Obesity and all-cause mortality among black adults and white adults

Association between low cognitive performance and diabetes-related health indicators across racial and ethnic groups in adults with diabetes

AIM

To examine the associations between low cognitive performance (LCP) and diabetes-related health indicators (including body mass index [BMI], HbA1c, systolic blood pressure [SBP], low-density lipoprotein [LDL] and self-reported poor physical health) and whether these associations vary across racial/ethnic subgroups.

METHODS

We identified adults aged 60 years or older with self-reported diabetes from the 2011-2014 National Health and Nutrition Examination Survey. Individuals with cognitive test scores in the lowest quartile were defined as having LCP. We used regression models to measure the associations of LCP with diabetes-related biometrics (BMI, HbA1c, SBP and LDL); and self-reported poor physical health. Moreover, we explored potential variations in these associations across racial/ethnic subgroups.

RESULTS

Of 873 (261 with LCP) adults with diabetes, LCP was associated with higher HbA1c, SBP and LDL (adjusted difference: 0.41%, 5.01 mmHg and 5.08 mg/dL, respectively; P < .05), and greater odds of reporting poor physical health (adjusted odds ratio: 1.59, P < .05). The association between LCP and HbA1c was consistent across racial/ethnic groups, and notably pronounced in Hispanic and Other. BMI worsened with LCP, except for non-Hispanic Black. Excluding the Other group, elevated SBP was observed in people with LCP, with Hispanic showing the most significant association. LDL levels were elevated with LCP for Hispanic and Other. Physical health worsened with LCP for both non-Hispanic Black and Hispanic.

CONCLUSIONS

We quantified the association between LCP and diabetes-related health indicators. These associations were more pronounced in Hispanic and Other racial/ethnic groups.

Trends in Obesity-Related Mortality and Racial Disparities

BACKGROUND

Across the globe, obesity stands as a prominent public health concern, linked to a heightened susceptibility to a range of metabolic and cardiovascular disorders. This study reveals a disproportionate impact of obesity on African American (AA) communities, irrespective of socioeconomic status. Structural racism plays a critical role in perpetuating healthcare disparities between AA and other racial/ethnic groups in the United States. These disparities are reflected in limited access to nutritious food, safe exercise spaces, health insurance, and medical care, all of which significantly influence healthcare outcomes and obesity prevalence. Additionally, both conscious and unconscious interpersonal racism adversely affect obesity care, outcomes, and patient-healthcare provider interactions among Blacks.

STUDY OBJECTIVE

This study aims to analyze and compare obesity-related mortality rates among AAs, Whites, and other racial groups.

METHODOLOGY

We queried the CDC WONDER dataset, incorporating all US death certificates. During data extraction, various ICD 10 codes were used to denote different obesity categories: E66.1 (drug-induced obesity), E66.2 (severe obesity with alveolar hypoventilation), E66.3 (overweight), E66.8 (other forms of obesity), E66.9 (unspecified obesity), E66.0 (obesity due to excess calorie intake), E66.01 (severe obesity due to excess calories), and E66.09 (other forms of obesity caused by excess calorie intake). Our study encompassed decedents aged ≥15 years, with obesity-related diseases as the underlying cause of death from 2018 to 2021. Sex- and race-specific obesity-related mortality rates were examined for AAs, Whites, and other races. Resultant mortality trends were computed and presented as ratios comparing AA and White populations.

RESULTS

This study reveals lower obesity-related mortality rates in AAs compared to Whites. Furthermore, women exhibited higher rates than men. In the 15 to 24 age bracket, males comprised 60.11% of the 361 deaths, whereas females made up 39.89%. In this demographic, 35.46% of deaths were among Blacks, with 64.54% among Whites. Within the 25 to 34 age group, females constituted 37.26% of the 1943 deaths, and males 62.74%. Whites made up 62.94% of the fatalities, Blacks 33.40%, with other racial groups accounting for the remainder. These trends extended through the 35-44, 45-54, 55-64, 65-74, and 75+ age categories, with variations in death proportions among genders and races. Whites consistently accounted for the highest death percentages across all age groups, followed by Blacks. Our data indicate that obesity-related mortality tends to occur earlier in life.

CONCLUSION

Our results corroborate previous studies linking elevated mortality risk to obesity and overweight conditions. The uniformity of our findings across age groups, as well as genders, supports the proposal for applying a single range of body weight throughout life. Given the ongoing rise in obesity and overweight conditions across the United States, excess mortality rates are projected to accelerate, potentially leading to decreased life expectancy. This highlights the urgency for developing and implementing effective strategies to control and prevent obesity nationwide.

Weight Bias in Reproductive Medicine: A Curiously Unexplored Frontier

Obesity has been associated with a multitude of medical comorbidities, infertility, and adverse obstetric outcomes. Weight stigma and weight bias pervade not only the medical field but also education, employment, and activities of daily living. The experience of weight stigma has been shown to adversely impact not only the mental health of individuals with overweight or obesity but also worsen obesogenic behaviors, and medical comorbidities. This review frames the rise of weight stigma and weight bias within the context of the "obesity epidemic" and explores its associations with infertility and decreased access to health care and its subsequent impact on the lives of individuals. Furthermore, it explores the concepts of intrinsic and extrinsic weight stigma/bias and highlights the need for further examination and research into the impact of these factors on access to reproductive medicine and subsequent outcomes.

Race-specific associations between psychological distress and obesity: the role of social cohesion

OBJECTIVE

Nearly two-thirds of Black women in the US are obese. Studies have focused more on lifestyle and behavioral factors to explain racial disparities; less research has examined psychosocial factors such as psychological distress and social cohesion. While research suggests that social cohesion may confer benefits for health, no studies have assessed how social cohesion is related to both mental health and obesity, and potential racial differences. Our study examined associations between psychological distress, social cohesion, and obesity among Black and White adult women.

DESIGN

Data are from the 2014-2018 National Health Interview Survey (n = 66,743). Participants self-reported psychological distress (Kessler K6 scale), obesity (body mass index≥30 kg/m2), and social cohesion. We fit logistic regression models of obesity with likelihood ratio tests for effect modification by social cohesion and by race.

RESULTS

Psychological distress was associated with a 1.19 and 1.31 higher odds of obesity for Black (95% confidence interval: 1.05, 1.36) and White women (1.24, 1.39), respectively. Social cohesion was associated with a 0.75 lower odds of obesity among White (0.69, 0.81) but not Black women (odds ratio 0.94; 0.80, 1.10). Tests of interaction indicated no differences by social cohesion or race in the association between psychological distress and obesity.

CONCLUSION

Findings highlight complex relationships between psychological distress, obesity, and social cohesion in Black and White women. Public health efforts should focus on understanding mechanisms relating social factors to health.

Current status of transanal total mesorectal excision for rectal cancer and the expanding indications of the transanal approach for extended pelvic surgeries

Transanal total mesorectal excision (taTME) has been rapidly accepted as a promising surgical approach to the distal rectum. The benefits include ease of access to the bottom of the deep pelvis linearly over a short distance in order to easily visualize the important anatomy. Furthermore, the distal resection margins can be secured under direct vision. Additionally, a two-team approach combining taTME with a transabdominal approach could decrease the operative time and conversion rate. Although taTME was expected to become more rapidly popularized worldwide, enthusiasm for it has stalled due to unfamiliar intraoperative complications, a lack of oncologic evidence from randomized trials, and the widespread use of robotic surgery. While international registries have reported favorable short- and medium-term outcomes from taTME, a Norwegian national study reported a high local recurrence rate of 9.5%. The characteristics of the recurrences included rapid, multifocal growth in the pelvis, which was quite different from recurrences following traditional transabdominal TME; thus, the Norwegian Colorectal Cancer Group reached a consensus for a temporary moratorium on the performance of taTME. To ensure acceptable baseline quality and patient safety, taTME should be performed by well-trained colorectal surgeons. Although the appropriate indications for taTME remain controversial, the transanal approach is extremely important as a means of goal setting in difficult TME cases and as an aid to the transabdominal approach in various types of extended pelvic surgeries. The benefits in transanal lateral lymph node dissection and pelvic exenteration are presented herein.

Association between Proximity to Food Sources and Dietary Behaviors in Black and White College Graduates

OBJECTIVES

Unequal access to healthy food environments is often implicated in racial inequities in health and behaviors that are largest among college graduates. The aim of this study was to determine associations between perceived proximity to food sources and dietary behaviors between black and white college graduates.

METHODS

In a cross-sectional online survey of dietary behaviors between black and white adults who have a ≥ 4-year bachelor's degree, respondents were asked how long it typically takes for them to get to grocery stores and fast-food restaurants from home. We used ordinal logit regression models to assess associations between perceived proximity to food sources and dietary behaviors.

RESULTS

Among black men, perceiving that a grocery store was ≥ 10 minutes from their home was associated with lower fruit consumption (beta=-0.94, SE=0.48). Perceiving that a grocery store was ≥ 10 minutes from their home was associated with more frequent fast-food consumption among black men (beta=1.21, SE=0.39), Black women (beta=0.98, SE=0.34), and white men (beta=0.74, SE=0.30).

CONCLUSIONS

The associations between perceived proximity to food sources and dietary behaviors differ by race and sex among college graduates with important implications for racial disparities in diet quality and obesity across SES.

Sociocultural Factors, Access to Healthcare, and Lifestyle: Multifactorial Indicators in Association with Colorectal Cancer Risk

Black Americans of low socioeconomic status (SES) have higher colorectal cancer incidence than other groups in the United States. However, much of the research that identifies colorectal cancer risk factors is conducted in cohorts of high SES and non-Hispanic White participants. Adult participants of the Southern Community Cohort Study (N = 75,182) were followed for a median of 12.25 years where 742 incident colorectal cancers were identified. The majority of the cohort are non-Hispanic White or Black and have low household income. Cox models were used to estimate HRs for colorectal cancer incidence associated with sociocultural factors, access to and use of healthcare, and healthy lifestyle scores to represent healthy eating, alcohol intake, smoking, and physical activity. The association between Black race and colorectal cancer was consistent and not diminished by accounting for SES, access to healthcare, or healthy lifestyle [HR = 1.34; 95% confidence interval (CI),1.10-1.63]. Colorectal cancer screening was a strong, risk reduction factor for colorectal cancer (HR = 0.65; 95% CI, 0.55-0.78), and among colorectal cancer-screened, Black race was not associated with risk. Participants with high school education were at lower colorectal cancer risk (HR = 0.81; 95% CI, 0.67-0.98). Income and neighborhood-level SES were not strongly associated with colorectal cancer risk. Whereas individual health behaviors were not associated with risk, participants that reported adhering to ≥3 health behaviors had a 19% (95% CI, 1-34) decreased colorectal cancer risk compared with participants that reported ≤1 behaviors. The association was consistent in fully-adjusted models, although HRs were no longer significant. Colorectal cancer screening, education, and a lifestyle that includes healthy behaviors lowers colorectal cancer risk. Racial disparities in colorectal cancer risk may be diminished by colorectal cancer screening.

PREVENTION RELEVANCE

Colorectal cancer risk may be reduced through screening, higher educational attainment and performing more health behaviors. Importantly, our data show that colorectal cancer screening is an important colorectal cancer prevention strategy to eliminate the racial disparity in colorectal cancer risk. See related Spotlight, p. 561.

Race, Flourishing, and All-Cause Mortality in the United States, 1995-2016

We assessed whether race moderates the association between flourishing and all-cause mortality. We used panel data from the Midlife in the United States Study (MIDUS) (1995-2016; n = 2,851). Approximately 19% of White respondents and 23% of Black respondents in the baseline sample died over the course of the 21-year study period (n = 564). Cox proportional hazard models showed that Blacks had a higher mortality rate relative to Whites and higher levels of flourishing were associated with a lower mortality rate. Furthermore, a significant interaction between flourishing and race in predicting death was observed. Blacks with higher levels of flourishing had a mortality rate that was not significantly different from that of Whites. However, Blacks, but not Whites, with low flourishing scores had a higher mortality rate. As such, health-promotion efforts focused on enhancing flourishing among Black populations may reduce the Black-White gap in mortalityrate.

Central fatness and risk of all cause mortality: systematic review and dose-response meta-analysis of 72 prospective cohort studies

OBJECTIVE

To quantify the association of indices of central obesity, including waist circumference, hip circumference, thigh circumference, waist-to-hip ratio, waist-to-height ratio, waist-to-thigh ratio, body adiposity index, and A body shape index, with the risk of all cause mortality in the general population, and to clarify the shape of the dose-response relations.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed and Scopus from inception to July 2019, and the reference lists of all related articles and reviews.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Prospective cohort studies reporting the risk estimates of all cause mortality across at least three categories of indices of central fatness. Studies that reported continuous estimation of the associations were also included.

DATA SYNTHESIS

A random effects dose-response meta-analysis was conducted to assess linear trend estimations. A one stage linear mixed effects meta-analysis was used for estimating dose-response curves.

RESULTS

Of 98 745 studies screened, 1950 full texts were fully reviewed for eligibility. The final analyses consisted of 72 prospective cohort studies with 2 528 297 participants. The summary hazard ratios were as follows: waist circumference (10 cm, 3.94 inch increase): 1.11 (95% confidence interval 1.08 to 1.13, I2=88%, n=50); hip circumference (10 cm, 3.94 inch increase): 0.90 (0.81 to 0.99, I2=95%, n=9); thigh circumference (5 cm, 1.97 inch increase): 0.82 (0.75 to 0.89, I2=54%, n=3); waist-to-hip ratio (0.1 unit increase): 1.20 (1.15 to 1.25, I2=90%, n=31); waist-to-height ratio (0.1 unit increase): 1.24 (1.12 to 1.36, I2=94%, n=11); waist-to-thigh ratio (0.1 unit increase): 1.21 (1.03 to 1.39, I2=97%, n=2); body adiposity index (10% increase): 1.17 (1.00 to 1.33, I2=75%, n=4); and A body shape index (0.005 unit increase): 1.15 (1.10 to 1.20, I2=87%, n=9). Positive associations persisted after accounting for body mass index. A nearly J shaped association was found between waist circumference and waist-to-height ratio and the risk of all cause mortality in men and women. A positive monotonic association was observed for waist-to-hip ratio and A body shape index. The association was U shaped for body adiposity index.

CONCLUSIONS

Indices of central fatness including waist circumference, waist-to-hip ratio, waist-to-height ratio, waist-to-thigh ratio, body adiposity index, and A body shape index, independent of overall adiposity, were positively and significantly associated with a higher all cause mortality risk. Larger hip circumference and thigh circumference were associated with a lower risk. The results suggest that measures of central adiposity could be used with body mass index as a supplementary approach to determine the risk of premature death.

Fat-free mass characteristics vary based on sex, race, and weight status in US adults

Common body composition estimation techniques necessitate assumptions of uniform fat-free mass (FFM) characteristics, although variation due to sex, race, and body characteristics may occur. National Health and Nutrition Examination Survey data from 1999 to 2004, during which paired dual-energy x-ray absorptiometry (DXA) and bioimpedance spectroscopy assessments were performed, were used to estimate FFM characteristics in a sample of 4619 US adults. Calculated FFM characteristics included the density and water, bone mineral, and residual content of FFM. A rapid 4-component model was also produced using DXA and bioimpedance spectroscopy data. Study variables were compared across sex, race/ethnicity, body mass index (BMI), and age categories using multiple pairwise comparisons. A general linear model was used to estimate body composition after controlling for other variables. Statistical analyses accounted for 6-year sampling weights and complex sampling design of the National Health and Nutrition Examination Survey and were based on 5 multiply imputed datasets. Differences in FFM characteristics across sex, race, and BMI were observed, with notable dissimilarities between men and women for all outcome variables. In racial/ethnic comparisons, non-Hispanic blacks most commonly presented distinct FFM characteristics relative to other groups, including greater FFM density and proportion of bone mineral. Body composition errors between DXA and the 4-component model were significantly influenced by sex, age, race, and BMI. In conclusion, FFM characteristics, which are often assumed in body composition estimation methods, vary due to sex, race/ethnicity, and weight status. The variation of FFM characteristics in diverse populations should be considered when body composition is evaluated.

Association of Weight Loss Between Early Adulthood and Midlife With All-Cause Mortality Risk in the US

IMPORTANCE

Describing potential mortality risk reduction associated with weight loss between early adulthood and midlife is important for informing primary and secondary prevention efforts for obesity.

OBJECTIVE

To examine the risk of all-cause mortality among adults who lost weight between early adulthood and midlife compared with adults who were persistently obese over the same period.

DESIGN, SETTING, AND PARTICIPANTS

Combined repeated cross-sectional analysis was conducted using data from the National Health and Nutrition Examination Survey III (1988-1994) and continuous waves collected in 2-year cycles between 1999 and 2014. The data analysis was conducted from February 10, 2019, to April 20, 2020. Individuals aged 40 to 74 years at the time of survey (baseline) were included in the analyses (n = 24 205).

EXPOSURES

Weight history was assessed by self-reported weight at age 25 years, at 10 years before baseline (midlife: mean age, 44 years; interquartile range, 37-55), and measured weight at baseline. Body mass index (BMI) (calculated as weight in kilograms divided by height in meters squared) at each time was categorized as normal (18.5-24.9), overweight (25.0-29.9), and obese (≥30.0). Weight change patterns were assessed from age 25 years (early adulthood) to 10 years before baseline (midlife).

MAIN OUTCOMES AND MEASURES

Incident all-cause mortality using linked data from the National Death Index.

RESULTS

Of the 24 205 participants, 11 617 were women (49.0%) and 11 567 were non-Hispanic White (76.9%). The mean (SD) BMI was 29.0 (6.1) at baseline. During a mean (SD) follow-up of 10.7 (7.2) years, 5846 deaths occurred. Weight loss from obese to overweight was associated with a 54% (hazard ratio, 0.46; 95% CI, 0.27-0.77) reduction in mortality risk compared with individuals with stable obesity between early adulthood and midlife. An estimated 3.2% (95% CI, 1.6%-4.9%) of early deaths could have been avoided if those who maintained an obese BMI instead lost weight to an overweight BMI by midlife. Overall, an estimated 12.4% (95% CI, 8.1%-16.5%) of early deaths may be attributable to having weight in excess of the normal BMI range at any point between early and mid-adulthood.

CONCLUSIONS AND RELEVANCE

In this study, weight loss from obesity to overweight between early adulthood through midlife appeared to be associated with a mortality risk reduction compared with persistent obesity. These findings support the importance of population-based approaches to preventing weight gain across the life course and a need for greater emphasis on treating obesity early in life.

Race and Sex Differences in Modifiable Risk Factors and Incident Heart Failure

OBJECTIVES

The purpose of this study was to examine race- and sex-based variation in the associations between modifiable risk factors and incident heart failure (HF) among the SCCS (Southern Community Cohort Study) participants.

BACKGROUND

Low-income individuals in the southeastern United States have high HF incidence rates, but relative contributions of risk factors to HF are understudied in this population.

METHODS

We studied 27,078 black or white SCCS participants (mean age: 56 years, 69% black, 63% women) enrolled between 2002 and 2009, without prevalent HF, receiving Centers for Medicare and Medicaid Services. The presence of hypertension, diabetes mellitus, physical underactivity, high body mass index, smoking, high cholesterol, and poor diet was assessed at enrollment. Incident HF was ascertained using International Classification of Diseases-9th revision, codes 428.x in Centers for Medicare and Medicaid Services data through December 31, 2010. Individual risk and population attributable risk for HF for each risk factor were quantified using multivariable Cox models.

RESULTS

During a median (25th, 75th percentile) 5.2 (3.1, 6.7) years, 4,341 (16%) participants developed HF. Hypertension and diabetes were associated with greatest HF risk, whereas hypertension contributed the greatest population attributable risk, 31.8% (95% confidence interval: 27.3 to 36.0). In black participants, only hypertension and diabetes associated with HF risk; in white participants, smoking and high body mass index also associated with HF risk. Physical underactivity was a risk factor only in white women.

CONCLUSIONS

In this high-risk, low-income cohort, contributions of risk factors to HF varied, particularly by race. To reduce the population burden of HF, interventions tailored for specific race and sex groups may be warranted.

Weight change across adulthood in relation to all cause and cause specific mortality: prospective cohort study

OBJECTIVE

To investigate the association between weight changes across adulthood and mortality.

DESIGN

Prospective cohort study.

SETTING

US National Health and Nutrition Examination Survey (NHANES) 1988-94 and 1999-2014.

PARTICIPANTS

36 051 people aged 40 years or over with measured body weight and height at baseline and recalled weight at young adulthood (25 years old) and middle adulthood (10 years before baseline).

MAIN OUTCOME MEASURES

All cause and cause specific mortality from baseline until 31 December 2015.

RESULTS

During a mean follow-up of 12.3 years, 10 500 deaths occurred. Compared with participants who remained at normal weight, those moving from the non-obese to obese category between young and middle adulthood had a 22% (hazard ratio 1.22, 95% confidence interval 1.11 to 1.33) and 49% (1.49, 1.21 to 1.83) higher risk of all cause mortality and heart disease mortality, respectively. Changing from obese to non-obese body mass index over this period was not significantly associated with mortality risk. An obese to non-obese weight change pattern from middle to late adulthood was associated with increased risk of all cause mortality (1.30, 1.16 to 1.45) and heart disease mortality (1.48, 1.14 to 1.92), whereas moving from the non-obese to obese category over this period was not significantly associated with mortality risk. Maintaining obesity across adulthood was consistently associated with increased risk of all cause mortality; the hazard ratio was 1.72 (1.52 to 1.95) from young to middle adulthood, 1.61 (1.41 to 1.84) from young to late adulthood, and 1.20 (1.09 to 1.32) from middle to late adulthood. Maximum overweight had a very modest or null association with mortality across adulthood. No significant associations were found between various weight change patterns and cancer mortality.

CONCLUSIONS

Stable obesity across adulthood, weight gain from young to middle adulthood, and weight loss from middle to late adulthood were associated with increased risks of mortality. The findings imply that maintaining normal weight across adulthood, especially preventing weight gain in early adulthood, is important for preventing premature deaths in later life.

Neighborhood Deprivation Predicts Heart Failure Risk in a Low-Income Population of Blacks and Whites in the Southeastern United States

BACKGROUND

Recent data suggest that neighborhood socioeconomic environment predicts heart failure (HF) hospital readmissions. We investigated whether neighborhood deprivation predicts risk of incident HF beyond individual socioeconomic status in a low-income population.

METHODS AND RESULTS

Participants were 27 078 whites and blacks recruited during 2002 to 2009 in the SCCS (Southern Community Cohort Study), who had no history of HF and were using Centers for Medicare or Medicaid Services. Incident HF diagnoses through December 31, 2010, were ascertained using International Classification of Diseases, Ninth Revision, codes 428.x via linkage with Centers for Medicare or Medicaid Services research files. Participant residential information was geocoded and census tract determined by a spatial join to the US Census Bureau TIGER/Line Shapefiles. The neighborhood deprivation index was constructed using principal components analysis based on census tract-level socioeconomic variables. Cox models with Huber-White cluster sandwich estimator of variance were used to investigate the association between neighborhood deprivation index and HF risk. The study sample was predominantly middle aged (mean, 55.5 years), black (69%), female (63%), low income (70% earned <$15 000/y), and >50% of participants lived in the most deprived neighborhoods (third neighborhood deprivation index tertile). Over median follow-up of 5.2 years, 4300 participants were diagnosed with HF. After adjustment for demographic, lifestyle, and clinical factors, a 1 interquartile increase in neighborhood deprivation index was associated with a 12% increase in risk of HF (hazard ratio, 1.12; 95% confidence interval, 1.07-1.18), and 4.8% of the variance in HF risk (intraclass correlation coefficient, 4.8; 95% confidence interval, 3.6-6.4) was explained by neighborhood deprivation.

CONCLUSIONS

In this low-income population, scant neighborhood resources compound the risk of HF above and beyond individual socioeconomic status and traditional cardiovascular risk factors. Improvements in community resources may be a significant axis for curbing the burden of HF.

Uniting the Vision for Health Equity through Partnerships: The 2nd Annual Dr. Elijah Saunders & Dr. Levi Watkins Memorial Lecture

Minority health research focuses on outcomes by race and ethnicity categories used in the United States census. Overall mortality has decreased significantly for African Americans, Latinos, and Asians over the past 20 years even though it has stopped improving for poor Whites and continues to increase for American Indians/Alaska Natives. Prevention and treatment of cardiovascular disease partly account for this trend, but there is room for improvement. Health disparities research also includes persons of less privileged socioeconomic status, underserved rural residents, and sexual and gender minorities of any race and ethnicity when the outcomes are worse than a reference population. Understanding mechanisms that lead to health disparities from behavioral, biological, environmental and health care perspectives will lead to interventions that reduce these disparities and promote health equity. Experiences with racism and discrimination generate a chronic stress response with measurable effects on biological processes and study is needed to evaluate long-term effects on health outcomes. A clinical example of effective approaches to reducing disparities is management of hypertension to promote stroke reduction that requires health system changes, patient-clinician partnerships and engagement of community organizations. Clinicians in health care settings have the potential to promote health equity by implementing standardized measures of social determinants, leveraging the power of health information technology, maximizing cultural competence and socially precise care and engaging communities to reduce health disparities. Strategic partnerships between health care institutions and community-based organizations need to parallel patient-clinician partnerships and are essential to promote health equity and reduce disparities.

Associations between Obesity, Obesogenic Environments, and Structural Racism Vary by County-Level Racial Composition

Obesity rates in the U.S. are associated with area-level, food-related characteristics. Studies have previously examined the role of structural racism (policies/practices that advantaged White Americans and deprived other racial/ethnic minority groups), but racial inequalities in socioeconomic status (SES) is a novel indicator. The aim of this study is to determine the associations between racial inequalities in SES with obesity and obesogenic environments. Data from 2007–2014 County Health Rankings and 2012–2016 County Business Patterns were combined to assess the associations between relative SES comparing Blacks to Whites with obesity, and number of grocery stores and fast food restaurants in U.S. counties. Random effects linear and Poisson regressions were used and stratified by county racial composition. Racial inequality in poverty, unemployment, and homeownership were associated with higher obesity rates. Racial inequality in median income, college graduates, and unemployment were associated with fewer grocery stores and more fast food restaurants. Associations varied by county racial composition. The results demonstrate that a novel indicator of structural racism on the county-level is associated with obesity and obesogenic environments. Associations vary by SES measure and county racial composition, suggesting the ability for targeted interventions to improve obesogenic environments and policies to eliminate racial inequalities in SES.

Secular and Religious Social Support Better Protect Blacks than Whites against Depressive Symptoms

Purpose: Although the protective effect of social support against depression is well known, limited information exists on racial differences in this association. The current study examined Black-White differences in the effects of religious and secular emotional social support on depressive symptoms in a national sample of older adults in the United States. Methods: With a longitudinal prospective design, the Religion, Aging and Health Survey, 2001⁻2004, followed 1493 Black (n = 734) and White (n = 759) elderly individuals (age 66 and older) for three years. Race, demographics (age and gender), socio-economics (education and marital status) and frequency of church attendance were measured at baseline in 2001. Secular social support, religious social support, chronic medical conditions and depressive symptoms [8- item Center for Epidemiological Studies-Depression scale (CES-D)] were measured in 2004. Multiple linear regression models were used for data analysis.

RESULTS

In the pooled sample, secular and religious social support were both protective against depressive symptoms, net of all covariates. Race interacted with secular (β = −0.62 for interaction) and religious (β = −0.21 for interaction) social support on baseline depressive symptoms (p < 0.05 for both interactions), suggesting larger protections for Blacks compared to Whites. In race-specific models, the regression weight for the effect of secular social support on depressive symptoms was larger for Blacks (β = −0.64) than Whites (β = −0.16). Conclusion: We found Black—White differences in the protective effects of secular and religious social support against depressive symptoms. Blacks seem to benefit more from the same level of emotional social support, regardless of its source, compared to Whites.

Exploring the "Obesity Paradox" as a Correlate of Cognitive and Physical Function in Community-dwelling Black and White Older Adults

Objective

The obesity paradox has been documented in aged populations, yet it remains unclear if this paradox persists for physical and cognitive outcomes in community-dwelling older adult populations. Our study examines associations between body mass index (BMI) classification, cognitive function, and physical function. We also investigate whether these associations are modified by race or age.

Design

Cross-sectional study.

Setting

Senior residential sites and community centers in Saint Louis, Missouri.

Participants

Study participants included 331 adults, aged >55 years. Age was stratified into young-old (aged 55-74 years) and older (aged ≥75 years).

Outcome Measures

Physical function was measured using the mini-Physical Performance Test (mini-PPT) and grip strength. Cognitive function was assessed with the Short Blessed Test (SBT) and the Trail Making Tests (TMT-A and TMT-B) performance.

Results

Older adults who were obese had significantly better cognitive flexibility (TMT-B) performance than normal weight older adults (P=.02), and this association was not influenced by age or race. Adiposity was not associated with psychomotor speed (TMT-A), general cognition (SBT), or measures of physical function (Ps>.05).

Conclusion

In a diverse sample of community-dwelling older adults, we found partial support for the controversial obesity paradox. Our results suggest excess adiposity may be protective for executive function processes. Future research is needed to examine the underlying physiological processes linking adiposity to executive function in older adults.

Body Mass Index, Waist Circumference, and Mortality in a Large Multiethnic Postmenopausal Cohort-Results from the Women's Health Initiative

OBJECTIVES

To determine whether the relationship between anthropometric measurements of obesity and mortality varies according to age, race, and ethnicity in older women.

DESIGN

Prospective cohort study of multiethnic postmenopausal women.

SETTING

Women's Health Initiative (WHI) observational study and clinical trials in 40 clinics.

PARTICIPANTS

Postmenopausal women aged 50-79 participating in WHI (N = 161,808).

MEASUREMENTS

Baseline height, weight, and waist circumference (WC) were measured, and body mass index (BMI) was calculated based on height and weight. Demographic, health, and lifestyle data from a baseline questionnaire were used as covariates. The outcome was adjudicated death (n = 18,320) during a mean follow-up of 11.4 ± 3.2 years.

RESULTS

Hazard ratios (HRs) and 95% confidence intervals (95% CIs) indicated that ethnicity and age modified (P < .01) the relationship between obesity and mortality. Underweight was associated with higher mortality, but overweight or slight obesity was not a risk factor for mortality in most ethnic groups except for Hispanic women in the obesity I category (HR = 1.42, 95% CI = 1.04-1.95). BMI was not or was only weakly associated with mortality in individuals aged 70-79 (HR = 0.90, 95% CI = 0.85-0.95 for overweight; HR = 0.98, 95 CI = 0.92-1.06 for obese I; HR = 1.11, 95% CI = 1.00-1.23 for obese II; HR = 1.08, 95% CI = 0.92-1.26 for obese III). In contrast, higher central obesity measured using WC was consistently associated with higher mortality in all groups.

CONCLUSION

Underweight is a significant risk factor for mortality in older women, and healthy BMI ranges may need to be specific for age, race, and ethnicity. The findings support a consistent relationship between central obesity and mortality.

A meta-analysis but not a systematic review: an evaluation of the Global BMI Mortality Collaboration

Meta-analyses of individual participant data (MIPDs) offer many advantages and are considered the highest level of evidence. However, MIPDs can be seriously compromised when they are not solidly founded upon a systematic review. These data-intensive collaborative projects may be led by experts who already have deep knowledge of the literature in the field and of the results of published studies and how these results vary based on different analytical approaches. If investigators tailor the searches, eligibility criteria, and analysis plan of the MIPD, they run the risk of reaching foregone conclusions. We exemplify this potential bias in a MIPD on the association of body mass index with mortality conducted by a collaboration of outstanding and extremely knowledgeable investigators. Contrary to a previous meta-analysis of group data that used a systematic review approach, the MIPD did not seem to use a formal search: it considered 239 studies, of which the senior author was previously aware of at least 238, and it violated its own listed eligibility criteria to include those studies and exclude other studies. It also preferred an analysis plan that was also known to give a specific direction of effects in already published results of most of the included evidence. MIPDs where results of constituent studies are already largely known need safeguards to their validity. These may include careful systematic searches, adherence to the Preferred Reporting Items for Systematic Review and Meta-Analyses of individual participant data guidelines, and exploration of the robustness of results with different analyses. They should also avoid selective emphasis on foregone conclusions based on previously known results with specific analytical choices.

Heart Failure Incidence and Mortality in the Southern Community Cohort Study

BACKGROUND

There is a paucity of data on heart failure (HF) incidence among low-income and minority populations. Our objective was to investigate HF incidence and post-HF survival by race and sex among low-income adults in the southeastern United States.

METHODS AND RESULTS

Participants were 27 078 white and black men and women enrolled during 2002 to 2009 in the SCCS (Southern Community Cohort Study) who had no history of HF and were receiving Centers for Medicare and Medicaid Services. Incident HF diagnoses through December 31, 2010 were ascertained using International Classification of Diseases 9th Revision codes 428.x via linkage with Centers for Medicare and Medicaid Services research files. Most participants were black (68.8%), women (62.6%), and earned <$15 000/y (69.7%); mean age was 55.5 (10.4) years. Risk factors for HF were common: hypertension (62.5%), diabetes mellitus (26.5%), myocardial infarction (8.6%), and obesity (44.8%). Over a median follow-up of 5.2 years, 4341 participants were diagnosed with HF. The age-standardized incidence rates were 34.8, 37.3, 34.9, and 35.6 /1000 person-years in white women, white men, black men, and black women, respectively, remarkably higher than previously reported. Among HF cases, 952 deaths occurred over a median follow-up of 2.3 years. Men had lower survival; hazard ratios and 95% confidence intervals were 1.63 (1.27-2.08), 1.38 (1.11-1.72), and 0.90 (0.73-1.12) for white men, black men, and black women compared with white women.

CONCLUSIONS

In this low-income population, HF incidence was higher for all race-sex groups than previously reported in other cohorts. The SCCS is a unique resource to investigate determinants of HF risk in a segment of the population underrepresented in other existing cohorts.

The Link between Mastery and Depression among Black Adolescents; Ethnic and Gender Differences

PURPOSE

Although the link between depression and lower levels of mastery is well established, limited information exists on ethnic and gender differences in the association between the two. The current study investigated ethnic, gender, and ethnic by gender differences in the link between major depressive disorder (MDD) and low mastery in the United States.

METHODS

We used data from the National Survey of American Life-Adolescent supplement (NSAL-A), 2003-2004. In total, 1170 Black adolescents entered the study. This number was composed of 810 African-American and 360 Caribbean Black youth (age 13 to 17). Demographic factors, socioeconomic status (family income), mastery (sense of control over life), and MDD (Composite International Diagnostic Interview, CIDI) were measured. Logistic regressions were used to test the association between mastery and MDD in the pooled sample, as well as based on ethnicity and gender.

RESULTS

In the pooled sample, a higher sense of mastery was associated with a lower risk of MDD. This association, however, was significant for African Americans but not Caribbean Blacks. Similarly, among African American males and females, higher mastery was associated with lower risk of MDD. Such association could not be found for Caribbean Black males or females.

CONCLUSION

Findings indicate ethnic rather than gender differences in the association between depression and mastery among Black youth. Further research is needed to understand how cultural values and life experiences may alter the link between depression and mastery among ethnically diverse Black youth.

Reciprocal Associations between Depressive Symptoms and Mastery among Older Adults; Black-White Differences

Purpose: Although higher levels of depressive symptoms and lower levels of sense of mastery tend to be comorbid, limited information exists on racial differences in the longitudinal associations between the two over time. The current study compared Black and White American older adults for the longitudinal links between depressive symptoms and mastery in the United States. Methods: Using data from the Religion, Aging, and Health Survey, 2001-2004, this longitudinal cohort study followed 1493 Black (n = 734) and White (n = 759) elderly individuals (age 66 or more) for 3 years. Depressive symptoms [Center for Epidemiological Studies-Depression scale (CES-D), 8 items] and mastery (Pearlin Mastery Scale, 7 items) were measured in 2001 and 2004. Demographics, socio-economics, and physical health were covariates and race was the focal moderator. Multi-group structural equation modeling was used for data analysis, where groups were defined based on race. Results: Among White but not Black older adults, higher levels of depressive symptoms at baseline predicted a greater decline in sense of mastery over 3 years of follow-up. Similarly among Whites but not Blacks, individuals with lower mastery at baseline developed more depressive symptoms over time. Conclusion: Findings are indicative of Black-White differences in reciprocal associations between depressive symptoms and mastery over time. Race alters how depression is linked to changes in evaluation of self (e.g., mastery) over time.

The Contribution of Weight Status to Black-White Differences in Mortality

This article examines the contribution of weight status to black-white (B-W) differences in mortality at ages 40-79 using data from the National Health and Nutrition Examination Survey. We measured body mass index (BMI) based on the highest BMI attained and contrasted the contribution of BMI to that of smoking and educational attainment. We estimated both additive and multiplicative models. In addition to estimating regression coefficients we asked what would happen to B-W differences in mortality if blacks had the BMI distribution of whites, the smoking prevalence of whites, or the educational distribution of whites. B-W differences in BMI account for close to 30 percent of the B-W difference in female mortality but only about 1 percent of the B-W difference in male mortality at ages 40-79. In contrast, smoking makes a much larger contribution to the B-W difference in male (17 percent) than female (6 percent) mortality. Differences in educational attainment in turn explain 19 to 25 percent of the B-W mortality difference among men and women, respectively. Our results underscore the importance of two key risk factors as well as educational attainment in generating B-W differences in mortality.

Racial disparities in adult all-cause and cause-specific mortality among us adults: mediating and moderating factors

BACKGROUND

Studies uncovering factors beyond socio-economic status (SES) that would explain racial and ethnic disparities in mortality are scarce.

METHODS

Using prospective cohort data from the Third National Health and Nutrition Examination Survey (NHANES III), we examined all-cause and cause-specific mortality disparities by race, mediation through key factors and moderation by age (20-49 vs. 50+), sex and poverty status. Cox proportional hazards, discrete-time hazards and competing risk regression models were conducted (N = 16,573 participants, n = 4207 deaths, Median time = 170 months (1-217 months)).

RESULTS

Age, sex and poverty income ratio-adjusted hazard rates were higher among Non-Hispanic Blacks (NHBs) vs. Non-Hispanic Whites (NHW). Within the above-poverty young men stratum where this association was the strongest, the socio-demographic-adjusted HR = 2.59, p < 0.001 was only partially attenuated by SES and other factors (full model HR = 2.08, p = 0.003). Income, education, diet quality, allostatic load and self-rated health, were among key mediators explaining NHB vs. NHW disparity in mortality. The Hispanic paradox was observed consistently among women above poverty (young and old). NHBs had higher CVD-related mortality risk compared to NHW which was explained by factors beyond SES. Those factors did not explain excess risk among NHB for neoplasm-related death (fully adjusted HR = 1.41, 95 % CI: 1.02-2.75, p = 0.044). Moreover, those factors explained the lower risk of neoplasm-related death among MA compared to NHW, while CVD-related mortality risk became lower among MA compared to NHW upon multivariate adjustment.

CONCLUSIONS

In sum, racial/ethnic disparities in all-cause and cause-specific mortality (particularly cardiovascular and neoplasms) were partly explained by socio-demographic, SES, health-related and dietary factors, and differentially by age, sex and poverty strata.

Trends in Obesity Among Adults in the United States, 2005 to 2014

IMPORTANCE

Between 1980 and 2000, the prevalence of obesity increased significantly among adult men and women in the United States; further significant increases were observed through 2003-2004 for men but not women. Subsequent comparisons of data from 2003-2004 with data through 2011-2012 showed no significant increases for men or women.

OBJECTIVE

To examine obesity prevalence for 2013-2014 and trends over the decade from 2005 through 2014 adjusting for sex, age, race/Hispanic origin, smoking status, and education.

DESIGN, SETTING, AND PARTICIPANTS

Analysis of data obtained from the National Health and Nutrition Examination Survey (NHANES), a cross-sectional, nationally representative health examination survey of the US civilian noninstitutionalized population that includes measured weight and height.

EXPOSURES

Survey period.

MAIN OUTCOMES AND MEASURES

Prevalence of obesity (body mass index ≥30) and class 3 obesity (body mass index ≥40).

RESULTS

This report is based on data from 2638 adult men (mean age, 46.8 years) and 2817 women (mean age, 48.4 years) from the most recent 2 years (2013-2014) of NHANES and data from 21,013 participants in previous NHANES surveys from 2005 through 2012. For the years 2013-2014, the overall age-adjusted prevalence of obesity was 37.7% (95% CI, 35.8%-39.7%); among men, it was 35.0% (95% CI, 32.8%-37.3%); and among women, it was 40.4% (95% CI, 37.6%-43.3%). The corresponding prevalence of class 3 obesity overall was 7.7% (95% CI, 6.2%-9.3%); among men, it was 5.5% (95% CI, 4.0%-7.2%); and among women, it was 9.9% (95% CI, 7.5%-12.3%). Analyses of changes over the decade from 2005 through 2014, adjusted for age, race/Hispanic origin, smoking status, and education, showed significant increasing linear trends among women for overall obesity (P = .004) and for class 3 obesity (P = .01) but not among men (P = .30 for overall obesity; P = .14 for class 3 obesity).

CONCLUSIONS AND RELEVANCE

In this nationally representative survey of adults in the United States, the age-adjusted prevalence of obesity in 2013-2014 was 35.0% among men and 40.4% among women. The corresponding values for class 3 obesity were 5.5% for men and 9.9% for women. For women, the prevalence of overall obesity and of class 3 obesity showed significant linear trends for increase between 2005 and 2014; there were no significant trends for men. Other studies are needed to determine the reasons for these trends.

BMI and all cause mortality: systematic review and non-linear dose-response meta-analysis of 230 cohort studies with 3.74 million deaths among 30.3 million participants

OBJECTIVE

To conduct a systematic review and meta-analysis of cohort studies of body mass index (BMI) and the risk of all cause mortality, and to clarify the shape and the nadir of the dose-response curve, and the influence on the results of confounding from smoking, weight loss associated with disease, and preclinical disease.

DATA SOURCES

PubMed and Embase databases searched up to 23 September 2015.

STUDY SELECTION

Cohort studies that reported adjusted risk estimates for at least three categories of BMI in relation to all cause mortality.

DATA SYNTHESIS

Summary relative risks were calculated with random effects models. Non-linear associations were explored with fractional polynomial models.

RESULTS

230 cohort studies (207 publications) were included. The analysis of never smokers included 53 cohort studies (44 risk estimates) with >738 144 deaths and >9 976 077 participants. The analysis of all participants included 228 cohort studies (198 risk estimates) with >3 744 722 deaths among 30 233 329 participants. The summary relative risk for a 5 unit increment in BMI was 1.18 (95% confidence interval 1.15 to 1.21; I(2)=95%, n=44) among never smokers, 1.21 (1.18 to 1.25; I(2)=93%, n=25) among healthy never smokers, 1.27 (1.21 to 1.33; I(2)=89%, n=11) among healthy never smokers with exclusion of early follow-up, and 1.05 (1.04 to 1.07; I(2)=97%, n=198) among all participants. There was a J shaped dose-response relation in never smokers (Pnon-linearity <0.001), and the lowest risk was observed at BMI 23-24 in never smokers, 22-23 in healthy never smokers, and 20-22 in studies of never smokers with ≥20 years' follow-up. In contrast there was a U shaped association between BMI and mortality in analyses with a greater potential for bias including all participants, current, former, or ever smokers, and in studies with a short duration of follow-up (<5 years or <10 years), or with moderate study quality scores.

CONCLUSION

Overweight and obesity is associated with increased risk of all cause mortality and the nadir of the curve was observed at BMI 23-24 among never smokers, 22-23 among healthy never smokers, and 20-22 with longer durations of follow-up. The increased risk of mortality observed in underweight people could at least partly be caused by residual confounding from prediagnostic disease. Lack of exclusion of ever smokers, people with prevalent and preclinical disease, and early follow-up could bias the results towards a more U shaped association.

Body Mass Index and Cancer Mortality Among Korean Older Middle-Aged Men: A Prospective Cohort Study

The association of body mass index (BMI; kg/m) with overall and site-specific cancer mortality in Asians is not well understood. A total of 113,478 men from the Korean Veterans Health Study who returned a postal survey in 2004 were followed up until 2010. The adjusted hazard ratios (HRs) of cancer mortality were calculated using a Cox model. During 6.4 years of follow-up, 3478 men died from cancer. A reverse J-curve association with a nadir at 25.0 to 27.4 kg/m was observed. Below 25 kg/m, the HRs of death for each 5 kg/m decrease in BMI were 1.72 (95% confidence interval = 1.57-1.90) for overall cancer; 3.63 (2.57-5.12) for upper aerodigestive tract (UADT) cancers, including oral cavity and larynx [HR = 4.21 (2.18-8.12)] and esophagus [HR = 2.96 (1.82-4.81)] cancers; 1.52 (1.35-1.71) for non-UADT and non-lung cancers, including stomach [HR = 2.72 (2.13-3.48)] and large intestine [HR = 1.68 (1.20-2.36)] cancers; and 1.93 (1.59-2.34) for lung cancer. In the range of 25 to 47 kg/m, the HRs for each 5 kg/m increase in BMI were 1.27 (1.03-1.56) for overall cancer mortality and 1.57 (1.02-2.43) for lung cancer mortality. In individuals <25 kg/m, inverse associations with mortality from overall cancer and non-UADT and non-lung cancer were stronger in never-smokers than in current smokers. Both low and high BMI were strong predictors of mortality from overall and several site-specific cancers in Korean men. Further research is needed to evaluate whether interventions involving weight change (loss or gain) reduce the risk of cancer or improve the survival.

Sex and Race Differences in the Relationship between Obesity and C-Reactive Protein

C-reactive protein (CRP) is a risk factor for cardiovascular disease and mortality; it is known to be positively associated with obesity but there is some evidence that this association differs by race or sex. We used nationally representative data of adults aged >50 years to investigate sex and race modifiers of the associations between obesity and CRP in non-Hispanic White males (n=3,517) and females (n=4,658), and non-Hispanic Black males (n=464) and females (n=826). Using multiple linear regression models with the natural logarithm of CRP as the dependent variable, we sequentially included body mass index (BMI), a body shape index (ABSI), and socioeconomic, health and health behavior covariates in the model. The association between BMI and CRP was significantly stronger in females than males. Obese White females had mean CRP values slightly above 3 mg/liter (vs 2 for White males) and Black females had mean CRP values >4 mg/liter (vs 3 for Black males). More than 50% of Black females in the United States have obesity. Continued research into racial and sex differences in the relationship between obesity, inflammation, and health risks may ultimately lead to more personalized weight loss recommendations.

Race, Depressive Symptoms, and All-Cause Mortality in the United States

PURPOSE

Despite the well-established association between baseline depressive symptoms and risk of all cause-mortality, limited information exists on racial differences in the residual effects of baseline depressive symptoms above and beyond socioeconomic status (SES) and physical health on this link. The current study compared Blacks and Whites for the residual effects of depressive symptoms over SES and health on risk of long-term all-cause mortality in the U.S.

METHODS

Data were obtained from the Americans' Changing Lives Study, a nationally representative longitudinal cohort of U.S. adults with up to 25 years of follow-up. The study followed 3,361 Blacks and Whites for all-cause mortality between 1986 and 2011. The main predictor of interest was baseline depressive symptoms measured at 1986 using an 11-item Center for Epidemiological Studies-Depression scale. Covariates included baseline demographics (age and gender), SES (education and income), and health [chronic medical conditions (CMCs), self-rated health (SRH), and body mass index (BMI)] measured at 1986. Race (Black versus White) was the focal moderator. We ran a series of Cox proportional hazard models in the pooled sample and also stratified by race.

RESULTS

In the pooled sample, higher depressive symptoms at baseline were associated with higher risk of all-cause mortality except when the CMC, SRH, and BMI were added to the model. In this later model, race interacted with baseline depressive symptoms, suggesting a larger effect of depressive symptoms on mortality among Whites compared to Blacks. Among Whites, depressive symptoms were associated with increased risk of mortality, after controlling for SES but not after controlling for health (CMC, SRH, and BMI). Among Blacks, depressive symptoms were not associated with mortality before health was introduced to the model. After controlling for health, baseline depressive symptoms showed an inverse association with all-cause mortality among Blacks. Although the effect of baseline depressive symptoms on mortality disappeared after controlling for health among Whites, SRH did not interfere (confound) with the effect of depressive symptoms on mortality among Blacks.

CONCLUSION

The effect of depressive symptoms on increased risk of all-cause mortality, which existed among Whites, could not be found for Blacks. In addition, race may modify the roles that SES and health play regarding the link between depressive symptoms and mortality over a long period of time.

The Obesity and Heart Failure Epidemics Among African Americans: Insights From the Jackson Heart Study

BACKGROUND

Higher rates of obesity and heart failure have been observed in African Americans, but associations with mortality are not well-described. We examined intermediate and long-term clinical implications of obesity in African Americans and associations between obesity and all-cause mortality, heart failure, and heart failure hospitalization.

METHODS AND RESULTS

We conducted a retrospective analysis of a community sample of 5292 African Americans participating in the Jackson Heart Study between September 2000 and January 2013. The main outcomes were associations between body mass index (BMI) and all-cause mortality at 9 years and heart failure hospitalization at 7 years using Cox proportional hazards models and interval development of heart failure (median 8 years' follow-up) using a modified Poisson model. At baseline, 1406 (27%) participants were obese and 1416 (27%) were morbidly obese. With increasing BMI, the cumulative incidence of mortality decreased (P= .007), whereas heart failure increased (P < .001). Heart failure hospitalization was more common among morbidly obese participants (9.0%; 95% confidence interval [CI] 7.6-11.7) than among normal-weight patients (6.3%; 95% CI 4.7-8.4). After risk adjustment, BMI was not associated with mortality. Each 1-point increase in BMI was associated with a 5% increase in the risk of heart failure (hazard ratio 1.05; 95% CI 1.03-1.06; P < .001) and the risk of heart failure hospitalization for BMI greater than 32 kg/m(2) (hazard ratio 1.05; 95% CI 1.03-1.07; P < .001).

CONCLUSIONS

Obesity and morbid obesity were common in a community sample of African Americans, and both were associated with increased heart failure and heart failure hospitalization.

Revealing the burden of obesity using weight histories

Analyses of the relation between obesity and mortality typically evaluate risk with respect to weight recorded at a single point in time. As a consequence, there is generally no distinction made between nonobese individuals who were never obese and nonobese individuals who were formerly obese and lost weight. We introduce additional data on an individual's maximum attained weight and investigate four models that represent different combinations of weight at survey and maximum weight. We use data from the 1988-2010 National Health and Nutrition Examination Survey, linked to death records through 2011, to estimate parameters of these models. We find that the most successful models use data on maximum weight, and the worst-performing model uses only data on weight at survey. We show that the disparity in predictive power between these models is related to exceptionally high mortality among those who have lost weight, with the normal-weight category being particularly susceptible to distortions arising from weight loss. These distortions make overweight and obesity appear less harmful by obscuring the benefits of remaining never obese. Because most previous studies are based on body mass index at survey, it is likely that the effects of excess weight on US mortality have been consistently underestimated.

Relationship between Body Mass Index and Mortality in HIV-Infected HAART Users in the Women's Interagency HIV Study

BACKGROUND

Early HIV studies suggested protective associations of overweight against mortality, yet data are lacking for the era of potent highly active antiretroviral therapy (HAART). We evaluated associations of pre-HAART initiation body mass index (BMI) with mortality among HAART-using women.

METHODS

Prospective study of time to death after HAART initiation among continuous HAART users in the Women's Interagency HIV Study. Unadjusted Kaplan-Meier and adjusted proportional hazards survival models assessed time to AIDS and non-AIDS death by last measured pre-HAART BMI.

RESULTS

Of 1428 continuous HAART users 39 (2.7%) were underweight, 521 (36.5%) normal weight, 441 (30.9%) overweight, and 427 (29.9%) obese at time of HAART initiation. A total of 322 deaths occurred during median follow-up of 10.4 years (IQR 5.9-14.6). Censoring at non-AIDS death, the highest rate of AIDS death was observed among underweight women (p = 0.0003 for all 4 categories). In multivariate models, women underweight prior to HAART died from AIDS more than twice as rapidly vs. normal weight women (aHR 2.04, 95% CI 1.03, 4.04); but being overweight or obese (vs. normal weight) was not independently associated with AIDS death. Cumulative incidence of non-AIDS death was similar across all pre-HAART BMI categories.

CONCLUSIONS

Among continuous HAART-using women, being overweight prior to initiation was not associated with lower risk of AIDS or non-AIDS death. Being underweight prior to HAART was associated with over double the rate of AIDS death in adjusted analyses. Although overweight and obesity may be associated with many adverse health conditions, neither was predictive of mortality among the HAART-using women.

Increased body mass index may be associated with greater risk of end-stage renal disease in whites compared to blacks: A nested case-control study

BACKGROUND

The relationship between body mass index (BMI) and end-stage renal disease (ESRD) may differ between blacks and whites due to underlying metabolic differences.

METHODS

We conducted a nested case-control study of 631 incident ESRD cases and 1,897 matched controls within the Southern Community Cohort Study. Current weight, height, and weight at age 21 were reported at enrollment. Occurrence of ESRD was ascertained by linkage with the United States Renal Data System. With normal BMI (18.5-24.9 kg/m²) as reference, conditional logistic regression was used to calculate adjusted odds ratios (OR) and corresponding 95% confidence intervals (CI) for ESRD across other BMI categories by race. In subsequent analysis, BMI at age 21 was modeled using restricted cubic splines with 5 knots. Predicted probabilities of incident ESRD were computed from the multivariable logistic models and plotted against BMI at age 21.

RESULTS

Among blacks, odds of ESRD were significantly increased among those who were overweight (OR: 1.41; 95%CI: 1.09, 1.83) or obese (OR: 2.56; 95%CI: 1.88, 3.47) at age 21. Among whites, the association between ESRD and BMI at age 21 was more pronounced, with corresponding ORs of 2.13 (95%CI: 0.92, 4.93) and 7.46 (95%CI: 2.90, 19.21; p-interaction 0.05). Only among whites was high BMI at enrollment associated with ESRD risk; OR for BMI≥40 kg/m², was 3.31 (95%CI: 1.08, 10.12). The plot of the predicted probabilities of incident ESRD vs BMI at age 21 showed a monotonic increase in the probability of ESRD after a BMI cutoff ≈ 25Kg/m² in both whites and blacks but the slope of the curve for whites appeared greater.

CONCLUSIONS

Our results suggest racial differences in the relationship between BMI, both in early adulthood and middle age, and ESRD. These findings warrant further research into understanding the underlying metabolic differences that may explain these differences.

Mediating Effect of Perceived Overweight on the Association between Actual Obesity and Intention for Weight Control; Role of Race, Ethnicity, and Gender

Background:

Although obesity is expected to be associated with intention to reduce weight, this effect may be through perceived overweight. This study tested if perceived overweight mediates the association between actual obesity and intention to control weight in groups based on the intersection of race and gender. For this purpose, we compared Non-Hispanic White men, Non-Hispanic White women, African American men, African American women, Caribbean Black men, and Caribbean Black women.

Methods:

National Survey of American Life, 2001–2003 included 5,810 American adults (3516 African Americans, 1415 Caribbean Blacks, and 879 Non-Hispanic Whites). Weight control intention was entered as the main outcome. In the first step, we fitted race/gender specific logistic regression models with the intention for weight control as outcome, body mass index as predictor and sociodemographics as covariates. In the next step, to test mediation, we added perceived weight to the model.

Results:

Obesity was positively associated with intention for weight control among all race × gender groups. Perceived overweight fully mediated the association between actual obesity and intention for weight control among Non-Hispanic White women, African American men, and Caribbean Black men. The mediation was only partial for Non-Hispanic White men, African American women, and Caribbean Black women.

Conclusions:

The complex relation between actual weight, perceived weight, and weight control intentions depends on the intersection of race and gender. Perceived overweight plays a more salient role for Non-Hispanic White women and Black men than White men and Black women. Weight loss programs may benefit from being tailored based on race and gender. This finding also sheds more light to the disproportionately high rate of obesity among Black women in US.

Body mass index in young adulthood, obesity trajectory, and premature mortality

Although much research has been conducted on the role adult body mass index (BMI) plays in mortality, there have been fewer studies that evaluated the associations of BMI in young adulthood and adult weight trajectory with mortality, and it remains uncertain whether associations differ by race or sex. We prospectively examined the relationships of BMI in young adulthood (21 years of age) and adult obesity trajectory with later-life mortality rates among 75,881 men and women in the Southern Community Cohort Study. Study participants were enrolled between 2002 and 2009 at ages 40-79 years and were followed through December, 2011. Multivariable Cox proportional hazards models were used to estimate hazard ratios and 95% confidence intervals. There were 7,301 deaths in the 474,970 person-years of follow-up. Participants who reported being overweight or obese as young adults had mortality rates that were 19% (95% confidence interval: 12, 27) and 64% (95% confidence interval: 52, 78) higher, respectively, than those of their normal weight counterparts. The results did not significantly differ by race or sex. Participants who reported being obese in young adulthood only or in both young and middle adulthood experienced mortality rates that were 40%-90% higher than those of participants who were nonobese at either time. These results suggest that obesity in young adulthood is associated with higher mortality risk regardless of race, sex, and obesity status in later life.

The relationship of female physical attractiveness to body fatness

Aspects of the female body may be attractive because they signal evolutionary fitness. Greater body fatness might reflect greater potential to survive famines, but individuals carrying larger fat stores may have poor health and lower fertility in non-famine conditions. A mathematical statistical model using epidemiological data linking fatness to fitness traits, predicted a peaked relationship between fatness and attractiveness (maximum at body mass index (BMI) = 22.8 to 24.8 depending on ethnicity and assumptions). Participants from three Caucasian populations (Austria, Lithuania and the UK), three Asian populations (China, Iran and Mauritius) and four African populations (Kenya, Morocco, Nigeria and Senegal) rated attractiveness of a series of female images varying in fatness (BMI) and waist to hip ratio (WHR). There was an inverse linear relationship between physical attractiveness and body fatness or BMI in all populations. Lower body fat was more attractive, down to at least BMI = 19. There was no peak in the relationship over the range we studied in any population. WHR was a significant independent but less important factor, which was more important (greater r (2)) in African populations. Predictions based on the fitness model were not supported. Raters appeared to use body fat percentage (BF%) and BMI as markers of age. The covariance of BF% and BMI with age indicates that the role of body fatness alone, as a marker of attractiveness, has been overestimated.

Repeated measures of body mass index and C-reactive protein in relation to all-cause mortality and cardiovascular disease: results from the consortium on health and ageing network of cohorts in Europe and the United States (CHANCES)

Obesity has been linked with elevated levels of C-reactive protein (CRP), and both have been associated with increased risk of mortality and cardiovascular disease (CVD). Previous studies have used a single 'baseline' measurement and such analyses cannot account for possible changes in these which may lead to a biased estimation of risk. Using four cohorts from CHANCES which had repeated measures in participants 50 years and older, multivariate time-dependent Cox proportional hazards was used to estimate hazard ratios (HR) and 95 % confidence intervals (CI) to examine the relationship between body mass index (BMI) and CRP with all-cause mortality and CVD. Being overweight (≥25-<30 kg/m(2)) or moderately obese (≥30-<35) tended to be associated with a lower risk of mortality compared to normal (≥18.5-<25): ESTHER, HR (95 % CI) 0.69 (0.58-0.82) and 0.78 (0.63-0.97); Rotterdam, 0.86 (0.79-0.94) and 0.80 (0.72-0.89). A similar relationship was found, but only for overweight in Glostrup, HR (95 % CI) 0.88 (0.76-1.02); and moderately obese in Tromsø, HR (95 % CI) 0.79 (0.62-1.01). Associations were not evident between repeated measures of BMI and CVD. Conversely, increasing CRP concentrations, measured on more than one occasion, were associated with an increasing risk of mortality and CVD. Being overweight or moderately obese is associated with a lower risk of mortality, while CRP, independent of BMI, is positively associated with mortality and CVD risk. If inflammation links CRP and BMI, they may participate in distinct/independent pathways. Accounting for independent changes in risk factors over time may be crucial for unveiling their effects on mortality and disease morbidity.

A pooled analysis of body mass index and mortality among African Americans

Pooled analyses among whites and East Asians have demonstrated positive associations between all-cause mortality and body mass index (BMI), but studies of African Americans have yielded less consistent results. We examined the association between BMI and all-cause mortality in a sample of African Americans pooled from seven prospective cohort studies: NIH-AARP, 1995-2009; Adventist Health Study 2, 2002-2008; Black Women's Health Study, 1995-2009; Cancer Prevention Study II, 1982-2008; Multiethnic Cohort Study, 1993-2007; Prostate, Lung, Colorectal and Ovarian Screening Trial, 1993-2009; Southern Community Cohort Study, 2002-2009. 239,526 African Americans (including 100,175 never smokers without baseline heart disease, stroke, or cancer), age 30-104 (mean 52) and 71% female, were followed up to 26.5 years (mean 11.7). Hazard ratios (HR) and 95% confidence intervals (CI) for mortality were derived from multivariate Cox proportional hazards models. Among healthy, never smokers (11,386 deaths), HRs (CI) for BMI 25-27.4, 27.5-29.9, 30-34.9, 35-39.9, 40-49.9, and 50-60 kg/m(2) were 1.02 (0.92-1.12), 1.06 (0.95-1.18), 1.32 (1.18-1.47), 1.54 (1.29-1.83), 1.93 (1.46-2.56), and 1.93 (0.80-4.69), respectively among men and 1.06 (0.99-1.15), 1.15 (1.06-1.25), 1.24 (1.15-1.34), 1.58 (1.43-1.74), 1.80 (1.60-2.02), and 2.31 (1.74-3.07) respectively among women (reference category 22.5-24.9). HRs were highest among those with the highest educational attainment, longest follow-up, and for cardiovascular disease mortality. Obesity was associated with a higher risk of mortality in African Americans, similar to that observed in pooled analyses of whites and East Asians. This study provides compelling evidence to support public health efforts to prevent excess weight gain and obesity in African Americans.

Sleep deprivation and obesity in shift workers in southern Brazil

OBJECTIVE

The objective of our study was to explore the association between sleep deprivation and obesity among shift workers.

DESIGN

A cross-sectional study was conducted. Obesity was defined as BMI ≥30 kg/m2. Time of sleep was categorized as: >5 h of continuous sleep/d; ≤5 h of continuous sleep/d with some additional rest (sleep deprivation level I); and ≤5 h of continuous sleep/d without any additional rest (sleep deprivation level II). Sociodemographic, parental and behavioural variables were evaluated by means of a standardized pre-tested questionnaire. Potential confounding factors were controlled for in the multivariable model.

SETTING

A poultry-processing plant in southern Brazil.

SUBJECTS

Nine hundred and five shift workers (63 % female).

RESULTS

Obesity was more prevalent in the participants who were female, aged 40 years and older, who had less schooling and reported excess weight in both parents. Sleep deprivation levels I and II were associated with increased income, number of meals consumed throughout the day and nightshift work. All of the workers who exhibited a degree of sleep deprivation worked the night shift. After controlling for potential confounding factors, the prevalence ratios of obesity were 1·4 (95 % CI 0·8, 2·2) and 4·4 (95 % CI 2·4, 8·0) in the workers with sleep deprivation levels I and II, respectively, compared with the reference group.

CONCLUSIONS

These results show a strong association between sleep deprivation and obesity in shift workers and that sleep deprivation may be a direct consequence of working at night.

Obesity and 10-year mortality in very old African Americans and Yoruba-Nigerians: exploring the obesity paradox

BACKGROUND

To compare the effect of obesity and related risk factors on 10-year mortality in two cohorts of older adults of African descent; one from the United States and one from Nigeria.

METHODS

Study participants were community residents aged 70 or older of African descent living in Indianapolis, Indiana (N = 1,269) or Ibadan, Nigeria (1,197). We compared survival curves between the two cohorts by obesity class and estimated the effect of obesity class on mortality in Cox proportional hazards models controlling for age, gender, alcohol use, and smoking history, and the cardiometabolic biomarkers blood pressure, triglycerides, high-density lipoprotein, low-density lipoprotein, and C-reactive protein.

RESULTS

We found that underweight was associated with an increased risk of death in both the Yoruba (hazards ratio = 1.35, 95% confidence interval: 1.12-1.63) and African American samples (hazards ratio = 2.49, 95% confidence interval: 1.40-4.43) compared with those with normal weight. The overweight and obese participants in both cohorts experienced survival similar to the normal weight participants. Controlling for cardiometabolic biomarkers had little effect on the obesity-specific hazard ratios in either cohort.

CONCLUSIONS

Despite significant differences across these two cohorts in terms of obesity and biomarker levels, overall 10-year survival and obesity class-specific survival were remarkably similar.

J-shapedness: an often missed, often miscalculated relation: the example of weight and mortality

We present three considerations in analysing the association between weight and mortality, as well as other relations that might be non-linear in nature. First, authors must graphically plot their independent and dependent variables in a continuous manner. Second, authors should assess the shape of that relation, and note its shape. If it is non-linear, and specifically, J-shaped or U-shaped, careful consideration should be given to using the 'best' statistical model, of which multivariate fractional polynomial regression is a reasonable choice. Authors should also refrain from truncating their data to avoid dealing with non-linear relations.

Cognitive function, body mass index and mortality in a rural elderly Chinese cohort

BACKGROUND

Previous studies have shown that poor cognition and low body mass index were associated with increased mortality. But few studies have investigated the association between cognition and mortality across the entire cognitive spectrum while adjusting for BMI. The objective of this study is to examine the associations between cognitive function, BMI and 7-year mortality in a rural elderly Chinese cohort.

METHODS

A prospective cohort of 2,000 Chinese age 65 and over from four rural counties in China were followed for 7-years. Cognitive function, BMI and other covariate information were obtained at baseline. Cox's proportional hazard models were used to determine the effects of cognitive function and BMI on mortality risk.

RESULTS

Of participants enrolled, 473 (23.7%) died during follow-up. Both lower cognitive function (HR = 1.48, p = 0.0049) and lower BMI (HR = 1.6, p < 0.0001) were independently associated with increased mortality risk compared to individuals with average cognitive function and normal weight. Higher cognitive function was associated with lower mortality risk (HR = 0.69, p = 0.0312). We found no significant difference in mortality risk between overweight/obese participants and those with normal weight.

CONCLUSIONS

Cognitive function and BMI were independent predictors of mortality risk. Intervention strategies for increasing cognitive function and maintaining adequate BMI may be important in reducing morality risk in the elderly population.

Body mass index categories and mortality risk in US adults: the effect of overweight and obesity on advancing death

OBJECTIVES

We examined the association of body mass index with all-cause and cardiovascular disease (CVD)-specific mortality risks among US adults and calculated the rate advancement period by which death is advanced among the exposed groups.

METHODS

We used data from the Third National Health and Nutrition Examination Survey (1988-1994) linked to the National Death Index mortality file with follow-up to 2006 (n = 16 868). We used Cox proportional hazards regression to estimate the rate of dying and rate advancement period for all-cause and CVD-specific mortality for overweight and obese adults relative to their normal-weight counterparts.

RESULTS

Compared with normal-weight adults, obese adults had at least 20% significantly higher rate of dying of all-cause or CVD. These rates advanced death by 3.7 years (grades II and III obesity) for all-cause mortality and between 1.6 (grade I obesity) and 5.0 years (grade III obesity) for CVD-specific mortality. The burden of obesity was greatest among adults aged 45 to 64 years for all-cause and CVD-specific mortality and among women for all-cause mortality.

CONCLUSIONS

These findings highlight the impact of the obesity epidemic on mortality risk and premature deaths among US adults.

Body mass index and mortality among blacks and whites adults in the Prostate, Lung, Colorectal, and Ovarian (PLCO) cancer screening trial

OBJECTIVE

In a large prospective cohort, we examined the relationship of body mass index (BMI) with mortality among blacks and compared the results to those among whites in this population.

DESIGN AND METHODS

The study population consisted of 7,446 non-Hispanic black and 130,598 white participants, ages 49-78 at enrollment, in the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial. BMI at baseline, BMI at age 20, and BMI change were calculated using self-reported and recalled height and weight. Relative risks were stratified by race and sex and adjusted for age, education, marital status, and smoking.

RESULTS

During follow-up, 1,495 black and 18,236 white participants died (mean = 13 years). Clear J-shaped associations between BMI and mortality were observed among white men and women. Among black men and women, the bottoms of these curves were flatter, and increasing risks of death with greater BMI were observed only at higher BMI levels (≥35.0). Associations for BMI at age 20 and BMI change also appeared to be stronger in magnitude in whites versus blacks, and these racial differences appeared to be more pronounced among women.

CONCLUSION

Our results suggest that BMI may be more weakly associated with mortality in blacks, particularly black women, than in whites.

A prospective study of statin use and mortality among 67,385 blacks and whites in the Southeastern United States

Purpose

The primary objective of this study is to examine the race-specific associations between statin use and overall mortality, as well as cardiovascular and cancer mortality, among blacks and whites in the Southeastern United States (US). Little is known about these associations in blacks.

Patients and methods

The Southern Community Cohort Study is an ongoing, prospective cohort study, which enrolled from 2002 through 2009 nearly 86,000 participants aged 40–79 years. We used Cox regression models to estimate race-specific hazard ratios (HRs) and 95% confidence intervals (CI) for overall and cause-specific mortality associated with statin use based on self-reported hypercholesterolemia and treatment at cohort entry. Mean age at cohort entry was 51.4 years in blacks (n=48,825) and 53.5 years in whites (n=18,560). Sixty-one percent of participants were women. Whites were more likely to have self-reported hypercholesterolemia (40% versus 27%, P<0.001), and to report being treated with either statins (52% versus 47%, P<0.001) or combination lipid therapy (9% versus 4%, P<0.001) compared with blacks, regardless of sex. During follow-up (median: 5.6 years) 5,199 participants died. Compared with untreated hypercholesterolemic individuals, statin use was associated with reduced all-cause mortality (adjusted HR [aHR] 0.86; 95% CI 0.77–0.95) and cardiovascular disease mortality overall (aHR 0.75; 95% CI 0.64–0.89) and among whites (aHR 0.67; 95% CI 0.50–0.90), blacks (aHR, 0.80; 95% CI 0.65–0.98), men (aHR 0.70; 95% CI 0.55–0.90), and women (aHR 0.79; 95% CI 0.63–0.99) (P>0.05 for race and sex interaction). Statin use was not associated with cancer mortality overall or in subgroup analyses.

Conclusion

Regardless of race or sex, self-reported statin use was linked to reduced all-cause and cardiovascular disease mortality. However, factors contributing to the modestly lower statin use and markedly lower prevalence of self-reported hypercholesterolemia among blacks remain to be determined.

Metabolic subtypes and risk of mortality in normal weight, overweight, and obese individuals with CKD

BACKGROUND AND OBJECTIVES

Higher body mass index (BMI) is paradoxically associated with lower mortality in persons with CKD, but whether cardiometabolic abnormalities modulate this association is unclear.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Participants with CKD from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study (n=4374) were analyzed. The harmonized criteria for metabolic syndrome were used to define metabolic health, and participants were categorized into one of six mutually exclusive categories defined by combined measures of metabolic health (metabolically healthy, <3 criteria for metabolic syndrome; metabolically unhealthy, ≥3 criteria) and weight status (normal weight, BMI 18.5-24.9 kg/m(2); overweight, BMI 25-29.9 kg/m(2); obese, BMI ≥30 kg/m(2)). Cox models were used to estimate the hazard ratio (HR) of death as a function of each category.

RESULTS

A total of 683 deaths were observed over a mean 4.5 years of follow-up. In analyses adjusted for age, race, sex, and geographic region of residence, compared with metabolically healthy normal weight persons, the HRs of mortality in metabolically healthy overweight and obese persons were 0.68 (95% confidence interval [95% CI], 0.53 to 0.87) and 0.71 (95% CI, 0.51 to 0.98), respectively, whereas there were no statistically significant differences in survival among metabolically unhealthy overweight or obese individuals. After further adjustment for lifestyle, clinical and laboratory factors including markers of kidney function, the HR of mortality remained lower in metabolically healthy overweight individuals compared with metabolically healthy normal weight individuals (HR, 0.74; 95% CI, 0.57 to 0.96).

CONCLUSIONS

Metabolic abnormalities may attenuate the magnitude and strength of survival benefits associated with higher BMI in individuals with CKD.

Association of all-cause mortality with overweight and obesity using standard body mass index categories: a systematic review and meta-analysis

IMPORTANCE

Estimates of the relative mortality risks associated with normal weight, overweight, and obesity may help to inform decision making in the clinical setting.

OBJECTIVE

To perform a systematic review of reported hazard ratios (HRs) of all-cause mortality for overweight and obesity relative to normal weight in the general population.

DATA SOURCES

PubMed and EMBASE electronic databases were searched through September 30, 2012, without language restrictions.

STUDY SELECTION

Articles that reported HRs for all-cause mortality using standard body mass index (BMI) categories from prospective studies of general populations of adults were selected by consensus among multiple reviewers. Studies were excluded that used nonstandard categories or that were limited to adolescents or to those with specific medical conditions or to those undergoing specific procedures. PubMed searches yielded 7034 articles, of which 141 (2.0%) were eligible. An EMBASE search yielded 2 additional articles. After eliminating overlap, 97 studies were retained for analysis, providing a combined sample size of more than 2.88 million individuals and more than 270,000 deaths.

DATA EXTRACTION

Data were extracted by 1 reviewer and then reviewed by 3 independent reviewers. We selected the most complex model available for the full sample and used a variety of sensitivity analyses to address issues of possible overadjustment (adjusted for factors in causal pathway) or underadjustment (not adjusted for at least age, sex, and smoking).

RESULTS

Random-effects summary all-cause mortality HRs for overweight (BMI of 25-<30), obesity (BMI of ≥30), grade 1 obesity (BMI of 30-<35), and grades 2 and 3 obesity (BMI of ≥35) were calculated relative to normal weight (BMI of 18.5-<25). The summary HRs were 0.94 (95% CI, 0.91-0.96) for overweight, 1.18 (95% CI, 1.12-1.25) for obesity (all grades combined), 0.95 (95% CI, 0.88-1.01) for grade 1 obesity, and 1.29 (95% CI, 1.18-1.41) for grades 2 and 3 obesity. These findings persisted when limited to studies with measured weight and height that were considered to be adequately adjusted. The HRs tended to be higher when weight and height were self-reported rather than measured.

CONCLUSIONS AND RELEVANCE

Relative to normal weight, both obesity (all grades) and grades 2 and 3 obesity were associated with significantly higher all-cause mortality. Grade 1 obesity overall was not associated with higher mortality, and overweight was associated with significantly lower all-cause mortality. The use of predefined standard BMI groupings can facilitate between-study comparisons.

Body mass index and mortality in non-Hispanic black adults in the NIH-AARP Diet and Health Study

Background

Although the prevalence of obesity (body mass index, kg/m², BMI ≥30) is higher in non-Hispanic blacks than in non-Hispanic whites, the relation of BMI to total mortality in non-Hispanic blacks is not well defined.

Purpose

We investigated the association between BMI and total mortality in 16,471 non-Hispanic blacks in the NIH-AARP Diet and Health Study, a prospective cohort of adults aged 50–71 years.

Methods

During an average of 13 years of follow-up, 2,609 deaths were identified using the Social Security Administration Death Master File and the National Death Index. Cox proportional hazard models were used to estimate relative risks and two-sided 95% confidence intervals (CI), adjusting for potential confounders.

Results

Among individuals with no history of cancer or heart disease at baseline and had a BMI of 20 or greater, the relative risk for total death was 1.12 (95% CI:1.05, 1.19, for a 5-unit increase in BMI) in men and 1.09 (95% CI:1.03, 1.15) in women. Among never smokers with no history of cancer or heart disease at baseline, relative risks for total death for BMI 25–<30, 30–<35, 35–<40, and 40–50, compared with BMI 20–<25, were 1.27 (95% CI: 0.91, 1.78), 1.56 (95% CI: 1.07, 2.28), 2.48 (95% CI: 1.53, 4.05), and 2.80 (95% CI: 1.46, 5.39), respectively, in men and 0.78 (95% CI: 0.59, 1.04), 1.17 (95% CI: 0.88, 1.57), 1.35 (95% CI: 0.96, 1.90), and 1.93 (95% CI: 1.33, 2.81), respectively, in women.

Conclusions

Our findings suggest that overweight is related to an increased risk of death in black men, but not in black women, while obesity is related to an increased risk of death in both black men and women. A large pooled analysis of existing studies is needed to systematically evaluate the association between a wide range of BMIs and total mortality in blacks.