Relation of Body Mass Index to Mortality Among Men With Coronary Heart Disease

  • Michal Benderly
    Corresponding author: Tel: 972-3-5344703; fax: 972-3-5342392
    The Israel Society for the Prevention of Heart Attacks, Neufeld Cardiac Research Institute, Sheba Medical Center, Tel-Hashomer, Israel

    Gertner Institute for Epidemiology and Health Research Policy, Sheba Medical Center, Tel-Hashomer, Israel

    Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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  • Valentina Boyko
    Gertner Institute for Epidemiology and Health Research Policy, Sheba Medical Center, Tel-Hashomer, Israel
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  • Uri Goldbourt
    The Israel Society for the Prevention of Heart Attacks, Neufeld Cardiac Research Institute, Sheba Medical Center, Tel-Hashomer, Israel

    Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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      Reports among patients with coronary heart disease regarding the association between body mass index (BMI) and long-term mortality are inconsistent, ranging among linear, U-shaped, or inverse (the “obesity paradox”) associations. BMI and mortality data were available for 12,466 men with chronic coronary heart disease. BMI was classified as <20 (lean), 20.0 to 22.99, 23.0 to 24.99 (reference), 25.0 to 26.99, 27.0 to 29.99, and ≥30 kg/m2 (obese). Age-adjusted (direct methods) mortality was investigated within risk factor categories. Adjusted hazard ratios compared with the reference group were estimated using a Cox proportional-hazards model. Two thirds of the patients had BMIs ≥25 kg/m2. A number of risk factors were progressively more frequent with increasing BMI (age, diabetes, past smoking, and metabolic components). Over a median follow-up period of 12 years, adjusted mortality rates per 1,000 patient-years followed a U-shaped association with BMI. The highest risk was noted in 148 lean (hazard ratio 1.41, 95% confidence interval 1.08 to 1.85) and 1,788 obese (hazard ratio 1.28, 95% confidence interval 1.15 to 1.42) patients. Mortality hazard in patients with BMIs of 20.0 to 29.99 kg/m2 (84% of patients) did not significantly differ from the reference group (lowest risk). Risk factor presence was associated with higher mortality in every BMI category. Lean patients had a particularly poor prognosis in the presence of past myocardial infarction, smoking, or renal insufficiency. A U-shaped association was found in most subgroups examined. In conclusion, BMI ≥25 kg/m2 is common in patients with coronary heart disease. A U-shaped association, with highest risk among lean and obese patients, is persistent regardless of risk factor presence. Further data are required to support the need of aggressive weight reduction in patients with BMIs <30 kg/m2.
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        • Goldbourt U.
        • Behar S.
        • Reicher-Reiss H.
        • Agmon J.
        • Kaplinsky E.
        • Graff E.
        • Kishon Y.
        • Caspi A.
        • Weisbort J.
        • Mandelzweig L.
        • Abinader E.
        • Aharon L.
        • Braun S.
        • David D.
        • Flich M.
        • Friedman Y.
        • Kristal N.
        • Leil N.
        • Markeiwicz W.
        • Marmor A.
        • Palant A.
        • Peled B.
        • Rabinowitz B.
        • Reisin L.
        • Roguin N.
        • Rosenfeld T.
        • Schlesinger Z.
        • Sclarovsky S.
        • Sherf L.
        • Tzivoni D.
        • Zahavi I.
        • Zion M.
        • Brunner D.
        • BIP Study Group
        Rationale and design of a secondary prevention trial of increasing serum HDL cholesterol and reducing triglycerides in patients with clinically manifest atherosclerotic heart disease.
        Am J Cardiol. 1993; 71: 909-915
        • The BIP Study Group
        Secondary prevention by raising HDL cholesterol and reducing triglycerides in patients with coronary artery disease: the Bezafibrate Infarction Prevention (BIP) study.
        Circulation. 2000; 102: 21-27
        • National Kidney Foundation
        K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification.
        Am J Kidney Dis. 2002; 39: S1-S266
        • Harrell F.E.
        • Lee K.L.
        • Mark D.B.
        Tutorial in biostatistics: multivariable prognostic models: issues in developing models, evaluating assumptions and adequacy, and measuring and reducing errors.
        Stat Med. 1996; 15: 361-387
        • McGee D.L.
        • Diverse Populations Collaboration
        Body mass index and mortality: a meta-analysis based on person-level data from twenty-six observational studies.
        Ann Epidemiol. 2005; 15: 87-97
        • Whitlock G.
        • Lewington S.
        • Sherliker P.
        • Clarke R.
        • Emberson J.
        • Halsey J.
        • Qizilbash N.
        • Collins R.
        • Peto R.
        • Prospective Studies Collaboration
        Body-mass index and cause-specific mortality in 900 000 adults: collaborative analyses of 57 prospective studies.
        Lancet. 2009; 373: 1083-1096
        • Anker S.D.
        • Sharma R.
        The syndrome of cardiac cachexia.
        Int J Cardiol. 2002; 85: 51-66
        • Willett W.C.
        • Dietz W.H.
        • Colditz G.A.
        Guidelines for healthy weight.
        N Engl J Med. 1999; 341: 427-434
        • Galal W.
        • van Gestel Y.R.
        • Hoeks S.E.
        • Sin D.D.
        • Winkel T.A.
        • Bax J.J.
        • Verhagen H.
        • Awara A.M.
        • Klein J.
        • van Domburg R.T.
        • Poldermans D.
        The obesity paradox in patients with peripheral arterial disease: the influence of chronic obstructive pulmonary disease.
        Chest. 2008; 134: 925-930
        • Romero-Corral A.
        • Montori V.M.
        • Somers V.K.
        • Korinek J.
        • Thomas R.J.
        • Allison T.G.
        • Mookadam F.
        • Lopez-Jimenez F.
        Association of bodyweight with total mortality and with cardiovascular events in coronary artery disease: a systematic review of cohort studies.
        Lancet. 2006; 368: 666-678
        • Galal W.
        • van Domburg R.T.
        • Feringa H.H.
        • Schouten O.
        • Elhendy A.
        • Bax J.J.
        • Awara A.M.
        • Klein J.
        • Poldermans D.
        Relation of body mass index to outcome in patients with known or suspected coronary artery disease.
        Am J Cardiol. 2007; 99: 1485-1490
        • Mak K.H.
        • Bhatt D.L.
        • Shao M.
        • Haffner S.M.
        • Hamm C.W.
        • Hankey G.J.
        • Johnston S.C.
        • Montalescot G.
        • Steg P.G.
        • Steinhubl S.R.
        • Fox K.A.
        • Topol E.J.
        The influence of body mass index on mortality and bleeding among patients with or at high-risk of atherothrombotic disease.
        Eur Heart J. 2009; 30: 857-865
        • Wienbergen H.
        • Gitt A.K.
        • Juenger C.
        • Schiele R.
        • Heer T.
        • Towae F.
        • Gohlke H.
        • Senges J.
        • MITRA PLUS Study Group
        Impact of the body mass index on occurrence and outcome of acute ST-elevation myocardial infarction.
        Clin Res Cardiol. 2008; 97: 83-88
        • Nigam A.
        • Wright R.S.
        • Allison T.G.
        • Williams B.A.
        • Kopecky S.L.
        • Reeder G.S.
        • Murphy J.G.
        • Jaffe A.S.
        Excess weight at time of presentation of myocardial infarction is associated with lower initial mortality risks but higher long-term risks including recurrent re-infarction and cardiac death.
        Int J Cardiol. 2006; 110: 153-159
        • Gurm H.S.
        • Whitlow P.L.
        • Kip K.E.
        • BARI Investigators
        The impact of body mass index on short- and long-term outcomes in patients undergoing coronary revascularization.
        J Am Coll Cardiol. 2002; 39: 834-840
        • Planat-Bénard V.
        • Menard C.
        • André M.
        • Puceat M.
        • Perez A.
        • Garcia-Verdugo J.M.
        • Pénicaud L.
        • Casteilla L.
        Spontaneous cardiomyocyte differentiation from adipose tissue stroma cells.
        Circ Res. 2004; 94: 223-229
        • Rubinshtein R.
        • Halon D.A.
        • Jaffe R.
        • Shahla J.
        • Lewis B.S.
        Relation between obesity and severity of coronary artery disease in patients undergoing coronary angiography.
        Am J Cardiol. 2006; 97: 1277-1280
        • Steinberg B.A.
        • Cannon C.P.
        • Hernandez A.F.
        • Pan W.
        • Peterson E.D.
        • Fonarow G.C.
        Medical therapies and invasive treatments for coronary artery disease by body mass: the “obesity paradox” in the Get With the Guidelines database.
        Am J Cardiol. 2007; 100: 1331-1335
        • Habbu A.
        • Lakkis N.M.
        • Dokainish H.
        The obesity paradox: fact or fiction?.
        Am J Cardiol. 2006; 98: 944-948
        • Kennedy L.M.
        • Dickstein K.
        • Anker S.D.
        • James M.
        • Cook T.J.
        • Kristianson K.
        • Willenheimer R.
        Weight-change as a prognostic marker in 12 550 patients following acute myocardial infarction or with stable coronary artery disease.
        Eur Heart J. 2006; 27: 2755-2762
        • Lopez-Jimenez F.
        • Wu C.O.
        • Tian X.
        • O'Connor C.
        • Rich M.W.
        • Burg M.M.
        • Sheps D.
        • Raczynski J.
        • Somers V.K.
        • Jaffe A.S.
        Weight change after myocardial infarction—the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) experience.
        Am Heart J. 2008; 155: 478-484
        • Eilat-Adar S.
        • Eldar M.
        • Goldbourt U.
        Association of intentional changes in body weight with coronary heart disease event rates in overweight subjects who have an additional coronary risk factor.
        Am J Epidemiol. 2005; 161: 352-358
        • Lavie C.J.
        • Milani R.V.
        Effects of cardiac rehabilitation, exercise training, and weight reduction on exercise capacity, coronary risk factors, behavioral characteristics, and quality of life in obese coronary patients.
        Am J Cardiol. 1997; 79: 397-401
        • Yaari S.
        • Goldbourt U.
        Voluntary and involuntary weight loss: associations with long term mortality in 9,228 middle-aged and elderly men.
        Am J Epidemiol. 1998; 148: 546-555
        • Yusuf S.
        • Hawken S.
        • Ounpuu S.
        • Bautista L.
        • Franzosi M.G.
        • Commerford P.
        • Lang C.C.
        • Rumboldt Z.
        • Onen C.L.
        • Lisheng L.
        • Tanomsup S.
        • Wangai Jr, P.
        • Razak F.
        • Sharma A.M.
        • Anand S.S.
        • INTERHEART Study Investigators
        Obesity and the risk of myocardial infarction in 27,000 participants from 52 countries: a case-control study.
        Lancet. 2005; 366: 1640-1649

      Linked Article

      • The “Obesity Paradox” in Coronary Heart Disease
        American Journal of CardiologyVol. 106Issue 11
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          We read with great interest the well-written and well-done study from Israel by Benderly et al1 from the Bezafibrate Infarction Prevention (BIP) database examining the relation of body mass index (BMI) to mortality in men with coronary heart disease (CHD). Importantly, in their study, they demonstrated a U-shaped association, with the highest risk in the lean (BMI <20 kg/m2) and in the obese (BMI ≥30 kg/m2) groups. It is critical to point out that these results are different from those of many other studies and meta-analyses, in which overweight (BMI 25 to 30 kg/m2) and obese (or at least mildly obese; BMI 30 to 35 kg/m2) patients have lower mortality than “normal”-BMI patients.
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