Race- and sex-specific associations of obesity measures with ischemic stroke incidence in the Atherosclerosis Risk in Communities (ARIC) study

Exploring Stroke Risk through Mendelian Randomization: A Comprehensive Study Integrating Genetics and Metabolic Traits in the Korean Population

Numerous risk factors play a role in the causation of stroke, and the cardiometabolic condition is a one of the most important. In Korea, various treatment methods are employed based on the constitutional type, which is known to differ significantly in cardiometabolic disease. In this study, we compared the estimates obtained for different groups by applying the Mendelian randomization method to investigate the causal effects of genetic characteristics on stroke, according to constitutional type. In clinical analysis, the subtypes differ significantly in diabetes or dyslipidemia. The genetic association estimates for the stroke subtype risk were obtained from MEGASTROKE, the International Stroke Genetics Consortium (ISGC), UKbiobank, and BioBank Japan (BBJ), using group-related SNPs as instrumental variables. The TE subtypes with higher risk of metabolic disease were associated with increased risk (beta = 4.190; s.e. = 1.807; p = 0.035) of cardioembolic stroke (CES), and the SE subtypes were associated with decreased risk (beta = -9.336, s.e. = 1.753; p = 3.87 × 10-5) of CES. The findings highlight the importance of personalized medicine in assessing disease risk based on an individual's constitutional type.

Interventions to prevent obesity in children aged 5 to 11 years old

BACKGROUND

Prevention of obesity in children is an international public health priority given the prevalence of the condition (and its significant impact on health, development and well-being). Interventions that aim to prevent obesity involve behavioural change strategies that promote healthy eating or 'activity' levels (physical activity, sedentary behaviour and/or sleep) or both, and work by reducing energy intake and/or increasing energy expenditure, respectively. There is uncertainty over which approaches are more effective and numerous new studies have been published over the last five years, since the previous version of this Cochrane review.

OBJECTIVES

To assess the effects of interventions that aim to prevent obesity in children by modifying dietary intake or 'activity' levels, or a combination of both, on changes in BMI, zBMI score and serious adverse events.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was February 2023.

SELECTION CRITERIA

Randomised controlled trials in children (mean age 5 years and above but less than 12 years), comparing diet or 'activity' interventions (or both) to prevent obesity with no intervention, usual care, or with another eligible intervention, in any setting. Studies had to measure outcomes at a minimum of 12 weeks post baseline. We excluded interventions designed primarily to improve sporting performance.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our outcomes were body mass index (BMI), zBMI score and serious adverse events, assessed at short- (12 weeks to < 9 months from baseline), medium- (9 months to < 15 months) and long-term (≥ 15 months) follow-up. We used GRADE to assess the certainty of the evidence for each outcome.

MAIN RESULTS

This review includes 172 studies (189,707 participants); 149 studies (160,267 participants) were included in meta-analyses. One hundred forty-six studies were based in high-income countries. The main setting for intervention delivery was schools (111 studies), followed by the community (15 studies), the home (eight studies) and a clinical setting (seven studies); one intervention was conducted by telehealth and 31 studies were conducted in more than one setting. Eighty-six interventions were implemented for less than nine months; the shortest was conducted over one visit and the longest over four years. Non-industry funding was declared by 132 studies; 24 studies were funded in part or wholly by industry. Dietary interventions versus control Dietary interventions, compared with control, may have little to no effect on BMI at short-term follow-up (mean difference (MD) 0, 95% confidence interval (CI) -0.10 to 0.10; 5 studies, 2107 participants; low-certainty evidence) and at medium-term follow-up (MD -0.01, 95% CI -0.15 to 0.12; 9 studies, 6815 participants; low-certainty evidence) or zBMI at long-term follow-up (MD -0.05, 95% CI -0.10 to 0.01; 7 studies, 5285 participants; low-certainty evidence). Dietary interventions, compared with control, probably have little to no effect on BMI at long-term follow-up (MD -0.17, 95% CI -0.48 to 0.13; 2 studies, 945 participants; moderate-certainty evidence) and zBMI at short- or medium-term follow-up (MD -0.06, 95% CI -0.13 to 0.01; 8 studies, 3695 participants; MD -0.04, 95% CI -0.10 to 0.02; 9 studies, 7048 participants; moderate-certainty evidence). Five studies (1913 participants; very low-certainty evidence) reported data on serious adverse events: one reported serious adverse events (e.g. allergy, behavioural problems and abdominal discomfort) that may have occurred as a result of the intervention; four reported no effect. Activity interventions versus control Activity interventions, compared with control, may have little to no effect on BMI and zBMI at short-term or long-term follow-up (BMI short-term: MD -0.02, 95% CI -0.17 to 0.13; 14 studies, 4069 participants; zBMI short-term: MD -0.02, 95% CI -0.07 to 0.02; 6 studies, 3580 participants; low-certainty evidence; BMI long-term: MD -0.07, 95% CI -0.24 to 0.10; 8 studies, 8302 participants; zBMI long-term: MD -0.02, 95% CI -0.09 to 0.04; 6 studies, 6940 participants; low-certainty evidence). Activity interventions likely result in a slight reduction of BMI and zBMI at medium-term follow-up (BMI: MD -0.11, 95% CI -0.18 to -0.05; 16 studies, 21,286 participants; zBMI: MD -0.05, 95% CI -0.09 to -0.02; 13 studies, 20,600 participants; moderate-certainty evidence). Eleven studies (21,278 participants; low-certainty evidence) reported data on serious adverse events; one study reported two minor ankle sprains and one study reported the incident rate of adverse events (e.g. musculoskeletal injuries) that may have occurred as a result of the intervention; nine studies reported no effect. Dietary and activity interventions versus control Dietary and activity interventions, compared with control, may result in a slight reduction in BMI and zBMI at short-term follow-up (BMI: MD -0.11, 95% CI -0.21 to -0.01; 27 studies, 16,066 participants; zBMI: MD -0.03, 95% CI -0.06 to 0.00; 26 studies, 12,784 participants; low-certainty evidence) and likely result in a reduction of BMI and zBMI at medium-term follow-up (BMI: MD -0.11, 95% CI -0.21 to 0.00; 21 studies, 17,547 participants; zBMI: MD -0.05, 95% CI -0.07 to -0.02; 24 studies, 20,998 participants; moderate-certainty evidence). Dietary and activity interventions compared with control may result in little to no difference in BMI and zBMI at long-term follow-up (BMI: MD 0.03, 95% CI -0.11 to 0.16; 16 studies, 22,098 participants; zBMI: MD -0.02, 95% CI -0.06 to 0.01; 22 studies, 23,594 participants; low-certainty evidence). Nineteen studies (27,882 participants; low-certainty evidence) reported data on serious adverse events: four studies reported occurrence of serious adverse events (e.g. injuries, low levels of extreme dieting behaviour); 15 studies reported no effect. Heterogeneity was apparent in the results for all outcomes at the three follow-up times, which could not be explained by the main setting of the interventions (school, home, school and home, other), country income status (high-income versus non-high-income), participants' socioeconomic status (low versus mixed) and duration of the intervention. Most studies excluded children with a mental or physical disability.

AUTHORS' CONCLUSIONS

The body of evidence in this review demonstrates that a range of school-based 'activity' interventions, alone or in combination with dietary interventions, may have a modest beneficial effect on obesity in childhood at short- and medium-term, but not at long-term follow-up. Dietary interventions alone may result in little to no difference. Limited evidence of low quality was identified on the effect of dietary and/or activity interventions on severe adverse events and health inequalities; exploratory analyses of these data suggest no meaningful impact. We identified a dearth of evidence for home and community-based settings (e.g. delivered through local youth groups), for children living with disabilities and indicators of health inequities.

Interventions to prevent obesity in children aged 12 to 18 years old

BACKGROUND

Prevention of obesity in adolescents is an international public health priority. The prevalence of overweight and obesity is over 25% in North and South America, Australia, most of Europe, and the Gulf region. Interventions that aim to prevent obesity involve strategies that promote healthy diets or 'activity' levels (physical activity, sedentary behaviour and/or sleep) or both, and work by reducing energy intake and/or increasing energy expenditure, respectively. There is uncertainty over which approaches are more effective, and numerous new studies have been published over the last five years since the previous version of this Cochrane Review.

OBJECTIVES

To assess the effects of interventions that aim to prevent obesity in adolescents by modifying dietary intake or 'activity' levels, or a combination of both, on changes in BMI, zBMI score and serious adverse events.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was February 2023.

SELECTION CRITERIA

Randomised controlled trials in adolescents (mean age 12 years and above but less than 19 years), comparing diet or 'activity' interventions (or both) to prevent obesity with no intervention, usual care, or with another eligible intervention, in any setting. Studies had to measure outcomes at a minimum of 12 weeks post baseline. We excluded interventions designed primarily to improve sporting performance.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our outcomes were BMI, zBMI score and serious adverse events, assessed at short- (12 weeks to < 9 months from baseline), medium- (9 months to < 15 months) and long-term (≥ 15 months) follow-up. We used GRADE to assess the certainty of the evidence for each outcome.

MAIN RESULTS

This review includes 74 studies (83,407 participants); 54 studies (46,358 participants) were included in meta-analyses. Sixty studies were based in high-income countries. The main setting for intervention delivery was schools (57 studies), followed by home (nine studies), the community (five studies) and a primary care setting (three studies). Fifty-one interventions were implemented for less than nine months; the shortest was conducted over one visit and the longest over 28 months. Sixty-two studies declared non-industry funding; five were funded in part by industry. Dietary interventions versus control The evidence is very uncertain about the effects of dietary interventions on body mass index (BMI) at short-term follow-up (mean difference (MD) -0.18, 95% confidence interval (CI) -0.41 to 0.06; 3 studies, 605 participants), medium-term follow-up (MD -0.65, 95% CI -1.18 to -0.11; 3 studies, 900 participants), and standardised BMI (zBMI) at long-term follow-up (MD -0.14, 95% CI -0.38 to 0.10; 2 studies, 1089 participants); all very low-certainty evidence. Compared with control, dietary interventions may have little to no effect on BMI at long-term follow-up (MD -0.30, 95% CI -1.67 to 1.07; 1 study, 44 participants); zBMI at short-term (MD -0.06, 95% CI -0.12 to 0.01; 5 studies, 3154 participants); and zBMI at medium-term (MD 0.02, 95% CI -0.17 to 0.21; 1 study, 112 participants) follow-up; all low-certainty evidence. Dietary interventions may have little to no effect on serious adverse events (two studies, 377 participants; low-certainty evidence). Activity interventions versus control Compared with control, activity interventions do not reduce BMI at short-term follow-up (MD -0.64, 95% CI -1.86 to 0.58; 6 studies, 1780 participants; low-certainty evidence) and probably do not reduce zBMI at medium- (MD 0, 95% CI -0.04 to 0.05; 6 studies, 5335 participants) or long-term (MD -0.05, 95% CI -0.12 to 0.02; 1 study, 985 participants) follow-up; both moderate-certainty evidence. Activity interventions do not reduce zBMI at short-term follow-up (MD 0.02, 95% CI -0.01 to 0.05; 7 studies, 4718 participants; high-certainty evidence), but may reduce BMI slightly at medium-term (MD -0.32, 95% CI -0.53 to -0.11; 3 studies, 2143 participants) and long-term (MD -0.28, 95% CI -0.51 to -0.05; 1 study, 985 participants) follow-up; both low-certainty evidence. Seven studies (5428 participants; low-certainty evidence) reported data on serious adverse events: two reported injuries relating to the exercise component of the intervention and five reported no effect of intervention on reported serious adverse events. Dietary and activity interventions versus control Dietary and activity interventions, compared with control, do not reduce BMI at short-term follow-up (MD 0.03, 95% CI -0.07 to 0.13; 11 studies, 3429 participants; high-certainty evidence), and probably do not reduce BMI at medium-term (MD 0.01, 95% CI -0.09 to 0.11; 8 studies, 5612 participants; moderate-certainty evidence) or long-term (MD 0.06, 95% CI -0.04 to 0.16; 6 studies, 8736 participants; moderate-certainty evidence) follow-up. They may have little to no effect on zBMI in the short term, but the evidence is very uncertain (MD -0.09, 95% CI -0.2 to 0.02; 3 studies, 515 participants; very low-certainty evidence), and they may not reduce zBMI at medium-term (MD -0.05, 95% CI -0.1 to 0.01; 6 studies, 3511 participants; low-certainty evidence) or long-term (MD -0.02, 95% CI -0.05 to 0.01; 7 studies, 8430 participants; low-certainty evidence) follow-up. Four studies (2394 participants) reported data on serious adverse events (very low-certainty evidence): one reported an increase in weight concern in a few adolescents and three reported no effect.

AUTHORS' CONCLUSIONS

The evidence demonstrates that dietary interventions may have little to no effect on obesity in adolescents. There is low-certainty evidence that activity interventions may have a small beneficial effect on BMI at medium- and long-term follow-up. Diet plus activity interventions may result in little to no difference. Importantly, this updated review also suggests that interventions to prevent obesity in this age group may result in little to no difference in serious adverse effects. Limitations of the evidence include inconsistent results across studies, lack of methodological rigour in some studies and small sample sizes. Further research is justified to investigate the effects of diet and activity interventions to prevent childhood obesity in community settings, and in young people with disabilities, since very few ongoing studies are likely to address these. Further randomised trials to address the remaining uncertainty about the effects of diet, activity interventions, or both, to prevent childhood obesity in schools (ideally with zBMI as the measured outcome) would need to have larger samples.

Non-linear dose-response relationship between body mass index and stroke risk in middle-aged and elderly Chinese men: a nationwide Longitudinal Cohort Study from CHARLS

Objective

Body mass index (BMI) and stroke risk have been linked, but these findings are still debated. This study investigated the relationship between BMI and stroke risk in a middle-aged and elderly Chinese population.

Methods

This study used four waves of CHARLS data (2011, 2013, 2015, and 2018), including 12,161 participants. The CHARLS sample was obtained by multi-stage probability sampling and all participants were assessed by one-to-one interviews using a standardized questionnaire. We used a Cox proportional-hazards regression model to examine the relationship between BMI and stroke risk. We used Cox proportional hazards regression with cubic spline functions and smooth curve fitting to identify the non-linear relationship between them. A series of sensitivity analyses were also conducted.

Results

The multivariate Cox proportional hazards regression model identified a positive association between BMI and stroke risk (HR=1.025, 95% CI: 1.010-1.040). We also found a non-linear relationship between BMI and stroke incidence, with an inflection point at 26.63 kg/m2 for BMI. Each 1 kg/m2 increase in BMI to the left of the inflection point was related to a 4.4% increase in stroke risk (HR=1.044, 95% CI: 1.019-1.069). We stratified individuals by gender to further investigate their association and found a particular non-linear relationship and saturation effect between BMI and stroke risk in men, with the inflection point at 25.94 kg/m2. Each 1 kg/m2 increase in BMI to the left of the inflection point was related to a 7.6% increase in stroke risk (HR=1.076, 95% CI 1.034-1.119). The association was linear in women, with each 1 kg/m2 increase in BMI associated with a 2.1% increase in stroke risk (HR=1.021, 95% CI 1.002, 1.040).

Conclusion

In men, there was a specific non-linear association and saturation effect of BMI with stroke (inflection point of 25.94 kg/m2), while in women, there was none. When males had a BMI below 25.94 kg/m2, the risk of stroke was significantly and positively associated with BMI. By controlling BMI below 25.94 kg/m2 in men, a further decrease in BMI may promote a significant reduction in stroke risk.

Risk factors for stroke among anthropometric indices and lipid profiles in the Korean population: a large-scale cross-sectional study

Stroke is strongly associated with death and disability. However, the associations between stroke and lipid profiles such as total cholesterol, triglycerides, high-density lipoprotein cholesterol (HDL-C), and red blood cells (RBCs) and anthropometric indices such as waist circumference and waist-to-height ratio (WHtR) remain unclear. The objective of this study was to investigate these relationships in a Korean population. This large-scale cross-sectional study included data from 38,190 subjects collected from 2010 to 2018 by the Korea National Health and Nutrition Examination Survey (KNHANES). Simple logistic regression models and multiple logistic regression models were used to evaluate the association of stroke with lipid profiles and anthropometric indices in the crude model, adjusted Model 1, and fully adjusted Model 2. In men, stroke was negatively associated with height, weight, and hematocrit level. Total cholesterol and triglycerides were strongly negatively associated with stroke in Model 2. Creatinine level and stroke were weakly associated. Additionally, height, weight, total cholesterol, triglycerides, and hematocrit and creatinine levels were associated with stroke both before and after adjustment. In women, in Model 2, stroke was positively associated with height, weight, and creatinine level. A strong negative association was found between total cholesterol and stroke. Stroke was negatively associated with hemoglobin level, hematocrit level, and RBCs. Additionally, total cholesterol, hemoglobin level, hematocrit level, creatinine level, and RBCs were associated with stroke both before and after adjustment. Weight and height were more closely associated with stroke than waist circumference and WHtR in Korean men. Our results suggested that the association of stroke with triglycerides, height, and weight differed according to sex and that HDL-C was not associated with stroke in people of either sex.

Stroke in Women: A Review Focused on Epidemiology, Risk Factors, and Outcomes

Stroke is a particularly important issue for women. Women account for over half of all persons who experienced a stroke. The lifetime risk of stroke is higher in women than in men. In addition, women have worse stroke outcomes than men. Several risk factors have a higher association with stroke in women than in men, and women-specific risk factors that men do not have should be considered. This focused review highlights recent findings in stroke epidemiology, risk factors, and outcomes in women.

Patient and primary care perspectives on hypertension management: short report of a qualitative study in a tribal health system

The prevalence of self-reported hypertension is higher among Alaska Native and American Indian (ANAI) individuals than in the majority USA population. Although hypertension is the primary modifiable risk factor for cardiovascular disease and stroke, it can be difficult to manage successfully. The objective of this study was to explore patients' and providers' perspectives about hypertension, hypertension management strategies, and patient-provider communication strategies within a tribally-owned and operated health system in Alaska. We conducted four focus groups that included 16 ANAI patients and five primary care providers. Patient participants tended to consider hypertension a transient state, in contrast with providers' understanding of hypertension as a chronic condition. Differences were noted in participants' perceptions regarding providers' counselling and education efforts, with providers feeling that current strategies are effective and patients desiring a more personalised discussion about hypertension. Patients expressed preferences for behaviour change approaches compared with pharmacotherapy; providers often resorted to medication as a first step towards controlling blood pressure. Our findings suggest areas of potentially promising future research with respect to patient-provider communication and treatment of hypertension.

The relationship between body mass index and stroke: a systemic review and meta-analysis

BACKGROUND

Stroke is an acute cerebrovascular event closely related to brain tissue damage, and is one of the major causes of death and disability in worldwide. Various studies have reported the effects of body mass index (BMI) on the risk of stroke, but the results remain varied and these results have not been synthesized. Therefore, a meta-analysis was performed to evaluate the relationship between BMI and the risk of stroke.

OBJECTIVES

This systematic review was conducted to explore the relationship between BMI and the risk of stroke.

METHODS

PubMed, EMBASE, Web of Science and Cochrane Library, China Knowledge Resource Integrated Database (CNKI), WanFang Database, Chinese Biomedical Database (CBM), and CQVIP were comprehensively searched for studies exploring the relationship between BMI and stroke from inception to December 1, 2021.

RESULTS

This review included 24 studies involving 5,798,826 subjects. The results of meta-analysis showed that the pooled RR of stroke risk was 0.93 (95% confidence interval [CI] 0.82-1.06, I² = 88.8%, P = 0.29) for the underweight group. Higher BMI (overweight or obese group) was associated with an increased overall risk of stroke, with pooled RR values of 1.25 (95% CI 1.16-1.34, I² = 84.8%, P = 0.00) and 1.47 (95% CI: 1.02-2.11, I² = 99.4%, P = 0.04).

CONCLUSION

The risk of stroke was positively correlated with BMI, and the association was stronger in male and ischemic stroke. Lowering BMI can be used as a way to prevent stroke, and for people who are overweight or obese, lowering body weight can reduce the risk of stroke.

Sex-specific association of BMI change with stroke in middle-aged and older adults with type 2 diabetes

BACKGROUND AND AIMS

We aimed to evaluate the association between BMI change and stroke in middle-aged and older adults with type 2 diabetes and identify sex differences.

METHODS AND RESULTS

The China Health and Retirement Longitudinal Study is an ongoing national population-based cohort study. Participants aged 45 or above with type 2 diabetes were enrolled and followed for stroke incidence. BMI change was defined as BMI at 2013-BMI at 2011. Of 1774 participants (mean [SD] age in 2011, 60.23 [8.88] years), 795 (44.8 %) were men. A total of 112 incident stroke cases were confirmed up to 2018. The incidence rate of stroke was similar between men and women (6.79 % vs 5.92 %, P = 0.516). BMI increase was independently associated with an increased stroke risk (adjusted odds ratio, 1.15; 95 % CI, 1.05-1.31) in men, while this positive association was not significant in women (adjusted odds ratio, 1.12; 95 % CI, 0.98-1.29). In addition, the positive dose-response relationship between BMI increase and stroke was observed only in men.

CONCLUSION

Among middle-aged and older adults with type 2 diabetes, there is a sex-specific association of BMI change with stroke. An increase in BMI could result in a higher risk of incident stroke in men.

Association of Body Mass Index with Ischemic and Hemorrhagic Stroke

Data on the association between body mass index (BMI) and stroke are scarce. We aimed to examine the association between BMI and incident stroke (ischemic or hemorrhagic) and to clarify the relationship between underweight, overweight, and obesity and stroke risk stratified by sex. We analyzed the JMDC Claims Database between January 2005 and April 2020 including 2,740,778 healthy individuals (Median (interquartile) age, 45 (38-53) years; 56.2% men; median (interquartile) BMI, 22.3 (20.2-24.8) kg/m²). None of the participants had a history of cardiovascular disease. Each participant was categorized as underweight (BMI <18.5 kg/m²), normal weight (BMI 18.5-24.9 kg/m²), overweight (BMI 25.0-29.9 kg/m²), or obese (BMI ≥ 30 kg/m²). We investigated the association of BMI with incidence stroke in men and women using the Cox regression model. We used restricted cubic spline (RCS) functions to identify the association of BMI as a continuous parameter with incident stroke. The incidence (95% confidence interval) of total stroke, ischemic stroke, and hemorrhagic stroke was 32.5 (32.0-32.9), 28.1 (27.6-28.5), and 5.5 (5.3-5.7) per 10,000 person-years in men, whereas 25.7 (25.1-26.2), 22.5 (22.0-23.0), and 4.0 (3.8-4.2) per 10,000 person-years in women, respectively. Multivariable Cox regression analysis showed that overweight and obesity were associated with a higher incidence of total and ischemic stroke in both men and women. Underweight, overweight, and obesity were associated with a higher hemorrhagic stroke incidence in men, but not in women. Restricted cubic spline showed that the risk of ischemic stroke increased in a BMI dose-dependent manner in both men and women, whereas there was a U-shaped relationship between BMI and the hemorrhagic stroke risk in men. In conclusion, overweight and obesity were associated with a greater incidence of stroke and ischemic stroke in both men and women. Furthermore, underweight, overweight, and obesity were associated with a higher hemorrhagic stroke risk in men. Our results would help in the risk stratification of future stroke based on BMI.

Classification and Prediction on the Effects of Nutritional Intake on Overweight/Obesity, Dyslipidemia, Hypertension and Type 2 Diabetes Mellitus Using Deep Learning Model: 4-7th Korea National Health and Nutrition Examination Survey

Few studies have been conducted to classify and predict the influence of nutritional intake on overweight/obesity, dyslipidemia, hypertension and type 2 diabetes mellitus (T2DM) based on deep learning such as deep neural network (DNN). The present study aims to classify and predict associations between nutritional intake and risk of overweight/obesity, dyslipidemia, hypertension and T2DM by developing a DNN model, and to compare a DNN model with the most popular machine learning models such as logistic regression and decision tree. Subjects aged from 40 to 69 years in the 4-7th (from 2007 through 2018) Korea National Health and Nutrition Examination Survey (KNHANES) were included. Diagnostic criteria of dyslipidemia (n = 10,731), hypertension (n = 10,991), T2DM (n = 3889) and overweight/obesity (n = 10,980) were set as dependent variables. Nutritional intakes were set as independent variables. A DNN model comprising one input layer with 7 nodes, three hidden layers with 30 nodes, 12 nodes, 8 nodes in each layer and one output layer with one node were implemented in Python programming language using Keras with tensorflow backend. In DNN, binary cross-entropy loss function for binary classification was used with Adam optimizer. For avoiding overfitting, dropout was applied to each hidden layer. Structural equation modelling (SEM) was also performed to simultaneously estimate multivariate causal association between nutritional intake and overweight/obesity, dyslipidemia, hypertension and T2DM. The DNN model showed the higher prediction accuracy with 0.58654 for dyslipidemia, 0.79958 for hypertension, 0.80896 for T2DM and 0.62496 for overweight/obesity compared with two other machine leaning models with five-folds cross-validation. Prediction accuracy for dyslipidemia, hypertension, T2DM and overweight/obesity were 0.58448, 0.79929, 0.80818 and 0.62486, respectively, when analyzed by a logistic regression, also were 0.52148, 0.66773, 0.71587 and 0.54026, respectively, when analyzed by a decision tree. This study observed a DNN model with three hidden layers with 30 nodes, 12 nodes, 8 nodes in each layer had better prediction accuracy than two conventional machine learning models of a logistic regression and decision tree.

Cerebrovascular disease in women

Cerebrovascular disease is a major cause of morbidity, mortality, and disability in women. The spectrum of disease differs between men and women, with women being particularly vulnerable to certain conditions, especially during specific periods of life such as pregnancy. There are several unique risk factors for cerebrovascular disease in women, and the influence of some traditional risk factors for stroke is stronger in women. Moreover, disparities persist in representation of women in clinical trials, acute intervention, and stroke outcomes. In this review, we aimed to explore the epidemiology, etiologies, and management of cerebrovascular disease in women, highlighting some of these differences and the growing need for sex-specific management guidelines and health policies.

Abdominal obesity and risk of CVD: a dose-response meta-analysis of thirty-one prospective studies

This meta-analysis aimed to study the relationship between abdominal obesity and the risk of CVD by waist circumference (WC), waist:hip ratio (WHR) and waist:height ratio (WHtR). We systematically searched PubMed, Embase and Web of Science. Prospective studies that estimated cardiovascular events by WC, WHR and WHtR were included in this study. Pooled relative risks with 95 % CI were calculated using random effects models. A total of thirty-one studies were included in the meta-analysis, including 669 560 participants and 25 214 cases. Compared the highest with the lowest category of WC, WHR and WHtR, the summary risk ratios were 1·43 (95 % CI, 1·30, 1·56, P < 0·001), 1·43 (95 % CI, 1·33, 1·54, P < 0·001) and 1·57 (95 % CI, 1·37, 1·79, P < 0·001), respectively. The linear dose-response analysis revealed that the risk of CVD increased by 3·4 % for each 10 cm increase of WC, and by 3·5 and 6·0 % for each 0·1 unit increase of WHR and WHtR in women, respectively. In men, the risk of CVD increased by 4·0 % for each 10 cm increase of WC, and by 4·0 and 8·6 % for each 0·1 unit increase of WHR and WHtR, respectively. Collectively, abdominal obesity is associated with an increased risk of CVD. WC, WHR and WHtR are good indicators for the prediction of CVD.

Clinical Performance of Nonvitamin K Antagonist Oral Anticoagulants in Real-World Obese Patients with Atrial Fibrillation

The prevalence of both atrial fibrillation (AF) and obesity has steadily increased. Nonvitamin K antagonist oral anticoagulants (NOACs) have been shown to be more effective and safer than vitamin K antagonists (VKAs) for long-term stroke prevention in patients with nonvalvular AF. There are still limited data in the literature regarding performance of NOACs in obese patients with AF in the “real world.” The aim of our study was to compare the safety and effectiveness of NOACs versus well-controlled VKA therapy in obese AF patients in a “real-world” setting. Here, we have considered patients with AF and obesity (body mass index [BMI] > 30 kg/m2) on NOAC or VKA therapy included in the multicenter Atrial Fibrillation Research Database (NCT03760874). The occurrence of major bleedings (MBs) and thromboembolic events (composite of ischemic stroke, transient ischemic attack, and systemic embolism) was respectively considered primary safety and effectiveness outcomes. We identified 1,047 AF patients with obesity who received NOAC (n = 272) or VKA (n = 775) treatment. After propensity score matching analysis, 248 NOAC and 496 VKA recipients with similar clinical characteristics, including BMI (34.8 ± 3.4 in NOAC vs. 35.1 ± 3.8 in the VKA group; p = 0.50), were evaluated. The mean follow-up was 39 ± 7 months. The incidence rate of thromboembolic events was 1.10 per 100 person-years (0.67 in NOAC vs. 1.28 in the VKA group; hazard ratio [HR]: 0.52; 95% confidence interval [CI]: 0.22–1.22; p = 0.19). The incidence rate of MB was 1.9 per 100 person-years (1.1 in NOAC vs. 2.28 in the VKA group; HR: 0.46; 95% CI: 0.24–0.88; p = 0.04). The incidence rate of intracranial hemorrhage was 0.4 per 100 person-years (0.27 in NOAC vs. 0.47 in the VKA group; HR: 0.57; 95% CI: 0.12–2.73; p = 0.48). A positive net clinical benefit (NCB) of NOACs over VKAs was found (+0.91). Presence of anemia (HR: 1.75; p = 0.003) and concomitant use of antiplatelet drugs (HR: 2.41; p = 0.001) were found to be independent predictors of MB; moreover, age (HR: 1.65; p = 0.003) was an independent predictor of thromboembolic events. Our data support the hypothesis of safe and effective use of NOACs in patients with AF and obesity, justified by a statistically significant lower incidence of MB and a favorable NCB over VKAs.

A model to predict risk of stroke in middle-aged adults with type 2 diabetes generated from a nationwide population-based cohort study in Korea

AIMS

The incidence of stroke differs between Asians and Caucasians, and between people with or without diabetes mellitus (DM). This study aimed to develop a model to predict the risk of stroke in middle-aged patients with type 2 DM.

METHODS

Using the National Health Insurance Database in Korea, data from patients aged 40-64 years with type 2 DM who received a health examination from 2009 to 2012 (n = 1,297,131) were analyzed as development (n = 907,992) and validation (n = 389,139) cohorts. Cox proportional-hazards regression model was used to derive a risk-scoring system, and 13 predictive variables were selected. A risk score nomogram based on the risk prediction model was created to estimate the 5-year risk of stroke.

RESULTS

In patients with type 2 DM, significant predictors for the development of stroke were older age, being male or a current smoker, lack of exercise, low body mass index, low estimated glomerular filtration rate, presence of coronary heart disease, longer duration of DM, insulin or multiple oral hypoglycemic agents use, low (<100 mg/dL) or high (≥140 mg/dL) fasting blood glucose, high systolic blood pressure, high total cholesterol, and presence of atrial fibrillation. The concordance indexes for stroke prediction were 0.703 (95% confidence interval [CI] 0.700-0.707) in the development cohort and 0.703 (95% CI 0.698-0.708) in the validation cohort.

CONCLUSIONS

We developed a risk model using various clinical parameters to predict stroke in patients with type 2 DM. This model may provide helpful information for identifying high-risk patients and guide prevention of stroke in this specific population.

Change in Body Weight and Long-Term Risk of Stroke and Death in Healthy Men

Background and Purpose—

The importance of weight change for the risk of stroke is not well known. We examined the associations between early- and mid-life weight change and risks of stroke and death during long-term follow-up of healthy men.

Methods—

We recruited healthy men aged between 40 and 59 years and performed a cardiovascular examination at baseline and again at 7 years. We collected data on weight change since the age of 25 (early-life weight change) and measured weight change from baseline to the visit at 7 years (mid-life weight change). For both weight change periods, participants were divided into the following categories: weight loss, weight gain 0 to 4.9 kg, weight gain 5 to 9.9 kg, and weight gain ≥10 kg. Data on stroke and death were collected up to 35 years, from study visits, hospital records, and the National Cause of Death Registry. We used Cox regression to analyze the associations between weight change during early-life and mid-life and risks of stroke and death.

Results—

Of the 2014 participants, 2014 (100%) had data on early-life weight change and were followed for a median of 30.1 years, while 1403 had data on mid-life weight change and were followed for a median of 24.6 years. During early-life, compared with those who had weight gain 0 to 4.9 kg, hazard ratio for stroke was 1.46 (95% CI, 1.09–1.95) among those with weight gain 5 to 9.9 kg, 1.39 (95% CI, 1.03–1.87) for those with weight gain ≥10 kg, and 1.46 (95% CI, 0.99–2.11) among those with weight loss. For all-cause death, the hazard ratios were 1.08 (95% CI, 0.92–1.23), 1.14 (95% CI, 0.98–1.33), and 1.29 (95% CI, 1.06–1.56), respectively. During mid-life, there were no significant differences in risk of stroke or death between the groups.

Conclusions—

Weight increase during early-life, but not mid-life, seems to be associated with increased long-term risk of stroke in healthy men. If these findings can be confirmed, efforts to prevent weight increase should target the younger population.

Interventions for preventing obesity in children

BACKGROUND

Prevention of childhood obesity is an international public health priority given the significant impact of obesity on acute and chronic diseases, general health, development and well-being. The international evidence base for strategies to prevent obesity is very large and is accumulating rapidly. This is an update of a previous review.

OBJECTIVES

To determine the effectiveness of a range of interventions that include diet or physical activity components, or both, designed to prevent obesity in children.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsychINFO and CINAHL in June 2015. We re-ran the search from June 2015 to January 2018 and included a search of trial registers.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of diet or physical activity interventions, or combined diet and physical activity interventions, for preventing overweight or obesity in children (0-17 years) that reported outcomes at a minimum of 12 weeks from baseline.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data, assessed risk-of-bias and evaluated overall certainty of the evidence using GRADE. We extracted data on adiposity outcomes, sociodemographic characteristics, adverse events, intervention process and costs. We meta-analysed data as guided by the Cochrane Handbook for Systematic Reviews of Interventions and presented separate meta-analyses by age group for child 0 to 5 years, 6 to 12 years, and 13 to 18 years for zBMI and BMI.

MAIN RESULTS

We included 153 RCTs, mostly from the USA or Europe. Thirteen studies were based in upper-middle-income countries (UMIC: Brazil, Ecuador, Lebanon, Mexico, Thailand, Turkey, US-Mexico border), and one was based in a lower middle-income country (LMIC: Egypt). The majority (85) targeted children aged 6 to 12 years.Children aged 0-5 years: There is moderate-certainty evidence from 16 RCTs (n = 6261) that diet combined with physical activity interventions, compared with control, reduced BMI (mean difference (MD) -0.07 kg/m2, 95% confidence interval (CI) -0.14 to -0.01), and had a similar effect (11 RCTs, n = 5536) on zBMI (MD -0.11, 95% CI -0.21 to 0.01). Neither diet (moderate-certainty evidence) nor physical activity interventions alone (high-certainty evidence) compared with control reduced BMI (physical activity alone: MD -0.22 kg/m2, 95% CI -0.44 to 0.01) or zBMI (diet alone: MD -0.14, 95% CI -0.32 to 0.04; physical activity alone: MD 0.01, 95% CI -0.10 to 0.13) in children aged 0-5 years.Children aged 6 to 12 years: There is moderate-certainty evidence from 14 RCTs (n = 16,410) that physical activity interventions, compared with control, reduced BMI (MD -0.10 kg/m2, 95% CI -0.14 to -0.05). However, there is moderate-certainty evidence that they had little or no effect on zBMI (MD -0.02, 95% CI -0.06 to 0.02). There is low-certainty evidence from 20 RCTs (n = 24,043) that diet combined with physical activity interventions, compared with control, reduced zBMI (MD -0.05 kg/m2, 95% CI -0.10 to -0.01). There is high-certainty evidence that diet interventions, compared with control, had little impact on zBMI (MD -0.03, 95% CI -0.06 to 0.01) or BMI (-0.02 kg/m2, 95% CI -0.11 to 0.06).Children aged 13 to 18 years: There is very low-certainty evidence that physical activity interventions, compared with control reduced BMI (MD -1.53 kg/m2, 95% CI -2.67 to -0.39; 4 RCTs; n = 720); and low-certainty evidence for a reduction in zBMI (MD -0.2, 95% CI -0.3 to -0.1; 1 RCT; n = 100). There is low-certainty evidence from eight RCTs (n = 16,583) that diet combined with physical activity interventions, compared with control, had no effect on BMI (MD -0.02 kg/m2, 95% CI -0.10 to 0.05); or zBMI (MD 0.01, 95% CI -0.05 to 0.07; 6 RCTs; n = 16,543). Evidence from two RCTs (low-certainty evidence; n = 294) found no effect of diet interventions on BMI.Direct comparisons of interventions: Two RCTs reported data directly comparing diet with either physical activity or diet combined with physical activity interventions for children aged 6 to 12 years and reported no differences.Heterogeneity was apparent in the results from all three age groups, which could not be entirely explained by setting or duration of the interventions. Where reported, interventions did not appear to result in adverse effects (16 RCTs) or increase health inequalities (gender: 30 RCTs; socioeconomic status: 18 RCTs), although relatively few studies examined these factors.Re-running the searches in January 2018 identified 315 records with potential relevance to this review, which will be synthesised in the next update.

AUTHORS' CONCLUSIONS

Interventions that include diet combined with physical activity interventions can reduce the risk of obesity (zBMI and BMI) in young children aged 0 to 5 years. There is weaker evidence from a single study that dietary interventions may be beneficial.However, interventions that focus only on physical activity do not appear to be effective in children of this age. In contrast, interventions that only focus on physical activity can reduce the risk of obesity (BMI) in children aged 6 to 12 years, and adolescents aged 13 to 18 years. In these age groups, there is no evidence that interventions that only focus on diet are effective, and some evidence that diet combined with physical activity interventions may be effective. Importantly, this updated review also suggests that interventions to prevent childhood obesity do not appear to result in adverse effects or health inequalities.The review will not be updated in its current form. To manage the growth in RCTs of child obesity prevention interventions, in future, this review will be split into three separate reviews based on child age.

Cell-Based Therapies for Stroke: Promising Solution or Dead End? Mesenchymal Stem Cells and Comorbidities in Preclinical Stroke Research

Stroke is a major health problem worldwide. It has been estimated that 90% of the population attributable risk of stroke is due to risk factors such as aging, hypertension, hyperglycemia, diabetes mellitus and obesity, among others. However, most animal models of stroke use predominantly healthy and young animals. These models ignore the main comorbidities associated with cerebrovascular disease, which could be one explanation for the unsuccessful bench-to-bedside translation of protective and regenerative strategies by not taking the patient's situation into account. This lack of success makes it important to incorporate comorbidities into animal models of stroke in order to study the effects of the various therapeutic strategies tested. Regarding cell therapy, the administration of stem cells in the acute and chronic phases has been shown to be safe and effective in experimental animal models of stroke. This review aims to show the results of studies with promising new therapeutic strategies such as mesenchymal stem cells, which are being tested in preclinical models of stroke associated with comorbidities and in elderly animals.

The Risk of Myocardial Infarction and Ischemic Stroke According to Waist Circumference in 21,749,261 Korean Adults: A Nationwide Population-Based Study

BACKGROUND

Waist circumference (WC) is a well-known obesity index that predicts cardiovascular disease (CVD). We studied the relationship between baseline WC and development of incident myocardial infarction (MI) and ischemic stroke (IS) using a nationwide population-based cohort, and evaluated if its predictability is better than body mass index (BMI).

METHODS

Our study included 21,749,261 Koreans over 20 years of age who underwent the Korean National Health Screening between 2009 and 2012. The occurrence of MI or IS was investigated until the end of 2015 using National Health Insurance Service data.

RESULTS

A total of 127,289 and 181,637 subjects were newly diagnosed with MI and IS. The incidence rate and hazard ratio of MI and IS increased linearly as the WC level increased, regardless of adjustment for BMI. When the analyses were performed according to 11 groups of WC, the lowest risk of MI was found in subjects with WC of 70 to 74.9 and 65 to 69.9 cm in male and female, and the lowest risk of IS in subjects with WC of 65 to 69.9 and 60 to 64.9 cm in male and female, respectively. WC showed a better ability to predict CVD than BMI with smaller Akaike information criterion. The optimal WC cutoffs were 84/78 cm for male/female for predicting MI, and 85/78 cm for male/female for predicting IS.

CONCLUSION

WC had a significant linear relationship with the risk of MI and IS and the risk began to increase from a WC that was lower than expected.

2D:4D Ratio Differs in Ischemic Stroke: A Single Center Experience

Background

The index to ring finger length (2D:4D) ratio is a proxy biomarker for prenatal exposure of sex hormones. Sex hormones are associated with the pathogenesis of ischemic stroke. The purpose of the study was to demonstrate the association between 2D:4D and ischemic stroke.

Methodology

This study retrospectively reviewed the data of 100 patients with first ever ischemic stroke between September, 2016 and June, 2017. The lengths of index finger and ring finger of both hands were measured using electronic calipers and calculated for 2D:4D ratios. Receive operating characteristic (ROC) mode was used to detect predicting performance of 2D:4D ratios for ischemic stroke.

Results

2D:4D ratios in ischemic stroke patients were higher than controls in both hands (P < 0.05), except right 2D:4D ratio in females. The ROC analyses showed that the area under the curve (AUC) were 0.635 (95%CI: 0.527-0.743) for left 2D:4D ratio, and 0.647 for right (95%CI: 0.539-0.755) (P < 0.05). The AUC of left and right 2D:4D ratio in male were 0.667 (95%CI: 0.514-0.820) and 0.670 (95%CI: 0.519-0.822) (P < 0.05). In female, no significance were found in ROC analysis. And there were no correlation between 2D:4D value and stroke severity (P > 0.05).

Conclusions

The current study indicated that the diagnostic value of 2D:4D ratio was limited in ischemic stroke. Further research is required to explore the role of it in screening ischemic stroke.

The association between physical inactivity and obesity is modified by five domains of environmental quality in U.S. adults: A cross-sectional study

Physical inactivity is a primary contributor to the obesity epidemic, but may be promoted or hindered by environmental factors. To examine how cumulative environmental quality may modify the inactivity-obesity relationship, we conducted a cross-sectional study by linking county-level Behavioral Risk Factor Surveillance System data with the Environmental Quality Index (EQI), a composite measure of five environmental domains (air, water, land, built, sociodemographic) across all U.S. counties. We estimated the county-level association (N = 3,137 counties) between 2009 age-adjusted leisure-time physical inactivity (LTPIA) and 2010 age-adjusted obesity from BRFSS across EQI tertiles using multi-level linear regression, with a random intercept for state, adjusted for percent minority and rural-urban status. We modelled overall and sex-specific estimates, reporting prevalence differences (PD) and 95% confidence intervals (CI). In the overall population, the PD increased from best (PD = 0.341 (95% CI: 0.287, 0.396)) to worst (PD = 0.645 (95% CI: 0.599, 0.690)) EQI tertile. We observed similar trends in males from best (PD = 0.244 (95% CI: 0.194, 0.294)) to worst (PD = 0.601 (95% CI: 0.556, 0.647)) quality environments, and in females from best (PD = 0.446 (95% CI: 0.385, 0.507)) to worst (PD = 0.655 (95% CI: 0.607, 0.703)). We found that poor environmental quality exacerbates the LTPIA-obesity relationship. Efforts to improve obesity through LTPIA may benefit from considering this relationship.

Low Body Mass Index is a Poor Prognosis Factor in Cardioembolic Stroke Patients with NonValvular Atrial Fibrillation

BACKGROUND

The relationship between body mass index (BMI) and the severity of cardioembolic stroke (CES) remains poorly understood.

METHOD

A total of 419 consecutive CES patients with nonvalvular atrial fibrillation (NVAF), and with a modified Rankin Scale (mRS) score of 0 or 1 before onset admitted within 48hours after onset to the Hirosaki Stroke and Rehabilitation Center were studied. The patients were divided into three groups, low BMI (L-BMI; n = 36, BMI < 18.5 kg/m²), normal BMI (N-BMI; n = 284, 18.5 ≤ BMI < 25.0), and high BMI (H-BMI; n = 99, BMI ≥ 25.0). We compared stroke severity and functional outcome among the three groups.

RESULTS

Stroke severity on admission, assessed by the National Institutes of Health Stroke Scale (NIHSS) showed that patients with L-BMI had the highest NIHSS score (median, 16 [11-25]), followed by N-BMI and H-BMI (11 [5-19] and 9 [3-19], P = .002). Functional outcome at discharge, assessed by mRS, was most severe in L-BMI patients (5 [3-5]), followed by N-BMI and H-BMI (3 [1-4] and 2 [1-4], P = .001). Multivariate analyses revealed that L-BMI was a significant determinant of severe stroke (NIHSS scores ≥8) at admission (odds ratio [OR] to N-BMI = 2.79, 95% confidence interval [CI], 1.17-7.78, P = .02) and poor functional outcome (mRS scores ≥3) at discharge (OR = 2.53, 95% CI, 1.12-6.31, P = .02). However, H-BMI did not affect stroke severity at admission or functional outcome at discharge.

CONCLUSION

Low BMI is a risk factor for severe stroke on admission and unfavorable functional outcome at discharge in Japanese CES patients with NVAF.

Phenotypic heterogeneity of obesity-related brain vulnerability: one-size interventions will not fit all

Intact memory and problem solving are key to functional independence and quality of life in older age. Considering the unprecedented demographic shift toward a greater number of older adults than children in the United States in the next few decades, it is critically important for older adults to maintain work productivity and functional independence for as long as possible. Implementing early interventions focused on modifiable risk factors for cognitive decline at midlife is a strategy with the highest chance of success at present, bearing in mind the current lack of dementia cures. We present a selective, narrative review of evidence linking nutrition, body composition, vascular health, and brain function in midlife to highlight the phenotypic heterogeneity of obesity-related brain vulnerability and to endorse the development of individually tailored lifestyle modification plans for primary prevention of cognitive decline.

Lifestyle Factors and Gender-Specific Risk of Stroke in Adults with Diabetes Mellitus: A Case-Control Study

BACKGROUND

The lifestyle interventions are effective preventive measures for stroke in general population, and the stroke risk with lifestyle factors may be modified by gender, health conditions, etc. Therefore, we conducted a case-control study to investigate the gender-specific association between stroke risk and lifestyle factors in adults with diabetes based on the China National Stroke Screening Survey.

METHODS

Structured questionnaires were used to collect demographic data and information regarding lifestyle factors, history of chronic medical conditions, and family history of stroke and the status of treatment. The case group comprised individuals diagnosed with first-ever stroke in 2013-2014 screening period. Their corresponding controls (frequency-matched for age group and urban/rural ratio) were randomly selected from individuals with diabetes without stroke.

RESULTS

There were 170 total stroke cases (500 controls) and 152 ischemic stroke cases (456 controls) among men with diabetes, and 183 total stroke cases (549 controls) and 168 ischemic stroke cases (504 controls) among women with diabetes. We found that physical inactivity was significantly associated with increased risk of total stroke (odds ratio [OR] = 1.50, 95% confidence interval [CI] 1.02-2.21) and of ischemic stroke (OR = 1.57, 95% CI 1.04-2.36) in women with diabetes. We found no significant association of smoking, overweight/obesity, or physical inactivity with risk of total or ischemic stroke in men with diabetes.

CONCLUSION

Among the lifestyle factors of smoking, overweight/obesity, and physical inactivity, physical inactivity might increase the risk of total and ischemic stroke in women with diabetes.

Impact of blood pressure, cholesterol and glucose in the association between adiposity measures and coronary heart disease and stroke among Iranian population

BACKGROUND & AIMS

To determine the association of body mass index (BMI) and central adiposity measures with coronary heart disease (CHD)/stroke, and to quantify the impact of blood pressure, cholesterol and glucose as metabolic mediators on these associations.

METHODS

The study population included 4631 Iranian participants (males = 2066) aged ≥40 years. Cox proportional hazard model was used to estimate the hazard ratio (HR) of BMI and central adiposity measures, using continuous and categorical variables, on CHD/stroke, with and without adjustment for three metabolic mediators, to calculate the attenuation of excess risk after adjustment for mediators.

RESULTS

During a median follow-up of 12.1 years, 606 and 132 subjects experienced incident CHD and stroke, respectively. In the sex and confounders adjusted model, overweight and obesity were associated with increased risk for CHD (HR: 1.56; 95% CI: 1.26-1.92) and [1.53 (1.21-1.94)], respectively; however, after further adjustment for all the mediators, the result was significant only for overweight status [1.29 (1.05-1.59)]. Considering stroke, a significant risk of 70% (1.05-2.72) was found only among obese population. The percentage of risk mediated by three mediators among obese population was 75.47% and 75.71% for CHD and stroke, respectively. Blood pressure was the most important mediator of obesity, accounting for at least 50% of the excess risk for CHD and 60% for stroke. Considering central obesity measures, in the presences of all mediators, a significant risk for CHD was demonstrated; regarding stroke events, the risk was marginally significant for waist to height [1.02 (0.99-1.05)] and waist to hip ratios [1.02 (1.00-1.05)].

CONCLUSIONS

Overweight and obesity for CHD and, obesity for stroke were associated with increased risk; the negative effect of obesity was potentially ameloriated about 70% after adjustment for mediators. However, overweight status and central adiposity highlighted significant risk that did not decrease after controlling for traditional risk factors.

Obesity: a chronic relapsing progressive disease process. A position statement of the World Obesity Federation

This paper considers the argument for obesity as a chronic relapsing disease process. Obesity is viewed from an epidemiological model, with an agent affecting the host and producing disease. Food is the primary agent, particularly foods that are high in energy density such as fat, or in sugar-sweetened beverages. An abundance of food, low physical activity and several other environmental factors interact with the genetic susceptibility of the host to produce positive energy balance. The majority of this excess energy is stored as fat in enlarged, and often more numerous fat cells, but some lipid may infiltrate other organs such as the liver (ectopic fat). The enlarged fat cells and ectopic fat produce and secrete a variety of metabolic, hormonal and inflammatory products that produce damage in organs such as the arteries, heart, liver, muscle and pancreas. The magnitude of the obesity and its adverse effects in individuals may relate to the virulence or toxicity of the environment and its interaction with the host. Thus, obesity fits the epidemiological model of a disease process except that the toxic or pathological agent is food rather than a microbe. Reversing obesity will prevent most of its detrimental effects.

Obesity paradox in stroke - Myth or reality? A systematic review

Background and purpose

Both stroke and obesity show an increasing incidence worldwide. While obesity is an established risk factor for stroke, its influence on outcome in ischemic stroke is less clear. Many studies suggest a better prognosis in obese patients after stroke (“obesity paradox”). This review aims at assessing the clinical outcomes of obese patients after stroke by performing a systematic literature search.

Methods

The reviewers searched MEDLINE from inception to December 2015. Studies were eligible if they included outcome comparisons in stroke patients with allocation to body weight.

Results

Twenty-five studies (299’750 patients) were included and none was randomised. Ten of 12 studies (162’921 patients) reported significantly less mortality rates in stroke patients with higher BMI values. Seven of 9 studies (92’718 patients) ascertained a favorable effect of excess body weight on non-fatal outcomes (good clinical outcome, recurrence of vascular events). Six studies (85’042 patients) indicated contradictory results after intravenous thrombolysis (IVT), however. Several methodological limitations were observed in major part of studies (observational study design, inaccuracy of BMI in reflecting obesity, lacking body weight measurement, selection bias, survival bias).

Conclusion

Most observational data indicate a survival benefit of obese patients after stroke, but a number of methodological concerns exist. No obesity paradox was observed in patients after IVT. There is a need for well-designed randomized controlled trials assessing the effects of weight reduction on stroke risk in obese patients.

Body mass index and stroke incidence in Japanese community residents: The Jichi Medical School (JMS) Cohort Study

BACKGROUND

High body mass index (BMI) has been reported as a risk factor for cardiovascular events in Western countries, while low BMI has been reported as a risk factor for cardiovascular death in Asian countries, including Japan. Although stroke is a major cause of death and disability in Japan, few cohort studies have examined the association between BMI and stroke incidence in Japan. This study aimed to examine the association between BMI and stroke incidence using prospective data from Japanese community residents.

METHODS

Data were analyzed from 12,490 participants in the Jichi Medical School Cohort Study. Participants were categorized into five BMI groups: ≤18.5, 18.6-21.9, 22.0-24.9, 25.0-29.9, and ≥30.0 kg/m². Multivariate-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using the Cox proportional hazard model. The group with a BMI of 22.0-24.9 kg/m² was used as the reference category.

RESULTS

During mean follow-up of 10.8 years, 395 participants (207 men and 188 women) experienced stroke, including 249 cerebral infarctions and 92 cerebral hemorrhages. Men with a BMI ≤18.5 kg/m² (HR 2.11; 95% CI, 1.17-3.82) and women with a BMI ≥30.0 kg/m² (HR 2.25; 95% CI, 1.28-5.08) were at significantly higher risk for all-stroke. Men with a BMI ≤18.5 kg/m² were at significantly higher risk for cerebral infarction (HR 2.15; 95% CI, 1.07-4.33).

CONCLUSIONS

The association between BMI and stroke incidence observed in this population was different than those previously reported: low BMI was a risk factor for all-stroke and cerebral infarction in men, while high BMI was a risk factor for all-stroke in women.

Association of high waist-to-height ratio with functional outcomes in patients with acute ischemic stroke: A report from the ACROSS-China study

The aim of our study was to investigate the relationship between the waist-to-height ratio (WHR) and all-cause mortality and functional outcomes after acute ischemic stroke in a prospective cohort study.A total of 2076 patients (36.66% females) with ischemic stroke were analyzed from ACROSS-China, which is a nationwide, prospective, hospital-based stroke registry aimed to detect the glucose abnormality in China. One-year follow-up evaluation was done by telephone interview. Outcome measures were all-cause mortality and functional outcome defined as modified Rankin score being 6 and from 0 to 6, respectively. We identified predictors for functional outcomes using logistic regression analysis, and mortality outcome using Cox proportional hazards model which incorporated covariates with P value of < 0.2 in the univariate analysis and those of clinical importance.The higher WHR was associated with worse functional outcome, but not predictive of the patients' mortality outcomes. Compared with the first quartile (≤0.48), the fourth quartile of the WHR was more likely to be associated with poor functional recovery (fourth quartile (≥0.56), OR = 1.38, CI: 1.08-1.77, P = 0.01; third quartile OR = 1.10, CI: 0.86-1.40, P = 0.45; second quartile OR = 1.05, CI: 0.83-1.33, P = 0.71).Our findings suggest that abdominal fat accumulation may be associated with functional recovery after stroke, and is not associated with mortality after stroke. Compared with the lowest quartile, the highest quartile of WHR at admission was possibly associated with worse postacute ischemic stroke functional recovery.

Modelling the potential impact of a sugar-sweetened beverage tax on stroke mortality, costs and health-adjusted life years in South Africa

BACKGROUND

Stroke poses a growing human and economic burden in South Africa. Excess sugar consumption, especially from sugar-sweetened beverages (SSBs), has been associated with increased obesity and stroke risk. Research shows that price increases for SSBs can influence consumption and modelling evidence suggests that taxing SSBs has the potential to reduce obesity and related diseases. This study estimates the potential impact of an SSB tax on stroke-related mortality, costs and health-adjusted life years in South Africa.

METHODS

A proportional multi-state life table-based model was constructed in Microsoft Excel (2010). We used consumption data from the 2012 South African National Health and Nutrition Examination Survey, previously published own and cross price elasticities of SSBs and energy balance equations to estimate changes in daily energy intake and BMI arising from increased SSB prices. Stroke relative risk, and prevalent years lived with disability estimates from the Global Burden of Disease Study and modelled disease epidemiology estimates from a previous study, were used to estimate the effect of the BMI changes on the burden of stroke.

RESULTS

Our model predicts that an SSB tax may avert approximately 72 000 deaths, 550 000 stroke-related health-adjusted life years and over ZAR5 billion, (USD400 million) in health care costs over 20 years (USD296-576 million). Over 20 years, the number of incident stroke cases may be reduced by approximately 85 000 and prevalent cases by about 13 000.

CONCLUSIONS

Fiscal policy has the potential, as part of a multi-faceted approach, to mitigate the growing burden of stroke in South Africa and contribute to the achievement of the target set by the Department of Health to reduce relative premature mortality (less than 60 years) from non-communicable diseases by the year 2020.

The Impact of Long-Term Physical Activity Interventions for Overweight/Obese Postmenopausal Women on Adiposity Indicators, Physical Capacity, and Mental Health Outcomes: A Systematic Review

Physical activity interventions have recently become a popular strategy to help postmenopausal women prevent and manage obesity. The current systematic review evaluates the efficacy of physical activity interventions among overweight and obese postmenopausal women and sheds light on the behavioral change techniques that were employed in order to direct future research. Method. Five electronic databases were searched to identify all prospective RCT studies that examine the impact of physical activity on adiposity indicators, physical capacity, and/or mental health outcomes among healthy, sedentary overweight, and obese postmenopausal women in North America. The behavior change technique taxonomy was used to identify the various strategies applied in the programs. Results. Five RCTs met the inclusion criteria. The findings showed that adiposity indicators and physical capacity outcomes significantly improved following long-term interventions; however, mental health outcomes showed nonsignificant changes. Furthermore, 17 behavior change techniques were identified with the taxonomy across all trials. The intrapersonal-level techniques were the most common. Conclusion. Physical activity interventions had a positive effect on adiposity measures and physical capacity. Future research should focus on testing the effectiveness of physical activity interventions on mental health and incorporate strategies at the individual and environmental level to maximize the health impact on the population.

Brain Aging in African-Americans: The Atherosclerosis Risk in Communities (ARIC) Experience

Reported rates of dementia differ by race, although most studies have not focused on carefully measured outcomes, confounding by education or other demographic factors, nor have they studied other outcomes other than dementia. In this review we will discuss the experience in the Atherosclerosis Risk in Communities (ARIC) study evaluating racial disparities relating to stroke, subclinical brain infarction, leukoaraiosis, as well as cognitive change and dementia. ARIC is a biracial cohort of 15,792 participants from four U.S. communities, initially recruited in 1987-1989, and seen at a total of 5 in-person visits (most recently seen in 2011-2013) with annual follow-up phone calls. We will provide evidence from ARIC studies that disproportionate rates of vascular risk factors explain at least some of these observed disparities by race, but particular risk factors, including diabetes, may differentially affect the brain in African-American versus white participants. In addition, we will review some of the disparities by race in studies focusing on the genetics of stroke, small vessel disease, and dementia.

The Abundance of Epicardial Adipose Tissue Surrounding Left Atrium Is Associated With the Occurrence of Stroke in Patients With Atrial Fibrillation

Epicardial adipose tissue (EAT) is positively associated with risk factors for cardiovascular disease, but the role of EAT in the development of atrial fibrillation (AF)-related stroke and its association with the anatomical and functional remodeling of the left atrium (LA) have not been elucidated.This was a comparative cross-sectional study. Twenty-seven patients with paroxysmal or persistent AF and cardioembolic stroke were selected and compared with 68 age- and sex-matched AF patients without stroke. In addition, 20 controls without a history of AF or stroke were included. The periatrial EAT and the structural and functional properties of the LA and left ventricle were evaluated using contrast-enhanced 64-slice multidetector computed tomography during sinus rhythm. Total EAT around the LA was significantly increased across the groups (control vs AF vs AF-related stroke, P < 0.001). The volumes of the LA and the LA appendage (LAA) were also significantly increased across the 3 groups (P < 0.001 for each). The emptying fraction of the LA and LAA and the booster-pump function of the LA and LAA were all reduced across the 3 groups (P < 0.001 for all). In addition, the Hounsfield unit (HU) ratio of the LAA to the ascending aorta (LAA/AA) was also decreased in patients with stroke (P < 0.001). Furthermore, EAT had a negative correlation with the dynamic function of the LA, LAA, and the HU ratio. After a multivariate analysis, increased EAT (P < 0.001) was shown to be independently associated with the occurrence of AF-related stroke.Periatrial EAT was increased and was correlated with atrial dysfunction in patients with AF-related stroke. Hence, EAT assessment may potentially offer an incremental value for grading the risk of cardioembolic stroke in patients with AF.

Interactive effects of physical fitness and body mass index on risk of stroke: A national cohort study

BACKGROUND

High body mass index (BMI) and low physical fitness are risk factors for stroke, but their interactive effects are unknown. Elucidation of interactions between these modifiable risk factors can help inform preventive interventions in susceptible subgroups.

METHODS

National cohort study of all 1,547,294 military conscripts in Sweden during 1969-1997 (97-98% of all 18-year-old males). Standardized aerobic capacity, muscular strength, and body mass index measurements were examined in relation to stroke identified from inpatient and outpatient diagnoses through 2012 (maximum age 62 years).

RESULTS

Sixteen thousand nine hundred seventy-nine men were diagnosed with stroke in 39.7 million person-years of follow-up. High body mass index, low aerobic fitness, and (less strongly) low muscular fitness were associated with higher risk of any stroke, ischemic stroke, and intracerebral hemorrhage, independently of family history and sociodemographic factors. High body mass index (overweight/obese vs. normal) and low aerobic capacity (lowest vs. highest tertile) had similar effect magnitudes, and their combination was associated with highest stroke risk (incidence rate ratio, 2.36; 95% CI, 2.14-2.60; P < 0.001). Aerobic capacity and muscular strength had a positive additive and multiplicative interaction (P < 0.001), indicating that low aerobic capacity accounted for more strokes among men with low compared with high muscular strength.

CONCLUSIONS

High body mass index and low aerobic capacity in late adolescence are associated with increased risk of stroke in adulthood. Low aerobic capacity and low muscular strength also have a synergistic effect on stroke risk. These findings suggest that preventive interventions should include weight control and aerobic fitness early in life, and muscular fitness especially among those with low aerobic capacity.

Association and relative importance of multiple obesity measures with bone mineral density: the National Health and Nutrition Examination Survey 2005-2006

All obesity measures were positively associated with femoral neck bone mineral density (BMD), but not with lumbar spine BMD. Hip circumference was the most important obesity measure in relation to BMD.

PURPOSE

Multiple measures are used to quantify obesity; different obesity measures have diverse relationship with BMD. Which obesity measure has the most important value in relation to BMD is still poorly understood. We examined the association between multiple obesity measures and BMD and determined the relative importance (RI, percentage of variation) of multiple obesity measures associated with BMD.

METHODS

Data from 5287 men and women aged between 8 and 69 years (mean age = 29 years) in the National Health and Nutrition Examination Survey 2005-2006 were analyzed. Body mass index (BMI), waist circumference, hip circumference, body fat mass (FM) index, total body FM, abdominal FM, and appendicular FM were considered the exposures and femoral neck and lumbar spine BMD the outcomes.

RESULTS

In the multivariable analysis, greater BMI and hip circumference were associated with increased BMD at the lumbar spine and femoral neck (all P < 0.001). The remaining obesity variables were positively associated with increased femoral neck BMD only (all P < 0.001). RI of all obesity measures associated with femoral neck BMD was much greater than that associated with lumbar spine BMD. Moreover, hip circumference had higher RI (19.8 for femoral neck BMD; 7.0 for lumbar spine BMD) than other obesity measures (all RIs ≤14.1 for femoral neck BMD; all RIs ≤3.5 for lumbar spine BMD) in relation to BMD.

CONCLUSIONS

All obesity measures were positively associated with femoral neck BMD, but not with lumbar spine BMD. Hip circumference was the most important obesity measure in relation to BMD.

Interleukin-1 and acute brain injury

Inflammation is the key host-defense response to infection and injury, yet also a major contributor to a diverse range of diseases, both peripheral and central in origin. Brain injury as a result of stroke or trauma is a leading cause of death and disability worldwide, yet there are no effective treatments, resulting in enormous social and economic costs. Increasing evidence, both preclinical and clinical, highlights inflammation as an important factor in stroke, both in determining outcome and as a contributor to risk. A number of inflammatory mediators have been proposed as key targets for intervention to reduce the burden of stroke, several reaching clinical trial, but as yet yielding no success. Many factors could explain these failures, including the lack of robust preclinical evidence and poorly designed clinical trials, in addition to the complex nature of the clinical condition. Lack of consideration in preclinical studies of associated co-morbidities prevalent in the clinical stroke population is now seen as an important omission in previous work. These co-morbidities (atherosclerosis, hypertension, diabetes, infection) have a strong inflammatory component, supporting the need for greater understanding of how inflammation contributes to acute brain injury. Interleukin (IL)-1 is the prototypical pro-inflammatory cytokine, first identified many years ago as the endogenous pyrogen. Research over the last 20 years or so reveals that IL-1 is an important mediator of neuronal injury and blocking the actions of IL-1 is beneficial in a number of experimental models of brain damage. Mechanisms underlying the actions of IL-1 in brain injury remain unclear, though increasing evidence indicates the cerebrovasculature as a key target. Recent literature supporting this and other aspects of how IL-1 and systemic inflammation in general contribute to acute brain injury are discussed in this review.

Guidelines for the primary prevention of stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association

The aim of this updated statement is to provide comprehensive and timely evidence-based recommendations on the prevention of stroke among individuals who have not previously experienced a stroke or transient ischemic attack. Evidence-based recommendations are included for the control of risk factors, interventional approaches to atherosclerotic disease of the cervicocephalic circulation, and antithrombotic treatments for preventing thrombotic and thromboembolic stroke. Further recommendations are provided for genetic and pharmacogenetic testing and for the prevention of stroke in a variety of other specific circumstances, including sickle cell disease and patent foramen ovale.

Echocardiographic epicardial fat thickness and neutrophil to lymphocyte ratio are novel inflammatory predictors of cerebral ischemic stroke

BACKGROUND

The role of epicardial fat thickness (EFT) in ischemic stroke (IS) has not been previously investigated. The aim of the present study was to evaluate EFT and neutrophil/lymphocyte ratio (NLR) among patients with IS and to examine the relationship between these inflammatory markers and the incidence of IS.

METHODS

The cross-sectional design includes 38 patients with IS and 47 age- and sex-matched healthy controls. Echocardiographic measurement of EFT was conducted according to previously published methods. An automated hematology analyzer was used to generate total and differential leukocyte counts from patient blood samples.

RESULTS

Mean EFT was 4.86 ± .68 mm in the control group and 5.95 ± 1.14 mm in the IS group. EFT was significantly greater in the IS patients in relation to the control group (P < .001). Mean NLR was significantly greater among IS patients in relation to the control group (2.5 ± .6 vs. 1.8 ± .4, P < .001). No significant confounding factors were identified in the data set. Spearman's correlation analysis revealed a mild, but highly significant correlation between EFT and NLR (r = .293, P = .006).

CONCLUSIONS

This study demonstrates for the first time the association between EFT and cerebral IS. Echocardiographic EFT was significantly correlated with NLR. NLR and echocardiographic EFT represent inexpensive and readily available clinical markers that maybe useful in estimating risk of IS.

Critical role of matrix metalloprotease-9 in chronic high fat diet-induced cerebral vascular remodelling and increase of ischaemic brain injury in mice†

AIMS

About one-third of American adults and 20% of teenagers are obese. Obesity and its associated metabolic disturbances including hyperlipidaemia are risk factors for cardiovascular diseases including stroke. They can worsen neurological outcome after stroke. We determined whether obesity and hyperlipidaemia could induce cerebral vascular remodelling via matrix metalloproteases (MMP) and whether this remodelling affected neurological outcome after brain ischaemia.

METHODS AND RESULTS

Six-week-old male CD1, C57BL/6J, and MMP-9(-/-) mice were fed regular diet (RD) or high-fat diet (HFD) for 10 weeks. They were subjected to vascular casting or a 90 min middle cerebral arterial occlusion (MCAO). Mice on HFD were heavier and had higher blood glucose and lipid levels than those on RD. HFD-fed CD1 and C57BL/6J mice had an increased cerebral vascular tortuosity index and decreased inner diameters of the middle cerebral arterial root. HFD increased microvessel density in CD1 mouse cerebral cortex. After MCAO, CD1 and C57BL/6J mice on HFD had a bigger infarct volume, more severe brain oedema and blood-brain barrier damage, higher haemorrhagic transformation rate, greater haemorrhagic volume, and worse neurological function. HFD increased MMP-9 activity in the ischaemic and non-ischaemic brain tissues. Although HFD increased the body weights, blood glucose, and lipid levels in the MMP-9(-/-) mice on a C57BL/6J genetic background, the HFD-induced cerebral vascular remodelling and worsening of neurological outcome did not occur in these mice.

CONCLUSION

HFD induces cerebral vascular remodelling and worsens neurological outcome after transient focal brain ischaemia. MMP-9 activation plays a critical role in these HFD effects.

Body adiposity indices are associated with hypertension in a black, urban Free State community

BACKGROUND

Non-communicable diseases, including hypertension, are increasing rapidly in resource-poor, developing countries amongst populations transitioning from traditional to westernised lifestyles; and are associated with excess weight.

AIM

To investigate the relationship between hypertension and various indices of body adiposity in a transitioning, urban, black population.

SETTING

Three hundred and thirty-nine adults (25-64 years) from a larger cross-sectional study (Assuring Health for All in the Free State) conducted in Mangaung, South Africa, were included.

METHODS

Standard techniques were used to determine blood pressure, HIV status, body mass index (BMI), waist-to-height ratio (WHtR) and body adiposity index (BAI).

RESULTS

Approximately 40% of the sample was HIV-positive and 63.4% hypertensive, with the greatest risk of hypertension being amongst older men. Based on BMI, 23.0% were overweight and 32.1% obese. Waist-to-height ratio showed that 58.6% had increased cardiovascular risk. Mean BAI was 34.1%, whilst 76.3% had a body fat percentage in the overweight/obese category. Waist circumference representing increased cardiovascular risk was found in 44.3% of women and 3.9% of men. Significant positive correlations between mean arterial bloodpressure and BMI (r = 0.261; p < 0.001), WHtR (r = 0.357; p < 0.001) and BAI (r = 0.245; p <0.001) were found. WHtR was a stronger predictor of mean arterial pressure than BMI or BAI. HIV status showed an inverse correlation with all adiposity indices (p < 0.001).

CONCLUSION

Our findings promote WHtR as a practical screening tool for increased hypertension risk in populations undergoing westernisation, and support weight loss as afirst-line intervention for the prevention and management of hypertension.

Guidelines for the prevention of stroke in women: a statement for healthcare professionals from the American Heart Association/American Stroke Association

PURPOSE

The aim of this statement is to summarize data on stroke risk factors that are unique to and more common in women than men and to expand on the data provided in prior stroke guidelines and cardiovascular prevention guidelines for women. This guideline focuses on the risk factors unique to women, such as reproductive factors, and those that are more common in women, including migraine with aura, obesity, metabolic syndrome, and atrial fibrillation.

METHODS

Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statement Oversight Committee and the AHA's Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through May 15, 2013. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA Stroke Council methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

We provide current evidence, research gaps, and recommendations on risk of stroke related to preeclampsia, oral contraceptives, menopause, and hormone replacement, as well as those risk factors more common in women, such as obesity/metabolic syndrome, atrial fibrillation, and migraine with aura.

CONCLUSIONS

To more accurately reflect the risk of stroke in women across the lifespan, as well as the clear gaps in current risk scores, we believe a female-specific stroke risk score is warranted.

Obesity and life expectancy among long-lived Black adults

BACKGROUND

In samples of African Americans and the elderly adults, obesity is often not found to be a risk factor for mortality. These data contradict the evidence linking obesity to chronic disease in these groups. Our objective was to determine whether obesity remains a risk factor for mortality among long-lived black adults.

METHODS

The Adventist Health Study 2 is a large prospective cohort study of Seventh-day Adventist church members who are encouraged by faith-based principles to avoid tobacco, alcohol, and meat consumption. We conducted an attained age survival analysis of 22,884 U.S. blacks of the cohort-half of whom attained an age of 58-108 years during the follow-up (adult life expectancy of 84 years in men, 89 years in women).

RESULTS

Women in the highest body mass index quintile (>33.8) experienced a significant 61% increase (hazard ratio [95% CI] = 1.62 [1.23, 2.11] relative to the middle quintile) in mortality risk and a 6.2-year (95% CI = 2.8-10.2 years) decrease in life expectancy. Men in the highest body mass index quintile (>30.8) experienced a significant 87% increase (hazard ratio [95% CI] = 1.87 [1.28, 2.73] relative to the middle quintile) in mortality risk and 5.9-year (95% CI = 2.1- 9.5 years) decrease in life expectancy. Obesity (>30) was a significant risk factor relative to normal weight (18.5-24.9) in never-smokers. Instantaneous hazards indicated excess risk from obesity was evident through at least age 85 years. The nonobese tended to follow plant-based diets and exercise vigorously.

CONCLUSIONS

Avoiding obesity promotes gains in life expectancy through at least the eighth decade of life in black adults. Evidence for weight control through plant-based diets and active living was found in long-lived nonobese blacks.