waist phenotype had higher blood pressure indices, higher levels of apolipoprotein B and C-reactive protein, lower levels of high-density lipoprotein cholesterol and apolipoprotein A-I, and smaller low-density lipoprotein particles. Among men, those with the hypertriglyceridemic-waist phenotype had an unadjusted hazard ratio for future coronary artery disease of 2.40 (95% confidence interval [CI] 2.02-2.87) compared with men who did not have the phenotype. Women with the phenotype had an unadjusted hazard ratio of 3.84 (95% CI 3.20-4.62) compared with women who did not have the phenotype.

INTERPRETATION

Among participants from a European cohort representative of a contemporary Western population, the hypertriglyceridemic-waist phenotype was associated with a deteriorated cardiometabolic risk profile and an increased risk for coronary artery disease.

Predictive performances of lipid accumulation product vs. adiposity measures for cardiovascular diseases and all-cause mortality, 8.6-year follow-up: Tehran lipid and glucose study

BACKGROUND

The body mass index (BMI) is the most commonly used marker for evaluating obesity related risks, however, central obesity measures have been proposed to be more informative. Lipid accumulation product (LAP) is an alternative continuous index of lipid accumulation. We sought in this study to assess if LAP can outperform BMI, waist-to-height-ratio (WHtR), or waist-to-hip-ratio (WHpR) in predicting incident cardiovascular disease (CVD) or all-cause mortality.

RESULTS

Among participants of Tehran Lipid and Glucose Study, 6,751 participants (2,964 men), aged ≥ 30 years, were followed for a median of 8.6 years. We observed 274 deaths (men: 168) and 447 CVD events (men: 257). Levels of common CVD risk factors significantly increased across LAP quartiles. Mortality rates did not differ by LAP quartiles. Among participants free of CVD at baseline [6331 (2,741 men)], CVD incident rates per 1000 person increased in a stepwise fashion with increasing LAP quartile values in both men (from 6.9 to 17.0) and women (from 1.3 to 13.0), (Ps < 0.001). Among women, a 1-SD increment in log-LAP conferred a 41% increased risk for CVD (HR 1.41, 95% CIs 1.02-1.96). Among men, however, LAP was not observed to be independently associated with increased risk of CVD; except in a sub-group of men assigned to the lifestyle modification interventions, where, LAP predicted CVD risk. After adjustment with CVD risk factors LAP turned to be inversely associated with risk of all-cause mortality (HR, men 0.74, 95% CIs 0.61-0.90; women, 0.94 95% CIs 0.74-1.20). Among women, magnitude of increased risk of CVD due to LAP was not different from those of anthropometric measures. Among men, however, WHpR was observed to be more strongly associated with increased risk of CVD than was LAP. Among neither men nor women were the predictive performances (discrimination, calibration, goodness-of-fit) of the LAP better than those of different anthropometric measures were.

CONCLUSIONS

If LAP is to be used for predicting CVD, it might not be superior to WHtR or WHpR.

Combined impact of lifestyle-related factors on total and cause-specific mortality among Chinese women: prospective cohort study

BACKGROUND

Although cigarette smoking, excessive alcohol drinking, obesity, and several other well-studied unhealthy lifestyle-related factors each have been linked to the risk of multiple chronic diseases and premature death, little is known about the combined impact on mortality outcomes, in particular among Chinese and other non-Western populations. The objective of this study was to quantify the overall impact of lifestyle-related factors beyond that of active cigarette smoking and alcohol consumption on all-cause and cause-specific mortality in Chinese women.

METHODS AND FINDINGS

We used data from the Shanghai Women's Health Study, an ongoing population-based prospective cohort study in China. Participants included 71,243 women aged 40 to 70 years enrolled during 1996-2000 who never smoked or drank alcohol regularly. A healthy lifestyle score was created on the basis of five lifestyle-related factors shown to be independently associated with mortality outcomes (normal weight, lower waist-hip ratio, daily exercise, never exposed to spouse's smoking, higher daily fruit and vegetable intake). The score ranged from zero (least healthy) to five (most healthy) points. During an average follow-up of 9 years, 2,860 deaths occurred, including 775 from cardiovascular disease (CVD) and 1,351 from cancer. Adjusted hazard ratios for mortality decreased progressively with an increasing number of healthy lifestyle factors. Compared to women with a score of zero, hazard ratios (95% confidence intervals) for women with four to five factors were 0.57 (0.44-0.74) for total mortality, 0.29 (0.16-0.54) for CVD mortality, and 0.76 (0.54-1.06) for cancer mortality. The inverse association between the healthy lifestyle score and mortality was seen consistently regardless of chronic disease status at baseline. The population attributable risks for not having 4-5 healthy lifestyle factors were 33% for total deaths, 59% for CVD deaths, and 19% for cancer deaths.

CONCLUSIONS

In this first study, to our knowledge, to quantify the combined impact of lifestyle-related factors on mortality outcomes in Chinese women, a healthier lifestyle pattern-including being of normal weight, lower central adiposity, participation in physical activity, nonexposure to spousal smoking, and higher fruit and vegetable intake-was associated with reductions in total and cause-specific mortality among lifetime nonsmoking and nondrinking women, supporting the importance of overall lifestyle modification in disease prevention. Please see later in the article for the Editors' Summary.

A systematic review of waist-to-height ratio as a screening tool for the prediction of cardiovascular disease and diabetes: 0·5 could be a suitable global boundary value

This systematic review collated seventy-eight studies exploring waist-to-height ratio (WHtR) and waist circumference (WC) or BMI as predictors of diabetes and CVD, published in English between 1950 and 2008. Twenty-two prospective analyses showed that WHtR and WC were significant predictors of these cardiometabolic outcomes more often than BMI, with similar OR, sometimes being significant predictors after adjustment for BMI. Observations from cross-sectional analyses, forty-four in adults, thirteen in children, supported these predictions. Receiver operator characteristic (ROC) analysis revealed mean area under ROC (AUROC) values of 0·704, 0·693 and 0·671 for WHtR, WC and BMI, respectively. Mean boundary values for WHtR, covering all cardiometabolic outcomes, from studies in fourteen different countries and including Caucasian, Asian and Central American subjects, were 0·50 for men and 0·50 for women. WHtR and WC are therefore similar predictors of diabetes and CVD, both being stronger than, and independent of, BMI. To make firmer statistical comparison, a meta-analysis is required. The AUROC analyses indicate that WHtR may be a more useful global clinical screening tool than WC, with a weighted mean boundary value of 0·5, supporting the simple public health message 'keep your waist circumference to less than half your height'.

Obesity, intentional weight loss and physical disability in older adults

We examine obesity, intentional weight loss and physical disability in older adults. Based on prospective epidemiological studies, body mass index exhibits a curvilinear relationship with physical disability; there appears to be some protective effect associated with older adults being overweight. Whereas the greatest risk for physical disability occurs in older adults who are ≥class II obesity, the effects of obesity on physical disability appears to be moderated by both sex and race. Obesity at age 30 years constitutes a greater risk for disability later in life than when obesity develops at age 50 years or later; however, physical activity may buffer the adverse effects obesity has on late life physical disability. Data from a limited number of randomized clinical trials reinforce the important role that physical activity plays in weight loss programmes for older adults. Furthermore, short-term studies have found that resistance training may be particularly beneficial in these programmes as this mode of exercise attenuates the loss of fat-free mass during caloric restriction. Multi-year randomized clinical trials are needed to examine whether weight loss can alter the course of physical disablement in aging and to determine the long-term feasibility and effects of combining resistance exercise with weight loss in older adults.

Effect of change in physical activity on body fatness over a 10-y period in the Doetinchem Cohort Study

BACKGROUND

Obesity is related to many adverse health-related outcomes.

OBJECTIVE

We investigated whether changes in physical activity were related to less gain in either body weight or waist circumference (WC).

DESIGN

The association between prospectively assessed physical activity and either body weight or WC was examined in 4944 participants of the Doetinchem Study (men and women aged between 26 and 66 y at baseline). Information on physical activity (derived from a validated physical activity index), body weight, and WC, measured according to standardized procedures, was collected at baseline and at the 5- and 10-y follow-ups.

RESULTS

Random mixed-effects models showed that a single measurement of physical activity was not clearly related to change in body weight and WC over a 5-y period. However, analyses of repeated measures showed that compared with those who maintained their activity level, those who increased their physical activity over a 5-y period had less gain in WC ( minus 0.35 cm; 95% CI: minus 0.65, minus 0.05 cm) and possibly in body weight ( minus 280 g; 95% CI: minus 620, 5 g). Most importantly, these effects were sustained (although not significantly) in the consecutive 5 y for WC ( minus 0.56 cm; 95% CI: minus 108, 0.04 cm) and for body weight ( minus 590 g; 95% CI: minus 1005, minus 130 g), which indicated that physical activity was truly a determinant of body size changes.

CONCLUSIONS

An increase in physical activity was associated with a statistically significant lower gain in body weight and in WC, which was maintained during the following 5 y. These findings support the need for public health programs that promote physical activity.

Addressing obesity in the hospitalized patient: a needs assessment

OBJECTIVE

To perform a needs assessment to determine the extent to which hospitalist providers recognize and intervene upon obese patients in the hospital setting.

METHODS

A chart review was performed for patients admitted to the hospitalist service at Johns Hopkins Bayview Medical Center between September 1 and October 1, 2008. Patient charts were reviewed for documentation of obesity and treatment plans were ordered and implemented. Demographic data for patients and hospitalist providers was also collected. Providers were also surveyed about their documentation practices related to obesity and any perceived barriers.

RESULTS

Forty-nine percent (136/276) of admitted patients were obese. Obesity was documented in 19% (26/136) of admission notes and a discrete plan was made to address obesity 7% (10/136) of the time. Hospitalist providers were more likely to document obesity in patients <60 years old (85% versus 55% respectively, P <0.007), and in patients with body mass indices (BMI) >or= 35 (77% versus 44% respectively, P < 0.004). Provider survey results suggest that providers do not document obesity because it is not considered to be an acute issue (67%), and they elect not to address obesity because they lack the time (63%), skill (37%), and they believe that their efforts will be unsuccessful (33%).

CONCLUSION

Documentation of obesity by hospitalist providers is poor. Because an inpatient admission has been characterized as a teachable moment when patients are willing to reflect on behavior change, this may be an ideal time to counsel and educate obese patients.

Effects of physical activity, body mass index, waist-to-hip ratio and waist circumference on total mortality risk in the Swedish National March Cohort

The health benefits of physical activity (PA) have been well documented. However, there is less research investigating whether or not these health benefits might differ among males and females or among subjects characterized by different levels of body mass index (BMI), waist-to-hip ratio (WHR), and waist circumference (WC). Baseline total PA, BMI, WHR and waist circumference were measured in 14,585 men and 26,144 women who participated in the Swedish National March. Their effects on all-cause mortality were analyzed with a follow-up time of almost 10 years. Sedentary men with a BMI ≥ 30 had a 98% (95% CI: 30-201%) increased risk of mortality compared to normal weight men with a high level of total PA. The same trend was observed for sedentary men with high WHR or waist circumference, compared to lean and highly active men. Sedentary women with a waist circumference of 88 cm or more had almost doubled, i.e. 97% (95% CI: 35-189%) increased mortality risk compared to physically active women with a waist circumference below 80 cm. BMI in men, but waist circumference in women better forecast all-cause mortality. We found no substantial effect modification between different measures of adiposity and physical activity-physical inactivity and obesity seem to increase total mortality risk independently and additively.

Effect of age on the association between body mass index and all-cause mortality: the Ohsaki cohort study

Background

To clarify the effect of age on the association between body mass index (BMI) and all-cause mortality.

Methods

We followed 43 972 Japanese participants aged 40 to 79 years for 12 years. Cox proportional hazards regression analysis was used to estimate hazard ratios (HRs), using the following BMI categories: <18.5 (underweight), 18.5–20.9, 21.0–22.9, 23.0–24.9 (reference), 25.0–27.4, 27.5–29.9, and ≥30.0 kg/m² (obese). Analyses were stratified by age group: middle-aged (40–64 years) vs elderly (65–79 years).

Results

We observed a significantly increased risk of mortality in underweight elderly men: the multivariate HR was 1.26 (0.92–1.73) in middle-aged men and 1.49 (1.26–1.76) in elderly men. In addition, we observed a significantly increased risk of mortality in obese middle-aged men: the multivariate HR was 1.71 (1.17–2.50) in middle-aged men and 1.25 (0.87–1.80) in elderly men. In women, there was an increased risk of mortality irrespective of age group in the underweight: the multivariate HR was 1.46 (0.96–2.22) in middle-aged women and 1.47 (1.19–1.82) in elderly women. There was no excess risk of mortality with age in obese women: the multivariate HR was 1.47 (0.94–2.27) in middle-aged women and 1.26 (0.95–1.68) in elderly women.

Conclusions

As compared with the reference category, obesity was associated with a high mortality risk in middle-aged men, whereas underweight, rather than obesity, was associated with a high mortality risk in elderly men. In women, obesity was associated with a high mortality risk during middle age; underweight was associated with a high mortality risk irrespective of age. The mortality risk due to underweight and obesity may be related to sex and age.

Weight change in later life and risk of death amongst the elderly: the European Prospective Investigation into Cancer and Nutrition-Elderly Network on Ageing and Health study

OBJECTIVE

Later life weight change and mortality amongst elders.

DESIGN

Nested case-control study.

SETTING

Six countries from the European Investigation into Cancer and nutrition-Elderly, Network on Ageing and Health.

SUBJECTS

A total of 1712 deceased (cases) and 4942 alive (controls) were selected from 34,239 participants, > or = 60 years at enrolment (1992-2000) who were followed-up until March 2007. Annual weight change was estimated as the weight difference from recruitment to the most distant from-date-of-death re-assessment, divided by the respective time.

OUTCOME MEASURES

Mortality in relation to weight change was examined using conditional logistic regression.

RESULTS

Weight loss > 1 kg year(-1) was associated with statistically significant increased death risk (OR = 1.65; 95% CI: 1.41-1.92) compared to minimal weight change (+/-1 kg year(-1)). Weight gain > 1 kg year(-1) was also associated with increased risk of death (OR = 1.15; 95% CI: 0.98-1.37), but this was evident and statistically significant only amongst overweight/obese (OR = 1.55; 95% CI: 1.17-2.05). In analyses by time interval since weight re-assessment, the association of mortality with weight loss was stronger for the interval proximal (< 1 year) to death (OR = 3.10; 95% CI: 2.03-4.72). The association of mortality with weight gain was stronger at the interval of more than 3 years and statistically significant only amongst overweight/obese (OR = 1.58; 95% CI: 1.07-2.33). Similar patterns were observed regarding death from circulatory diseases and cancer.

CONCLUSIONS

In elderly, stable body weight is a predictor of lower subsequent mortality. Weight loss is associated with increased mortality, particularly short-term, probably reflecting underlying nosology. Weight gain, especially amongst overweight/obese elders, is also associated with increased mortality, particularly longer term.

The maternal and fetal impacts of obesity and gestational diabetes on pregnancy outcome

Obesity has reached pandemic proportions and is of growing concern worldwide. Adverse health outcomes associated with a raised body mass index present the greatest challenge currently facing clinicians across all disciplines. Obesity is a chronic illness which is associated with metabolic disease, nutritional deficiency, musculoskeletal complications and cancer. These obesity-related health issues extend to pregnancy where they are responsible for producing a variety of medical and obstetric complications resulting in an increased incidence of maternal and fetal adverse outcomes. Management of diet, gestational diabetes and gestational and inter-gestational weight may improve outcomes in women who are obese during pregnancy. Specific recommendations for the management of obesity in pregnancy have recently been published.

Obesity and outcomes among patients with established atrial fibrillation

Atrial fibrillation (AF) and obesity have reached epidemic proportions. The impact of obesity on clinical outcomes in patients with established AF is unknown. We analyzed 2,492 patients in the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) study. Body mass index (BMI) was evaluated as a categorical variable (normal 18.5 to <25 kg/m(2), overweight 25 to <30 kg/m(2), obese >or=30 kg/m(2)). Rate of death from any cause was higher in the normal BMI group (5.8 per 100 patient-years) than in the overweight and obese groups (3.9 and 3.7, respectively). Cardiovascular death rate was highest in the normal BMI group (3.1 per 100 patient-years), lowest in the overweight group (1.5 per 100 patient-years), and intermediate in the obese group (2.1 per 100 patient-years). After adjustment for baseline factors, differences in risk of death from any cause were no longer significant. However, overweight remained associated with a lower risk of cardiovascular death (hazard ratio 0.47, p = 0.002). Obese patients were more likely to have an uncontrolled heart rate at rest, but rhythm-control strategy success was similar across BMI categories. In each BMI category, risk of death from any cause was similar for patients randomized to a rhythm- or rate-control strategy. In conclusion, in patients with established AF, overweight and obesity do not adversely affect overall survival. Obesity does not appear to affect the relative benefit of a rate- or rhythm-control strategy.

Influence of lifestyle aspects on the association of body size and shape with all-cause mortality in middle-aged men and women

OBJECTIVE

Waist circumference, BMI and hip circumference are differentially associated with mortality. We investigated the potential influence of selected lifestyle aspects such as smoking, alcohol intake, sports activity and education.

METHOD

The Danish prospective study 'Diet, Cancer and Health' recruited 27,179 men and 29,875 women from 1993 to 1997. Cox regression models were used to estimate mortality rate ratios.

RESULTS

Adjustment for smoking habits attenuated the associations between mortality and the three body size measurements in both sexes. Adjustment for sport activity and, to a lesser extent, alcohol intake weakened the associations further for the men, whereas alcohol intake slightly weakened associations for the women. In the fully adjusted models, mortality increased highly significantly with higher waist circumference and lower hip circumference, and decreased highly significantly with higher BMI for BMI below 25 kg/m(2). This pattern was seen for all levels of the selected lifestyle factor.

CONCLUSION

A large waist circumference remained a strong risk indicator for mortality, and a large hip circumference appeared to be protective when smoking habits, alcohol intake and sport activity were accounted for. BMI below 25 kg/m(2) remained a risk factor, but not above 25 kg/m(2) once waist circumference was adjusted for.

Body mass index and chronic obstructive pulmonary disease-related mortality: a nationally representative prospective study of 220,000 men in China

BACKGROUND

Low body mass index (BMI) is associated with chronic obstructive pulmonary disease (COPD) in populations where many are overweight. Substantial uncertainty remains about the relationship in populations with lower mean BMI levels, and about the relevance to it of the effects of smoking or of reverse causality.

METHODS

A nationally representative prospective cohort study included 221,194 Chinese men aged 40-79 years in 1990-91, who were followed up for 15 years or to the age of 80 years. Hazard ratios for COPD-related mortality vs baseline BMI were adjusted for age, smoking, drinking and other factors. To reduce reverse causality, main analyses excluded all men with prior history of any respiratory diseases or abnormal lung function at baseline, leaving 2960 COPD-related deaths (16% of all deaths).

RESULTS

The mean baseline BMI was 21.7 kg/m(2). There was a highly significant inverse association between BMI and COPD-related mortality among men without any apparent impairment of lung function. Approximately 90% of men had a baseline BMI <25 kg/m(2), and among them, 5 kg/m(2) lower BMI was associated with 31% (95% confidence interval 18-45%) higher COPD-related mortality. The excess risk persisted after restricting the analysis to never-smokers or excluding the first 5 years of follow-up.

CONCLUSIONS

Low BMI is associated with increased COPD mortality in a relatively lean adult male population in China where COPD is one of the most common causes of death.

Mortality, morbidity and special issues of obese ICU patients

Obesity is on the advance in western industrialised countries and is therefore increasingly relevant also to intensive care medicine. In contrast to the common prejudice that obese patients probably have a higher ICU mortality than lean patients, convincing meta-analyses have revealed that this is not the case. Nevertheless, obese ICU patients are challenging. Especially mechanic ventilation has to be addressed: besides obesity-related anatomical problems that may complicate intubation, obstructive sleep apnoea, obesity hypoventilation syndrome and increased intra-abdominal pressure are of major relevance concerning ventilation, weaning and successful extubation. Also the risk of infections is increased in obese ICU patients, although this does not seem to increase the risk of sepsis. Nevertheless, the interplay of obesity and sepsis is a fascinating field in that adipous tissue is not just a passive reservoir of energy but an active endocrine and immunomodulating organ. However, the way of how adipokines interact with inflammation and coagulation in sepsis has yet to be clarified.

Dietary determinants of changes in waist circumference adjusted for body mass index - a proxy measure of visceral adiposity

BACKGROUND

Given the recognized health effects of visceral fat, the understanding of how diet can modulate changes in the phenotype "waist circumference for a given body mass index (WC(BMI))", a proxy measure of visceral adiposity, is deemed necessary. Hence, the objective of the present study was to assess the association between dietary factors and prospective changes in visceral adiposity as measured by changes in the phenotype WC(BMI).

METHODS AND FINDINGS

We analyzed data from 48,631 men and women from 5 countries participating in the European Prospective Investigation into Cancer and Nutrition (EPIC) study. Anthropometric measurements were obtained at baseline and after a median follow-up time of 5.5 years. WC(BMI) was defined as the residuals of waist circumference regressed on body mass index, and annual change in WC(BMI) (DeltaWC(BMI), cm/y) was defined as the difference between residuals at follow-up and baseline, divided by follow-up time. The association between energy, energy density (ED), macronutrients, alcohol, glycemic index (GI), glycemic load (GL), fibre and DeltaWC(BMI) was modelled using centre-specific adjusted linear regression, and random-effects meta-analyses to obtain pooled estimates. Men and women with higher ED and GI diets showed significant increases in their WC(BMI), compared to those with lower ED and GI [1 kcal/g greater ED predicted a DeltaWC(BMI) of 0.09 cm (95% CI 0.05 to 0.13) in men and 0.15 cm (95% CI 0.09 to 0.21) in women; 10 units greater GI predicted a DeltaWC(BMI) of 0.07 cm (95% CI 0.03 to 0.12) in men and 0.06 cm (95% CI 0.03 to 0.10) in women]. Among women, lower fibre intake, higher GL, and higher alcohol consumption also predicted a higher DeltaWC(BMI).

CONCLUSIONS

Results of this study suggest that a diet with low GI and ED may prevent visceral adiposity, defined as the prospective changes in WC(BMI). Additional effects may be obtained among women of low alcohol, low GL, and high fibre intake.

[Physical activity and training against obesity]

A short review deals with the role of physical activity in the prevention and treatment of obesity, in order to avoid cardio-metabolic consequences of accumulation of the fat. Community-level interventions are necessary, based on estimations of the physical activity. Mechanisms and effects of the proper training on the body fat and muscle are summarized, and practical advices are presented for implementation of the regular physical activity.

Waist-to-Hip Ratio, Cardiovascular Outcomes, and Death in Peritoneal Dialysis Patients

Objectives. The primary objective of this study was to determine the relationship between waist-to-hip ratio (WHR), cardiovascular (CV) events, and mortality in peritoneal dialysis (PD) patients. A secondary objective was to investigate the association between abdominal obesity and systemic inflammatory markers. Methods. This is a prospective study of 22 prevalent PD patients. WHR was measured at baseline. C-reactive protein (CRP), tumour necrosis factor-α (TNF-α), and interleukin-6 (IL-6) were measured. Main outcomes were first CV event and death from all causes. Survival analysis was used to examine the relationship between anthropomorphic measures and clinical outcomes. Results. Mean follow-up period was 3.1 years. In Kaplan-Meier analysis, survival was lower in those with higher WHR (P = .002). In Cox regression, WHR independently predicted mortality and first CV event after adjustment for known ischemic heart disease (hazard ratio [HR] 1.17, confidence interval [CI] 1.05-1.30 for death; HR 1.13, CI 1.01-1.26 for CV event). WHR correlated with serum TNF-α (r = 0.45; P = .05). Conclusion. The results of this study suggest WHR may be a risk factor for increased CV events and mortality in PD patients. Abdominal obesity is also associated with inflammatory markers. Larger studies are warranted to confirm these findings.

Body mass index, waist circumference, and the risk of type 2 diabetes mellitus: implications for routine clinical practice

BACKGROUND

Current guidelines for assessing the risk of developing type 2 diabetes mellitus (DM) recommend using the patient's body-mass index (BMI) as a primary measure. Waist circumference measurement is recommended for overweight or obese patients only (BMI > or = 25).

METHODS

We studied the interaction between BMI and waist circumference with respect to the risk of developing type 2 DM in a cohort of 9753 men and 15491 women, aged 35 to 65, who participated in the European Prospective Investigation into Cancer and Nutrition (EPIC)-Potsdam. The statistical analysis was performed with multivariable-adjusted Cox proportional hazard regression.

RESULTS

During a mean follow-up interval of 8 years, type 2 DM was newly diagnosed in 583 men and 425 women. A statistically significant interaction was found between BMI and waist circumference with respect to the risk of type 2 DM (p<0.0001). The positive association between waist circumference and diabetes risk was stronger in persons with lower BMI. The relative risk (RR) of developing type 2 DM among persons of low or normal weight (BMI < 25) who had a large waist circumference was at least as high as that among overweight persons (BMI 25-29.9) with a small waist circumference: for the first case, the RR was 3.62 [1.67-7.83] in men and 2.74 [1.52-4.94] in women; for the second case, the RR was 2.26 [1.51-3.37] in men and 1.40 [0.61-3.19] in women (The figures in square brackets are 95% confidence intervals). These relative risks were calculated in comparison to the risk among persons of low or normal weight (BMI < 25) with a small waist circumference.

CONCLUSION

These findings imply that the waist circumference is an important additional piece of information for assessing the risk of type 2 DM, particularly among persons of low or normal weight.

Methods for measuring abdominal obesity in the prediction of severe acute pancreatitis, and their correlation with abdominal fat areas assessed by computed tomography

BACKGROUND

Obesity increases the risk for severe acute pancreatitis, although abdominal obesity may be a better prognostic marker.

AIM

To determine if a single anthropometric parameter best predicts severe acute pancreatitis and correlates with intra-abdominal fat.

METHODS

Ninety-nine patients with acute pancreatitis were studied prospectively. Anthropometry included body mass index (BMI) and girths (umbilical/minimum waist, iliac/trochanter hip, thigh). Several waist-to-hip/waist-to-thigh ratios (WHR/WTR) were constructed. A CT-scan with calculation of cross-sectional abdominal fat areas was obtained in 37 cases.

RESULTS

Severe acute pancreatitis occurred in 25 patients. Waist circumference (WC), WHR and WTR - all using the umbilical reference - most accurately predicted severe acute pancreatitis. Only umbilical WC was retained in multivariate analysis: the risk for severe acute pancreatitis increased 16% with every 1 cm (OR 1.16, 95%CI: 1.1-1.3). Abdominal obesity caused a 6-fold increase in risk. Umbilical WC correlated best with subcutaneous fat area (r = 0.791, P < 0.001), whereas WHR with intra-abdominal (r = 0.594, P < 0.001).

CONCLUSIONS

Abdominal obesity according to umbilical WC is a better predictor for development of severe acute pancreatitis than BMI, minimum WC, WHR and WTR. The protocol for anthropometry must be standardized as it may affect results. Both subcutaneous and intra-abdominal fat appears to affect the likelihood of a severe outcome.

The impact of combined health factors on cardiovascular disease mortality

BACKGROUND

The combined effect of modifiable health factors on the risk of cardiovascular disease (CVD) mortality has not been well established. The objective of this study was to determine the association between 5 modifiable health factors in combination on the risk of CVD mortality in a sample of adult men.

METHODS

A cohort of 38,110 men (aged 20-84 years and of middle and upper socioeconomic strata) was followed over time until their date of death or December 31, 2003. A health profile score (unweighted and weighted) was developed based on cardiorespiratory fitness (CRF; moderate or high vs low), self-reported physical activity (active vs inactive), smoking status (not current vs current), alcohol consumption (1-14 drinks per week vs 0 or >14 drinks per week), and body mass index (BMI; 18.5-24.9 vs >or=25.0 kg/m(2)).

RESULTS

During 16.1 +/- 8.4 years of follow-up and 613,571 man-years of exposure, there were 949 deaths from CVD. High CRF, normal BMI, being physically active, and not currently smoking were individually associated with reduced risk of CVD mortality after adjusting for confounders. When considered in combination, a minimum of 2 of 5 positive health factors reduced the risk of CVD mortality (hazard ratio = 0.67, 95% CI 0.49-0.91). The weighted score indicated that a combination of high CRF, not currently smoking, and normal BMI is of most clinical importance to CVD mortality (hazard ratio = 0.31, 95% CI 0.24-0.39).

CONCLUSIONS

Exposure to increasing numbers of beneficial health factors in adulthood reduced the risk of CVD mortality in men, and multibehavioral prevention efforts in adulthood should be encouraged.

The role of adipose tissue and adipokines in obesity-related inflammatory diseases

Obesity is an energy-rich condition associated with overnutrition, which impairs systemic metabolic homeostasis and elicits stress. It also activates an inflammatory process in metabolically active sites, such as white adipose tissue, liver, and immune cells. As consequence, increased circulating levels of proinflammatory cytokines, hormone-like molecules, and other inflammatory markers are induced. This determines a chronic active inflammatory condition, associated with the development of the obesity-related inflammatory diseases. This paper describes the role of adipose tissue and the biological effects of many adipokines in these diseases.

Abdominal fat from spine dual-energy x-ray absorptiometry and risk for subsequent diabetes

CONTEXT

Abdominal obesity is a major risk factor for diabetes. Dual-energy x-ray absorptiometry (DXA) of the lumbar spine provides an index of abdominal fat.

OBJECTIVE

Our objective was to examine the hypothesis that DXA-derived abdominal fat measurement in women undergoing osteoporosis investigation predicts risk for subsequent diagnosis of diabetes.

DESIGN

This historical cohort study was derived from the Manitoba Bone Density Program Database for the Province of Manitoba, Canada.

SETTING AND PATIENTS

30,252 nondiabetic women aged 40 yr and older were referred for baseline osteoporosis assessment with DXA between January 1990 and March 2007.

MAIN OUTCOME MEASURES

Each woman's longitudinal provincial health service record was assessed for the presence of diabetes diagnosis codes after DXA testing.

RESULTS

During 5.2 + or - 2.6 yr of observation, 1252 (4.1%) women met the case definition for diabetes. A greater proportion of abdominal fat from spine DXA was strongly related to subsequent diabetes diagnosis in models adjusted for age, body mass index, and other comorbidities. Those in the highest quintile had 3.56 (95% confidence interval = 2.67-4.75) times the risk for subsequent diabetes diagnosis compared with those in the lowest (reference) quintile. Fat from hip DXA was not predictive of subsequent diabetes after adjustment for the same variables (1.00, 95% confidence interval = 0.79-1.26).

CONCLUSIONS

Predictive information about diabetes risk can be obtained from spine DXA scans performed for osteoporosis risk assessment. This is consistent with evidence linking abdominal fat with insulin resistance and the metabolic syndrome.

Dichotomization: 2 x 2 (x2 x 2 x 2...) categories: infinite possibilities

BACKGROUND

Consumers of epidemiology may prefer to have one measure of risk arising from analysis of a 2-by-2 table. However, reporting a single measure of association, such as one odds ratio (OR) and 95% confidence interval, from a continuous exposure variable that was dichotomized withholds much potentially useful information. Results of this type of analysis are often reported for one such dichotomization, as if no other cutoffs were investigated or even possible.

METHODS

This analysis demonstrates the effect of using different theory and data driven cutoffs on the relationship between body mass index and high cholesterol using National Health and Nutrition Examination Survey data. The recommended analytic approach, presentation of a graph of ORs for a range of cutoffs, is the focus of most of the results and discussion.

RESULTS

These cutoff variations resulted in ORs between 1.1 and 1.9. This allows investigators to select a result that either strongly supports or provides negligible support for an association; a choice that is invisible to readers. The OR curve presents readers with more information about the exposure disease relationship than a single OR and 95% confidence interval.

CONCLUSION

As well as offering results for additional cutoffs that may be of interest to readers, the OR curve provides an indication of whether the study focuses on a reasonable representation of the data or outlier results. It offers more information about trends in the association as the cutoff changes and the implications of random fluctuations than a single OR and 95% confidence interval.

Radical prostatectomy in obese patients: Improved surgical outcomes in recent years

OBJECTIVES

Obesity has been proposed as a risk factor for reduced disease-specific survival, increased positive surgical margin (PSM) and biochemical recurrence (BCR) after radical prostatectomy (RP) in patients with prostate cancer. The aim of this study was to clarify the relationship between obesity and surgical outcomes in patients undergoing RP.

METHODS

Medical records of 491 patients who underwent RP from 2004 to 2007 were retrieved from our institutional database. Patients were divided into three groups based on their body mass index (BMI): <25, 25-30 (overweight) and >30 kg/m (obese). Outcomes after RP were compared between the groups in terms of length of stay, perioperative complications, BCR, PSM and Gleason scores.

RESULTS

Age, stage and preoperative prostate-specific antigen were similar between BMI categories. Operating time was prolonged in obese patients (146 vs 135 min, P = 0.01) and blood loss was greater (mean estimated blood loss 640 vs 504 mL, P = 0.02), but did not translate into higher transfusion rates. Early complication rates, PSM rates and Gleason scores were not statistically different between the groups. Significant differences in late outcomes, such as the need for adjunct procedures or BCR (hazard ratio 0.44, 95% CI 0.18-1.09), were not shown.

CONCLUSION

As surgical experience with high BMI patients has developed, RP appears to be a well tolerated procedure in contemporary series, irrespective of BMI. In particular, early outcome parameters, such as PSM and BCR rates, are similar.

Weight loss and mortality: a gender-specific analysis of the Tromsø study

BACKGROUND

Weight loss has been associated with increased mortality, but findings have been inconsistent.

OBJECTIVE

The aim of this study was to examine the association between weight loss and mortality, with a focus on gender differences.

METHODS

This was a population-based cohort study in northern Norway of adults, aged 20 to 54 years in 1979, who participated in 2 or 3 consecutive health surveys in 1979-80, 1986-87, and 1994-95. Weight and height were measured at each survey. The Cox proportional hazards regression model was used to estimate hazard ratios for mortality between levels of body mass index (BMI) change during 11 years of follow-up. Participants with prior cardiovascular disease or cancer, or incident cancer within the first 2 years of follow-up, were excluded, as were participants who were pregnant, had missing data, or did not give written consent.

RESULTS

A total of 4881 men and 5051 women participated in the present study. The mean age at start of follow-up was 50.8 years (range, 35-70 years) in men and 49.2 years (range, 35-65 years) in women. In men, weight loss was associated with increased all-cause, cardiovascular, and noncardiovascular mortality. The hazard ratio for men for all-cause mortality with a 10-year BMI decrease of 2 kg/m(2) versus a BMI increase of 1 kg/m(2) was 2.09 (95% CI, 1.56-2.81). The association was not significantly modified by initial BMI, age, smoking status, or self-reported attempts of weight loss, or by exclusion of subjects with self-reported poor health, diabetes mellitus, high blood pressure, or high alcohol intake. In women, no association between BMI change and mortality was observed. However, in the subgroup of women who reported no weight-loss attempts, BMI change was significantly associated with mortality risk (P = 0.022).

CONCLUSIONS

In this study of a Norwegian population, weight loss was associated with excess mortality in men in all subgroups of weight-loss attempts, daily smoking, and overweight. In women, the only significant effect of BMI change on mortality was observed in those who reported no weight-loss attempts. The observed findings could not be explained by preexisting disease.

Impact of weight on long-term survival among patients without known coronary artery disease and a normal stress SPECT MPI

BACKGROUND

While obesity has been shown to be associated with a worse mortality, an "obesity paradox"--lower mortality in obese patients--has been noted among many patients with coronary artery disease (CAD). The extent to which an obesity paradox operates among patients with only suspected CAD, is not well determined.

METHODS AND RESULTS

A total of 3,673 patients (60 +/- 13 years, 36% males) with no history of heart disease and a normal stress SPECT were included in this study. Normal weight was defined as BMI of 18.5-24.9 kg x m(2); overweight 25-29.9 kg . m(2), obese >30 kg x m(2). The baseline clinical risk factors were recorded for each patient. The end point of the study was all-cause mortality. Of patients 942 (26%) were normal weight, 1,261 (34%) were overweight, and 1,470 (40%) were obese. Mean patient follow-up was 7.5 +/- 3 years. When compared to normal weight patients (event rate 3.2%/year), there was a lower incidence of death in the overweight (event rate 1.5%/year, P < .0001) and the obese (event rate 1.2%/year, P < .0001) groups. After controlling for baseline risk factors, using a reference HR = 1 for normal weight patients, there was a lower risk of death in the overweight (HR = .54, 95% CI .43-.7) and the obese groups (HR = .49, 95% CI .38-.63).

CONCLUSION

In patients without known cardiac disease and a normal stress SPECT, overweight and obese patients had a lower rate of all-cause mortality compared to normal weight patients over long-term follow-up. This study substantially extends the spectrum of patients in whom the obesity paradox is present.