The U-shaped association between body mass index and mortality: Relationship with weight gain in a native American population

doi:10.1016/0895-4356(94)00217-E

Journal of Clinical Epidemiology

Volume 48, Issue 7, July 1995, Pages 903-916

https://doi.org/10.1016/0895-4356(94)00217-E Get rights and content

Abstract

In order to determine whether weight loss explains high mortality rates in those with a low body mass index (BMI), the relationships between BMI, rate of weight gain and mortality were examined in Pima Indians. Subjects were 814 diabetic and 1814 nondiabetic participants in a longitudinal survey who had at least two examinations after age 20. Median duration of follow-up was 8.1 (range 0.03–25.1) years. BMI showed a U-shaped relationship with mortality rates in men with the lowest rates in the 30–35 kg/m² category; an inverse relationship was seen in women. Subjects who were losing weight had higher mortality rates than those who were gaining. However, excess mortality among the lightest subjects was present among those who were gaining weight. Among nondiabetic subjects, the mortality ratio (MR) for BMI < 25 kg/m² compared with 30–35 kg/m² was 1.5 [95% confidence interval (CI) 1.0–2.2] unadjusted for weight gain, while the adjusted MR was 1.3 [95% CI 0.9–1.9]. Weight loss, which may reflect underlying illness, is associated with high mortality rates in Pima Indians but does not fully account for the high mortality in the lightest individuals.

References (86)

GC Rhoads et al.
The relation of coronary disease, stroke and mortality to weight in youth and middle age
Lancet
(1983)
P Avons et al.
Weight and mortality
Lancet
(1983)
C Rumpel et al.
Modification of the relationship between the Quetlet Index and mortality by weight-loss history among older women
Ann Epidemiol
(1993)
SM Garn et al.
Fatness and mortality in the West of Scotland
Am J Clin Nutr
(1983)
A Rissanen et al.
Weight and mortality in Finnish men
J Clin Epidemiol
(1989)
A Rissanen et al.
Weight and mortality in Finnish women
J Clin Epidemiol
(1991)
P Allebeck et al.
Height, body mass index and mortality: do social factors explain the association?
Public Health
(1992)
N Borhani et al.
Report of a ten-year follow-up study of the San Francisco longshoremen
J Chron Dis
(1963)
AR Dyer et al.
Relationship of relative weight and body mass index to 14-year mortality in the Chicago Peoples Gas Company Study
J Chron Dis
(1975)
EA Lew et al.
Variations in mortality by weight among 750,000 men and women
J Chron Dis
(1979)

U.S. Public Health Service

Nutrition

Society of Actuaries

Metropolitan Life Insurance Company

New weight standards for men and women

Stat Bull

(1959)

K Lindsted et al.

Body mass index and patterns of mortality among Seventh-day Adventist men

Int J Obes

(1991)

J Stevens et al.

Body mass index and body girths as predictors of mortality in black and white women

Arch Intern Med

(1992)

IM Lee et al.

Body weight and mortality: A 27 year follow-up of middle-aged men

Am J Epidemiol

(1993)

G Wannamethee et al.

Body weight and mortality in middle aged British men: impact of smoking

Br Med J

(1989)

HT Waaler

Height, weight and mortality: the Norwegian experience

Acta Med Scand

(1984)

S Sidney et al.

Thinness and mortality

Am J Public Health

(1987)

AP Fitzgerald et al.

Body weight and coronary heart disease mortality: an analysis in relation to age and smoking habit, 15 years follow-up data from the Whitehall Study

Int J Obes

(1992)

J Stevens et al.

Body mass index and body girths as predictors of mortality in black and white men

Am J Epidemiol

(1992)

K Westlund et al.

Ten-year mortality and morbidity related to serum cholesterol

Scand J Clin Lab Invest

(1972)

P Sorlie et al.

Body build and mortality: the Framingham Study

JAMA

(1980)

DJ Pettitt et al.

Mortality as a function of obesity and diabetes mellitus

Am J Epidemiol

(1982)

JP Vandenbroucke et al.

Weight, smoking and mortality

JAMA

(1984)

J Tuomilehto et al.

Body weight and risk of myocardial infarction and death in the adult population of eastern Finland

Br Med J

(1987)

T Gordon et al.

Weight and mortality in men: the Albany Study

Int J Epidemiol

(1988)

T Harris et al.

Body mass index and mortality among nonsmoking older persons: the Framingham Heart Study

JAMA

(1988)

B Larsson et al.

Obesity, adipose tissue distribution and health—the study of men born in 1913

M Tayback et al.

Body weight as a risk factor in the elderly

Arch Intern Med

(1990)

WC Knowler et al.

Inverse association of obesity and mortality in diabetic and nondiabetic Pima Indians

Diabetes

(1991)

J Tuomilehto

Body mass index and prognosis in elderly hypertensive patients: a report from the European Working Party on High Blood Pressure in the Elderly

Am J Med

(1991)

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Original articleThe U-shaped association between body mass index and mortality: Relationship with weight gain in a native American population

Abstract

Lancet

Lancet

Ann Epidemiol

Am J Clin Nutr

J Clin Epidemiol

J Clin Epidemiol

Public Health

J Chron Dis

J Chron Dis

J Chron Dis

Am Heart J

J Clin Epidemiol

J Clin Epidemiol

J Clin Epidemiol

J Clin Epidemiol

Lancet

Am J Clin Nutr

Arch Gerontol Geriatr

Med Clin North Am

J Clin Epidemiol

Nutrition

New weight standards for men and women

Stat Bull

Body mass index and patterns of mortality among Seventh-day Adventist men

Int J Obes

Body mass index and body girths as predictors of mortality in black and white women

Arch Intern Med

Body weight and mortality: A 27 year follow-up of middle-aged men

Am J Epidemiol

Body weight and mortality in middle aged British men: impact of smoking

Br Med J

Height, weight and mortality: the Norwegian experience

Acta Med Scand

Thinness and mortality

Am J Public Health

Body weight and coronary heart disease mortality: an analysis in relation to age and smoking habit, 15 years follow-up data from the Whitehall Study

Int J Obes

Body mass index and body girths as predictors of mortality in black and white men

Am J Epidemiol

Ten-year mortality and morbidity related to serum cholesterol

Scand J Clin Lab Invest

Body build and mortality: the Framingham Study

JAMA

Mortality as a function of obesity and diabetes mellitus

Am J Epidemiol

Weight, smoking and mortality

JAMA

Body weight and risk of myocardial infarction and death in the adult population of eastern Finland

Br Med J

Weight and mortality in men: the Albany Study

Int J Epidemiol

Body mass index and mortality among nonsmoking older persons: the Framingham Heart Study

JAMA

Obesity, adipose tissue distribution and health—the study of men born in 1913

Body weight as a risk factor in the elderly

Arch Intern Med

Inverse association of obesity and mortality in diabetic and nondiabetic Pima Indians

Diabetes

Body mass index and prognosis in elderly hypertensive patients: a report from the European Working Party on High Blood Pressure in the Elderly

Am J Med

Original article
The U-shaped association between body mass index and mortality: Relationship with weight gain in a native American population