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Body-mass index and cause-specificmortality in 900 000 adults: collaborative

analyses of 57 prospective studies

Prospective Studies Collaboration

Lancet 2009; 373: 1083-96

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Blood pressure, cholesterol and BMI

Systolic

Diastolic

15 25 35 50

80

100

120

140

160

Non-HDL-C

HDL-C

Ratio of means

(non-HDL-C/HDL-C)

15 25 35 500

1

2

3

4

5

mm Hg

Baseline BMI (kg/m2)

mmol/L

(or ratio)

M

Adjusted for age, smoking and study

F

M

F M

F

FM

M

F

Fig 1a & b, Lancet 2009; 373: 1083-9

Blood pressure Cholesterol

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Ratio non-HDL:HDL cholesterol and BMI

15 25 35 500

1

2

3

4

5

Ratio of meansMean of ratios

Ratio

Baseline BMI (kg/m2)

Adjusted for age, smoking and study

M

F

(Mean of ratios

~10% higher than

ratio of means)

Fig 1b variant, Lancet 2009; 373: 1083-9

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Drinking, smoking, diabetes and BMI

15 25 35 500

20

40

60

80

100

15 25 35 500

20

40

60

80

100

Adjusted for age, smoking and study

Male Female

Baseline BMI (kg/m2)

Drinking

Smoking

Diabetes

Drinking

Smoking

Diabetes

Prevalence%

Fig 1c & d, Lancet 2009; 373: 1083-9

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All-cause mortality and BMI

15 20 25 30 35 40 504

8

16

32

64

Annual

deaths

per 1000

Baseline BMI (kg/m2)

Adjusted for age, smoking and study; 1st 5 years of follow-up excluded

Male

Female

Fig 2, Lancet 2009; 373: 1083-9

& 95% CI (floated

so matches PSC

rate at ages 35-79)

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IHD and stroke mortality and BMI

15 20 25 30 35 40 5005

1

2

4

8 IHD

Stroke

Adjusted for age, sex, smoking and study; 1st 5 years of follow-up excluded Fig 3, Lancet 2009; 373: 1083-9

Baseline BMI (kg/m2)

Annual

deaths

per 1000& 95% CI (floated

so matches PSC

rate at ages 35-79)

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IHD mortality and BMI in the range 2550 kg/m2 onlyNo. of

deathsMean age

at deathHR & 95% CI

0-4* 2069 602 126 (116-136)

5-9 3291 629 133 (124-143)

10-14 3407 661 143 (133-153)

15+ 4085 712 142 (134-151)Trend, 4 groups: c12=66 (p=001)

35-59 2461 541 150 (139-162)

60-69 3904 646 140 (132-149)

70-79 3264 740 131 (123-140)

80-89 1154 834 130 (117-145)Trend, 4 groups: c12=78 (p=0005)

Male 8556 657 142 (135-148)

Female 2227 724 135 (128-143)Heterogeneity: c

1

2=14 (p=02)

Never smoker 2651 710 141 (133-150)

Other/unknown 3442 680 145 (136-154)

Current cigarette 4690 641 133 (125-141)Heterogeneity: c22=37 (p=02)

All (BMI 25-50 kg/m2, years 5+) 10 783 671 139 (134-144)

10 15 2

Hazard ratio (& 95% CI) for5 kg/m2 higher baseline BMI

Follow-up period

(years)

Age at risk

(years)

Sex

Smoking at

entry

Fig 4a, Lancet 2009; 373: 1083-9

Adjusted, when appropriate, for age, sex,

smoking and study, and (except where

marked *) 1st 5 years of follow-up excluded

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Stroke mortality and BMI in the range 2550 kg/m2 only

583 625 121 (105-141)

889 656 136 (120-154)

906 690 137 (120-156)

1369 734 138 (124-153)

Trend, 4 groups: c12 =14 (p=02)

463 537 176 (152-204)

997 649 149 (134-167)

1152 743 133 (119-148)

552 835 110 (094-130)

Trend, 4 groups: c12 =194 (p

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IHD & stroke mortality and BMI in the range 2550 kg/m2 onlyApproximately standardised to overall mean age at IHD, or at stroke, death

Fig 4 variant, Lancet 2009; 373: 1083-9

IHDNo. of

deaths

Mean age

at deathHR & 95% CI

Followupperiod

(years)

0-4* 2069 602 120 (110-130)

5-9 3291 629 129 (121-139)

10-14 3407 661 142 (132-152)

15+ 4085 712 146 (138-155)

Trend, 4 groups:c

1

2

=173 (p

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Male Female

2

4

6

8

10

12

14

0

2

4

6

8

10

12

14

015 20 25 30 35 50 15 20 25 30 35 50

Vascular

Respiratory

Cancer (lung,mouth, pharynx,

larynx, oes.)

Vascular

Resp.

Main mortality categories and BMI

Cancer (otherspecified)

Baseline BMI (kg/m2)

Cancer (lung,mouth, pharynx,larynx, oes.)

Cancer (otherspecified)

Fig 5, Lancet 2009; 373: 1083-9Adjusted for age, smoking and study; 1st 5 years of follow-up excluded

Annual

deaths

per 1000

& 95% CI (floated

so matches EU rate

at ages 35-79)

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All-cause mortality and BMI, by smoking

15 20 25 30 35 500

5

10

15

20

25

30

Baseline BMI (kg/m2)

Currentcigarette

smoker

Neversmokedregularly

Adjusted for age, sex and study; 1st 5 years of follow-up excluded Fig 6, Lancet 2009; 373: 1083-9

Annual

deaths

per 1000

& 95% CI (floated

so matches EU rate

at ages 35-79)(N.B. The vertical separation of the

curves underestimates effects of

lifelongcigarette smoking)

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Lifespan and BMI in western Europe, year 2000

40 50 60 70 80 90 100

Yearly dots

BMI range, kg/m2

22.5-25 (mean 24)

25-30 (mean 27)

30-35 (mean 32)

0

20

40

60

80

100

Age (years)

40 50 60 70 80 90 1000

20

40

60

80

100

Male Female

Causal PSC relative risks applied to EU mortality rates Fig 7 variant, Lancet 2009; 373: 1083-9

%alive

77%

69%

88%

84%

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Lifespan and BMI in western Europe, year 2000

40 50 60 70 80 90 100

Yearly dots

Male

BMI range, kg/m2

22.5-25 (mean 24)

25-30

30-35 (mean 32)

35-40

40-50 (mean 43)

0

20

40

60

80

100

Age (years)

40 50 60 70 80 90 100

Female

0

20

40

60

80

100

Causal PSC relative risks applied to EU mortality rates Fig 7, Lancet 2009; 373: 1083-9

%

alive

77%

49%

88%

72%

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Comparison with smoking in the British Doctors Study

From figure 3 in Doll, Peto et al., BMJ 2004: 328: 1519-33

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All-cause mortality and BMI, by age at risk

15 20 25 30 35 50

2

4

8

16

32

64

128

256

512

35-59

60-69

70-79

80-89

Age at

risk:

15 20 25 30 35 50

2

4

8

16

32

64

128

256

512

Male Female

Baseline BMI (kg/m2)

35-59

60-69

70-79

80-89

Age atrisk:

Adjusted for age, smoking and study; 1st 5 years of follow-up excluded Webfig 1, Lancet 2009; 373: 1083-9

Annual

deaths

per 1000

& 95% CI (floated

so matches PSC

rate at ages 35-89)

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IHD mortality and BMI in never smokers

15 20 25 30 35 40 5005

1

2

4

8

16

Baseline BMI (kg/m2)

Adjusted for age, sex and study; 1st 5 years of follow-up excluded Webfig 2, Lancet 2009; 373: 1083-9

Annual

deaths

per 1000

& 95% CI (floated

so matches PSC

rate at ages 35-79)

S f

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Stroke mortality and BMI in specific subgroups

15 20 25 30 35 50

1

2

4

first 5 years of

followup

15 20 25 30 35 50

1

2

4

first 10 years of

followup

15 20 25 30 35 50

1

2

4

first 5 years and

ever smokers

Adjusted for age, sex, study and, when appropriate, smoking Webfig 3, Lancet 2009; 373: 1083-9

Baseline BMI (kg/m2)

Excluding:

Annual

deaths

per 1000

& 95% CI (floated

so matches PSC

rate at ages 35-79)

St k bt t lit d BMI

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Stroke subtype mortality and BMI

15 20 25 30 35 50

1/4

1/2

1

2

Ischaemic

15 20 25 30 35 50

1/4

1/2

1

2

Haemorrhagic

15 20 25 30 35 50

1/4

1/2

1

2

Unclassified

Baseline BMI (kg/m2)

Adjusted for age, sex, smoking and study; 1st 5 years of follow-up excluded Webfig 4, Lancet 2009; 373: 1083-9

Annual

deaths

per 1000

& 95% CI (floated

so matches PSC

rate at ages 35-79)

IHD t lit d BMI b t d

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IHD mortality and BMI by study

No. ofdeaths

Finnish Mobile Clinic 1724

Finrisk, Finland 1014UK HDPP 703

Israeli IHD 571

Whitehall, UK 568

NHEFS, US 494

Framingham, US 481

Renfrew/Paisley, UK 438

Norwegian Counties 438

BUPA, UK 362

Oslo, Norway 339

Midspan, UK 318

Copenhagen, Denmark 231

BRHS, UK 227

Busselton, Australia 222

Tecumseh, US 215

Studies with

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Stroke mortality and BMI by study

Finnish Mobile Clinic 556

Finrisk, Finland 270

Israeli IHD 206

NHEFS, US 148

Renfrew/Paisley, UK 143

Framingham, US 133

UK HDPP 122

Honolulu, US 111

Studies with

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COPD mortality and BMI by follow-up period

15 20 25 30 35

1/8

1/4

1/2

1

2

40-4 years

15 20 25 30 35

1/8

1/4

1/2

1

2

45-9 years

15 20 25 30 35

1/8

1/4

1/2

1

2

410-14 years

15 20 25 30 35

1/8

1/4

1/2

1

2

415+ years

Baseline BMI (kg/m2)

Adjusted for age, sex, smoking and study Webfig 6, Lancet 2009; 373: 1083-9

Annual

deaths

per 1000

& 95% CI (floated

so matches PSC

rate at ages 35-79)

All cause mortality and BMI by smoking

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All-cause mortality and BMI by smoking

15 20 25 30 35 50

5

10

15

20

0

Male (35-69 years)

15 20 25 30 35 50

5

10

15

20

0

Female (35-69 years)

Baseline BMI (kg/m2)

Currentcigarettesmoker

Neversmokedregularly

Currentcigarettesmoker

Neversmokedregularly

Adjusted for age and study; 1st 5 years of follow-up excluded Webfig 7a & b, Lancet 2009; 373: 1083-9

Annual

deaths

per 1000& 95% CI (floated

so matches EU rate

at ages 35-69)

All cause mortality and BMI by smoking

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All-cause mortality and BMI by smoking

15 20 25 30 35 50

25

50

75

100

015 20 25 30 35 50

25

50

75

100

0

Male (70-79 years) Female (70-79 years)

Currentcigarettesmoker

Neversmokedregularly

Current

cigarettesmoker

Neversmokedregularly

Adjusted for age and study; 1st 5 years of follow-up excluded Webfig 7c & d, Lancet 2009; 373: 1083-9

Baseline BMI (kg/m2)

Annual

deaths

per 1000& 95% CI (floated

so matches EU rate

at ages 70-79)

Vascular mortality and BMI by smoking

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Vascular mortality and BMI by smoking

15 20 25 30 35 500

2

4

6

15 20 25 30 35 500

2

4

6

Male (35-69 years) Female (35-69 years)

Baseline BMI (kg/m2)

Currentcigarettesmoker

Neversmokedregularly

Currentcigarettesmoker

Neversmokedregularly

Adjusted for age and study; 1st 5 years of follow-up excluded Webfig 8a & b, Lancet 2009; 373: 1083-9

Annual

deaths

per 1000& 95% CI (floated

so matches EU rate

at ages 35-69)

Vascular mortality and BMI by smoking

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Vascular mortality and BMI by smoking

15 20 25 30 35 500

10

20

30

15 20 25 30 35 500

10

20

30Current

cigarettesmoker

Neversmokedregularly Current

cigarettesmoker

Neversmokedregularly

Adjusted for age and study; 1st 5 years of follow-up excluded Webfig 8c & d, Lancet 2009; 373: 1083-9

Baseline BMI (kg/m2)

Male (70-79 years) Female (70-79 years)

Annual

deaths

per 1000& 95% CI (floated

so matches EU rate

at ages 35-79)