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Obesity Paradox: Conditioning on Disease Enhances Biases in Estimating the Mortality Risks of Obesity

Published on May 1, 2014in Epidemiology4.719
· DOI :10.1097/EDE.0000000000000075
Samuel H. Preston53
Estimated H-index: 53
,
Andrew Stokes18
Estimated H-index: 18
Abstract
In a wide variety of disease states, obese persons have been shown to experience lower mortality and better survival than that shown by the nonobese. These states include diabetes,1–3 coronary artery disease,4,5 heart failure,6 peripheral arterial disease,5 hypertension,7 chronic obstructive pulmonary disease,8 lung cancer,9 and esophageal adenocarcinoma.10 Superior survival among the obese patients has also been demonstrated after myocardial infarction,11 coronary revascularization,12 and angiography,13 and among hemodialysis patients.14 Better survival for obese patients in these disease states is considered paradoxical because obesity is associated with higher mortality in the vast majority of studies where it has been investigated.15 In this article, we argue that the obesity paradox is a product of statistical biases. Although these biases are present in most observational cohort studies of the mortality risks of obesity, they are exaggerated when attention is limited to populations that are conditioned on a disease state. We demonstrate these biases through formal reasoning and by application to a population with diabetes and prediabetes.
  • References (29)
  • Citations (80)
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References29
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#1Catherine Jackson (Harvard University)H-Index: 21
#2Hsin Chieh Yeh (JHUSOM: Johns Hopkins University School of Medicine)H-Index: 2
Last. Frederick L. Brancati (Johns Hopkins University)H-Index: 87
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BACKGROUND 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.
42 CitationsSource
60 CitationsSource
#1Oskar Angerås (University of Gothenburg)H-Index: 14
#2Per Albertsson (University of Gothenburg)H-Index: 32
Last. Elmir Omerovic (University of Gothenburg)H-Index: 34
view all 9 authors...
Aims The obesity paradox refers to the epidemiological evidence that obesity compared with normal weight is associated with counter-intuitive improved health in a variety of disease conditions. The aim of this study was to investigate the relationship between body mass index (BMI) and mortality in patients with acute coronary syndromes (ACSs). Methods and results We extracted data from the Swedish Coronary Angiography and Angioplasty Registry and identified 64 436 patients who underwent coronary...
136 CitationsSource
#1Wolfram Doehner (Charité)H-Index: 46
#2Erland ErdmannH-Index: 58
Last. Stefan D. Anker (Charité)H-Index: 122
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Abstract Context Although weight reduction is a recommended goal in type 2 diabetes mellitus (T2DM), weight loss is linked to impaired survival in patients with some chronic cardiovascular diseases. Objective To assess the association of weight and weight change with mortality and non-fatal cardiovascular outcomes (hospitalisation, myocardial infarction and stroke) in T2DM patients with cardiovascular co-morbidity and the effect of pioglitazone-induced weight change on mortality. Setting and par...
120 CitationsSource
#1Isabel Ferreira (UM: Maastricht University)H-Index: 44
#2Coen D. A. StehouwerH-Index: 108
O besity is a major risk factor for cardiovascular disease (CVD) and all-cause mortality [1]. On the basis of individuals’ level of BMI, this relationship is characterized by a J-shape with the nadir – that is, the point of the highest survival rate – around 22.5– 25 kg/m. Paradoxically, among patients with established CVD, this relationship seems to change in such a way that the nadir shifts to the right, with levels of BMI belonging to the overweight–obese categories apparently conferring the ...
32 CitationsSource
Using a standardized series of dose– response cancer-specific meta-analyses, we previously reported positive associations between body mass index (BMI) and the risks of several cancers (1). Two smokingrelated cancers, namely lung and esophageal squamous cell carcinoma, were notable exceptions: the risks of these cancers were inversely associated with BMI. Given the established observation that BMI values are generally lower in current smokers than in never smokers, we reasoned that the observed ...
14 CitationsSource
OBJECTIVES: An inverse relationship between body mass index (BMI) and the risk of lung cancer has been reported in several studies. In this study, we aimed to assess whether BMI can affect survival after lung resection for cancer. METHODS: We reviewed patient data for a 10-year period; 337 patients with BMI ≥30 who underwent lung resection for non-small cell lung cancer were identified. This group of patients was matched at a ratio of 1:1 to a group with BMI <30 and with similar characteristics ...
38 CitationsSource
#1Mercedes R. Carnethon (NU: Northwestern University)H-Index: 56
#2Peter John D De Chavez (NU: Northwestern University)H-Index: 8
Last. Alan Richard Dyer (NU: Northwestern University)H-Index: 82
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#1Emily M. Bucholz (Yale University)H-Index: 18
#2Saif S. Rathore (Yale University)H-Index: 47
Last. Harlan M. Krumholz (Yale University)H-Index: 170
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Background Previous studies have described an “obesity paradox” with heart failure, whereby higher body mass index (BMI) is associated with lower mortality. However, little is known about the impact of obesity on survival after acute myocardial infarction.
78 CitationsSource
#1Harry H. Yoon (Mayo Clinic)H-Index: 14
#2Mark Andrew LewisH-Index: 7
Last. Frank A. Sinicrope (Mayo Clinic)H-Index: 55
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Purpose Given that smoking affects body mass index (BMI) and survival, stratification by smoking status may be required to determine the true prognostic impact of BMI. Although obesity increases risk for developing esophageal adenocarcinoma (EAC), the prognostic influence of obesity and its potential modification by smoking status is unknown in this disease. Patients and Methods All patients (N = 778) underwent potentially curative esophagectomy. BMI was calculated using measured height and weig...
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#1Ayesha A. Javed (McMaster University)
#2Rumaisa Aljied (McMaster University)
Last. Parminder Raina (McMaster University)H-Index: 42
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In older age, body composition changes as fat mass increases and redistributes. Therefore, the current body mass index (BMI) classification may not accurately reflect risk in older adults (65+). This study aimed to review the evidence on the association between BMI and all-cause mortality in older adults and specifically, the findings regarding overweight and obese BMI. A systematic search of the OVID MEDLINE and Embase databases was conducted between 2013 and September 2018. Observational studi...
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ABSTRACT OBJECTIVE We aimed to investigate the obesity paradox and assess the effect of BMI on early and late clinical outcomes after cardiac surgery. DESIGN We conducted a cohort study, performing a retrospective analysis of prospectively collected data. SETTING Single institution cardiology medical center. PARTICIPANTS Consecutive patients undergoing cardiac surgery from January 2009 to January 2019. Patients were divided into 4 groups defined by body mass index (BMI): underweight (UW) (≤18,5 ...
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#1Joel Tate (UWA: University of Western Australia)H-Index: 1
#2Matthew Knuiman (UWA: University of Western Australia)H-Index: 60
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Aims/hypothesis This prospective association study aimed to compare the relationship between each of four obesity indices and mortality risk in people with type 2 diabetes.
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#1Lu Wang (Capital Medical University)H-Index: 1
#2Xin Du (UNSW: University of New South Wales)
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Abstract Introduction Metformin, a common medication used in the treatment of diabetes mellitus is known to have anticancer effects. We hypothesized that the salutary effect of metformin on the survival of patients with stage I NSCLC is influenced by body mass index (BMI). Methods Patients undergoing lobectomy for stage I NSCLC without neoadjuvant therapy were included. Univariate and multivariate survival analyses to examine the association between metformin use and overall survival (OS), disea...
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#1Joshua F. Baker (UPenn: University of Pennsylvania)H-Index: 24
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#1Hailey R. Banack (SUNY: State University of New York System)H-Index: 10
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