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. Prevalence and trends in obesity among US adults, 1999–2008. JAMA: j Am Med Assoc. 2010;303:235–241. 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. The epidemiology of obesity. Gastroenterology. 2007;132:2087–2102. CrossRef
- Calle EE, Teras LR, Thun MJ. Obesity and mortality. N Engl J Med. 2005;353:2197–2199. CrossRef
- Schneider HJ, Wittchen HU, Wallaschofski H. Obesity and risk of death. N Engl J Med. 2009;360:1043.
- Finkelstein EA, Fiebelkorn IC, Wang G. State-level estimates of annual medical expenditures attributable to obesity. Obes Res. 2004;12:18–24. CrossRef
- Flegal KM, Graubard BI, Williamson DF, Cooper RS. Reverse causation and illness-related weight loss in observational studies of body weight and mortality. Am J Epidemiol. 2011;173:1–9. 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. Obesity and mortality in the Lipid Research Clinics Program Follow-up Study. J clin epidemiol. 1990;43:743–752. CrossRef
- Wolters KM. Introduction to Variance Estimation. New York, NY: Springer; 1990.
- Rao JN, Scott AJ. A simple method for the analysis of clustered binary data. Biometrics. 1992;48:577–585. CrossRef
- Barros AJ, Hirakata VN. Alternatives for logistic regression in cross-sectional studies: an empirical comparison of models that directly estimate the prevalence ratio. BMC Med Res Methodol. 2003;3:21. CrossRef
- Berrington de Gonzalez A, 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. CrossRef
- Carnethon MR, De Chavez PJ, Biggs ML, et al. Association of weight status with mortality in adults with incident diabetes. JAMA. 2012;308:581–590.
- Fleischmann E, Teal N, Dudley J, May W, Bower JD, Salahudeen AK. Influence of excess weight on mortality and hospital stay in 1,346 hemodialysis patients. Kidney Int. 1999;55:1560–1567. CrossRef
- Badheka AO, Rathod A, Kizilbash MA, et al. Influence of obesity on outcomes in atrial fibrillation: yet another obesity paradox. Am J Med. 2010;123:646–651. CrossRef
- Chazot C, Gassia JP, Di BA, Cesare S, Ponce P, Marcelli D. Is there any survival advantage of obesity in Southern European haemodialysis patients? Nephrol Dial Transplant. 2009;24:2871–2876. CrossRef
- Curtis JP, Selter JG, Wang Y, et al. The obesity paradox: body mass index and outcomes in patients with heart failure. Arch Intern Med. 2005;165:55–61. CrossRef
- Fonarow GC, Srikanthan P, Costanzo MR, Cintron GB, Lopatin M. 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. 2007;153:74–81. CrossRef
- Galal W, van Gestel YR, Hoeks SE, et al. The obesity paradox in patients with peripheral arterial disease. Chest. 2008;134:925–930. CrossRef
- Kumakura H, Kanai H, Aizaki M, et al. 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. 2010;52:110–117. CrossRef
- Mullen JT, Moorman DW, Davenport DL. The obesity paradox: body mass index and outcomes in patients undergoing nonbariatric general surgery. Ann Surg. 2009;250:166–172. CrossRef
- Bertoni AG, Saydah S, Brancati FL. Diabetes and the risk of infection-related mortality in the U.S. Diabetes Care. 2001;24:1044–1049. CrossRef
- Habbu A, Lakkis NM, Dokainish H. The obesity paradox: fact or fiction? Am J Cardiol. 2006;98:944–948. CrossRef
- McAuley PA, Kokkinos PF, Oliveira RB, Emerson BT, Myers JN. Obesity paradox and cardiorespiratory fitness in 12,417 male veterans aged 40 to 70 years. Mayo Clin Proc. 2010;85:115–121. CrossRef
- Schmidt DS, Salahudeen AK. Obesity-survival paradox-still a controversy? Semin Dial. 2007;20:486–492. CrossRef
- Kalantar-Zadeh K, Kopple JD. Relative contributions of nutrition and inflammation to clinical outcome in dialysis patients. Am J Kidney Dis. 2001;38:1343–1350. CrossRef
- Kalantar-Zadeh K, Kopple JD, Block G, Humphreys MH. A malnutrition-inflammation score is correlated with morbidity and mortality in maintenance hemodialysis patients. Am J Kidney Dis. 2001;38:1251–1263. CrossRef
- Hernan MA, Hernandez-Diaz S, Robins JM. A structural approach to selection bias. Epidemiology. 2004;15:615–625. CrossRef
- Banack HR, Kaufman JS. The “obesity paradox” explained. Epidemiology. 2013;24:461–462. CrossRef
- Ferreira I, Stehouwer CD. Obesity paradox or inappropriate study designs? Time for life-course epidemiology. J Hypertens. 2012;30:2271–2275. CrossRef
- McEwen LN, Karter AJ, Waitzfelder BE, et al. Predictors of mortality over 8 years in type 2 diabetic patients: Translating Research Into Action for Diabetes (TRIAD). Diabetes Care. 2012;35:1301–1309. CrossRef
- Zoppini G, Verlato G, Targher G, Bonora E, Trombetta M, Muggeo M. 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. 2008;24:624–628. CrossRef
- Ross C, Langer RD, Barrett-Connor E. Given diabetes, is fat better than thin? Diabetes Care. 1997;20:650–652. CrossRef
- Chaturvedi N, Fuller JH. Mortality risk by body weight and weight change in people with NIDDM. The WHO Multinational Study of Vascular Disease in Diabetes. Diabetes Care. 1995;18:766–774. 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, et al. Association between body-mass index and risk of death in more than 1 million Asians. N Engl J Med. 2011;364:719–729. CrossRef
- Byers T. Body-mass index and mortality. N Engl J Med. 2000;342:286–287. CrossRef
- Calle EE, Thun MJ, Petrelli JM, Rodriguez C, Heath CW Jr. Body-mass index and mortality in a prospective cohort of U.S. adults. N Engl J Med. 1999;341:1097–1105. CrossRef
- Adams KF, Schatzkin A, Harris TB, et al. Overweight, obesity, and mortality in a large prospective cohort of persons 50 to 71 years old. N Engl J Med. 2006;355:763–778. 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. Accuracy and usefulness of BMI measures based on self-reported weight and height: findings from the NHANES & NHIS 2001–2006. BMC Publ Health. 2009;9:421. CrossRef
- Whitlock G, Lewington S, Sherliker P, et al. Body-mass index and cause-specific mortality in 900 000 adults: collaborative analyses of 57 prospective studies. Lancet. 2009;373:1083–1096. 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. Does obesity contribute as much to morbidity as poverty or smoking? Public health. 2001;115:229–235.
- 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