A comparison of adiposity measures as predictors of all-cause mortality

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Hi All, The below not in our archives pdf-availed paper should inform. Yes, and waist/hip ratio is good too, it seems. It appears healthy to be lower weight, if we never smoked. Simpson JA, MacInnis RJ, Peeters A, Hopper JL, Giles GG, English DR.A comparison of adiposity measures as predictors of all-cause mortality: the Melbourne Collaborative Cohort Study.Obesity (Silver Spring). 2007 Apr;15(4):994-1003. PMID: 17426335 Abstract Objective: Our goal was to examine five different measures of adiposity as predictors of all-cause mortality. Research Methods and Procedures: Subjects were 16,969 men and 24,344 women enrolled between 1990 and 1994 in the Melbourne Collaborative Cohort Study (27 to 75 years of age). There were 2822 deaths over a median

follow-up period of 11 years. BMI, waist circumference, and waist-to-hip ratio were obtained from direct anthropometric measurements. Fat mass and percentage fat were estimated by bioelectric impedance analysis. Results: Comparing the top quintile with the second quintile, for men there was an increased risk of between 20% and 30% for all-cause mortality associated with each of the anthropometric measures. For women, there was an increased risk of 30% (95% confidence interval for hazard ratio, 1.1–1.6) observed for waist circumference and 50% (1.2–1.8) for waist-to-hip ratio, but little or no increased risk for BMI, fat mass, and percentage fat. Waist-to-hip ratio was positively and monotonically associated with all-cause mortality for both men and women. There was a linear association between waist circumference and all-cause mortality for men, whereas a U-shaped association was observed for women. Discussion: Measures of central adiposity were better predictors of mortality in women in the Melbourne Collaborative Cohort Study compared with measures of overall adiposity. We recommend measuring waist and hip circumferences in population studies investigating the risk of all-cause mortality associated with obesity. The use of additional measures such as bioelectric impedance is not justified for this outcome. ... waist circumference (WC) ... waist-to-hip ratio (WHR) ... ... Results Table 1 shows the distribution of the anthropometric measurements for men and women. Men had a higher median BMI, WC, and WHR, whereas women had a higher median fat mass and percentage fat. For men and women, respectively, 53% and 36% were overweight (BMI, 25.0–29.9 kg/m2), and 19% and 22% were obese

(BMI 30 kg/m2). Only 0.2% men and 0.9% women were underweight (BMI <18.5 kg/m2). ... All-Cause Mortality There were 2822 deaths (1656 men and 1166 women) over a median follow-up period of 11 years. The mortality was 9.0 per 1000 person-years [95% confidence interval (CI), 8.6 to 9.4] for men and 4.3 per 1000 person-years (4.1 to 4.6) for women. Men in the top quintile of each anthropometric measure had 20% to 30% higher mortality than those in the second quintile (Table 3) . Men with a BMI or fat mass in the lowest quintile also had 20% higher mortality. For both WC and WHR, there was a linear trend across the quintile groups for the risk of all-cause mortality (p = 0.003 and p = 0.001, respectively), but this was not observed for the other measures of adiposity (BMI, p = 0.74; fat mass, p = 0.11;

percentage fat, p = 0.06). Table 3. Anthropometric risk factors for all-cause mortality for males and females.=================================================== ---Hazard ratio* (95% CI) for each quintile grouping---pTrendMeasurement---1st 2nd 3rd 4th 5th---===================================================Men BMI (kg/m2) 1.2 (1.0, 1.4) 1.0 1.0 (0.9, 1.2) 1.0 (0.9, 1.2) 1.2 (1.0, 1.4) 0.74 WC (cm) 1.1 (0.9, 1.3) 1.0 1.0 (0.9, 1.2) 1.1 (0.9, 1.2) 1.3 (1.1, 1.5) 0.003 WHR 1.1 (0.9, 1.3) 1.0 1.1 (0.9, 1.3) 1.2 (1.0, 1.4) 1.3 (1.1, 1.5) 0.001 Fat mass (kg) 1.2 (1.0, 1.4) 1.0 1.0 (0.9, 1.2) 1.1 (0.9, 1.3) 1.3 (1.1, 1.5) 0.11 Percentage fat (%) 1.1 (0.9, 1.3) 1.0 0.9 (0.8, 1.1) 1.0 (0.9, 1.2)

1.2 (1.1, 1.4) 0.06 Women BMI (kg/m2) 1.2 (1.0, 1.5) 1.0 0.9 (0.7, 1.1) 0.9 (0.8, 1.1) 1.1 (0.9, 1.3) 0.70 WC (cm) 1.4 (1.1, 1.7) 1.0 1.1 (0.9, 1.4) 1.1 (0.9, 1.3) 1.3 (1.1, 1.6) 0.28 WHR 1.3 (1.0, 1.6) 1.0 1.3 (1.0, 1.5) 1.2 (1.0, 1.4) 1.5 (1.2, 1.8) 0.002 Fat mass (kg) 1.0 (0.8, 1.1) 1.0 0.7 (0.6, 0.9) 0.9 (0.7, 1.0) 1.0 (0.8, 1.2) 0.98 Percentage fat (%) 1.0 (0.9, 1.2) 1.0 0.8 (0.7, 1.0) 0.8 (0.7, 1.0) 1.0 (0.8, 1.2) 0.42 =================================================== CI, confidence interval; WC, waist circumference; WHR, waist-to-hip ratio. * Adjusted for age at attendance, country of birth, physical activity, alcohol intake, education, smoking status, living alone (men only), and family history of heart attack (men only); and stratified by "previous history of heart attack, angina, diabetes, stroke, and cancer." Women in the top quintile of WC and WHR had 30% and 50% higher mortality, respectively, compared with those in the second quintile, but there was little or no increased risk for those in the top quintile of BMI, fat mass, and percentage fat. Women in the lowest quintiles of WC, WHR, and BMI had 40%, 30%, and 20% higher mortality, respectively, than those in the second quintiles (Table 3) . Only for WHR was there a linear trend across the quintile groups for the risk of all-cause mortality (WHR, p = 0.002; BMI, p = 0.70; WC, p = 0.28; fat mass, p = 0.98; percentage fat, p = 0.42). For both sexes, the specificities at each quintile cut-off were similar for all of the anthropometric measures. However, the sensitivities at each quintile cut-off were higher for WC and WHR than for BMI, fat mass, and percentage fat (Table 4) . Table 4. Sensitivity and specificity

corresponding to quintile cut-offs of each anthropometric measures in males and females.===================================================Measurement---Sensitivity (percentile)/specificity (percentile) for quintile cut-offs ---20th 40th 60th 80th===================================================Men BMI (kg/m2) 81/20 64/40 44/60 24/80 WC (cm) 85/20 68/41 50/61 31/80 WHR 86/21 71/41 51/61 29/81 Fat mass (kg) 80/20 62/40 43/60 23/80 Percentage fat (%) 82/20 64/40 46/61 26/81 Women BMI (kg/m2) 80/20 62/40 45/60 25/80 WC (cm) 84/19 69/40 50/60 29/80 WHR 87/20 73/41 53/61 32/81 Fat mass (kg) 80/20 60/40 43/60 24/80 Percentage fat (%) 81/20 61/40 44/60 24/80

=================================================== ... CI, confidence interval; WC, waist circumference; WHR, waist-to-hip ratio. Using World Health Organization cut-offs, for men, those with BMI <23 had a significantly increased risk of 1.3-fold (95% CI, 1.1 to 1.6), whereas those with a BMI 30 (i.e., obese) had only a risk of 1.1 (1.0 to 1.3) compared with subjects with a BMI between 23 and 24.9. Similar findings were observed for the women (Table 5) . If the referent category was changed to between 18.5 and 24.9 (World Health Organization definition of "normal range"), the risk for mortality associated with a BMI 30 was 1.0 for both men and women. There was a 30% higher mortality in the top WC group for men (>102 cm) and women (>88 cm) and in the bottom WC cut-off for women (<68 cm). A significant linear trend was observed across the WC cut-offs for men (p = 0.002), but not for

women (p = 0.23). Table 5. Anthropometric risk factors for all-cause mortality for males and females.=================================================== Hazard ratio* (95% CI) for men---Hazard ratio* (95% CI) for women All Never-smokers Past smokers Current smokers---All Never-smokers Past smokers Current smokers ===================================================BMI (kg/m2) <23 1.3 (1.1,1.6) 0.9 (0.6,1.3) 1.3 (1.0,1.7) 1.8 (1.2,2.6) 1.2 (1.0,1.5) 1.1 (0.9,1.4) 1.3 (0.9,1.9) 1.4 (0.9,2.1) 23 to 24.9 1 1 1 1 1 1 1 1 25 to 27.4 0.9 (0.8,1.1) 1.1 (0.8,1.4) 0.9 (0.8,1.2) 0.7 (0.5,1.0) 0.8 (0.7,1.0) 0.8 (0.6,1.1) 0.8 (0.6,1.2) 0.8 (0.5,1.3) 27.5 to 29.9 1.0 (0.8,1.1) 0.9 (0.7,1.2) 1.0 (0.8,1.2) 1.1 (0.7,1.5) 0.9

(0.8,1.2) 1.0 (0.8,1.3) 0.9 (0.6,1.4) 0.7 (0.4,1.2) =/>30 1.1 (1.0,1.3) 1.2 (0.9,1.6) 1.1 (0.9,1.4) 1.0 (0.7,1.5) 1.1 (0.9,1.3) 1.2 (0.9,1.5) 1.2 (0.8,1.7) 0.7 (0.4,1.1) WC (cm) <79 (M)/<68 (F) 1.1 (0.8,1.4) 0.8 (0.5,1.3) 1.0 (0.7,1.5) 1.6 (1.0,2.4) 1.3 (1.1,1.6) 1.2 (0.9,1.6) 1.7 (1.1,2.4) 1.3 (0.8,2.1) 79 to 93.9 (M)/68 to 79.9(F) 1 1 1 1 1 1 1 1 94 to 102 (M)/80 to 88 (F) 1.0 (0.9,1.1) 1.0 (0.8,1.2) 1.0 (0.9,1.2) 1.0 (0.7,1.3) 1.0 (0.8,1.1) 1.0 (0.8,1.2) 1.0 (0.7,1.4) 0.9 (0.6,1.4) =/>102 (M)/88 (F) 1.3 (1.1,1.4) 1.3 (1.0,1.6) 1.3 (1.1,1.5) 1.3 (1.0,1.7) 1.3 (1.1,1.5) 1.4 (1.1,1.6) 1.1 (0.9,1.5) 1.0 (0.7,1.5) WHR <0.88 (M)/<0.73 (F) 1.1 (0.9,1.3) 1.2 (0.9,1.6) 0.9 (0.7,1.2) 1.4 (0.9,2.1) 1.3 (1.0,1.6) 1.4 (1.0,1.8) 1.4 (0.9,2.2) 0.6 (0.3,1.3) 0.88 to 0.90 (M)/0.73 to 0.75 (F) 1 1 1

1 1 1 1 1 0.91 to 0.93 (M)/0.76 to 0.79 (F) 1.1 (0.9,1.3) 1.4 (1.0,1.9) 1.0 (0.8,1.2) 1.2 (0.8,1.7) 1.3 (1.0,1.5) 1.5 (1.1,1.9) 1.0 (0.7,1.5) 1.0 (0.6,1.6) 0.94 to 0.96 (M)/0.80 to 0.83 (F) 1.2 (1.0,1.4) 1.3 (1.0,1.8) 1.1 (0.9,1.4) 1.2 (0.8,1.8) 1.2 (1.0,1.4) 1.3 (1.0,1.7) 1.1 (0.8,1.7) 0.9 (0.5,1.4) =/>0.97 (M)/0.84 (F) 1.3 (1.1,1.5) 1.5 (1.1,2.1) 1.2 (0.9,1.4) 1.5 (1.1,2.2) 1.5 (1.2,1.8) 1.7 (1.4,2.2) 1.3 (0.9,1.8) 1.2 (0.7,1.8) Fat mass (kg) <17.4 (M)/<20.1 (F) 1.2 (1.0,1.4) 1.2 (0.9,1.6) 1.0 (0.8,1.3) 1.6 (1.1,2.2) 1.0 (0.8,1.1) 0.8 (0.6,1.0) 1.2 (0.9,1.8) 1.2 (0.8,1.9) 17.4 to 21.2 (M)/20.1 to 24.3 (F) 1 1 1 1 1 1 1 1 21.3 to 24.8 (M)/24.4 to 28.7 (F) 1.0 (0.9,1.2) 1.1 (0.9,1.5) 0.9 (0.7,1.1) 1.1 (0.8,1.6) 0.7 (0.6,0.9) 0.7 (0.6,0.9) 0.7 (0.4,1.0) 0.9 (0.6,1.5) 24.9 to 29.3 (M)/28.8 to 34.9 (F) 1.1 (0.9,1.3) 1.1 (0.8,1.5) 1.0 (0.8,1.2) 1.3

(0.9,1.9) 0.9 (0.7,1.0) 0.8 (0.7,1.0) 0.9 (0.6,1.3) 1.0 (0.6,1.6) =/>29.4 (M)/35.0 (F) 1.3 (1.1,1.5) 1.3 (1.0,1.7) 1.2 (1.0,1.5) 1.3 (0.9,1.9) 1.0 (0.8,1.2) 1.0 (0.8,1.2) 1.0 (0.7,1.5) 0.8 (0.5,1.4) Percentage fat (%) <24.0 (M)/<34.1 (F) 1.1 (0.9,1.3) 1.1 (0.8,1.5) 0.9 (0.7,1.2) 1.6 (1.1,2.3) 1.0 (0.9,1.2) 0.9 (0.7,1.2) 1.3 (0.9,1.8) 1.0 (0.7,1.6) 24.0 to 27.4 (M)/34.1 to 38.4 (F) 1 1 1 1 1 1 1 1 27.5 to 30.3 (M)/38.5 to 41.8 (F) 0.9 (0.8,1.1) 0.9 (0.6,1.2) 0.9 (0.7,1.1) 1.3 (0.9,1.9) 0.8 (0.7,1.0) 0.8 (0.7,1.1) 0.7 (0.5,1.1) 0.8 (0.5,1.3) 30.4 to 33.5 (M)/41.9 to 45.7 (F) 1.0 (0.9,1.2) 1.2 (0.9,1.6) 0.9 (0.7,1.1) 1.2 (0.8,1.7) 0.8 (0.7,1.0) 0.9 (0.7,1.1) 0.9 (0.6,1.3) 0.6 (0.4,1.0) =/>33.6 (M)/45.8 (F) 1.2 (1.1,1.4) 1.2 (0.9,1.6) 1.2 (1.0,1.5) 1.5 (1.0,2.1) 1.0 (0.8,1.2) 1.0 (0.8,1.3) 1.1 (0.7,1.5) 0.9 (0.6,1.4)

=================================================== CI, confidence interval; WC, waist circumference; WHR, waist-to-hip ratio. * Adjusted for age at attendance, country of birth, physical activity, alcohol intake, education, smoking status, living alone (men only) and family history of heart attack (men only); and stratified by "previous history of heart attack, angina, diabetes, stroke, and cancer." When interactions with smoking were analyzed for men, the highest mortality among current smokers was seen in those with BMI <23; whereas for never smokers, the highest mortality was for obese participants (Table 5 , test for interaction: p = 0.005). Similar patterns were seen for the other four anthropometric measures, with never smokers in the highest category having the highest mortality but current smokers in the lowest category having the highest mortality, but the tests for

interaction were not significant (p values ranged from 0.2 to 0.5). For female never smokers, the highest mortality was in the highest category of all five measures (Table 5) . However, in past and current female smokers, the highest mortality was in the lowest category except for WHR and current smokers. None of the tests for interaction was significant (p values ranged from 0.2 to 0.6). Country of birth did not modify the association between any of the anthropometric measures and mortality (all p values >0.1). When fitting BMI, WC, WHR, fat mass, and percentage fat as continuous variables using two-term fractional polynomials, the associations between BMI, WC, fat mass, percentage fat, and all-cause mortality were U-shaped (data not shown) for both men and women. However, the association between WHR and all-cause mortality, for both men and women, was best described using a linear relationship (data not shown). Cause-Specific Mortality There were 593 deaths (417 men and 176 women) due to CVD and 1218 deaths (658 men and 560 women) due to cancer. For men, a higher risk for CVD death was observed for the top quintile grouping of all anthropometric measures, with hazard ratios ranging from 1.4 to 1.8 (Figure 1A) . For women, an increased risk for CVD death was observed in the highest quintile for WC [hazard ratio (95% CI): 1.5 (0.9 to 2.4)] and WHR [1.4 (0.9 to 2.1)] and in the lowest quintile for WC [1.7 (1.0 to 2.9)]. In the top quintile of BMI, fat mass and percentage fat the hazard ratios were less than 1 (Figure 1B) . For men, no associations between any of the anthropometric measures and cancer mortality were observed (Figure 1C) , although all of the hazard ratios in

the highest two quintiles were greater than unity. For women, an increased risk for cancer mortality was observed for the top quintile grouping of WC [hazard ratio (95% CI): 1.4 (1.0 to 1.8)] and WHR [1.5 (1.1 to 1.9)], but for this quintile, the hazard ratios for the other anthropometric measures were not greater than unity (Figure 1D) . Sensitivity Analyses The above analyses were repeated (data not shown), with 1) the exclusion of subjects with a previous history of angina, heart attack, diabetes, stroke, or cancer (5359 subjects/1017 deaths) and 2) the exclusion of the first 2 years of follow-up (262 deaths). The results were unchanged. -- Al Pater, alpater@...

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