Revealing the burden of obesity using weight histories
Contributed by Samuel H. Preston, December 4, 2015 (sent for review August 4, 2015; reviewed by David B. Allison and John Bongaarts)
Significance
There is substantial uncertainty about the association between obesity and mortality. A major issue is the treatment of reverse causation, a phrase referring to the loss of weight among people who become ill. Weight histories are vital to addressing reverse causality, but few studies incorporate them. Here we introduce nationally representative data on lifetime maximum weight to distinguish individuals who were never obese from those who were formerly obese and lost weight. We formally investigate the performance of various models, finding that models that incorporate history perform better than the conventional approach based on a single observation of weight at the time of survey. We conclude that the burden of obesity is likely to be greater than is commonly appreciated.
Abstract
Analyses of the relation between obesity and mortality typically evaluate risk with respect to weight recorded at a single point in time. As a consequence, there is generally no distinction made between nonobese individuals who were never obese and nonobese individuals who were formerly obese and lost weight. We introduce additional data on an individual’s maximum attained weight and investigate four models that represent different combinations of weight at survey and maximum weight. We use data from the 1988–2010 National Health and Nutrition Examination Survey, linked to death records through 2011, to estimate parameters of these models. We find that the most successful models use data on maximum weight, and the worst-performing model uses only data on weight at survey. We show that the disparity in predictive power between these models is related to exceptionally high mortality among those who have lost weight, with the normal-weight category being particularly susceptible to distortions arising from weight loss. These distortions make overweight and obesity appear less harmful by obscuring the benefits of remaining never obese. Because most previous studies are based on body mass index at survey, it is likely that the effects of excess weight on US mortality have been consistently underestimated.
Acknowledgments
We are grateful to the reviewers of the manuscript for helpful comments and suggestions. This work was supported by a grant from the National Institute on Aging at the National Institutes of Health (R01AG040212).
References
1
A Berrington de Gonzalez, et al., Body-mass index and mortality among 1.46 million white adults. N Engl J Med 363, 2211–2219 (2010).
2
DA Boggs, et al., General and abdominal obesity and risk of death among black women. N Engl J Med 365, 901–908 (2011).
3
EE Calle, MJ Thun, JM Petrelli, C Rodriguez, Jr CW Heath, Body-mass index and mortality in a prospective cohort of U.S. adults. N Engl J Med 341, 1097–1105 (1999).
4
KM Flegal, BI Graubard, DF Williamson, MH Gail, Excess deaths associated with underweight, overweight, and obesity. JAMA 293, 1861–1867 (2005).
5
KM Flegal, BK Kit, H Orpana, BI Graubard, Association of all-cause mortality with overweight and obesity using standard body mass index categories: A systematic review and meta-analysis. JAMA 309, 71–82 (2013).
6
JE Manson, et al., Body weight and mortality among women. N Engl J Med 333, 677–685 (1995).
7
G Whitlock, et al., Body-mass index and cause-specific mortality in 900 000 adults: Collaborative analyses of 57 prospective studies. Lancet; Prospective Studies Collaboration 373, 1083–1096 (2009).
8
W Zheng, et al., Association between body-mass index and risk of death in more than 1 million Asians. N Engl J Med 364, 719–729 (2011).
9
DB Allison, KR Fontaine, JE Manson, J Stevens, TB VanItallie, Annual deaths attributable to obesity in the United States. JAMA 282, 1530–1538 (1999).
10
SS Cohen, et al., Obesity and all-cause mortality among black adults and white adults. Am J Epidemiol 176, 431–442 (2012).
11
KM Flegal, BI Graubard, DF Williamson, MH Gail, Cause-specific excess deaths associated with underweight, overweight, and obesity. JAMA 298, 2028–2037 (2007).
12
D Gu, et al., Body weight and mortality among men and women in China. JAMA 295, 776–783 (2006).
13
SH Jee, et al., Body-mass index and mortality in Korean men and women. N Engl J Med 355, 779–787 (2006).
14
RJ Jarrett, MJ Shipley, G Rose, Weight and mortality in the Whitehall Study. Br Med J (Clin Res Ed) 285, 535–537 (1982).
15
PT Katzmarzyk, CL Craig, C Bouchard, Underweight, overweight and obesity: Relationships with mortality in the 13-year follow-up of the Canada Fitness Survey. J Clin Epidemiol 54, 916–920 (2001).
16
DL McGee, Body mass index and mortality: A meta-analysis based on person-level data from twenty-six observational studies. Ann Epidemiol; Diverse Populations Collaboration 15, 87–97 (2005).
17
GK Reeves, et al., Cancer incidence and mortality in relation to body mass index in the Million Women Study: Cohort study. BMJ; Million Women Study Collaboration 335, 1134 (2007).
18
P Sorlie, T Gordon, WB Kannel, Body build and mortality. The Framingham study. JAMA 243, 1828–1831 (1980).
19
S-W Yi, H Ohrr, S-A Shin, J-J Yi, Sex-age-specific association of body mass index with all-cause mortality among 12.8 million Korean adults: A prospective cohort study. Int J Epidemiol, July 23, 2015).
20
SH Preston, NK Mehta, A Stokes, Modeling obesity histories in cohort analyses of health and mortality. Epidemiology 24, 158–166 (2013).
21
A Abdullah, et al., The number of years lived with obesity and the risk of all-cause and cause-specific mortality. Int J Epidemiol 40, 985–996 (2011).
22
NK Mehta, et al., Weight histories and mortality among Finnish adults: The role of duration and peak body mass index. Epidemiology 25, 707–710 (2014).
23
DD Ingram, ME Mussolino, Weight loss from maximum body weight and mortality: The Third National Health and Nutrition Examination Survey Linked Mortality File. Int J Obes 34, 1044–1050 (2010).
24
M Myrskylä, VW Chang, Weight change, initial BMI, and mortality among middle- and older-aged adults. Epidemiology 20, 840–848 (2009).
25
H Zheng, D Tumin, Z Qian, Obesity and mortality risk: New findings from body mass index trajectories. Am J Epidemiol 178, 1591–1599 (2013).
26
A Zajacova, J Ailshire, Body mass trajectories and mortality among older adults: A joint growth mixture-discrete-time survival analysis. Gerontologist 54, 221–231 (2014).
27
L Ferrucci, D Alley, Obesity, disability, and mortality: A puzzling link. Arch Intern Med 167, 750–751 (2007).
28
F Hu, Obesity and mortality. Obesity Epidemiology, ed FB Hu (Oxford University Press, New York), pp. 216–233 (2008).
29
DA Lawlor, CL Hart, DJ Hole, G Davey Smith, Reverse causality and confounding and the associations of overweight and obesity with mortality. Obesity (Silver Spring) 14, 2294–2304 (2006).
30
JE Manson, MJ Stampfer, CH Hennekens, WC Willett, Body weight and longevity. A reassessment. JAMA 257, 353–358 (1987).
31
N Metha, Obesity and mortality. International Encyclopedia of the Social & Behavioral Sciences, ed J Wright (Elsevier, 2nd Ed, Oxford), pp. 75–81 (2015).
32
DK Tobias, FB Hu, Does being overweight really reduce mortality? Obesity (Silver Spring) 21, 1746–1749 (2013).
33
SG Wannamethee, AG Shaper, M Walker, Weight change, body weight and mortality: The impact of smoking and ill health. Int J Epidemiol 30, 777–786 (2001).
34
WC Willett, WH Dietz, GA Colditz, Guidelines for healthy weight. N Engl J Med 341, 427–434 (1999).
35
WC Willett, FB Hu, GA Colditz, JE Manson, Underweight, overweight, obesity, and excess deaths. JAMA 294, 551–553 (2005).
36
JE Manson, et al., Estimating the number of deaths due to obesity: Can the divergent findings be reconciled? J Womens Health (Larchmt) 16, 168–176 (2007).
37
WC Willett, FB Hu, M Thun, Overweight, obesity, and all-cause mortality. JAMA 309, 1681 (2013).
38
KM Flegal, BI Graubard, DF Williamson, RS Cooper, Reverse causation and illness-related weight loss in observational studies of body weight and mortality. Am J Epidemiol 173, 1–9 (2011).
39
KM Flegal, K Kalantar-Zadeh, Overweight, mortality and survival. Obesity (Silver Spring) 21, 1744–1745 (2013).
40
K Flegal, BI Graubard, DF Williamson, Underweight, overweight, obesity, and excess deaths: Authors’ reply. JAMA 294, 552–553 (2005).
41
DB Allison, MS Faith, M Heo, D Townsend-Butterworth, DF Williamson, Meta-analysis of the effect of excluding early deaths on the estimated relationship between body mass index and mortality. Obes Res 7, 342–354 (1999).
42
DB Allison, M Heo, DW Flanders, MS Faith, DF Williamson, Examination of “early mortality exclusion” as an approach to control for confounding by occult disease in epidemiologic studies of mortality risk factors. Am J Epidemiol 146, 672–680 (1997).
43
DB Allison, et al., Simulation study of the effects of excluding early deaths on risk factor-mortality analyses in the presence of confounding due to occult disease: The example of body mass index. Ann Epidemiol 9, 132–142 (1999).
44
DE Alley, et al., Changes in weight at the end of life: Characterizing weight loss by time to death in a cohort study of older men. Am J Epidemiol 172, 558–565 (2010).
45
KM Flegal, BI Graubard, DF Williamson, MH Gail, Impact of smoking and preexisting illness on estimates of the fractions of deaths associated with underweight, overweight, and obesity in the US population. Am J Epidemiol 166, 975–982 (2007).
46
EF Schisterman, SR Cole, RW Platt, Overadjustment bias and unnecessary adjustment in epidemiologic studies. Epidemiology 20, 488–495 (2009).
47
A Stokes, Using maximum weight to redefine body mass index categories in studies of the mortality risks of obesity. Popul Health Metr 12, 6 (2014).
48
US Department of Health and Human Services (1994) Plan and operation of the Third National Health and Nutrition Examination Survey, 1988-94. Series 1: Programs and collection procedures. Vital Heal Stat 1(32):1–407.
49
G Zipf, et al., National health and nutrition examination survey: Plan and operations, 1999-2010. Vital Heal Stat 1, 1–37 (2010).
50
National Center for Health Statistics, Office of Analysis and Epidemiology. (2009) The Third National Health and Nutrition Examination Survey (NHANES III) Linked Mortality File Matching Methodology (National Center for Health Statistics, Hyattsville, MD).
51
National Center for Health Statistics Survey (2012) Questionnaires, Datasets, and Related Documentation. Available at www.cdc.gov/nchs/nhanes/nhanes_questionnaires.htm. Accessed June 1, 2015.
52
National Heart, Lung, and Blood Institute (1998) Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report. Obes Res 6:51S–209S.
53
; World Health Organization, Obesity: Preventing and managing the global epidemic. Report of a WHO consultation. WHO Technical Report Series 894 (World Health Organization, Geneva). (2000).
54
DO Stram, M Huberman, AH Wu, Is residual confounding a reasonable explanation for the apparent protective effects of beta-carotene found in epidemiologic studies of lung cancer in smokers? Am J Epidemiol 155, 622–628 (2002).
55
AG Renehan, MF Leitzmann, M Zwahlen, Re: Body mass index and risk of lung cancer among never, former, and current smokers. J Natl Cancer Inst 104(21):1680–1681. (2012).
56
D Cox, Regression models and life tables. J R Stat Soc, B 34, 187–220 (1972).
57
EL Korn, BI Graubard, D Midthune, Time-to-event analysis of longitudinal follow-up of a survey: Choice of the time-scale. Am J Epidemiol 145, 72–80 (1997).
58
KB Burnham, DR Anderson Model Selection and Multimodel Inference: A Practical Information-Theoretic Approach (Springer, 2nd Ed, New York, 2003).
59
VA Casey, et al., Long-term memory of body weight and past weight satisfaction: A longitudinal follow-up study. Am J Clin Nutr 53, 1493–1498 (1991).
60
GG Rhoads, A Kagan, The relation of coronary disease, stroke, and mortality to weight in youth and in middle age. Lancet 1, 492–495 (1983).
61
J Stevens, JE Keil, LR Waid, PC Gazes, Accuracy of current, 4-year, and 28-year self-reported body weight in an elderly population. Am J Epidemiol 132, 1156–1163 (1990).
62
GS Perry, TE Byers, AH Mokdad, MK Serdula, DF Williamson, The validity of self-reports of past body weights by U.S. adults. Epidemiology 6, 61–66 (1995).
63
CL Ogden, MD Carroll, BK Kit, KM Flegal, Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA 311, 806–814 (2014).
Information & Authors
Information
Published in
Classifications
Copyright
Freely available online through the PNAS open access option.
Submission history
Published online: January 4, 2016
Published in issue: January 19, 2016
Keywords
Acknowledgments
We are grateful to the reviewers of the manuscript for helpful comments and suggestions. This work was supported by a grant from the National Institute on Aging at the National Institutes of Health (R01AG040212).
Authors
Competing Interests
The authors declare no conflict of interest.
Metrics & Citations
Metrics
Citation statements
Altmetrics
Citations
Cite this article
Revealing the burden of obesity using weight histories, Proc. Natl. Acad. Sci. U.S.A.
113 (3) 572-577,
https://doi.org/10.1073/pnas.1515472113
(2016).
Copied!
Copying failed.
Export the article citation data by selecting a format from the list below and clicking Export.
Cited by
Loading...
View Options
View options
PDF format
Download this article as a PDF file
DOWNLOAD PDFLogin options
Check if you have access through your login credentials or your institution to get full access on this article.
Personal login Institutional LoginRecommend to a librarian
Recommend PNAS to a LibrarianPurchase options
Purchase this article to access the full text.