Body-Mass Index and All-Cause Mortality in US Adults With and Without Diabetes
Previous studies found normal weight compared to overweight/obese adults with type 2 diabetes had a higher mortality risk, and body-mass index (BMI)–mortality studies do not typically account for baseline diabetes status.
To determine if diabetes influences the BMI–mortality relationship.
Using a prospective study design, we analyzed data from a nationally representative sample of US adults participating in the National Health Interview Survey from 1997 to 2002, and followed for mortality through 2006.
Excluding those with heart disease or cancer, our final analytic sample included 74,710 (34,805 never smoker) adults.
BMI was calculated from self-reported height and weight. Diabetes status was based on self-reported diagnosis from a health professional. We used direct age standardization to calculate all-cause mortality rates and adjusted Cox models for all-cause mortality hazard ratios by BMI quintile; this was done separately for adults with diabetes and without diabetes.
Among never smokers, mean age was 50.1 years and 43 % were men. Mean BMI was 27.4 kg/m2, 26 % were obese, and 2,035 (5 %) reported diagnosed diabetes. After 9 years, there were 4,355 deaths (754 of 4,740 with diabetes; 3,601 of 69,970 without) among 74,710 participants, and 1,238 (247 of 2,035 with diabetes; 991 of 32,770 without) among 34,805 never smokers. We observed a qualitative interaction with diabetes on the BMI–mortality relationship (p = 0.002). Death rates were substantially higher among participants with diabetes compared to those without diabetes across all BMI quintiles. However, death rates in participants with diabetes fell with increasing BMI quintile, while rates followed a J-shaped curve among those without diabetes. In adjusted Cox models, BMI was positively associated with mortality in adults without diabetes, but inversely associated with mortality among participants with diabetes.
Mortality increased with increasing BMI in adults without diabetes, but decreased with increasing BMI among their counterparts with diabetes. Future studies need to be better designed to answer the question of whether normal weight adults with diabetes have a higher risk of mortality, by minimizing the possibility of reverse causation. Future studies should also account for prevalent diabetes in all investigations of the BMI–mortality relationship.
- Flegal, KM, Carroll, MD, Ogden, CL, Curtin, LR (2010) Prevalence and trends in obesity among US adults, 1999–2008. JAMA: j Am Med Assoc 303: pp. 235-241 CrossRef
- Ogden CL, Lamb MM, Carroll MD, Flegal KM. Obesity and socioeconomic status in adults: United States, 2005–2008. NCHS Data Brief 2010:1–8.
- Overweight, obesity, and health risk. National Task Force on the Prevention and Treatment of Obesity. Archives of internal medicine. 2000;160:898–904.
- Ogden, CL, Yanovski, SZ, Carroll, MD, Flegal, KM (2007) The epidemiology of obesity. Gastroenterology 132: pp. 2087-2102 CrossRef
- Calle, EE, Teras, LR, Thun, MJ (2005) Obesity and mortality. N Engl J Med 353: pp. 2197-2199 CrossRef
- Schneider, HJ, Wittchen, HU, Wallaschofski, H (2009) Obesity and risk of death. N Engl J Med 360: pp. 1043
- Finkelstein, EA, Fiebelkorn, IC, Wang, G (2004) State-level estimates of annual medical expenditures attributable to obesity. Obes Res 12: pp. 18-24 CrossRef
- Flegal, KM, Graubard, BI, Williamson, DF, Cooper, RS (2011) Reverse causation and illness-related weight loss in observational studies of body weight and mortality. Am J Epidemiol 173: pp. 1-9 CrossRef
- National Center for Health Statistics, Centers for Disease Control and Prevention. National Health Interview Survey. Hyattsville, MD. Available at: http://www.cdc.gov/nchs/nhis.htm. Accessed June, 2013.
- Wilcosky, T, Hyde, J, Anderson, JJ, Bangdiwala, S, Duncan, B (1990) Obesity and mortality in the Lipid Research Clinics Program Follow-up Study. J clin epidemiol 43: pp. 743-752 CrossRef
- Wolters, KM (1990) Introduction to Variance Estimation. Springer, New York, NY
- Rao, JN, Scott, AJ (1992) A simple method for the analysis of clustered binary data. Biometrics 48: pp. 577-585 CrossRef
- Barros, AJ, Hirakata, VN (2003) Alternatives for logistic regression in cross-sectional studies: an empirical comparison of models that directly estimate the prevalence ratio. BMC Med Res Methodol 3: pp. 21 CrossRef
- Berrington de Gonzalez, A, Hartge, P, Cerhan, JR (2010) Body-mass index and mortality among 1.46 million white adults. N Engl J Med 363: pp. 2211-2219 CrossRef
- Carnethon, MR, Chavez, PJ, Biggs, ML (2012) Association of weight status with mortality in adults with incident diabetes. JAMA 308: pp. 581-590
- Fleischmann, E, Teal, N, Dudley, J, May, W, Bower, JD, Salahudeen, AK (1999) Influence of excess weight on mortality and hospital stay in 1,346 hemodialysis patients. Kidney Int 55: pp. 1560-1567 CrossRef
- Badheka, AO, Rathod, A, Kizilbash, MA (2010) Influence of obesity on outcomes in atrial fibrillation: yet another obesity paradox. Am J Med 123: pp. 646-651 CrossRef
- Chazot, C, Gassia, JP, Di, BA, Cesare, S, Ponce, P, Marcelli, D (2009) Is there any survival advantage of obesity in Southern European haemodialysis patients?. Nephrol Dial Transplant 24: pp. 2871-2876 CrossRef
- Curtis, JP, Selter, JG, Wang, Y (2005) The obesity paradox: body mass index and outcomes in patients with heart failure. Arch Intern Med 165: pp. 55-61 CrossRef
- Fonarow, GC, Srikanthan, P, Costanzo, MR, Cintron, GB, Lopatin, M (2007) An obesity paradox in acute heart failure: analysis of body mass index and inhospital mortality for 108,927 patients in the Acute Decompensated Heart Failure National Registry. Am Heart J 153: pp. 74-81 CrossRef
- Galal, W, Gestel, YR, Hoeks, SE (2008) The obesity paradox in patients with peripheral arterial disease. Chest 134: pp. 925-930 CrossRef
- Kumakura, H, Kanai, H, Aizaki, M (2010) The influence of the obesity paradox and chronic kidney disease on long-term survival in a Japanese cohort with peripheral arterial disease. J Vasc Surg 52: pp. 110-117 CrossRef
- Mullen, JT, Moorman, DW, Davenport, DL (2009) The obesity paradox: body mass index and outcomes in patients undergoing nonbariatric general surgery. Ann Surg 250: pp. 166-172 CrossRef
- Bertoni, AG, Saydah, S, Brancati, FL (2001) Diabetes and the risk of infection-related mortality in the U.S. Diabetes Care 24: pp. 1044-1049 CrossRef
- Habbu, A, Lakkis, NM, Dokainish, H (2006) The obesity paradox: fact or fiction?. Am J Cardiol 98: pp. 944-948 CrossRef
- McAuley, PA, Kokkinos, PF, Oliveira, RB, Emerson, BT, Myers, JN (2010) Obesity paradox and cardiorespiratory fitness in 12,417 male veterans aged 40 to 70 years. Mayo Clin Proc 85: pp. 115-121 CrossRef
- Schmidt, DS, Salahudeen, AK (2007) Obesity-survival paradox-still a controversy?. Semin Dial 20: pp. 486-492 CrossRef
- Kalantar-Zadeh, K, Kopple, JD (2001) Relative contributions of nutrition and inflammation to clinical outcome in dialysis patients. Am J Kidney Dis 38: pp. 1343-1350 CrossRef
- Kalantar-Zadeh, K, Kopple, JD, Block, G, Humphreys, MH (2001) A malnutrition-inflammation score is correlated with morbidity and mortality in maintenance hemodialysis patients. Am J Kidney Dis 38: pp. 1251-1263 CrossRef
- Hernan, MA, Hernandez-Diaz, S, Robins, JM (2004) A structural approach to selection bias. Epidemiology 15: pp. 615-625 CrossRef
- Banack, HR, Kaufman, JS (2013) The “obesity paradox” explained. Epidemiology 24: pp. 461-462 CrossRef
- Ferreira, I, Stehouwer, CD (2012) Obesity paradox or inappropriate study designs? Time for life-course epidemiology. J Hypertens 30: pp. 2271-2275 CrossRef
- McEwen, LN, Karter, AJ, Waitzfelder, BE (2012) Predictors of mortality over 8 years in type 2 diabetic patients: Translating Research Into Action for Diabetes (TRIAD). Diabetes Care 35: pp. 1301-1309 CrossRef
- Zoppini, G, Verlato, G, Targher, G, Bonora, E, Trombetta, M, Muggeo, M (2008) Variability of body weight, pulse pressure and glycaemia strongly predict total mortality in elderly type 2 diabetic patients. The Verona Diabetes Study. Diabetes Metab Res Rev 24: pp. 624-628 CrossRef
- Ross, C, Langer, RD, Barrett-Connor, E (1997) Given diabetes, is fat better than thin?. Diabetes Care 20: pp. 650-652 CrossRef
- Chaturvedi, N, Fuller, JH (1995) Mortality risk by body weight and weight change in people with NIDDM. The WHO Multinational Study of Vascular Disease in Diabetes. Diabetes Care 18: pp. 766-774 CrossRef
- Berrington de GA, Hartge P, Cerhan JR, et al. Body-mass index and mortality among 1.46 million white adults. N Engl J Med. 2010;363:2211–2219.
- Zheng, W, McLerran, DF, Rolland, B (2011) Association between body-mass index and risk of death in more than 1 million Asians. N Engl J Med 364: pp. 719-729 CrossRef
- Byers, T (2000) Body-mass index and mortality. N Engl J Med 342: pp. 286-287 CrossRef
- Calle, EE, Thun, MJ, Petrelli, JM, Rodriguez, C, Heath, CW (1999) Body-mass index and mortality in a prospective cohort of U.S. adults. N Engl J Med 341: pp. 1097-1105 CrossRef
- Adams, KF, Schatzkin, A, Harris, TB (2006) Overweight, obesity, and mortality in a large prospective cohort of persons 50 to 71 years old. N Engl J Med 355: pp. 763-778 CrossRef
- Logue J, Walker JJ, Leese G, et al. The association between bmi measured within a year after diagnosis of type 2 diabetes and mortality. Diabetes care. 2012.
- Stommel, M, Schoenborn, CA (2009) Accuracy and usefulness of BMI measures based on self-reported weight and height: findings from the NHANES & NHIS 2001–2006. BMC Publ Health 9: pp. 421 CrossRef
- Whitlock, G, Lewington, S, Sherliker, P (2009) Body-mass index and cause-specific mortality in 900 000 adults: collaborative analyses of 57 prospective studies. Lancet 373: pp. 1083-1096 CrossRef
- National Diabetes Fact Sheet: National Estimates and General Information on Diabetes and Prediabetes in the United States A, GA: Centers for Disease Control and Prevention; 2011. Available at: http://www.cdc.gov/diabetes/pubs/pdf/ndfs%5F2011.pdf. Accessed June 2013.
- Sturm, R, Wells, KB (2001) Does obesity contribute as much to morbidity as poverty or smoking?. Public health 115: pp. 229-235
- Body-Mass Index and All-Cause Mortality in US Adults With and Without Diabetes
Journal of General Internal Medicine
Volume 29, Issue 1 , pp 25-33
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- Author Affiliations
- 1. Department of Nutrition, Harvard School of Public Health, Boston, MA, USA
- 2. Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- 3. Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- 7. Departments of Nutrition and Epidemiology, Harvard School of Public Health, Boston, MA, USA
- 4. INSERM, U1018, CESP, Occupational and Social Determinants of Health, Villejuif, France
- 5. University Paris XI, Villejuif, France
- 6. University Versailles Saint-Quentin, Versailles, France