Shape of the BMI-Mortality Association by Cause of Death,Using Generalized Additive Models

Abstract

Objectives: Numerous studies have examined the association between body mass index (BMI) and mortality. The precise shape of their association, however, has not been established. We use nonparametric methods to determine the relationship between BMI and mortality. Method: Data from the National Health Interview Survey-Linked Mortality Files 1986-2006 for adults aged 50 to 80 are analyzed using a Poisson approach to survival modeling within the generalized additive model (GAM) framework. Results: The BMI-mortality association is more V shaped than U shaped, with the odds of dying rising steeply from the lowest risk point at BMIs of 23 to 26. The association varies considerably by time since interview and cause of death. For instance, the association has an inverted J shape for respiratory causes but is monotonically increasing for diabetes deaths. Discussion: Our findings have implications for interpreting results from BMI-mortality studies and suggest caution in translating the findings into public health messages.

Keywords

body mass index obesity mortality cause-specific mortality nonparametric models

Get full access to this article

View all access options for this article.

References

Alley

D. E.

Metter

E. J.

Griswold

M. E.

Harris

T. B.

Simonsick

E. M.

Longo

D. L.

Ferrucci

(2010). Changes in weight at the end of life: Characterizing weight loss by time to death in a cohort study of older men. American Journal of Epidemiology. Advance online publication. doi:10.1093/aje/kwq16810.1093/aje/kwq168

Allison

D. B.

Faith

M. S.

Heo

Townsend-Butterworth

Williamson

D. F.

(1999). Meta-analysis of the effect of excluding early deaths on the estimated relationship between body mass index and mortality. Obesity Research, 7, 342-354.

Allison

D. B.

Heo

Flanders

D. W.

Faith

M. S.

Williamson

D. F.

(1997). Examination of “early mortality exclusion” as an approach to control for confounding by occult disease in epidemiologic studies of mortality risk factors. American Journal of Epidemiology, 146, 672-680.

Allison

D. B.

Zhu

Plankey

Faith

M. S.

Heo

(2002). Differential associations of body mass index and adiposity with all-cause mortality among men in the First and Second National Health and Nutrition Examination Surveys (NHANES I and NHANES II) Follow-up Studies. International Journal of Obesity, 26, 410-416.

Andersen

(2009). Nonparametric methods for modeling nonlinearity in regression analysis. Annual Review of Sociology, 35, 67-85.

Barros

A. J.

Hirakata

V. N.

(2003). Alternatives for logistic regression in cross-sectional studies: An empirical comparison of models that directly estimate the prevalence ratio. Medical Research Methodology, 3, 1-13.

Beck

Jackman

(1998). Beyond linearity by default: Generalized additive models. American Journal of Political Science, 42, 596-627.

Bender

Jockel

K. H.

Trautner

Spraul

Berger

(1999). Effect of age on excess mortality in obesity. Journal of the American Medical Association, 281, 1498-1504.

Botman

S. L.

Moore

T. F.

Moriarity

C. L.

Parsons

V. L.

(2000). Design and estimation for the National Health Interview Survey, 1995-2004. Vital Health Statistics, 2, 1-31.

10.

Callas

P. W.

Pastides

Hosmer

D. W.

(1998). Empirical comparisons of proportional hazards, Poisson, and logistic regression modeling of occupational cohort data. American Journal of Industrial Medicine, 33, 33-47.

11.

Calle

E. E.

(2007). Obesity and cancer. British Medical Journal, 335, 1107-1108.

12.

Calle

E. E.

Kaaks

(2004). Overweight, obesity and cancer: Epidemiological evidence and proposed mechanisms. Nature Reviews Cancer, 4, 579-591.

13.

Calle

E. E.

Thun

M. J.

Petrelli

J. M.

Rodriquez

Heath

C. W.

(1999). Body-mass index and mortality in a prospective cohort of U.S. adults. New England Journal of Medicine, 341, 1097-1105.

14.

Carstensen

(2005, May). Demography and epidemiology: Practical use of the lexis diagram in the computer age. Paper presented at the Annual Meeting of the Finnish Statistical Society, Oulu, Finland.

15.

Centers for Disease Control and Prevention. (2002). 2000 National Health Interview Survey (NHIS) public use data release. Hyattsville, MD: Division of Health Interview Statistics, National Center for Health Statistics.

16.

Diehr

O’Meara

E. S.

Fitzpatrick

Newman

A. B.

Kuller

Burke

(2008). Weight, mortality, years of healthy life, and active life expectancy in older adults. Journal of the American Geriatrics Society, 56, 76-83.

17.

Durrleman

Simon

(1989). Flexible regression models with cubic splines. Statistics in Medicine, 8, 551-561.

18.

Finkelstein

E. A.

Fiebelkorn

I. C.

Wang

(2003). National medical spending attributable to overweight and obesity: How much, and who’s paying? Health Affairs Supplement Web Exclusives, W3, 219-226.

19.

Flegal

K. M.

Carroll

M. D.

Ogden

C. L.

Curtin

L. R.

(2010). Prevalence and trends in obesity among US adults, 1999-2008. Journal of the American Medical Association, 303, 235-241.

20.

Flegal

K. M.

Graubard

B. I.

Williamson

D. F.

Gail

M. H.

(2007). Cause-specific excess deaths associated with underweight, overweight, and obesity. Journal of the American Medical Association, 298, 2028-2037.

21.

Flegal

K. M.

Graubard

B. L.

Williamson

D. F.

Gail

M. H.

(2005). Excess deaths associated with underweight, overweight, and obesity. Journal of the American Medical Association, 293, 1861-1867.

22.

Flegal

K. M.

Troiano

R. P.

Pamuk

E. R.

Kuczmarski

R. J.

Campbell

S. M.

(1995). The influence of smoking cessation on the prevalence of overweight in the United States. New England Journal of Medicine, 333, 1165-1170.

23.

Ford

E. S.

(1999). Body mass index, diabetes, and C-reactive protein among US adults. Diabetes Care, 22, 1971-1977.

24.

Frome

E. L.

(1983). The analysis of rates using Poisson regression models. Biometrics, 39, 665-674.

25.

Greenberg

J. A.

(2001). Biases in the mortality risk versus body mass index relationship in the NHANES-1 Epidemiologic Follow-Up Study. International Journal of Obesity, 25, 1071-1078.

26.

Greenberg

J. A.

(2006). Correcting biases in estimates of mortality attributable to obesity. Obesity, 14, 2071-2079.

27.

Greenberg

J. A.

Fontaine

K. R.

Allison

D. B.

(2007). Putative biases in estimating mortality attributable to obesity in the US population. International Journal of Obesity, 31, 1449-1455.

28.

Gregg

E. W.

Cheng

Y. J.

Cadwell

B. L.

Imperatore

Williams

D. E.

Flegal

K. M.

Venkat Narayan

K. M.

Williamson

D. F.

(2005). Secular trends in cardiovascular disease risk factors according to body mass index in US adults.” Journal of the American Medical Association, 293, 1868-1874.

29.

Gronniger

J. T.

(2006). A semiparametric analysis of the relationship of body mass index to mortality American Journal of Public Health, 96, 173-178.

30.

Hastie

Tibshirani

(1986). Generalized additive models (with discussion). Statistical Science, 1, 297-318.

31.

Hastie

Tibshirani

(1990). Generalized additive models. London, UK: Chapman and Hall.

32.

Hedley

A. A.

Ogden

C. L.

Johnson

C. L.

Carroll

M. D.

Curtin

L. R.

Flegal

K. M.

(2004). Prevalence of overweight and obesity among US children, adolescents, and adults, 1999-2002. Journal of the American Medical Association, 291, 2847-2850.

33.

Hummer

R. A.

Rogers

R. G.

Nam

C. B.

LeClere

F. B.

(1999). Race/ethnicity, nativity, and U.S. adult mortality. Social Science Quarterly, 80, 136-153.

34.

Jemal

Thun

M. J.

Ward

E. E.

Henley

S. J.

Cokkinides

V. E.

Murray

T. E.

(2008). Mortality from leading causes by education and race in the United States, 2001. American Journal of Preventive Medicine, 34, 1-8.

35.

Kahn

S. E.

Hull

R. L.

Utzschneider

K. M.

(2006). Mechanisms linking obesity to insulin resistance and type 2 diabetes. Nature, 444, 840-846.

36.

Lee

Manson

J. E.

Hennekens

C. H.

(1993). Body weight and mortality. A 27-year follow-up of middle-aged men. Journal of the American Medical Association, 270, 2823-2828.

37.

Lochner

K. A.

Hummer

R. A.

Cox

C. S.

(2007). Comparative analysis of the public-use and restricted-use NHIS linked mortality files. Retrieved from http://www.cdc.gov/nchs/data/datalinkage/nhis_mort_compare_2007.pdf

38.

Manson

J. E.

Willett

W. C.

Stampfer

M. J.

Colditz

G. A.

Hunter

D. J.

Hankinson

S. E.

. . . Speizer

F. E.

(1995). Body weight and mortality among women. New England Journal of Medicine, 333, 677-685.

39.

Marinou

Tousoulis

Antonopoulos

A. S.

Stefanadi

Stefanadis

(2010). Obesity and cardiovascular disease: From pathophysiology to risk stratification. International Journal of Cardiology, 138, 3-8.

40.

Massey

J. T.

Moore

T. F.

Parsons

V. L.

Tadros

(1989). Design and estimation for the National Health Interview Survey, 1985-94. Retrieved from http://www.cdc.gov/nchs/data/series/sr_02/sr02_110.pdf

41.

McDade

T. W.

Rutherford

J. N.

Adair

Kuzawa

(2009). Population differences in associations between C-reactive protein concentration and adiposity: Comparison of young adults in the Philippines and the United States. American Journal of Clinical Nutrition, 89, 1237-1245.

42.

McGee

D. L.

(2005). Body mass index and mortality: A meta-analysis based on person-level data from twenty-six observational studies. Annals of Epidemiology, 15, 87-97.

43.

McTigue

K. M.

Kuller

(2008). Cardiovascular risk factors, mortality, and overweight. Journal of the American Medical Association, 299, 1260-1261.

44.

Mehta

N. K.

Chang

V. W.

(2009). Mortality attributable to obesity among middle-aged adults in the United States. Demography, 46, 851-872.

45.

Mokdad

A. H.

Ford

E. S.

Bowman

B. A.

Dietz

W. H.

Vinicor

Bales

V. S.

Marks

J. S.

(2003). Prevalence of obesity, diabetes, and obesity-related health risk factors, 2001. Journal of the American Medical Association, 289, 76-79.

46.

Mokdad

A. H.

Marks

J. S.

Stroup

D. F.

Gerberding

J. L.

(2004). Actual causes of death in the United States, 2000. Journal of the American Medical Association, 291, 1238-1245.

47.

NHLBI, Obesity Initiative Expert Panel. (1998). Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults—The evidence report. Obesity Research, 6,(Suppl.), 51s-209s.

48.

Reeves

G. K.

Pirie

Beral

Green

Spencer

Bull

(2007, December). Cancer incidence and mortality in relation to body mass index in the Million Women Study: Cohort study. British Medical Journal, 335, 1134.

49.

Stommel

Schoenborn

C. A.

(2010). Variations in BMI and prevalence of health risks in diverse racial and ethnic populations. Obesity, 18, 1821-1826.

50.

Stone

C. J.

(1985). Additive regression and other nonparametric methods. Annals of Statistics, 12, 689-705.

51.

Van Gaal

L. F.

Mertens

I. L.

De Block

C. E.

(2006). Mechanisms linking obesity with cardiovascular disease. Nature, 444, 875-880.

52.

Wee

C. C.

Mukamal

K. J.

Huang

Davis

R. B.

McCarthy

E. P.

Mittleman

M. A.

(2008). Obesity and C-reactive protein levels among White, Black, and Hispanic US adults. Epidemiology, 16, 875-880.

53.

Wee

C. C.

Mukamal

K. J.

Huang

Davis

R. B.

McCarthy

E. P.

Mittleman

M. A.

(2003). Thin plate regression splines. Journal of the Royal Statistical Society: Series B (Statistical Methodology), 65(1), 95-114.

54.

Wood

S. N.

(2006). Generalized additive models: An introduction with R. Boca Raton, FL: Chapman & Hall.

55.

Zajacova

Burgard

S. A.

(2010). Body weight and health from early to mid-adulthood: A longitudinal analysis. Journal of Health and Social Behavior, 51(1), 92-107.

56.

Zhu

Heo

Plankey

Faith

M. S.

Allison

D. B.

(2003). Associations of body mass index and anthropometric indicators of fat mass and fat free mass with all-cause mortality among women in the First and Second National Health and Nutrition Examination Surveys Follow-up Studies. Annals of Epidemiology, 13, 286-293.