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Lassale C, Tzoulaki I, Moons KG, Sweeting M, Boer J, Johnson L, Huerta JM, Agnoli C, Freisling H, Weiderpass E, Wennberg P, van der A D, Arriola L, Benetou V, Boeing H, Bonnet F, Colorado-Yohar SM, Engström G, Eriksen AK, Ferrari P, Grioni S, Johansson M, Kaaks R, Katsoulis M, Katzke V, Key TJ, Matullo G, Melander O, Molina-Portillo E, Moreno-Iribas C, Norberg M, Overvad K, Panico S, Quirós JR, Saieva C, Skeie G, Steffen A, Stepien M, Tjønneland A, Trichopoulou A, Tumino R, van der Schouw YT, Verschuren W, Langenberg C, Di Angelantonio E, Riboli E, Wareham NJ, Danesh J, Butterworth AS. Separate and combined associations of obesity and metabolic health with coronary heart disease: a pan-European case-cohort analysis. Eur Heart J 2018; 39:397-406. [PMID: 29020414 PMCID: PMC6198928 DOI: 10.1093/eurheartj/ehx448] [Citation(s) in RCA: 173] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 07/18/2017] [Indexed: 12/13/2022] Open
Abstract
Aims The hypothesis of 'metabolically healthy obesity' implies that, in the absence of metabolic dysfunction, individuals with excess adiposity are not at greater cardiovascular risk. We tested this hypothesis in a large pan-European prospective study. Methods and results We conducted a case-cohort analysis in the 520 000-person European Prospective Investigation into Cancer and Nutrition study ('EPIC-CVD'). During a median follow-up of 12.2 years, we recorded 7637 incident coronary heart disease (CHD) cases. Using cut-offs recommended by guidelines, we defined obesity and overweight using body mass index (BMI), and metabolic dysfunction ('unhealthy') as ≥ 3 of elevated blood pressure, hypertriglyceridaemia, low HDL-cholesterol, hyperglycaemia, and elevated waist circumference. We calculated hazard ratios (HRs) and 95% confidence intervals (95% CI) within each country using Prentice-weighted Cox proportional hazard regressions, accounting for age, sex, centre, education, smoking, diet, and physical activity. Compared with metabolically healthy normal weight people (reference), HRs were 2.15 (95% CI: 1.79; 2.57) for unhealthy normal weight, 2.33 (1.97; 2.76) for unhealthy overweight, and 2.54 (2.21; 2.92) for unhealthy obese people. Compared with the reference group, HRs were 1.26 (1.14; 1.40) and 1.28 (1.03; 1.58) for metabolically healthy overweight and obese people, respectively. These results were robust to various sensitivity analyses. Conclusion Irrespective of BMI, metabolically unhealthy individuals had higher CHD risk than their healthy counterparts. Conversely, irrespective of metabolic health, overweight and obese people had higher CHD risk than lean people. These findings challenge the concept of 'metabolically healthy obesity', encouraging population-wide strategies to tackle obesity.
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Affiliation(s)
- Camille Lassale
- Department of Epidemiology and Biostatistics, Imperial College London, London, United Kingdom
- Department of Epidemiology and Public Health, University College London, London, United Kingdom
| | - Ioanna Tzoulaki
- Department of Epidemiology and Biostatistics, Imperial College London, London, United Kingdom
| | - Karel G.M. Moons
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Michael Sweeting
- MRC/BHF Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Jolanda Boer
- National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Laura Johnson
- Centre for Exercise, Nutrition and Health Sciences, School for Policy Studies, University of Bristol, Bristol, United Kingdom
| | - José María Huerta
- Department of Epidemiology, Murcia Regional Health Council, IMIB-Arrixaca, Murcia, Spain
- CIBER Epidemiología y Salud Pública (CIBERESP), Spain
| | - Claudia Agnoli
- Epidemiology and Prevention Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Heinz Freisling
- Section of Nutrition and Metabolism, International Agency for Research on Cancer (IARC-WHO), Lyon, France
| | - Elisabete Weiderpass
- Department of Community Medicine, Faculty of Health Sciences, University of Tromsø, The Arctic University of Norway, Tromsø, Norway
- Department of Research, Cancer Registry of Norway, Institute of Population-Based Cancer Research, Oslo, Norway
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Genetic Epidemiology Group, Folkhälsan Research Center, Helsinki, Finland
| | - Patrik Wennberg
- Department of Public Health and Clinical Medicine, Family medicine, Umeå University, Umeå, Sweden
| | - Daphne van der A
- National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Larraitz Arriola
- Public Health Division of Gipuzkoa, Instituto Bio-Donostia, Basque Government
| | - Vassiliki Benetou
- WHO Collaborating Center for Nutrition and Health, Unit of Nutritional Epidemiology and Nutrition in Public Health, Dept. of Hygiene, Epidemiology and Medical Statistics, School of Medicine, National and Kapodistrian University of Athens, Greece
- Hellenic Health Foundation, Athens, Greece
| | - Heiner Boeing
- Department of Epidemiology, German Institute of Human Nutrition (DIfE), Potsdam-Rehbrücke, Germany
| | - Fabrice Bonnet
- Université de Rennes 1, CHU de Rennes, Rennes, France
- Inserm (Institut National De La Santé Et De La Recherche Médical), Centre for Research in Epidemiology and Population Health (CESP), U1018, Villejuif, France
| | - Sandra M. Colorado-Yohar
- Department of Epidemiology, Murcia Regional Health Council, IMIB-Arrixaca, Murcia, Spain
- National School of Public Health, Research Group on Demography and Health, University of Antioquia, Medellín, Colombia
| | - Gunnar Engström
- Dept Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Anne K Eriksen
- Diet, Genes and Environment, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Pietro Ferrari
- Section of Nutrition and Metabolism, International Agency for Research on Cancer (IARC-WHO), Lyon, France
| | - Sara Grioni
- Epidemiology and Prevention Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Matthias Johansson
- Section of Nutrition and Metabolism, International Agency for Research on Cancer (IARC-WHO), Lyon, France
| | - Rudolf Kaaks
- German Cancer Research Center (DKFZ), Division of Cancer Epidemiology, Heidelberg, Germany
| | | | - Verena Katzke
- German Cancer Research Center (DKFZ), Division of Cancer Epidemiology, Heidelberg, Germany
| | - Timothy J Key
- Cancer Epidemiology Unit, Nuffield Department of Population Health University of Oxford, Oxford, United Kingdom
| | - Giuseppe Matullo
- Human Genetics Foundation, Turin, Italy
- Department of Medical Sciences, University of Turin, Italy
| | - Olle Melander
- Dept Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Elena Molina-Portillo
- CIBER Epidemiología y Salud Pública (CIBERESP), Spain
- Escuela Andaluza de Salud Pública. Instituto de Investigación Biosanitaria ibs.GRANADA. Hospitales Universitarios de Granada/Universidad de Granada, Granada, Spain
| | | | - Margareta Norberg
- Department of Public Health and Clinical Medicine, Epidemiology and Global Health, Umeå University, Umeå, Sweden
| | - Kim Overvad
- Department of Public Health, Section for Epidemiology, Aarhus University, Aarhus, Denmark
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Salvatore Panico
- Dipartimento di Medicina Clinica e Chirurgia, Federico II University, Naples, Italy
| | | | - Calogero Saieva
- Cancer Risk Factors and Lifestyle Epidemiology Unit, Cancer Research and Prevention Institute (ISPO), Florence, Italy
| | - Guri Skeie
- Department of community medicine, University of Tromsø – the Arctic University of Norway, Tromsø, Norway
| | - Annika Steffen
- Department of Epidemiology, German Institute of Human Nutrition (DIfE), Potsdam-Rehbrücke, Germany
| | - Magdalena Stepien
- Section of Nutrition and Metabolism, International Agency for Research on Cancer (IARC-WHO), Lyon, France
| | - Anne Tjønneland
- Diet, Genes and Environment, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Antonia Trichopoulou
- WHO Collaborating Center for Nutrition and Health, Unit of Nutritional Epidemiology and Nutrition in Public Health, Dept. of Hygiene, Epidemiology and Medical Statistics, School of Medicine, National and Kapodistrian University of Athens, Greece
- Hellenic Health Foundation, Athens, Greece
| | - Rosario Tumino
- Cancer Registry and Histopathology Unit, Civic - M.P. Arezzo Hospital, ASP Ragusa, Italy
| | - Yvonne T. van der Schouw
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - W.M.Monique Verschuren
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Claudia Langenberg
- Medical Research Council Epidemiology Unit, University of Cambridge, Cambridge, United Kingdom
| | - Emanuele Di Angelantonio
- MRC/BHF Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Elio Riboli
- Department of Epidemiology and Public Health, University College London, London, United Kingdom
| | - Nicholas J Wareham
- Medical Research Council Epidemiology Unit, University of Cambridge, Cambridge, United Kingdom
| | - John Danesh
- MRC/BHF Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
- Dept of Human Genetics, Wellcome Trust Sanger Institute, Hinxton, UK
- National Institute for Health Research Blood and Transplant Research Unit in Donor Health and Genomics, University of Cambridge, Cambridge, UK
| | - Adam S Butterworth
- MRC/BHF Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
- National Institute for Health Research Blood and Transplant Research Unit in Donor Health and Genomics, University of Cambridge, Cambridge, UK
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Peirson L, Douketis J, Ciliska D, Fitzpatrick-Lewis D, Ali MU, Raina P. Treatment for overweight and obesity in adult populations: a systematic review and meta-analysis. CMAJ Open 2014; 2:E306-17. [PMID: 25485258 PMCID: PMC4251513 DOI: 10.9778/cmajo.20140012] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Obesity is a major public health issue. This review updates the evidence on the effectiveness of behavioural and pharmacologic treatments for overweight and obesity in adults. METHODS We updated the search conducted in a previous review. Randomized trials of primary-care-relevant behavioural (diet, exercise and lifestyle) and pharmacologic (orlistat and metformin) with or without behavioural treatments in overweight and obese adults were included if 12-month, postbaseline data were provided for weight outcomes. Studies reporting harms were included regardless of design. Data were extracted and pooled wherever possible for 5 weight outcomes, 6 secondary health outcomes and 4 adverse events categories. RESULTS We identified 68 studies, most consisted of short-term (≤ 12 mo) treatments using diet (n = 8), exercise (n = 4), diet and exercise (n = 10), lifestyle (n = 19), orlistat (n = 25) or metformin (n = 4). Compared with the control groups, intervention participants had a greater weight loss of -3.02 kg (95% confidence interval [CI] -3.52 to -2.52), a greater reduction in waist circumference of -2.78 cm (95% CI -3.34 to -2.22) and a greater reduction in body mass index of -1.11 kg/m(2) (95% CI -1.39 to -0.84). The relative risk for loss of ≥ 5% body weight was 1.77 (95% CI 1.58-1.99, [number needed to treat 5, 95% CI 4-7]), and the relative risk for loss of ≥ 10% body weight was 1.91 (95% CI 1.69-2.16, [number needed to treat 9, 95% CI 7-12]). Incidence of type 2 diabetes was lower among pre-diabetic intervention participants (relative risk 0.62 [95% CI 0.50-0.77], number needed to treat 17 [95% CI 13-29]). With prevalence rates for type 2 diabetes on the rise, weight loss coupled with a reduction in the incidence of type 2 diabetes could potentially have a significant benefit on population health and a possible reduction in need for drug treatments for glycemic control. INTERPRETATION There is moderate quality evidence that behavioural and pharmacologic plus behvioural, treatments for overweight and obesity in adults lead to clinically important reductions in weight and incidence of type 2 diabetes in pre-diabetic populations. REGISTRATION PROSPERO no. CRD42012002753.
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Affiliation(s)
- Leslea Peirson
- McMaster Evidence Review and Synthesis Centre, McMaster University Hamilton, Ont
| | - James Douketis
- Department of Medicine, McMaster University, Hamilton, Ont
- St. Joseph’s HealthCare, Hamilton, Ont
| | - Donna Ciliska
- McMaster Evidence Review and Synthesis Centre, McMaster University Hamilton, Ont
| | | | - Muhammad Usman Ali
- McMaster Evidence Review and Synthesis Centre, McMaster University Hamilton, Ont
| | - Parminder Raina
- McMaster Evidence Review and Synthesis Centre, McMaster University Hamilton, Ont
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