Sex-age-specific association of body mass index with all-cause mortality among 12.8 million Korean adults: a prospective cohort study

Moderation of associations between weight discrimination and diabetes status by psychosocial factors

Weight discrimination has adverse effects on health that include increasing the risk factors for developing type 2 diabetes. Preliminary evidence suggests a positive association between weight discrimination and diagnosed diabetes; however, it is unknown whether psychosocial resources may buffer this association. In logistic regressions stratified by gender, we examined links between weight discrimination and diabetes among a nationally representative sample of U.S. adults (the National Social Life, Health, and Aging Project; N = 2,794 adults age 50 and older in 2015-16). We also tested the extent to which trait-resilience and social support from a spouse/partner, family, and friends buffered any observed association. We adjusted for known predictors of diabetes (age, race/ethnicity, Body Mass Index) and conducted sensitivity analyses restricted to men and women with obesity. Net of covariates, in the overall sample, weight discrimination was associated with significantly greater odds of having ever had diabetes among women (OR = 2.00, 95% CI [1.15, 3.47]), but not men. Among women with obesity, weight discrimination was only significantly associated with greater odds of diabetes for those with low resilience (OR = 1.84, 95% CI [1.01, 3.35]). Among men overall, weight discrimination was associated with lower odds of diabetes for those with high family support (OR = 0.03, 95% CI [0.003, 0.25]) as well as those with high friend support (OR = 0.34, 95% CI [0.13, 0.91]); similar effects were observed in men with obesity. These novel findings evince a role for psychosocial resources in buffering associations between weight discrimination and diabetes.

Prevention of obesity and carbohydrate metabolism disorders in the population at an industrial facility

Introduction

One of the urgent tasks of modern healthcare is the development of measures aimed at preventing obesity in the able-bodied population, including in the Republic of Kazakhstan, which would reduce economic losses and increase the coefficient of life expectancy in the population.

Aim

To identify measures for the early prevention of excess weight, obesity, and carbohydrate metabolism disorders in the able-bodied population at an industrial facility in Kazakhstan.

Material and methods

The study involved 662 people (574 men and 88 women) aged 19 to 64 years. The subjects were divided into 2 groups: the main group - persons with obesity (242 people) and the control group - relatively healthy persons (422 people). The diagnosis of obesity was made based on the medical history of a patient, external examination, and physical, laboratory, and instrumental assessment.

Results

Three main factors influencing the development of obesity have been identified: a significant level of inactivity; serum glucose; the presence of comorbidities. Other factors (gender and age, smoking) do not have a significant effect on the increase in the body mass index of persons working at an industrial facility.

Conclusions

Accordingly, a priority in the prevention of obesity is a healthy lifestyle, involving regular physical activity and a healthy balanced diet.

Mobile health (m-health) smartphone interventions for adolescents and adults with overweight or obesity

BACKGROUND

Obesity is considered to be a risk factor for various diseases, and its incidence has tripled worldwide since 1975. In addition to potentially being at risk for adverse health outcomes, people with overweight or obesity are often stigmatised. Behaviour change interventions are increasingly delivered as mobile health (m-health) interventions, using smartphone apps and wearables. They are believed to support healthy behaviours at the individual level in a low-threshold manner.

OBJECTIVES

To assess the effects of integrated smartphone applications for adolescents and adults with overweight or obesity.

SEARCH METHODS

We searched CENTRAL, MEDLINE, PsycINFO, CINAHL, and LILACS, as well as the trials registers ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform on 2 October 2023 (date of last search for all databases). We placed no restrictions on the language of publication.

SELECTION CRITERIA

Participants were adolescents and adults with overweight or obesity. Eligible interventions were integrated smartphone apps using at least two behaviour change techniques. The intervention could target physical activity, cardiorespiratory fitness, weight loss, healthy diet, or self-efficacy. Comparators included no or minimal intervention (NMI), a different smartphone app, personal coaching, or usual care. Eligible studies were randomised controlled trials of any duration with a follow-up of at least three months.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodology and the RoB 2 tool. Important outcomes were physical activity, body mass index (BMI) and weight, health-related quality of life, self-efficacy, well-being, change in dietary behaviour, and adverse events. We focused on presenting studies with medium- (6 to < 12 months) and long-term (≥ 12 months) outcomes in our summary of findings table, following recommendations in the core outcome set for behavioural weight management interventions.

MAIN RESULTS

We included 18 studies with 2703 participants. Interventions lasted from 2 to 24 months. The mean BMI in adults ranged from 27 to 50, and the median BMI z-score in adolescents ranged from 2.2 to 2.5. Smartphone app versus no or minimal intervention Thirteen studies compared a smartphone app versus NMI in adults; no studies were available for adolescents. The comparator comprised minimal health advice, handouts, food diaries, smartphone apps unrelated to weight loss, and waiting list. Measures of physical activity: at 12 months' follow-up, a smartphone app compared to NMI probably reduces moderate to vigorous physical activity (MVPA) slightly (mean difference (MD) -28.9 min/week (95% confidence interval (CI) -85.9 to 28; 1 study, 650 participants; moderate-certainty evidence)). We are very uncertain about the results of estimated energy expenditure and cardiorespiratory fitness at eight months' follow-up. A smartphone app compared with NMI probably results in little to no difference in changes in total activity time at 12 months' follow-up and leisure time physical activity at 24 months' follow-up. Anthropometric measures: a smartphone app compared with NMI may reduce BMI (MD of BMI change -2.6 kg/m2, 95% CI -6 to 0.8; 2 studies, 146 participants; very low-certainty evidence) at six to eight months' follow-up, but the evidence is very uncertain. At 12 months' follow-up, a smartphone app probably resulted in little to no difference in BMI change (MD -0.1 kg/m2, 95% CI -0.4 to 0.3; 1 study; 650 participants; moderate-certainty evidence). A smartphone app compared with NMI may result in little to no difference in body weight change (MD -2.5 kg, 95% CI -6.8 to 1.7; 3 studies, 1044 participants; low-certainty evidence) at 12 months' follow-up. At 24 months' follow-up, a smartphone app probably resulted in little to no difference in body weight change (MD 0.7 kg, 95% CI -1.2 to 2.6; 1 study, 245 participants; moderate-certainty evidence). A smartphone app compared with NMI may result in little to no difference in self-efficacy for a physical activity score at eight months' follow-up, but the results are very uncertain. A smartphone app probably results in little to no difference in quality of life and well-being at 12 months (moderate-certainty evidence) and in little to no difference in various measures used to inform dietary behaviour at 12 and 24 months' follow-up. We are very uncertain about adverse events, which were only reported narratively in two studies (very low-certainty evidence). Smartphone app versus another smartphone app Two studies compared different versions of the same app in adults, showing no or minimal differences in outcomes. One study in adults compared two different apps (calorie counting versus ketogenic diet) and suggested a slight reduction in body weight at six months in favour of the ketogenic diet app. No studies were available for adolescents. Smartphone app versus personal coaching Only one study compared a smartphone app with personal coaching in adults, presenting data at three months. Two studies compared these interventions in adolescents. A smartphone app resulted in little to no difference in BMI z-score compared to personal coaching at six months' follow-up (MD 0, 95% CI -0.2 to 0.2; 1 study; 107 participants). Smartphone app versus usual care Only one study compared an app with usual care in adults but only reported data at three months on participant satisfaction. No studies were available for adolescents. We identified 34 ongoing studies.

AUTHORS' CONCLUSIONS

The available evidence is limited and does not demonstrate a clear benefit of smartphone applications as interventions for adolescents or adults with overweight or obesity. While the number of studies is growing, the evidence remains incomplete due to the high variability of the apps' features, content and components, which complicates direct comparisons and assessment of their effectiveness. Comparisons with either no or minimal intervention or personal coaching show minor effects, which are mostly not clinically significant. Minimal data for adolescents also warrants further research. Evidence is also scarce for low- and middle-income countries as well as for people with different socio-economic and cultural backgrounds. The 34 ongoing studies suggest sustained interest in the topic, with new evidence expected to emerge within the next two years. In practice, clinicians and healthcare practitioners should carefully consider the potential benefits, limitations, and evolving research when recommending smartphone apps to adolescents and adults with overweight or obesity.

Impact of hypertriglyceridaemia on cardiovascular mortality according to low-density lipoprotein cholesterol in a 15.6-million population

AIMS

The aim of this study was to assess the association between triglyceride (TG) levels and cardiovascular disease (CVD) mortality concerning low-density lipoprotein cholesterol (LDL-C) and age in the general population.

METHODS AND RESULTS

From the Korean National Health Insurance Service database, 15 672 028 participants aged 18-99 who underwent routine health examinations were followed up for CVD mortality. Hazard ratios for CVD mortality were calculated using Cox models after adjusting for various confounders. During a mean of 8.8 years of follow-up, 105 174 individuals died of CVD. There was a clear log-linear association between TG and overall CVD mortality down to 50 mg/dL. Each two-fold increase in TG was associated with 1.10-fold (overall CVD), 1.22-fold [ischaemic heart disease (IHD)], 1.24-fold [acute myocardial infarction (AMI)], and 1.10-fold (ischaemic stroke) higher CVD mortality. Haemorrhagic stroke and heart failure were not associated with TG levels. The impact of hypertriglyceridaemia (HTG) on CVD weakened but remained present in persons with LDL-C < 100 mg/dL, in whom each two-fold higher TG was associated with 1.05-fold (overall CVD), 1.12-fold (IHD), 1.15-fold (AMI), and 1.05-fold (ischaemic stroke) higher CVD mortality. The younger population (18-44 years) had stronger associations between TG levels and mortality from overall CVD, IHD, and AMI than the older population.

CONCLUSION

Hypertriglyceridaemia independently raises CVD mortality with lingering risks in young and older individuals with low LDL-C levels, suggesting the importance of management of HTG even with controlled LDL-C.

Reducing the Bias of Norm Scores in Non-Representative Samples: Weighting as an Adjunct to Continuous Norming Methods

We investigated whether the accuracy of normed test scores derived from non-demographically representative samples can be improved by combining continuous norming methods with compensatory weighting of test results. To this end, we introduce Raking, a method from social sciences, to psychometrics. In a simulated reference population, we modeled a latent cognitive ability with a typical developmental gradient, along with three demographic variables that were correlated to varying degrees with the latent ability. We simulated five additional populations representing patterns of non-representativeness that might be encountered in the real world. We subsequently drew smaller normative samples from each population and used an one-parameter logistic Item Response Theory (IRT) model to generate simulated test results for each individual. Using these simulated data, we applied norming techniques, both with and without compensatory weighting. Weighting reduced the bias of the norm scores when the degree of non-representativeness was moderate, with only a small risk of generating new biases.

Joint associations of physical activity and sedentary time with body mass index: A prospective study of mortality risk

Device-measured physical activity and sedentary time are suggested to be more important determinants of all-cause mortality compared to body mass index (BMI) in mainly older adults. However, the joint associations of physical activity and sedentary time with BMI in relation to mortality risk in relatively healthy middle-aged individuals are unclear. We followed 770 adults (56% women, mean age 55.6 years) from a population-based cohort study for up to 15.3 years. BMI categories were combined with tertiles of total, light, and moderate-to-vigorous physical activity and sedentary time. Cox proportional hazards models estimated hazard ratios (HR) of all-cause mortality with 95% confidence intervals (CI). High total and light intensity physical activity and low sedentary time were associated with a lower risk of mortality in normal weight individuals compared with low active overweight/obese; HR: 0.35 (CI: 0.14, 0.86), HR: 0.33 (CI: 0.12, 0.89), and HR: 0.34 (CI: 0.13, 0.92). Among overweight/obese individuals, those who were medium active in light physical activity had a lower mortality risk, HR: 0.36 (CI: 0.15, 0.83), compared with low active. Medium sedentary individuals had a lower risk, HR: 0.43 (CI: 0.20, 0.94) compared with those who were most sedentary. Associations among the most active or least sedentary tertiles were similar irrespective of BMI category. In conclusion, higher physical activity and lower sedentary time were associated with lower mortality risk irrespective of BMI. Physical activity should be promoted and prescribed to individuals with low physical activity levels irrespective of weight status.

Type 2 Diabetes Incidence and Mortality: Associations with Physical Activity, Fitness, Weight Loss, and Weight Cycling

Cardiometabolic diseases, including cardiovascular disease (CVD) and type 2 diabetes (T2D), are the leading cause of death globally. Because T2D and obesity are strongly associated, weight loss is the cornerstone of treatment. However, weight loss is rarely sustained, which may lead to weight cycling, which is associated with increased mortality risk in patients with T2D. Meta-analyses show that weight loss is not generally associated with reduced mortality risk in T2D, whereas weight cycling is associated with increased all-cause and CVD mortality. This may be attributable in part to increased variability in CVD risk factors that often accompany weight cycling, which studies show is consistently associated with adverse CVD outcomes in patients with T2D. The inconsistent associations between weight loss and mortality risk in T2D, and consistent findings of elevated mortality risk associated with weight cycling, present a conundrum for a weight-loss focused T2D prevention and treatment strategy. This is further complicated by the findings that among patients with T2D, mortality risk is lowest in the body mass index (BMI) range of ~25-35 kg/ m 2 . Because this "obesity paradox" has been consistently demonstrated in 7 meta-analyses, the lower mortality risk for individuals with T2D in this BMI range may not be all that paradoxical. Physical activity (PA), cardiorespiratory fitness (CRF), and muscular fitness (MF) are all associated with reduced risk of T2D, and lower risk of CVD and all-cause mortality in individuals with T2D. Reducing sedentary behavior, independent of PA status, also is strongly associated with reduced risk of T2D. Improvements in cardiometabolic risk factors with exercise training are comparable to those observed in weight loss interventions, and are largely independent of weight loss. To minimize risks associated with weight cycling, it may be prudent to adopt a weight-neutral approach for prevention and treatment of individuals with obesity and T2D by focusing on increasing PA and improving CRF and MF without a specific weight loss goal.

Impact of diabetes, obesity, and dyslipidemia on the risk of hepatocellular carcinoma in patients with chronic liver diseases

Despite the increasing prevalence of metabolic disorders, the potential effects of metabolic factors on hepatocellular carcinoma (HCC) development in individuals with chronic liver diseases (CLDs) are not well understood. For a metabolic factor to be identified as a risk factor for HCC in patients with CLDs, such as hepatitis B virus (HBV) and hepatitis C virus (HCV) infection, there should be a strong synergistic interaction between the carcinogenic mechanisms of the metabolic factor and the CLD itself. This review aims to comprehensively summarize the published data on the relationship between metabolic factors such as diabetes mellitus (DM), obesity, and blood lipids and the risk of HCC in patients with CLDs. DM consistently increases the risk of HCC in patients with CLD. When associated with DM, the risk of HCC seems to be highest in HCV and non-alcoholic fatty liver disease (NAFLD), followed by alcoholic liver disease (ALD) and HBV. Obesity may increase the risk of HCC. Among CLDs, the evidence is relatively consistent and clear for ALD, while clear evidence is limited in other CLDs including HBV, HCV, and NAFLD. Total cholesterol, potentially low-density lipoprotein cholesterol and triglyceride, seems to have strong inverse associations with HCC in individuals with CLDs. Despite evidence from observational studies, statins had no effect in preventing HCC in randomized controlled trials. Whether statins have a preventive effect against HCC is unclear. A better understanding and management of metabolic factors may be beneficial to reduce the risk of HCC in patients with CLDs.

Association between low-density lipoprotein cholesterol and cardiovascular mortality in statin non-users: a prospective cohort study in 14.9 million Korean adults

BACKGROUND

Limited information is available on detailed sex/age-specific associations between low-density lipoprotein cholesterol (LDL-C) and cardiovascular disease (CVD) mortality and 'the optimal range' associated with the lowest CVD mortality in the general population.

METHODS

Korean adults (N = 14 884 975) who received routine health screenings during 2009-2010 were followed until 2018 for CVD mortality.

RESULTS

During 8.8 years (mean) of follow-up, 94 344 individuals died from CVD. LDL-C had U-curve associations with mortality from CVD and its subtypes, except haemorrhagic stroke. Optimal range was 90-149 mg/dL for CVD; 70-114 for ischaemic heart disease; 85-129 for ischaemic stroke; ≥85 for subarachnoid haemorrhage; ≥130 for intracerebral haemorrhage; 115-159 for hypertension and heart failure; and 100-144 for sudden cardiac death. Assuming linear associations between 100 and 300 mg/dL, LDL-C was positively associated with CVD mortality [hazard ratio (HR) per 39-mg/dL (1-mmol/L) higher LDL-C = 1.10], largely due to ischaemic heart disease (HR = 1.26), followed by sudden cardiac death (HR = 1.13), ischaemic stroke (HR = 1.11) and heart failure (HR = 1.05). Intracerebral haemorrhage (HR = 0.90), but not subarachnoid haemorrhage, had inverse associations. Women and older adults had weaker positive associations than men and younger adults (Pinteraction < 0.001 for both sex and age). Individuals aged 75-84 years had modest positive associations with CVD mortality, especially ischaemic heart disease and ischaemic stroke.

CONCLUSION

LDL-C had U-curve associations for CVD mortality. The associations and optimal ranges differed across CVD subtypes. Women and older adults had weaker positive associations than men and younger adults. Positive associations with ischaemic heart disease and ischaemic stroke were maintained in adults aged 75-84 years.

Relationship between body mass index and fracture risk at different skeletal sites: a nationwide cohort study

The association between obesity and fracture was skeletal site-specific with no gender difference. Obesity was associated with a higher risk of proximal humerus fractures but not for wrist or clinical vertebral fractures.

PURPOSE

The association between body mass index (BMI) and the risk of clinical fractures at different sites is unclear. This study aimed to examine associations between BMI and fractures at different sites in Korean men and women.

METHODS

This study analyzed 285,643 Korean adults (aged 50-80 years) who participated in health examinations from 2002 to 2003 and were followed up until 2015. The incidences of osteoporotic fractures were assessed using the International Classification of Diseases (10th revision; ICD-10) and procedure or radiographic codes. After adjusting for confounders, hazard ratios (HRs) were calculated using Cox proportional hazard models for fracture risk.

RESULTS

Site-specific associations between BMI and fractures were found without gender difference. Specifically, an L-shaped association was found for clinical vertebral fractures, wherein the adjusted HRs per 5 kg/m² increase were 0.80 (95% confidence interval [CI] = 0.76-0.83) in BMI groups < 25 kg/m² and 0.97 (95% CI = 0.92-1.03) in BMI ≥ 25 kg/m². A linear inverse correlation for wrist fractures was observed, wherein the HRs were 0.83 (95% CI = 0.81-0.86) per 5 kg/m² increase. For proximal humerus fractures, a non-linear U-shape association was found, wherein the adjusted HRs per 5 kg/m² increase were 0.66 (95% CI = 0.50-0.88) in BMI groups < 23 kg/m² and 1.25 (95% CI = 1.08-1.45) in BMI ≥ 23 kg/m².

CONCLUSION

Low BMI was a risk factor for all tested fractures. Obesity was a risk factor for proximal humerus fracture, but it is a protective factor for wrist fracture.

Device-measured physical activity, adiposity and mortality: a harmonised meta-analysis of eight prospective cohort studies

BACKGROUND

The joint associations of total and intensity-specific physical activity with obesity in relation to all-cause mortality risk are unclear.

METHODS

We included 34 492 adults (72% women, median age 62.1 years, 2034 deaths during follow-up) in a harmonised meta-analysis of eight population-based prospective cohort studies with mean follow-up ranging from 6.0 to 14.5 years. Standard body mass index categories were cross-classified with sample tertiles of device-measured total, light-to-vigorous and moderate-to-vigorous physical activity and sedentary time. In five cohorts with waist circumference available, high and low waist circumference was combined with tertiles of moderate-to-vigorous physical activity.

RESULTS

There was an inverse dose-response relationship between higher levels of total and intensity-specific physical activity and mortality risk in those who were normal weight and overweight. In individuals with obesity, the inverse dose-response relationship was only observed for total physical activity. Similarly, lower levels of sedentary time were associated with lower mortality risk in normal weight and overweight individuals but there was no association between sedentary time and risk of mortality in those who were obese. Compared with the obese-low total physical activity reference, the HRs were 0.59 (95% CI 0.44 to 0.79) for normal weight-high total activity and 0.67 (95% CI 0.48 to 0.94) for obese-high total activity. In contrast, normal weight-low total physical activity was associated with a higher risk of mortality compared with the obese-low total physical activity reference (1.28; 95% CI 0.99 to 1.67).

CONCLUSIONS

Higher levels of physical activity were associated with lower risk of mortality irrespective of weight status. Compared with obesity-low physical activity, there was no survival benefit of being normal weight if physical activity levels were low.

Impact of overweight and obesity on the risk of hepatocellular carcinoma: a prospective cohort study in 14.3 million Koreans

BACKGROUND

Whether obesity and being overweight, defined by body mass index (BMI), increase hepatocellular carcinoma (HCC) has been less apparent in Asian populations.

METHODS

Overall, 14,265,822 Korean adults who underwent routine health examinations during 2003-2006 were followed up for HCC. Multivariable-adjusted hazard ratios (HRs) associated with BMI were calculated.

RESULTS

During 13.7 years (mean) of follow-up, 47,308 individuals developed HCC. HRs of HCC associated with BMIs of 25.0-26.4, 26.5-27.9, 28.0-29.4, 29.5-30.9 and ≥31 kg/m² compared to those for 23.5-24.9 kg/m² were 1.05, 1.20, 1.39, 1.59 and 2.13, respectively. For BMI < 25 kg/m², linear associations were not apparent. For BMI ≥ 25 kg/m², the HR per 5 kg/m² increase in BMI was 1.60 (total), 1.60 (men), and 1.59 (women). The corresponding HRs were 1.56, 1.61 and 1.60 for individuals aged <45, 45-64 and ≥65 years, respectively. Further adjustment for alanine transaminase (ALT) levels substantially reduced the HRs for high BMI, especially in men and younger adults.

CONCLUSIONS

Overweight and obesity clearly increase HCC risk in Koreans. ALT levels are a mediator of the impact of obesity, but it may not accurately predict high BMI-induced liver damage that can potentially progress to HCC, especially in women and older adults.

Body Mass Index Combined With Possible Sarcopenia Status Is Better Than BMI or Possible Sarcopenia Status Alone for Predicting All-Cause Mortality Among Asian Community-Dwelling Older Adults

Background

Body mass index (BMI) and sarcopenia are common indicators of nutritional status. Possible sarcopenia, defined as low muscle strength or performance, was recently introduced by the Asian Working Group for Sarcopenia (AWGS) in 2019. We investigated for association between all-cause mortality and BMI combined with possible sarcopenia severity in Asian older adults.

Methods

This study included a subpopulation (8,195 participants aged ≥60 years; male gender: 49.4%; mean age: 69.2 ± 6.8 years) from the Fourth Thai National Health Examination Survey (NHES-IV). BMI was classified using Asia-Pacific cut-offs. Possible sarcopenia was defined using quadriceps strength based on AWGS 2019 criteria, and possible sarcopenia severity was determined using study population quartile cut-offs. All-cause mortality data was derived from the national vital registry in 2020.

Results

The prevalence of underweight status and possible sarcopenia was 11.8 and 38.9%, respectively. Multivariate analysis showed underweight individuals with severe possible sarcopenia to be at highest risk for increased mortality [adjusted hazard ratio (aHR): 3.98, 95% confidence interval (CI): 2.89-5.48], and higher risk was found in men compared to women (aHR: 5.35, 95% CI: 1.19-8.97). Obese status without possible sarcopenia was an independent protective factor (aHR: 0.61, 95% CI: 0.38-0.97).

Conclusion

BMI combined with possible sarcopenia severity is a better predictor of mortality risk than either parameter alone.

Age-dependent associations of body mass index with myocardial infarction, heart failure, and mortality in over 9 million Koreans

BACKGROUND

While obesity is a well-known cardiovascular risk factor, little is known whether age has a modifying effect.

AIM

To determine the age-dependent associations of BMI with cardiovascular outcomes.

METHODS

A population-based cohort of 9,278,433 Koreans without prior cardiovascular disease were followed up for the incidence of myocardial infarction (MI), heart failure (HF), and all-cause death. The effect of BMI with optimal normal weight (18.5-22.9 kg/m2) as reference was analyzed according to age groups [young (20-39 years), middle-aged (40-64 years), and elderly (≥65 years)] and age decades.

RESULTS

During 8.2 years, MI, HF, and all-cause death occurred in 65,607 (0.71%), 131,903 (1.42%), and 306,065 (3.30%), respectively. Associations between BMI and all outcomes were significantly modified by age (p-for-interaction < 0.001). There was a proportional increase in incident MI according to BMI in young subjects; this relationship became U-shaped in middle-aged subjects, and inversely proportional/plateauing in elderly subjects. A U-shaped relationship between BMI and incident HF was observed, but the impact of obesity was stronger in young subjects while the impact of underweight was stronger in middle-aged and elderly subjects. Meanwhile, lower BMI was associated with higher all-cause mortality in all ages, although this association was attenuated at young age, and pre-obesity was associated with the greatest survival benefit. These associations were independent of sex, smoking, physical activity, and comorbidities.

CONCLUSIONS

The impact of BMI on cardiovascular risk differs according to age. Weight loss may be recommended for younger overweight subjects, while being mildly overweight may be beneficial at old age.

Independent and joint effects of body mass index and metabolic health in mid- and late-life on all-cause mortality: a cohort study from the Swedish Twin Registry with a mean follow-up of 13 Years

BACKGROUND

There is robust evidence that in midlife, higher body mass index (BMI) and metabolic syndrome (MetS), which often co-exist, are associated with increased mortality risk. However, late-life findings are inconclusive, and few studies have examined how metabolic health status (MHS) affects the BMI-mortality association in different age categories. We, therefore, aimed to investigate how mid- and late-life BMI and MHS interact to affect the risk of mortality.

METHODS

This cohort study included 12,467 participants from the Swedish Twin Registry, with height, weight, and MHS measures from 1958-2008 and mortality data linked through 2020. We applied Cox proportional hazard regression with age as a timescale to examine how BMI categories (normal weight, overweight, obesity) and MHS (identification of MetS determined by presence/absence of hypertension, hyperglycemia, low HDL, hypertriglyceridemia), independently and in interaction, are associated with the risk of all-cause mortality. Models were adjusted for sex, education, smoking, and cardiovascular disease.

RESULTS

The midlife group included 6,252 participants with a mean age of 59.6 years (range = 44.9-65.0) and 44.1% women. The late-life group included 6,215 participants with mean age 73.1 years (65.1-95.3) and 46.6% women. In independent effect models, metabolically unhealthy status in midlife increased mortality risks by 31% [hazard ratio 1.31; 95% confidence interval 1.12-1.53] and in late-life, by 18% (1.18;1.10-1.26) relative to metabolically healthy individuals. Midlife obesity increased the mortality risks by 30% (1.30;1.06-1.60) and late-life obesity by 15% (1.15; 1.04-1.27) relative to normal weight. In joint models, the BMI estimates were attenuated while those of MHS were less affected. Models including BMI-MHS categories revealed that, compared to metabolically healthy normal weight, the metabolically unhealthy obesity group had increased mortality risks by 53% (1.53;1.19-1.96) in midlife, and across all BMI categories in late-life (normal weight 1.12; 1.01-1.25, overweight 1.10;1.01-1.21, obesity 1.31;1.15-1.49). Mortality risk was decreased by 9% (0.91; 0.83-0.99) among those with metabolically healthy overweight in late-life.

CONCLUSIONS

MHS strongly influenced the BMI-mortality association, such that individuals who were metabolically healthy with overweight or obesity in mid- or late-life did not carry excess risks of mortality. Being metabolically unhealthy had a higher risk of mortality independent of their BMI.

Comparison of Risk Factors for Cholangiocarcinoma and Hepatocellular Carcinoma: A Prospective Cohort Study in Korean Adults

Cholangiocarcinoma (CCA), especially intrahepatic CCA, is known to share several risk factors with hepatocellular carcinoma (HCC) and liver cirrhosis has been proposed as a common pathogenic factor. We aimed to identify the risk factors of CCA and to examine differences in risk factors between CCA and HCC. We followed 510,217 Korean adults who underwent health checkups during 2002−2003 until 2013 via linkage to national hospital discharge records. Hazard ratios (HRs) were calculated after adjustment for confounders. During the mean follow-up of 10.5 years, 1388 and 2920 individuals were diagnosed with CCA and HCC, respectively. Choledocholithiasis (HR = 13.7; 95% confidence interval (CI) = 7.58−24.88) was the strongest risk factor for CCA, followed by cholelithiasis (HR = 2.94) and hepatitis B virus (HBV) infection (HR = 2.71). Two of the strongest risk factors for HCC—liver cirrhosis (HR = 1.29; 95% CI = 0.48−3.45) and hepatitis C virus infection (HR = 1.89; 95% CI = 0.49−7.63)—were not significantly associated with the risk of CCA. HBV infection and diabetes increased the risk of both HCC and CCA, but the HRs were lower for CCA than for HCC (Pheterogeneity < 0.001 for HBV; Pheterogeneity = 0.001 for diabetes). The magnitudes of the effects of age, sex, obesity, alcohol consumption, and smoking on the development of both cancers were different (Pheterogeneity < 0.05 for each variable). In conclusion, choledocholithiasis, cholelithiasis, HBV, older age, male sex, diabetes, smoking, alcohol drinking, and obesity were found to be potential risk factors of CCA. Liver cirrhosis did not increase the risk of CCA. The magnitudes of the potential effects of common risk factors were generally different between CCA and HCC.

Body mass index and 12-year mortality among older Mexican Americans aged 75 years and older

Background

The role of obesity in mortality in the very old and old-oldest Hispanic population has not been studied. The objective of this study was to examine the effect of body mass index (BMI) on 12-year mortality among older Mexican Americans aged 75 years and older.

Methods

Twelve year prospective cohort study consisting of a population-based sample of 1415 non-institutionalized Mexican American men and women aged 75 and older from 5 southwestern states: Arizona, California, Colorado, New Mexico, and Texas. Data was from Wave 5 of the Hispanic Established Population for the Epidemiologic Study of the Elderly (2004/2005–2016). Socio-demographics, body mass index (BMI), self-reported medical conditions, disability, depressive symptoms, falls, Mini-Mental-State-Examination (MMSE), and Short Physical Performance Battery (SPPB) were assessed at baseline during 2004–2005. BMI (Kg/m²) was classified as underweight (< 18.5), normal weight (18.5 to < 25), overweight (25 to < 30), obesity category I (30 to < 35), and obesity category II/morbid obesity (≥ 35). For assessment of mortality, deaths were ascertained through the National Death Index and report from relatives. Cox proportional hazards regression analysis was performed to estimate the hazard ratio (HR) of 12-year mortality as a function of BMI categories at baseline.

Results

The mean BMI was 27.5 ± 1.7 with participants classified as 1.8% underweight, 30.8% normal weight, 39.2% overweight, 20.7% obesity category I, and 7.6% obesity category II/morbid obesity. Mexican Americans aged ≥75 years with overweight or obesity category I had a reduced HR of death (0.82, 95% CI = 0.70–0.96 and 0.75, 95% CI = 0.62–0.91, respectively) over 12-years of follow-up. The HR of death for underweight and obesity category II/morbid obesity participants was 1.59 (95% CI = 1.03–2.45) and 1.12 (95% CI = 0.85–1.46), respectively. Female participants and those with high scores in the MMSE and SPPB had decreased risk of death.

Conclusions

This study showed the protective effect of overweight and obesity on mortality in Mexican Americans above 75 years of age, which might have implications when treating older adults with overweight and obesity.

Prevalence of Cardiometabolic Syndrome and its Association With Body Shape Index and A Body Roundness Index Among Type 2 Diabetes Mellitus Patients: A Hospital-Based Cross-Sectional Study in a Ghanaian Population

Cardiometabolic syndrome (MetS) is closely linked to type 2 diabetes mellitus (T2DM) and is the leading cause of diabetes complications. Anthropometric indices could be used as a cheap approach to identify MetS among T2DM patients. We determined the prevalence of MetS and its association with sociodemographic and anthropometric indices among T2DM patients in a tertiary hospital in the Ashanti region of Ghana. A comparative cross-sectional study was conducted among 241 T2DM outpatients attending the Komfo Anokye Teaching Hospital (KATH) and the Kumasi South Hospital for routine check-up. Sociodemographic characteristics, clinicobiochemical markers, namely, systolic blood pressure (SBP), diastolic blood pressure (DBP), fasting blood glucose (FBG), and glycated hemoglobin (HbA1C) were measured. Anthropometric indices, namely, body mass index (BMI), Conicity index (CI), body adiposity index (BAI), A body shape index (ABSI), body roundness index (BRI), Waist-to-hip ratio (WHR), and Waist-to-height ratio (WHtR) were computed based on either the Height, Weight, Waist circumference (WC) or Hip circumference (HC) of the patients. Metabolic syndrome (MetS) was classified using the National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) criteria. Data entry and analysis were done using Excel 2016 and SPSS version 25.0 respectively. Of the 241 T2DM patients, 99 (41.1%) were males whereas 144 (58.9%) were females. The prevalence of cardiometabolic syndrome (MetS) was 42.7% with dyslipidemia and hypertension recording a prevalence of 6.6 and 36.1%, respectively. Being a female T2DM patient [aOR = 3.02, 95%CI (1.59-5.76), p = 0.001] and divorced [aOR = 4.05, 95%CI (1.22-13.43), p = 0.022] were the independent sociodemographic predictors of MetS among T2DM patients. The 4th quartile for ABSI and 2nd to 4th quartiles for BSI were associated with MetS on univariate logistic regression (p <0.05). Multivariate logistic regression identified the 3rd quartile (aOR = 25.15 (2.02-313.81), p = 0.012) and 4th quartile (aOR = 39.00, 95%CI (2.68-568.49), p = 0.007) for BRI as the independent predictors of MetS among T2DM. The prevalence of cardiometabolic syndrome is high among T2DM patients and this was influenced by female gender, being divorced, and increased BRI. Integration of BRI as part of routine assessment could be used as early indicator of cardiometabolic syndrome among T2DM patients.

Effects of orthodontic treatment on body mass index, food habits and self-esteem of patients: A prospective single-arm cohort study

Objectives

During orthodontic treatment, patients are often apprehensive about reduced food intake and loss of body weight. Body mass index (BMI) assessment is an inexpensive, easy method for screening and studying changes in weight categories. This research aimed to determine whether long-term changes in BMI, self-esteem, and food habits occur in patients during the first year of orthodontic treatment.

Methods

BMI was calculated for 120 patients undergoing orthodontic treatment. Data were collected at baseline, and after the end of the first, second, third, sixth, and twelfth months. Rosenberg's self-esteem scale was used for scoring self-esteem. The Food Habit Assessment Scale was used to study changes in eating habits. Statistical analysis was performed with repeated measures ANOVA followed by Tukey HSD post-hoc test for BMI scores and Kruskal–Wallis test followed by Dunn's multiple comparison post-hoc tests for the Rosenberg scale and food habits questionnaire.

Results

At the end of 12 months, 43.4% of patients had a decrease in BMI, 45.8% had a mild to moderate increase in BMI, and 10.8% of patients maintained their BMI levels. The changes were not statistically significant. Self-esteem changes were statistically significant for both genders. Changes in food habits were also significant.

Conclusion

BMI decreased for the first 3 months and gradually recovered by the end of the first year of treatment. Self-esteem scores showed a significant improvement in both genders. Patients reverted to pre-treatment food habits by the end of the year.

High-density lipoprotein cholesterol and cardiovascular mortality: a prospective cohort study among 15.8 million adults

AIMS

We aimed to investigate whether the associations between high-density lipoprotein cholesterol (HDL-C) and cardiovascular disease (CVD) mortality and the optimal range differ by age and CVD subtypes.

METHODS AND RESULTS

Korean adults (n = 15,859,501) with no CVD/cancer who received routine health examinations during 2009-2010 were followed until 2018 for CVD mortality. During a mean 8.8 years of follow-up, 108,123 individuals died from CVD. U-curve associations were found between HDL-C and CVD mortality, regardless of sex, age, and CVD subtype. The optimal range was 50-79 mg/dL (1.29-2.06 mmol/L), while it was 40-69 (1.03-1.80), 50-79 (1.29-2.06), and 60-89 (1.55-2.32) mg/dL (mmol/L) in adults aged <45 years, 45-64 years, and 65-99 years, respectively. Assuming linear associations <60 mg/dL, the multivariable-adjusted hazard ratios (HRs) per 39 mg/dL (1 mmol/L) higher level were 0.58 (95% CI = 0.56-0.60), and they were 0.61 (0.52-0.72), 0.58 (0.54-0.62), and 0.59 (0.56-0.61) in individuals aged 18-44, 45-64, and 65-99 years, respectively (P  interaction[age]=0.845). Assuming linear associations in the 60-150 mg/dL range, HDL-C was positively associated with CVD mortality (HR = 1.09, 1.04-1.14). The strongest association was for sudden cardiac death (HR = 1.37), followed by heart failure (HR = 1.20) and intracerebral hemorrhage (HR = 1.13). The HRs were 1.47 (1.23-1.76), 1.17 (1.08-1.28), and 1.03 (0.97-1.08) in individuals aged 18-44, 45-64, and 65-99 years, respectively (P  interaction[age]<0.001).

CONCLUSIONS

Both low and high levels of HDL-C were associated with increased mortality from CVD in the general population, especially sudden cardiac death, heart failure, and intracerebral hemorrhage. High HDL-C levels are not necessarily a sign of good cardiovascular health, especially in younger adults.

Metabolomic Profiling of Blood-Derived Microvesicles in Breast Cancer Patients

Malignant cells differ from benign ones in their metabolome and it is largely unknown whether this difference is reflected in the metabolic profile of their microvesicles (MV), which are secreted into the blood of cancer patients. Here, they are present together with MV from the various blood and endothelial cells. Harvesting MV from 78 breast cancer patients (BC) and 30 controls, we characterized the whole blood MV metabolome using targeted and untargeted mass spectrometry. Especially (lyso)-phosphatidylcholines and sphingomyelins were detected in a relevant abundance. Eight metabolites showed a significant discriminatory power between BC and controls. High concentrations of lysoPCaC26:0 and PCaaC38:5 were associated with shorter overall survival. Comparing BC subtype-specific metabolome profiles, 24 metabolites were differentially expressed between luminal A and luminal B. Pathway analysis revealed alterations in the glycerophospholipid metabolism for the whole cancer cohort and in the ether lipid metabolism for the molecular subtype luminal B. Although this mixture of blood-derived MV contains only a minor number of tumor MV, a combination of metabolites was identified that distinguished between BC and controls as well as between molecular subtypes, and was predictive for overall survival. This suggests that these metabolites represent promising biomarkers and, moreover, that they may be functionally relevant for tumor progression.

Identification of Mood and Body Mass Index as Modifiable Factors for Health Improvement in Spinal Cord Injury

•

Higher body mass index (BMI) is associated with lower positive affect in individuals with spinal cord injury (SCI).

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Women with SCI are at higher risk of developing increased negative affect than men.

•

Older individuals with SCI have a greater chance of developing higher BMI.

•

Premorbid personality traits with respect to mood and BMI are essential to interpret the association of BMI and positive affect.

Objective

Design

Setting

Participants

Interventions

Main Outcome Measures

Results

Conclusions

Obesity treatment: Weight loss versus increasing fitness and physical activity for reducing health risks

We propose a weight-neutral strategy for obesity treatment on the following grounds: (1) the mortality risk associated with obesity is largely attenuated or eliminated by moderate-to-high levels of cardiorespiratory fitness (CRF) or physical activity (PA), (2) most cardiometabolic risk markers associated with obesity can be improved with exercise training independent of weight loss and by a magnitude similar to that observed with weight-loss programs, (3) weight loss, even if intentional, is not consistently associated with lower mortality risk, (4) increases in CRF or PA are consistently associated with greater reductions in mortality risk than is intentional weight loss, and (5) weight cycling is associated with numerous adverse health outcomes including increased mortality. Adherence to PA may improve if health care professionals consider PA and CRF as essential vital signs and consistently emphasize to their patients the myriad benefits of PA and CRF in the absence of weight loss.

High-density lipoprotein cholesterol and all-cause mortality by sex and age: a prospective cohort study among 15.8 million adults

BACKGROUND

The associations between high-density lipoprotein cholesterol (HDL-C) levels and all-cause mortality are unclear in young adults (<45 years) and in Asian populations.

METHODS

In total, 15 860 253 Korean adults underwent routine health examinations during 2009-10 and were followed until June 2018 for all-cause mortality. Hazard ratios (HRs) were calculated using Cox proportional hazard models.

RESULTS

During a mean 8.4 years of follow-up, 555 802 individuals died. U-curve associations were found between HDL-C levels and mortality, irrespective of sex or age. The HDL-C ranges associated with the lowest mortality were 40-59 and 50-69 mg/dL (1.03-1.54 and 1.29-1.80 mmol/L) in men aged <65 and ≥65 years, respectively, and the corresponding ranges were 40-69 and 50-79 mg/dL (1.03-1.80 and 1.29-2.06 mmol/L) in women aged <45 and ≥45 years, respectively. For HDL-C ranges of 60-149 mg/dL (1.55-3.86 mmol/L), each 39 mg/dL (1 mmol/L) increase in HDL-C was associated with higher mortality [men: HR = 1.39; 95% confidence interval (CI) = 1.36-1.42; women: HR = 1.15, 95% CI = 1.11-1.18], adjusting for age. These positive associations were generally stronger at younger than older ages, whereas inverse associations for HDL-C ranges <60 mg/dL (1.55 mmol/L) were strongest in middle age (45-64 years). The U-curve associations were generally unchanged after adjustment for various confounders.

CONCLUSIONS

Korean adults showed U-curve associations of HDL-C with mortality, regardless of sex, and age. Younger adults had a lower optimal range and a stronger positive association with mortality than older adults in the high HDL-C range. Even moderately high HDL-C levels are not necessarily a sign of good health, especially in young adults.

Anthropometric Indicators as a Tool for Diagnosis of Obesity and Other Health Risk Factors: A Literature Review

Obesity is characterized by the accumulation of an excessive amount of fat mass (FM) in the adipose tissue, subcutaneous, or inside certain organs. The risk does not lie so much in the amount of fat accumulated as in its distribution. Abdominal obesity (central or visceral) is an important risk factor for cardiovascular diseases, diabetes, and cancer, having an important role in the so-called metabolic syndrome. Therefore, it is necessary to prevent, detect, and appropriately treat obesity. The diagnosis is based on anthropometric indices that have been associated with adiposity and its distribution. Indices themselves, or a combination of some of them, conform to a big picture with different values to establish risk. Anthropometric indices can be used for risk identification, intervention, or impact evaluation on nutritional status or health; therefore, they will be called anthropometric health indicators (AHIs). We have found 17 AHIs that can be obtained or estimated from 3D human shapes, being a noninvasive alternative compared to X-ray-based systems, and more accessible than high-cost equipment. A literature review has been conducted to analyze the following information for each indicator: definition; main calculation or obtaining methods used; health aspects associated with the indicator (among others, obesity, metabolic syndrome, or diabetes); criteria to classify the population by means of percentiles or cutoff points, and based on variables such as sex, age, ethnicity, or geographic area, and limitations.

Association of BMI with cardiovascular disease incidence and mortality in patients with type 2 diabetes mellitus: A systematic review and dose-response meta-analysis of cohort studies

AIMS

The relation of body mass index (BMI) with cardiovascular disease (CVD) and mortality has been extensively investigated in the general population but is less clear in individuals with type 2 diabetes mellitus (T2DM). We performed a meta-analysis of cohort studies to quantitatively evaluate the association of BMI with CVD incidence and mortality in patients with T2DM.

DATA SYNTHESIS

PubMed and Embase databases were searched for relevant cohort articles published up to June 8, 2020. Restricted cubic splines were used to evaluate the potential linear or non-linear dose-response associations. We identified 17 articles (21 studies) with 1,349,075 participants and 57,725 cases (49,354 CVD incidence and 8371 CVD mortality) in the meta-analysis. We found a linear association between BMI and risk of CVD incidence (P_{non-linearity} = 0.182); the pooled RR for CVD incidence was 1.12 (95% CI, 1.04-1.20) with a 5-unit increase in BMI. We found an overall nonlinear relationship between BMI and CVD mortality (P_{non-linearity} < 0.001). The lowest risk was at BMI about 28.4 kg/m², with increased mortality risk for higher BMI values; the RR with a 5-unit increase in BMI was 0.87 (95% CI, 0.79-0.96) and 1.11 (95% CI, 1.04-1.18) for BMI ≤28.4 kg/m² and BMI >28.4 kg/m², respectively.

CONCLUSIONS

In individuals with T2DM, BMI may have a positive linear association with risk of CVD incidence but a nonlinear association with CVD mortality. Our results can provide evidence for weight control and lifestyle intervention for preventing and managing cardiovascular disease in T2DM.

Body mass index and severity/fatality from coronavirus disease 2019: A nationwide epidemiological study in Korea

OBJECTIVE

Obesity has been reported as a risk factor for severe coronavirus disease 2019 (COVID-19) in recent studies. However, the relationship between body mass index (BMI) and COVID-19 severity and fatality are unclear.

RESEARCH DESIGN AND METHODS

This study included 4,141 COVID-19 patients who were released from isolation or had died as of April 30, 2020. This nationwide data was provided by the Korean Centers for Disease Control and Prevention Agency. BMI was categorized as follows; < 18.5 kg/m2, 18.5-22.9 kg/m2, 23.0-24.9 kg/m2, 25.0-29.9 kg/m2, and ≥ 30 kg/m2. We defined a fatal illness if the patient had died.

RESULTS

Among participants, those with a BMI of 18.5-22.9 kg/m2 were the most common (42.0%), followed by 25.0-29.9 kg/m2 (24.4%), 23.0-24.9 kg/m2 (24.3%), ≥ 30 kg/m2 (4.7%), and < 18.5 kg/m2 (4.6%). In addition, 1,654 (41.2%) were men and 3.04% were fatalities. Multivariable analysis showed that age, male sex, BMI < 18.5 kg/m2, BMI ≥ 25 kg/m2, diabetes mellitus, chronic kidney disease, cancer, and dementia were independent risk factors for fatal illness. In particular, BMI < 18.5 kg/m2 (odds ratio [OR] 3.97, 95% CI 1.77-8.92), 25.0-29.9 kg/m2 (2.43, 1.32-4.47), and ≥ 30 kg/m2 (4.32, 1.37-13.61) were found to have higher ORs than the BMI of 23.0-24.9 kg/m2 (reference). There was no significant difference between those with a BMI of 18.5-22.9 kg/m2 (1.59, 0.88-2.89) and 23.0-24.9 kg/m2.

CONCLUSIONS

This study demonstrated a non-linear (U-shaped) relationship between BMI and fatal illness. Subjects with a BMI of < 18.5 kg/m2 and those with a BMI ≥ 25 kg/m2 had a high risk of fatal illness. Maintaining a healthy weight is important not only to prevent chronic cardiometabolic diseases, but also to improve the outcome of COVID-19.

Underweight rather than adiposity is an important predictor of death in rural Chinese adults: a cohort study

BACKGROUND

To assess the associations of body mass index (BMI) with all-cause and cause-specific mortalities among rural Chinese.

METHODS

A prospective study of 28 895 individuals was conducted from 2006 to 2014 in rural Deqing, China. Height and weight were measured. The association of BMI with mortality was assessed by using Cox proportional hazards model and restricted cubic spline regression.

RESULTS

There were a total of 2062 deaths during an average follow-up of 7 years. As compared with those with BMI of 22.0-24.9 kg/m², an increased risk of all-cause mortality was found for both underweight men (BMI <18.5 kg/m²) (adjusted HR (aHR): 1.45, 95% CI: 1.18 to 1.79) and low normal weight men (BMI of 18.5-21.9 kg/m²) (aHR: 1.20, 95% CI: 1.03 to 1.38). A J-shaped association was observed between BMI and all-cause mortality in men. Underweight also had an increased risk of cardiovascular disease and cancer mortalities in men. The association of underweight with all-cause mortality was more pronounced in ever smokers and older men (60+ years). The results remained after excluding participants who were followed up less than 1 year.

CONCLUSION

The present study suggests that underweight is an important predictor of mortality, especially for elderly men in the rural community of China.

Age-Related Cognitive Decline and the Olfactory Identification Deficit Are Associated to Increased Level of Depression

PURPOSE

Previous studies reported a correlation between olfactory function and depression. However, in literature, no data are available for the correlation between depression and all other factors such as age, sex, olfactory, gustatory, and cognitive function in healthy subjects taken together. The aim of this study was to provide a systematic account regarding the association between those variables in a non-clinical population.

METHODS

Two hundred and seventy-three participants were recruited with an age range of 19-84 years. Olfactory, gustatory, cognitive function, and depression level were evaluated by means of the following tests: the Sniffin' Sticks test, Taste Strips test, Montreal Cognitive Assessment (MoCA), and Beck Depression Inventory (BDI).

RESULTS

In our data, an age-related decrease in olfactory and gustatory function and a decline in cognitive functions such as attention, memory, and language were observed. Instead, no significant differences were observed for the depression level in relation to the different age ranges. However, our results indicated that the depression level could be associated to sex, odor identification impairment, and decreased attention and language.

CONCLUSION

Sex, the odor identification impairment, and an age-related decrease in attention and language are associated with increased level of depression in healthy subjects. Our data can be useful and informative for health care workers, that is, to have adequate preventive strategies to be used whenever these conditions are detected and recognized.

Adiposity and risk of death: A prospective cohort study of 463,002 adults

BACKGROUND

It is crucial to have simple and appropriate measures to identify people with adiposity-related risk. We compared the associations of mortality with body mass index (BMI), waist circumference (WC), waist-to-height ratio (WHtR), and body fat percentage (BF%) in a prospective cohort.

METHODS

A total of 463,002 adults were recruited between 1996 and 2017. Vital data were obtained from the National Death Registry System in Taiwan. Cox proportional hazards model was used to assess the associations of BMI, WC, WHtR, and BF% with mortality.

RESULT

Clear U-shape relationships were observed for all four parameters. In both men and women, the lowest risk of mortality was observed in the BMI category of 23.5-24.9 kg/m². Regarding WC, men in the third quintile (79.0-82.9 cm) and women in the fourth quintile (70.0-74.9 cm) had the lowest risk of mortality. For WHtR, men in the third quintile (0.46-0.49) and women in the fourth quintile (0.45-0.48) had the lowest risk of mortality. For BF%, both men and women in the fourth quintile (24.0-27.2% and 28.7-32.8%, respectively) had the lowest risk of mortality. The WC, WHtR, and BF% exhibited slightly associations with the risk of mortality across the three BMI categories [low (10.8-20.9 kg/m²), normal (21.0-27.4 kg/m²) and high (27.5-51.7 kg/m²)]. C-statistics of the four parameters ranged from 0.51 to 0.69.

CONCLUSION

Our results suggest that BMI should remain the primary marker for screening excessive adiposity. However, our findings also support the use of the WC, WHtR, and/or BF%, in addition to BMI when assessing the risk of mortality.

Body mass index and all-cause mortality in older adults: A scoping review of observational studies

In older age, body composition changes as fat mass increases and redistributes. Therefore, the current body mass index (BMI) classification may not accurately reflect risk in older adults (65+). This study aimed to review the evidence on the association between BMI and all-cause mortality in older adults and specifically, the findings regarding overweight and obese BMI. A systematic search of the OVID MEDLINE and Embase databases was conducted between 2013 and September 2018. Observational studies examining the association between BMI and all-cause mortality within a community-dwelling population aged 65+ were included. Seventy-one articles were included. Studies operationalized BMI categorically (n = 60), continuously (n = 8) or as a numerical change/group transition (n = 7). Reduced risk of mortality was observed for the overweight BMI class compared with the normal BMI class (hazard ratios [HR] ranged 0.41-0.96) and for class 1 or 2 obesity in some studies. Among studies examining BMI change, increases in BMI demonstrated lower mortality risks compared with decreases in BMI (HR: 0.83-0.95). Overweight BMI classification or a higher BMI value may be protective with regard to all-cause mortality, relative to normal BMI, in older adults. These findings demonstrate the potential need for age-specific BMI cut-points in older adults.

Complex interaction of fasting glucose, body mass index, age and sex on all-cause mortality: a cohort study in 15 million Korean adults

AIMS/HYPOTHESIS

The aim of this work was to examine whether synergistic associations with mortality exist for BMI and fasting blood glucose (FBG) and to identify FBG-BMI combined subgroups with higher mortality according to sex and age.

METHODS

A total of 15,149,275 Korean adults participated in health examinations during 2003-2006 and were followed up until December 2018. Mortality HRs of 40 FBG-BMI combined groups were assessed by Cox proportional hazards models.

RESULTS

During a mean 13.7 years of follow-up, 1,213,401 individuals died. A J-shaped association was seen between FBG and all-cause mortality for all BMI categories. Those with BMI <20 kg/m² had the highest mortality for any given FBG level, followed by those with BMI 20-22.4 kg/m². The detrimental effect of elevated FBG was greater among leaner individuals than more corpulent individuals. Moreover, the synergistic adverse effects of hyperglycaemia and leanness was stronger in younger adults than in older adults. Compared with the reference group (overweight with normoglycaemia), age- and sex-adjusted HRs of the leanest with normoglycaemia (BMI <20 kg/m² and FBG 4.4-5.2 mmol/l), overweight with diabetes (BMI 25-27.4 kg/m² and FBG ≥10.0 mmol/l) and leanest with diabetes (BMI <20 kg/m² and FBG ≥10.0 mmol/l) were 1.29, 2.59 and 11.18, respectively, in those aged 18-44 years and 1.56, 1.72 and 2.87, respectively, in those aged 75-99 years. The identification of BMI-FBG subgroups associated with higher mortality was not straightforward, illustrated by the group with FBG 6.1-6.9 mmol/l and BMI 20-22.4 kg/m² having a similar or higher mortality compared with the group with FBG 7.0-9.9 mmol/l and BMI ≥22.5 kg/m². In women aged <45 years with FBG <6.9 mmol/l, those with BMI ≥27.5 kg/m² had the highest mortality, whereas individuals with BMI <20 kg/m² had the highest mortality for each given FBG level in other age and sex groups.

CONCLUSIONS/INTERPRETATION

Leanness and hyperglycaemia interact together to increase mortality in a supra-multiplicative manner, especially in younger adults; the interactions of BMI, FBG, sex and age with mortality are complex. Graphical abstract.

Mortality association between obesity and pneumonia using a dual restricted cohort model

BACKGROUND

An obesity survival paradox has been reported among obese patients with pneumonia.

AIMS

To determine the impact of obesity on pneumonia outcomes and analyze the correlation between in-hospital all-cause mortality and obesity among patients with pneumonia.

METHODS

The United States Nationwide Readmissions Database (NRD) was retrospectively analyzed for patients with pneumonia from 2013 to 2014. We used a step-wise restricted and propensity score matching cohort model (dual model) to compare mortality rates and other outcomes among pneumonia patients based on BMI. Mortality was calculated by a Cox proportional hazard model, adjusted for potential confounders with propensity score matched analysis.

RESULTS

A total of 70,886,775 patients were registered in NRD during the study period. Of these, 7,786,913 patients (11.0%) were considered obese and 1,652,456 patients (2.3%) were admitted to the hospital with pneumonia. Based on the step-wise restricted cohort model, the hazard ratio comparing the mortality rates among obese pneumonia patients to mortality rates among normal BMI pneumonia patients was 0.75 (95% CI 0.60-0.94). The propensity score matched analysis estimated a hazard rate of 0.84 (95% CI 0.79-0.90) and the hazard ratio estimated from the dual model was 0.82 (95% CI 0.63-1.07).

CONCLUSIONS

With the application of a dual model, there appears to be no significant difference in mortality of obese patients with pneumonia compared to normal BMI patients with pneumonia.

Chronic Kidney Disease Increases the Risk of Hip Fracture: A Prospective Cohort Study in Korean Adults

This study was conducted to examine the association between renal function and hip fracture. We followed up 352,624 Korean adults, who participated in health examinations during 2009-2010 until 2013. Kidney function was assessed by creatinine-based estimated glomerular filtration rate (eGFR) and albuminuria using urine reagent strip results. The incidence of hip fracture was examined by hospital discharge records. Hazard ratios (HRs) for hip fracture were calculated using Cox proportional hazard models after adjusting for multiple confounders. During a mean follow-up of 4.0 years, 1177 participants suffered a hip fracture. Lower eGFR and more severe albuminuria were associated with a higher risk of hip fracture. The HRs for hip fracture were 1.89 (95% confidence interval [CI] 1.47-2.43) and 3.75 (95% CI 2.30-6.11) among participants with eGFRs of 30 to 44 and 15 to 29 mL/min/1.73m² relative to those with an eGFR ≥60 mL/min/1.73m² , respectively. The HRs were 1.30 (95% CI 1.02-1.65) for moderate albuminuria and 1.58 (95% CI 1.07-2.35) for severe albuminuria (p for trend = 0.002). Participants with albuminuria had a higher risk of hip fracture than those without albuminuria, even when they belonged to the same eGFR category (HR = 1.75 versus 3.30 for an eGFR of 30 to 44 mL/min/1.73m² ; HR = 2.72 versus 7.84 for an eGFR of 15 to 29 mL/min/1.73m² ). The effects of each 10 mL/min/1.73m² decrease in eGFR were stronger with advancing albuminuria severity (p_interaction = 0.016). In conclusion, both low eGFR and albuminuria were risk factors for incident hip fracture in Korean adults. Moreover, these factors exerted a synergistic effect on the risk of hip fracture. © 2020 American Society for Bone and Mineral Research.

Association of Body Mass Index with the Risk of Incident Type 2 Diabetes, Cardiovascular Disease, and All-Cause Mortality: A Community-Based Prospective Study

BACKGROUND

Type 2 diabetes and cardiovascular disease (CVD) are the most important sequelae of obesity and the leading cause of death. We evaluated the association between body mass index (BMI) and the risk of incident type 2 diabetes, CVD, and all-cause mortality in a prospective study of a Korean population.

METHODS

The shapes of the associations were modeled by restricted cubic splines regression analysis. After categorizing all subjects (n=8,900) into octiles based on their BMI levels, we estimated the hazard ratio (HR) for the association of categorized BMI levels with the risk of incident CVD and type 2 diabetes using a Cox's proportional hazard analysis.

RESULTS

The mean age of participants was 52 years and 48% were men. Of the subjects at baseline, 39.0% of men and 45.6% of women were classified as obese (BMI ≥25 kg/m2). Over a mean follow-up of 8.1 years, CVD events occurred in 509 participants; 436 died; and 1,258 subjects developed type 2 diabetes. The increased risk of incident diabetes began to be significant at BMI 23 to 24 kg/m2 in both sexes (HR, 1.8). For CVD events, the risk began to increase significantly at BMI 26 to 28 kg/m2 (HR, 1.6). We found a reverse J-shaped relationship between BMI and all-cause mortality, with an increased risk among individuals with BMI values in lower range (BMI &lt;21 kg/m2).

CONCLUSION

These results suggest that the BMI cut-off points for observed risk were varied depending on the diseases and that the BMI classification of obesity need to be revised to reflect differential risk of obesity-related diseases.

Prevalence and complications of nonsurgical hypoparathyroidism in Korea: A nationwide cohort study

OBJECTIVE

The risk of complications of nonsurgical hypoparathyroidism in Asia is unclear. We estimated the prevalence and risk of complications in patients with nonsurgical hypoparathyroidism.

METHODS

We performed a retrospective cohort study using a nationwide claims database from 2005 to 2016. Among the entire Korean population, we identified 897 patients diagnosed with nonsurgical hypoparathyroidism during 2005-2015. We selected 210 patients with nonsurgical hypoparathyroidism during 2005-2008 who had no complications at baseline and followed them to 2016. Control subjects (n = 2075) were matched using propensity scores based on age, sex, and comorbid disease with a 1:10 ratio and monitored until 2016.

RESULTS

The age-standardized prevalence of nonsurgical hypoparathyroidism was 0.2 cases per 100,000 persons in 2005. During a mean follow-up period of 9.5 years, patients with nonsurgical hypoparathyroidism had a higher risk of cardiovascular disease, especially arrhythmia (hazard ratio [HR], 2.03; 95% confidence interval [CI], 1.11-3.70) and heart failure (HR, 2.43; 95% CI, 1.22-4.83). The risk of vertebral fracture was higher in patients than in controls (HR, 2.27; 95% CI, 1.09-4.72). Patients had a significantly increased risk of renal disease (HR, 2.57; 95% CI, 1.56-4.21), seizure (HR, 5.74; 95% CI, 3.34-9.86), depression and bipolar disease (HR, 1.82; 95% CI, 1.30-2.56), and cataract (HR, 1.90; 95% CI, 1.30-2.79) compared with controls.

CONCLUSIONS

The prevalence of nonsurgical hypoparathyroidism was very low in Korea but was associated with a higher risk of incident cardiovascular disease and vertebral fracture as well as known complications including renal disease, seizure, and cataract.

Mobile health (m‐health) smartphone interventions for overweight or obese adolescents and adults

This is a protocol for a Cochrane Review (intervention). The objectives are as follows:

To assess the effects of smartphone‐based m‐health interventions for overweight or obese adolescents and adults.

Effect of Olfactory and Gustatory Dysfunction and Motor Symptoms on Body Weight in Patients with Parkinson's Disease

BACKGROUND

Non-motor symptoms in Parkinson's disease (PD) are often associated with a negative impact on the patients' quality of life and on their weight regulation. The aim of this study was to assess the effect of olfactory and gustatory dysfunction, apathy, fatigue, depression, and motor symptoms on weight regulation in PD patients.

METHODS

We analyzed 112 participants, 63 PD patients (mean age ± SD: 69.2 ± 10.1), and 49 controls (mean age ± SD: 68 ± 9.6). For each participant we collected age, weight, height, BMI, olfactory and gustatory function, cognitive performance, apathy and fatigue.

RESULTS

Our data showed that 61.9% (n = 39) of PD patients had hyposmia, while 38.1% (n = 24) had anosmia. In PD patients, we observed a significant effect of Unified Parkinson's Disease Rating Scale (UPDRS), apathy, odor threshold, sweet perception and fatigue on weight regulation. Instead, there was no significant effect for depression and levodopa equivalent daily dosage (LEDD).

CONCLUSION

Our results suggest that PD non-motor symptoms such as olfactory/gustatory deficits and mood disorders may influence body weight.

Dose-response relationship between gamma-glutamyltransferase and the risk of atherosclerotic cardiovascular diseases in Korean adults

BACKGROUND AND AIMS

The value of gamma-glutamyltransferase (GGT) in the putative mechanisms underlying its association with cardiovascular disease is unclear. This study examined whether serum GGT value has an independent association and dose-response relationship with the risk of atherosclerotic cardiovascular disease (ASCVD).

METHODS

This observational study included 419,433 subjects from the National Health Insurance Service database. Serum GGT levels were classified into sex-specific quartiles. We used Cox proportional hazard models to examine the effect of serum GGT values on the risk of ASCVD. We quantified associations of the serum GGT quartile groups with risk of ASCVD or each subtype through multivariate sub-distribution hazard models adjusted for covariates at baseline.

RESULTS

During 4,572,993.8 person-years of follow-up for ASCVD, we documented 40,359 (9.6%) incident cases of ASCVD. The highest serum GGT group had a significant association with ASCVD in contrast to the lowest serum GGT quartile group (hazard ratio [HR] = 1.23, 95% confidence interval [CI] = 1.19-1.27). Serum GGT quartile groups 2, 3, and 4 had a significantly higher risk for incident hemorrhagic stroke than the serum GGT quartile group 1 (Q 2: HR = 0.92, 95% CI = 0.83-1.02; Q 3: HR = 1.03, 95% CI = 0.93-1.15; Q 4: HR = 1.29, 95% CI = 1.16-1.42; p for trend <0.001). For ischemic heart disease (IHD) and myocardial infarction, non-linear trends were shown according to increasing log-transformed GGT values. In the dose-response trends to assess the interaction effect of obese status, differences of trends were shown between serum GGT level and IHD or hemorrhagic stroke.

CONCLUSIONS

The serum GGT value, which is known as a factor linked to cardiovascular diseases, has a strong independent association and dose-response relationship with hemorrhagic stroke risk in contrast to that with ischemic stroke or IHD.

Mortality association between obesity and pneumonia using a dual restricted cohort model

BACKGROUND

An obesity survival paradox has been reported among obese patients with pneumonia.

AIMS

To determine the impact of obesity on pneumonia outcomes and analyze the correlation between in-hospital all-cause mortality and obesity among patients with pneumonia.

METHODS

The United States Nationwide Readmissions Database (NRD) was retrospectively analyzed for patients with pneumonia from 2013 to 2014. We used a step-wise restricted and propensity score matching cohort model (dual model) to compare mortality rates and other outcomes among pneumonia patients based on BMI. Mortality was calculated by a Cox proportional hazard model, adjusted for potential confounders with propensity score matched analysis.

RESULTS

A total of 70,886,775 patients were registered in NRD during the study period. Of these, 7,786,913 patients (11.0%) were considered obese and 1,652,456 patients (2.3%) were admitted to the hospital with pneumonia. Based on the step-wise restricted cohort model, the hazard ratio comparing the mortality rates among obese pneumonia patients to mortality rates among normal BMI pneumonia patients was 0.75 (95% CI 0.60-0.94). The propensity score matched analysis estimated a hazard rate of 0.84 (95% CI 0.79-0.90) and the hazard ratio estimated from the dual model was 0.82 (95% CI 0.63-1.07).

CONCLUSIONS

With the application of a dual model, there appears to be no significant difference in mortality of obese patients with pneumonia compared to normal BMI patients with pneumonia.

Low Alanine Aminotransferase Cut-Off for Predicting Liver Outcomes; A Nationwide Population-Based Longitudinal Cohort Study

BACKGROUND AND AIM

Recent practice guidelines suggest healthy normal alanine aminotransferase (ALT) levels should be less than 30 U/L for males and 19 U/L for females. We tried to validate the prediction power of the "low cut off" for liver related outcomes in the general population.

METHODS

A total of 426,013 subjects were followed up for 10 years using the National Health Screening Cohort database. Prediction ability of long term mortality and liver related outcomes between conventional (<40 U/L in men and women) and low (<30 U/L in men and <19 U/L in women) ALT cut-off values were compared.

RESULTS

Both conventional and low ALT cut-offs predicted liver related unfavorable outcomes in Kaplan-Meier analysis. Following adjustment for age, body mass index, smoking, exercise, alcohol consumption, fasting blood glucose, and cholesterol via multivariate Cox regression, abnormal ALT using new 'low ALT cut off' was a significant independent predictor for liver-related mortality, HCC, and decompensated liver events. When the low cut-off criteria were added to the prediction model, the ability to predetect liver-related hard outcomes significantly increased in both men and women (p-values < 0.0001). The C-index values for predicting liver-related adverse events were the same in both ALT cut-offs, after adjusting confounding factors (C index value: 0.73~0.88).

CONCLUSIONS

New low ALT cut-off showed good prediction power for liver related unfavorable outcomes.

Total cholesterol and mortality from ischemic heart disease and overall cardiovascular disease in Korean adults

It is not completely clear whether "the lower, the better" cholesterol hypothesis for cardiovascular disease (CVD) and ischemic heart disease (IHD) can be applied to general populations with a low risk of heart disease mortality.We prospectively followed up 503,340 Koreans who participated in routine health checkups during 2002-2003 until 2013 via linkage to national mortality records.Nonlinear associations with total cholesterol (TC) were found: U-curves for overall CVD (I00-I99; nadir at 180-200 mg/dL) and a reverse-L-curve for IHD (I20-I25). Assuming a linear association in the lower range (<200 mg/dL), TC was inversely associated with CVD mortality (HR per 39 mg/dL [1 mmol/L] increase = 0.90). In the upper range (200-349 mg/dL), TC was positively associated with CVD mortality, largely due to IHD (HR = 1.19), especially acute myocardial infarction (HR = 1.23). The associations were generally similar in men versus women and in middle-aged (40-64 years) versus elderly (≥65 years) adults.TC levels of 180-200 mg/dL were associated with the lowest CVD mortality. Below 200 mg/dL, TC had no graded positive associations with IHD mortality. It remains unclear whether the lowest cholesterol levels are associated with the least mortality from CVD and IHD in Korean adults with a low risk of heart disease.

Malnutrition and Survival - Bioimpedance Data in Head Neck Cancer Patients

BACKGROUND/AIM

Bioimpedance analysis (BIA) reflects the nutritional status of patients. The aim of this study was to examine whether BIA is able to document the possible impact of malnutrition on survival.

MATERIALS AND METHODS

The registered data of 42 head and neck cancer patients were analyzed. Survival data of 22 women and 20 men were included. The mean age was 67.3±10.77 years. BIA was measured by the Biocorpus 4000 RX (MEDIcal Health Care GmbH Karlsruhe) and summarized in individual phase angle (PA) of each patient.

RESULTS

Patients with normal PA>5.0 had a significantly better survival (p=0.016). The median survival time was 13.84 months (range=0.69-125.19 months) in malnourished patients (PA<5.0) compared to 51.16 months (range=7.02-116.79 months) in normally nourished head and neck cancer (HNC) patients (PA>5.0). Age adjusted body mass index had a similar impact on prognosis, but was not statistically significant (p=0.068) in the investigated study groups.

CONCLUSION

BIA is able to document the impact of malnutrition on the survival of head and neck cancer patients.

Low-normal hemoglobin levels and anemia are associated with increased risk of end-stage renal disease in general populations: A prospective cohort study

Background

The impact of low-normal hemoglobin (Hb) levels and anemia on the risk of end-stage renal disease (ESRD) in general populations has rarely been examined.

Methods

510,620 Korean adults aged 40–80 years without known chronic kidney disease (CKD) underwent health examinations during 2002–2003 and were followed-up until 2013. Incidence of ESRD was identified by hospital discharge and clinical visit records.

Results

During a mean follow-up of 10.5, 575 women and 1047 men were diagnosed with ESRD. Lower Hb levels were associated with an increased risk of ESRD at given severity of albuminuria and at given estimated glomerular filtration rate (eGFR). Hb 13–13.9 g/dL in men, Hb 11–11.9 g/dL in women, and trace albuminuria assessed by dipstick urinalysis were associated with more than doubled risk. The risk associated with lower Hb was stronger in older (≥60 years) than younger women. Among 349,993 participants with information on eGFR, the multivariable-adjusted HRs associated with 1 g/dL lower Hb in participants with eGFR values ≥60, 30–59, and <30 mL/min/1.73 m² were 1.34 (95% CI, 1.17–1.54), 1.55 (1.38–1.74), and 1.75 (1.47–2.09), respectively (Pinteraction between eGFR groups = .06).

Conclusions

Low-normal Hb levels and anemia are risk factors for ESRD incidence in person without CKD and for CKD progression to ESRD. Lower Hb increases the risk of ESRD through synergistic biological interactions with lower eGFR and albuminuria. The impacts of lower Hb may be stronger in older than younger women. Proper management and screening at earlier stage of Hb decline and anemia might reduce the burden of CKD.

Inhibitory control mediates a negative relationship between body mass index and intelligence: A neurocognitive investigation

The structure and function of the human brain is closely related to cognitive processes of the mind and physiological processes of the body, suggesting that an intricate relationship exists between cognitive health, body health, and underlying neural architecture. In the current study, morphometric differences in cortical and subcortical gray matter regions, white matter integrity, and resting-state functional connectivity was assessed to determine what combinations of neural variables best explain an interconnected behavioral relationship between body mass index (BMI), general intelligence, and specific measures of executive function. Data for 82 subjects were obtained from the Nathan Kline Institute Rockland Sample. Behavioral results indicated a negative relationship between BMI and intelligence, which exhibited mediation by an inhibitory measure of executive function. Neural analyses further revealed generally contrasting associations of BMI, intelligence, and executive function with cortical morphometric regions important for inhibitory control and directed attention. Moreover, BMI related to morphometric alterations in components of a frontolimbic network, namely reduced thickness in the anterior cingulate cortex and ventromedial prefrontal cortex, whereas intelligence and inhibitory control primarily related to increased thickness and volume in parietal regions, as well as significantly increased across-network connectivity of visual and default mode resting-state networks. These results propose that medial prefrontal structure and interconnected frontolimbic and frontoparietal networks are important to consider in the relationship between BMI, intelligence, and executive function.

Total cholesterol and all-cause mortality by sex and age: a prospective cohort study among 12.8 million adults

It is unclear whether associations between total cholesterol (TC) levels and all-cause mortality and the optimal TC ranges for lowest mortality vary by sex and age. 12,815,006 Korean adults underwent routine health examinations during 2001–2004, and were followed until 2013. During follow-up, 694,423 individuals died. U-curve associations were found. In the TC ranges of 50–199 and 200–449 mg/dL, each 39 mg/dL (1 mmol/L) increase in TC was associated with 23% lower (95% CI:23%,24%) and 7% higher (6%,7%) mortality, respectively. In the age groups of 18–34, 35–44, 45–54, 55–64, 65–74, and 75–99 years, each 1 mmol/L higher TC increased mortality by 14%, 13%, 8%, 7%, 6%, and 3%, respectively (P < 0.001 for each age group), for TC ≥ 200 mg/dL, while the corresponding TC changes decreased mortality by 13%, 27%, 34%, 31%, 20%, and 13%, respectively, in the range < 200 mg/dL (P < 0.001 for each age group). TC had U-curve associations with mortality in each age-sex group. TC levels associated with lowest mortality were 210–249 mg/dL, except for men aged 18–34 years (180–219 mg/dL) and women aged 18–34 years (160–199 mg/dL) and 35–44 years (180–219 mg/dL). The inverse associations for TC < 200 mg/dL were stronger than the positive associations in the upper range.

Flawed methods and inappropriate conclusions for health policy on overweight and obesity: the Global BMI Mortality Collaboration meta-analysis

Guideline recommendations and health policy decisions rely on evidence from clinical and epidemiological studies. Adequate methodology and appropriate conclusions are essential to support healthcare and health policy decisions. An analysis of body mass index and mortality by the Global BMI Mortality Collaboration (GBMC) concluded that the association of excess body weight with higher mortality was similar worldwide and that overweight and obesity should be combated everywhere. To reach this conclusion, the GBMC used highly selected data, rather than a systematic approach. The GBMC initially chose individual participant data from 239 prospective studies with approximately 10.6 million participants. The GBMC then excluded over 60% of data and over 75% of fatal events by eliminating all cases with any reported disease at baseline or smoking history and all events within the first 5 years of follow-up. After applying these restrictions, the association of overweight with lower mortality was reversed and the association of obesity with higher mortality was increased. Given the major flaws in the selection process, in the adequacy of the data, in the data analysis, and in the interpretation, the GBMC conclusions should be viewed sceptically as a guide to action, either for clinical decisions or for public health in general. The flawed conclusion that overweight is uniformly associated with substantially increased risk of death and thus should be combated in any circumstances may lead not only to unjustified treatment efforts and potential harm in a wide range of clinical conditions but also to a tremendous waste of resources.