Donate Help Contact The AHA Sign In Home
American Heart Association
Circulation
Search: search_blue_button Advanced Search
« Previous Article | Table of Contents | Next Article »
Circulation. 1996;93:1372-1379

This Article
Right arrow Abstract Freely available
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow Request Permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Jousilahti, P.
Right arrow Articles by Puska, P.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Jousilahti, P.
Right arrow Articles by Puska, P.
Right arrowPubmed/NCBI databases
*Compound via MeSH
*Substance via MeSH
Hazardous Substances DB
*CHOLESTEROL

(Circulation. 1996;93:1372-1379.)
© 1996 American Heart Association, Inc.

Articles

Body Weight, Cardiovascular Risk Factors, and Coronary Mortality

15-Year Follow-up of Middle-aged Men and Women in Eastern Finland

Pekka Jousilahti, MD, MSc; Jaakko Tuomilehto, MD, PhD, MPolSc; Erkki Vartiainen, MD, PhD; Juha Pekkanen, MD, PhD; Pekka Puska, MD, PhD, MPolSc

From the National Public Health Institute, Department of Epidemiology and Health Promotion, Helsinki, Finland (P.J., J.T., E.V., P.P.), and the National Public Health Institute, Department of Environmental Epidemiology, Kuopio, Finland (J.P.).

Correspondence to Pekka Jousilahti, National Public Health Institute, Department of Epidemiology and Health Promotion, Mannerheimintie 166, FIN-00300 Helsinki, Finland.


*    Abstract
up arrowTop
 *Abstract
down arrowIntroduction
 down arrowMethods
 down arrowResults
 down arrowDiscussion
 down arrowReferences
 
Background Body weight is closely related to several known cardiovascular risk factors, but it may also have an independent effect on the risk of coronary heart disease (CHD). In this study, we analyzed the association between body mass index (BMI) and smoking, serum cholesterol, and blood pressure at baseline, as well as how BMI and the other risk factors are related to CHD mortality.

Methods and Results A total of 16 113 men and women aged 30 to 59 years were examined in eastern Finland in either 1972 or 1977. Serum cholesterol and blood pressure had a positive association and smoking had a negative association with BMI. During the 15-year prospective follow-up, mortality from CHD was positively associated with BMI. The BMI-associated risk ratio of CHD mortality, adjusted for age and study year, estimated from the Cox proportional hazards model was 1.04 (per kg/m2) (P<.001) among men. Inclusion of smoking in the model increased the risk ratio for BMI, whereas inclusion of serum cholesterol and blood pressure decreased it. In the model that included age, study year, and all three major cardiovascular risk factors, the BMI-associated risk ratio was 1.03 (P=.027). Among women, the BMI-associated risk ratio of CHD mortality adjusted for age and study year was 1.05 (P=.023) and the multifactorial adjusted risk ratio was 1.03 (P=.151).

Conclusions Obesity is an independent risk factor for CHD mortality among men and also contributes to the risk of CHD among women. Part of the BMI-associated risk of CHD mortality is mediated through other known cardiovascular risk factors. By preventing overweight, a substantial part of CHD mortality may be prevented.


Key Words: coronary disease • mortality • obesity


*    Introduction
up arrowTop
 up arrowAbstract
 *Introduction
down arrowMethods
 down arrowResults
 down arrowDiscussion
 down arrowReferences
 
The negative effect of severe obesity on health and longevity is well documented.1 2 3 4 5 6 7 8 9 10 11 Results of studies concerning less extreme body weights are conflicting and depend strongly on the chosen health indicator. Many studies3 4 5 6 7 12 also showed that increased mortality and morbidity are associated with extremely low body weight.

Body weight is determined by many factors, such as genetic, behavioral, cultural, socioeconomic, psychosocial, and psychological mechanisms. Many of these factors influence health independently or through mechanisms other than body weight. Excess body weight is a risk factor for a variety of health hazards, but it is also a marker of other factors that are directly or indirectly related to health, such as physical activity, diet, socioeconomic status, and smoking.6 13 14 15 16

Despite the positive association between body weight and the risk of CHD in many studies, the question of whether this risk is independent of other factors is still debated.1 5 6 9 11 Obesity is closely related to several known cardiovascular risk factors, such as hypertension, lipid abnormalities, and impaired glucose metabolism, and it has a complicated association with smoking. Obese subjects, on average, have higher BP, higher serum total cholesterol, lower HDL-cholesterol, higher serum triglyceride level, higher blood glucose, and a higher plasma insulin level than lean persons.1 4 9 10 14 17 18 19 20 21 22 23 24 25 26 27 28 29 30 On the other hand, smokers tend to be leaner than nonsmokers, although this difference may be diminishing.15 16 The individual and independent effect of body weight on the risk of CHD is difficult to estimate because obesity exerts much of its effect through the enhancement of other risk factors.

The aim of the present study is to analyze the association between BMI and three major cardiovascular risk factors: smoking, serum cholesterol, and BP at baseline. Furthermore, the present study analyzes how BMI alone and with the other cardiovascular risk factors predicts 15-year CHD mortality among middle-aged men and women in eastern Finland.


*    Methods
up arrowTop
 up arrowAbstract
 up arrowIntroduction
 *Methods
down arrowResults
 down arrowDiscussion
 down arrowReferences
 
Risk factor surveys were conducted in 1972 and 1977 in the provinces of North Karelia and Kuopio in eastern Finland. A random sample of 6.6% of the population aged 30 to 59 years was drawn in both areas. In the present analyses, the two cohorts were pooled together. The total sample size was 19 894. The participation rate was 90% among men and 93% among women. Those subjects who participated in both surveys were included only in the first survey cohort. Of 17 682 participants, 683 were excluded because of reported history of myocardial infarction, stroke, or diabetes before the survey. Another 886 participants were excluded because of incomplete data on either BMI or at least one of the risk factors (smoking, serum cholesterol, or BP). Thus, 7740 men and 8373 women were included in the present analyses.

The survey methods have been described earlier in detail.31 A self-administered questionnaire was sent to the participants in advance, and it included questions about medical history and health behavior. At the study site, specially trained nurses measured height, weight, and BP using a standardized protocol. Weight was measured with subjects wearing light clothing and height was measured without shoes. BMI (kg/m2) was used as a measure of relative body weight. The BP measurement was taken from the right arm of the subject, who had been asked to sit for 5 minutes before the measurement. After the BP measurement, a venous blood specimen was taken. Serum cholesterol was determined from frozen samples by the Lieberman-Burchard method. All samples were analyzed in the same laboratory.

Smoking was assessed in the surveys by a set of standardized questions in a self-administered questionnaire. On the basis of the responses, the participants were classified into three categories: (1) current smokers, or persons who had smoked regularly for at least 1 year more than once a day on average and who had smoked during the preceding month; (2) ex-smokers; and (3) lifelong nonsmokers, or those who had never smoked. In the present study, those ex-smokers who had not smoked during the past 6 months were considered nonsmokers, and those ex-smokers who had quit smoking <6 months earlier were considered smokers.

Mortality data were obtained from the Central Statistical Office of Finland and linked to the risk factor data by use of the identification numbers assigned to every resident of Finland. The rate of deaths ascertained in the study cohorts was therefore complete. The eighth revision of the ICD was used in Finland from 1969 to 1986 and the ninth revision was adopted at the beginning of 1987. ICD codes 410 through 414 were classified as CHD deaths. The follow-up time of each subject considered in our present analyses was 15 years. The number of CHD deaths during the follow-up was 480 among men and 103 among women.

The association between BMI and serum cholesterol and between BMI and BP at baseline was analyzed by use of a multiple regression model. The association between BMI and smoking prevalence was analyzed by use of a logistic regression model. In both analyses, BMI was used as a continuous variable and the analyses were adjusted for age. To calculate CIs for mortality rates, deaths during the follow-up were assumed to follow a Poisson distribution. Multivariate analyses were performed by use of a Cox proportional hazards model.32 The estimates of relative risks and their 95% CIs were based on this model. Furthermore, to assess the extent to which the risk of CHD mortality associated with BMI may be modified by or mediated through the known cardiovascular risk factors, smoking, serum cholesterol, and systolic BP were included in the models. Interactions between BMI and other risk factors were analyzed by adding all first-level interactions between BMI, smoking, serum cholesterol, and systolic BP, one at a time, into the model together with all main variables. A stratified analysis by smoking status, dichotomized values of serum cholesterol and BP, and different levels of BMI was also performed. Because of the relatively small number of deaths due to CHD among women, the stratified analysis by smoking status was performed only for men. Statistical analyses were done with use of the SAS statistical programs.33


*    Results
up arrowTop
 up arrowAbstract
 up arrowIntroduction
 up arrowMethods
 *Results
down arrowDiscussion
 down arrowReferences
 
Serum cholesterol and both diastolic and systolic BP had a positive association with BMI (Tables 1Down and 2Down). Smoking, on the other hand, had an inverse association with BMI, except that the most obese men smoked more than the moderately overweight men. Among men, the inverse association of smoking with BMI was explained by smoking cessation. The proportion of ex-smokers increased as BMI increased, but the proportion of lifelong nonsmokers did not have a significant association with BMI. Among women, in contrast to men, the proportion of lifelong nonsmokers increased as BMI increased, but the proportion of ex-smokers did not associate with BMI. There was a strong positive association between age and BMI in women but not in men. However, in both sexes, the positive association of BMI with serum cholesterol and BP and the negative association with smoking were still statistically significant after adjustment for age.


View this table:
[in this window]
[in a new window]
  		Table 1. Distribution of Age, Serum Cholesterol, BP, and Smoking Prevalence by BMI Level in 7740 Men Aged 30 to 59 Years


View this table:
[in this window]
[in a new window]
  		Table 2. Distribution of Age, Serum Cholesterol, BP, and Smoking Prevalence by BMI Level in 8373 Women Aged 30 to 59 Years

Age-adjusted coronary mortality increased from 39 per 10 000 person-years among men with a BMI between 20 and 22.5 kg/m2 to 78 per 10 000 person-years among men with a BMI >=32.5 kg/m2 (Fig 1Down). Among the lean women with a BMI <22.5 kg/m2, age-adjusted CHD mortality was very low, <2 per 10 000 person-years (Fig 2Down). It increased to about 10 per 10 000 person-years among women with a BMI between 22.5 and 32.5 kg/m2 and to 13 per 10 000 person-years among the most obese women. In both sexes, the number of subjects with a BMI <20 kg/m2 was small, and therefore CIs for mortality rates in the leanest group are wide.



View larger version (22K):
[in this window]
[in a new window]
  		Figure 1. CHD mortality and 95% CI per 10 000 person-years by BMI level in 7740 men aged 30 to 59 years.



View larger version (19K):
[in this window]
[in a new window]
  		Figure 2. CHD mortality and 95% CI per 10 000 person-years by BMI level in 8373 women aged 30 to 59 years.

Among men, the BMI-associated RR of CHD mortality, adjusted for age and study year, was 1.04 per kg/m2 (P<.001) (Table 3Down). Inclusion of smoking in the model increased the RR, whereas inclusion of serum cholesterol decreased it slightly. Inclusion of systolic BP in the model decreased the RR to 1.02 per kg/m2 (P=.092). In the model that included all three major cardiovascular risk factors, the BMI-associated RR was 1.03 per kg/m2 (P=.027). Among women, the respective RRs were 1.05 per kg/m2 (P=.023), 1.02 per kg/m2 (P=.417), and 1.03 per kg/m2 (P=.151).


View this table:
[in this window]
[in a new window]
  		Table 3. BMI-Associated RR of CHD Mortality for Men and Women Aged 30 to 59 Years in a Univariate Model, in Bivariate Models Including Either Smoking, Serum Cholesterol, or Systolic BP, and in a Multivariate Model Including All Three Risk Factors

In men aged 30 to 49 years, age- and study year–adjusted BMI-associated RR of CHD mortality was 1.02 per kg/m2 (P=.299) (Table 4Down). After including smoking in the model, the RR was 1.04 per kg/m2 (P=.042). After further inclusion of serum cholesterol and systolic BP in the model, the association between BMI and CHD mortality disappeared (P=.837). In men aged 50 to 59 years, age- and study year–adjusted RR was 1.05 per kg/m2 (P<.001) and the multivariate-adjusted RR was 1.04 per kg/m2 (P=.006).


View this table:
[in this window]
[in a new window]
  		Table 4. BMI-Associated RR of CHD Mortality in Men (N=7740) and Women (N=8373) Aged 30 to 59 Years by Age Group in a Univariate Model, in Bivariate Models Including Either Smoking, Serum Cholesterol, or Systolic BP, and in a Multivariate Model Including All Three Risk Factors

Unlike in men, the BMI-associated RR of CHD mortality was higher among younger compared with older women. In women aged 30 to 49 years, the BMI-associated RR of CHD mortality, adjusted for age and study year, was 1.09 per kg/m2 (P=.020). Inclusion of smoking in the model increased the RR to 1.10 per kg/m2 (P=.012). The further inclusion of serum cholesterol and systolic BP decreased the RR to 1.05 per kg/m2 (P=.266). In women aged 50 to 59 years, the age- and study year–adjusted RR was 1.03 per kg/m2 (P=.185) and the multivariate adjusted RR was 1.02 per kg/m2 (P=.374).

The first-level interaction between BMI and systolic BP as continuous variables was statistically significant among men (P=.033) but not among women. In both sexes, interactions between BMI and smoking and between BMI and serum cholesterol were not significant statistically.

Among men, as stratified by smoking status and BMI, there was a trend toward an increase in the risk of CHD mortality as BMI increased among lifelong nonsmokers, ex-smokers, and smokers (Table 5Down). This trend diminished after adjustment for serum cholesterol and systolic BP. Among lean and moderately overweight men, ie, BMI <30 kg/m2, the risk of CHD mortality was similar among lifelong nonsmokers and ex-smokers, but among the most obese men, the RR was higher among ex-smokers than lifelong nonsmokers.


View this table:
[in this window]
[in a new window]
  		Table 5. RR and 95% CI of CHD Mortality by Smoking Status and BMI in 7740 Men Aged 30 to 59 Years, Adjusted for Age and Study Year and Multifactorial Adjusted

When stratified by serum cholesterol and BMI, the risk of CHD mortality increased as BMI increased both among men with serum cholesterol <6.5 mmol/L and among men with serum cholesterol >6.5 mmol/L (Table 6Down). Among women, there was also an increasing tendency, but the trend was not as regular as among men. In both sexes and at all BMI levels, the RR was higher in the high-cholesterol group compared with the low-cholesterol group.


View this table:
[in this window]
[in a new window]
  		Table 6. RR and 95% CI of CHD in 7740 Men and 8373 Women Aged 30 to 59 Years by Serum Cholesterol Level and BMI Level, Adjusted for Age and Study Year and Multifactorial Adjusted

In both sexes as stratified by BP and BMI, the risk of CHD mortality increased as BMI increased only among normotensive subjects (diastolic BP <95 mm Hg and systolic BP <160 mm Hg) (Table 7Down). Among hypertensive subjects (diastolic BP >=95 mm Hg or systolic BP >=160 mm Hg), the risk of CHD mortality did not vary by BMI level. At low and moderate BMI levels (BMI <30 kg/m2), the RR was higher among hypertensive than among normotensive subjects, but among the most obese subjects, the RR was similar in both low and high BP groups.


View this table:
[in this window]
[in a new window]
  		Table 7. RR and 95% CI of CHD Mortality in 7740 Men and 8373 Women Aged 30 to 59 Years by BP Level and BMI Level, Adjusted for Age and Study Year and Multifactorial Adjusted


*    Discussion
up arrowTop
 up arrowAbstract
 up arrowIntroduction
 up arrowMethods
 up arrowResults
 *Discussion
down arrowReferences
 
Obesity was an independent risk factor for CHD mortality among men and also contributed to the risk of CHD death among women. Starting at a BMI of {approx}22 kg/m2, an increase in body weight equivalent to 1 BMI unit (kg/m2) was related to a 4% to 5% increase in CHD mortality. In other words, an increase in body weight of {approx}1 kg increased the risk of CHD mortality by 1% to 1.5%.

BMI was closely related to the other major cardiovascular risk factors (smoking, serum cholesterol, and BP). Several studies showed that smokers have, on average, a lower BMI than nonsmokers and that smoking cessation is often associated with weight gain.34 This may be due to metabolic effects of smoking that increase energy consumption or to psychological factors that affect eating habits. Thus, smoking has a rather complicated association with CHD. Smoking is, without a doubt, one of the most important risk factors for CHD mortality, but at the same time, smoking seems to protect against another risk factor, obesity.35 36 37 Weight control should be an integral part of CHD prevention among both nonsmokers and smokers, but among smokers, smoking cessation is obviously the most important single preventive measure. Particular emphasis is also needed to prevent weight gain after quitting smoking. Risk of coronary death among lean and moderately overweight ex-smokers was similar to that of lifelong nonsmokers, but among the most obese ex-smokers, the risk seemed to be higher than among lifelong nonsmokers at the same BMI level. One possible explanation for this could be that the obese ex-smokers may have started to smoke again to control weight. Also, the concurrent presence of severe obesity and smoking in an individual may be an indicator of a particular unhealthy lifestyle in general.

Serum cholesterol level correlated positively with BMI at baseline. In the longitudinal analyses, part of the CHD mortality risk associated with overweight was mediated through serum cholesterol. Overweight was associated with increased CHD mortality both in high- and low-cholesterol groups. Even though we did not assess the effect of weight change on serum cholesterol level, it can be assumed that weight reduction also decreases serum cholesterol level.14 38 Therefore, weight control probably can prevent CHD mortality more than is estimated from analysis of BMI alone.

Our results are in agreement with the well-documented association between body weight and BP.9 14 17 18 19 20 21 22 23 24 Several studies showed that hypertension is more common in obese than in lean persons. Body weight also correlates with BP within the so-called normotensive range of BP. In longitudinal studies, weight gain is independently related to increased BP.18 19 20 Among people with slightly increased BP (borderline hypertension), long-term intervention with weight loss has been shown to be effective in the prevention of hypertension.21 Since obesity is the strongest determinant of hypertension, weight control could be the most effective way to prevent hypertension in a population and to reduce BP among overweight hypertensive subjects.

In the present study, a substantial part of the CHD mortality risk associated with BMI was mediated through the association between body weight and BP, as the BMI-associated risk of CHD mortality decreased when systolic BP was added to the model. Nevertheless, this finding does not diminish the practical value of weight control as an integral part of cardiovascular disease prevention. To the contrary, it is a very strong argument for nonpharmacological control and prevention of high BP.

Some studies39 40 suggested that lean hypertensive subjects may have a higher risk of cardiovascular disease than obese hypertensive subjects. In the current study, the risk of CHD death did not increase much as BMI increased among hypertensive subjects. It is likely that there are several etiologic subtypes of hypertension. A fraction of hypertensive subjects may have a genetic predisposition to hypertension that is independent of body weight. On the other hand, it has been observed that at least part of the excess mortality among lean hypertensive subjects is due to deleterious lifestyles, such as smoking and excessive alcohol intake.41 Among the majority of hypertensive patients who are also overweight, overweight is probably the central factor in the origin of hypertension. Estimating the effect of weight control on CHD mortality among hypertensive subjects should not be based on BMI level alone but also on its simultaneous effect on BP.

Diabetes is the third possible mediator between obesity and the risk of CHD. Obesity increases the risk of diabetes, which is a known cardiovascular risk factor.9 14 25 26 27 Even though those subjects who had diabetes before the baseline measurements were excluded from the present study, diabetes developing during the follow-up may still play a role in the risk estimates of obesity-associated CHD mortality in our study. Findings that obesity, lipid abnormalities, and diabetes often coexist in hypertensive subjects suggest that hyperinsulinemia may be the common link between the four phenomena.25 26 27 Several studies42 also showed that subjects with an increased level of these risk factors have a highly increased risk of cardiovascular disease. In the interrelation between hyperinsulinemia, obesity, diabetes, hypertension, and lipid abnormalities, the most natural target of primary intervention is obesity, which further stresses the importance of weight control in cardiovascular disease prevention.

From the public health point of view, the question of whether obesity is an independent risk factor for CHD among subjects with elevated BP, high serum cholesterol, or diabetes is not very relevant. The two components of the risk associated with obesity, operating either independently or through other risk factors, cannot be separated in healthcare practice. Most likely, the best prediction of the practical value of weight control for the prevention of cardiovascular disease can be obtained by using the models presented in the current study without adjustment for other risk factors or by adjustment for smoking only. Furthermore, by replacing and supporting the current drug therapy in the treatment of hypertension, lipid abnormalities, and non–insulin-dependent diabetes with nonpharmacological treatment methods, substantial savings in costs can be obtained. Simultaneously, an optimal health effect may be reached without the risk of the possible side effects of antihypertensive, lipid-lowering, and antidiabetic drugs.43 44

Among young men, the association between BMI and CHD mortality was weaker than among older men, and among younger men, this risk was mainly mediated through serum cholesterol and BP. Because body weight in young adulthood usually correlates with body weight in older age, we can assume that in the younger age group, the risk may also increase during a longer follow-up. Some studies3 45 showed that the risk associated with body weight appears only after a relatively long follow-up. In contrast to men, the association between BMI and CHD mortality among young women was stronger than that among older women. Among women, body weight increases with age much more than among men. Young women are leaner than young men but, because of hormonal and other factors, women gain weight later. After 50 years of age, women are more obese than men of the same age. It is possible that among women, the weight gain at an older age is not as dangerous as if the weight gain occurred at a younger age. Also, body fat distribution differs between sexes. Men more often have central adiposity, which may associate more strongly with the risk of CHD mortality than peripheral adiposity, which is more common among women.46

The current study did not include weight history and the effect of weight change on CHD mortality. Therefore, we cannot conclude from our data how the optimal weight should be achieved. Some reports7 11 47 48 showed a negative health effect associated with weight fluctuation, but the data are still limited in this regard. Nevertheless, obesity ideally should be prevented in young adulthood when the risk of weight gain is at its highest, particularly among men. The safest way to reach the optimal weight by weight reduction is probably to lose weight over a relatively long time period. There are no data on the long-term health effects of using very low caloric diets or other methods that cause rapid weight reduction.

BMI is the most commonly used indicator of obesity in population studies, although it is not a perfect one. It does not take into account body fat patterning as waist-hip ratio and skin-fold measurements do. It seems that increased central or visceral fat, independent of relative body weight, is associated with a variety of metabolic disorders and increased cardiovascular mortality.49 50 51 Furthermore, weight is usually positively related to increased morbidity and mortality, whereas height is often associated with good health. Therefore, among obese subjects, BMI can reflect the negative effects of both fatness and shortness. The risks of fatness and shortness are most likely mediated via different mechanisms. However, BMI also has several advantages compared with other methods of measuring obesity. BMI measurement is simple, inexpensive, and reliable. It is widely used, and the results of different studies are therefore easily compared. Results are also easily transferred for use in practical health care and disease prevention.

We conclude that weight control should be an integral part of the prevention of cardiovascular disease. The question of whether obesity is an independent risk factor for cardiovascular diseases or whether its effect is mediated via BP, lipid abnormalities, impaired glucose metabolism, or other mechanisms is not very important in health practice because these components cannot be separated. Similarly, although fat distribution plays an important role in the research of the pathophysiological mechanism of obesity and its relation to other diseases, in practical prevention it can be used only in individual counseling. In community-based prevention programs, identification and use of different subtypes of obesity are difficult. By preventing overweight in early adulthood, it is likely that a substantial amount of CHD mortality can be prevented.


*    Selected Abbreviations and Acronyms
 
BMI = body mass index
BP = blood pressure
CHD = coronary heart disease
ICD = International Classification of Diseases, Injuries, and Causes of Death
RR = risk ratio

Received August 14, 1995; revision received October 30, 1995; accepted October 31, 1995.


*    References
up arrowTop
 up arrowAbstract
 up arrowIntroduction
 up arrowMethods
 up arrowResults
 up arrowDiscussion
 *References
 

  1. Hubert HB, Feinleib M, McNamara PM, Castelli WB. Obesity as an independent risk factor for cardiovascular disease: a 26-year follow-up of participants in the Framingham Heart Study. Circulation. 1983;67:968-977. [Abstract/Free Full Text]
  2. Garrison RJ, Gastelli WP. Weight and thirty-year mortality of men in the Framingham Study. Ann Intern Med. 1985;103:1006-1009.
  3. Feinleib M. Epidemiology of obesity in relation to health hazards. Ann Intern Med. 1985;103:1019-1024.
  4. Burton BT, Foster WR, Hirsch J, Van Itallie TB. Health implications of obesity: an NIH Consensus Development Conference. Int J Obes. 1985;9:155-170. [Medline] [Order article via Infotrieve]
  5. Manson JE, Stampfer MJ, Hennekens CH, Willet WC. Body weight and longevity: a reassessment. JAMA. 1987;257:353-358. [Abstract]
  6. Rissanen A, Heliövaara M, Knekt P, Aromaa A, Reunanen A, Maatela J. Weight and mortality in Finnish men. J Clin Epidemiol. 1989;42:781-789. [Medline] [Order article via Infotrieve]
  7. Wilcosky T, Hyde J, Anderson JJB, Bangdiwala S, Duncan B. Obesity and mortality in the Lipid Research Clinics Programme follow-up study. J Clin Epidemiol. 1990;43:743-752. [Medline] [Order article via Infotrieve]
  8. Lindsted K, Tonstad S, Kuzma JW. Body mass index and patterns of mortality among Seventh-day Adventist men. Int J Obes. 1991;15:397-406. [Medline] [Order article via Infotrieve]
  9. Pi-Sunyer FX. Medical hazards of obesity. Ann Intern Med. 1993;119:655-660. [Abstract/Free Full Text]
  10. Kushner RF. Body weight and mortality. Nutr Rev. 1993;51:127-136. [Medline] [Order article via Infotrieve]
  11. Manson JE, Colditz GA, Stampfer MJ, Willet WC, Rosner B, Monson RR, Speizer FE, Hennekens CH. A prospective study of obesity and risk of coronary heart disease in women. N Engl J Med. 1990;322:882-889. [Abstract]
  12. Sidney S, Friedman GD, Siegelaub AB. Thinness and mortality. Am J Public Health. 1987;77:317-322. [Abstract/Free Full Text]
  13. Seidell JC, Cigolini M, Deslypere J-P, Charzewska J, Ellsinger B-M, Cruz A. Body fat distribution in relation to physical activity and smoking habits in 38-year-old European men: the European Fat Distribution Study. Am J Epidemiol. 1991;133:257-265. [Abstract/Free Full Text]
  14. Van Itallie TB. Health implications of overweight and obesity in the United States. Ann Intern Med. 1985;103:983-988.
  15. Garrison RJ, Feinleib M, Gastelli WP, McNamara PM. Cigarette smoking as a confounder of relationship between relative weight and long-term mortality: the Framingham Heart Study. JAMA. 1983;249:2199-2203. [Abstract]
  16. Marti B, Tuomilehto J, Korhonen HJ, Kartovaara L, Vartiainen E, Pietinen P, Puska P. Smoking and leanness: evidence for change in Finland. BMJ. 1989;298:1287-1298.
  17. Stamler R, Stamler J, Riedlinger WF, Algera G, Roberts RH. Weight and blood pressure: findings of hypertension screening of 1 million Americans. JAMA. 1978;240:1607-1610. [Abstract]
  18. Havlik RJ, Hubert HB, Fabsitz RR, Feinleib M. Weight and hypertension. Ann Intern Med. 1983;98:855-859.
  19. Friedman GD, Selby JV, Quesenberry CP Jr, Armstrong MA, Klatsky AL. Precursors of essential hypertension: body weight, alcohol and salt use, and parental history of hypertension. Prev Med. 1988;17:387-402. [Medline] [Order article via Infotrieve]
  20. Hunt SC, Stephenson SH, Hopkins PN, Williams RR. Predictors of an increased risk of future hypertension in Utah: a screening analysis. Hypertension. 1991;17:969-976. [Abstract/Free Full Text]
  21. The Hypertension Prevention Trial Research Group. The Hypertension Prevention Trial (HPT): three-year effects of dietary changes on blood pressure. Arch Intern Med. 1990;150:153-162. [Abstract]
  22. Weinsier RL, Norris DJ, Birch R, Bernstein RS, Wang J, Yang M-U, Pierson RN, Van Itallie TB. The relative contribution of body fat and fat pattern to blood pressure level. Hypertension. 1985;7:578-585. [Abstract/Free Full Text]
  23. Garrison RJ, Kannel WB, Stokes J III, Castelli WP. Incidence and precursors of hypertension in young adults: the Framingham Offspring Study. Prev Med. 1987;16:235-251. [Medline] [Order article via Infotrieve]
  24. Dyer AR, Elliot P, Shipley M, Stamler R, Stamler J, on behalf of the INTERSALT Cooperative Research Group. Body mass index and associations of sodium and potassium with blood pressure in INTERSALT. Hypertension. 1994;23:729-736. [Abstract/Free Full Text]
  25. Modan M, Halkin H, Almog S, Lusky A, Eshkol A, Shefi M, Shitrit A, Fuchs Z. Hyperinsulinemia: a link between hypertension, obesity and glucose tolerance. J Clin Invest. 1985;75:809-817.
  26. Ferrannini E, Buzzigoli G, Bonadonna R, Giorigo MA, Oleggini M, Graziadei L, Pedrinelli R, Brandi L, Bevilacqua S. Insulin resistance in essential hypertension. N Engl J Med. 1987;317:350-357. [Abstract]
  27. Donahue RP, Skyler JS, Schneiderman N, Prineas RJ. Hyperinsulinemia and elevated blood pressure: cause, confounder, or coincidence? Am J Epidemiol. 1990;132:827-836. [Free Full Text]
  28. Ashley RW, Kannel WB. Relation of weight changes to changes in atherogenic traits: the Framingham Study. J Chron Dis. 1974;27:103-114. [Medline] [Order article via Infotrieve]
  29. Stamler J. Overweight, hypertension, hypercholesterolemia and coronary heart disease. In: Mancini M, Lewis B, Contaldo F, eds. Medical Complications of Obesity. London, England: Academic Press, Inc; 1979:191-216.
  30. Björntorp P. `Portal' adipose tissue as a generator of risk factors for cardiovascular disease and diabetes. Atherosclerosis. 1990;10:493-496.
  31. Puska P, Tuomilehto J, Salonen J, Nissinen A, Virtamo J, Björkqvist S, Koskela K, Neittaanmäki L, Takalo T, Kottke TE, Mäki J, Sipilä P, Varvikko P. Community Control of Cardiovascular Disease: The North Karelia Project—evaluation of a comprehensive community programme for control of cardiovascular diseases in 1972-1977 in North Karelia. Copenhagen, Denmark: World Health Organization, Regional Office for Europe; 1981.
  32. Cox DR. Regression models and life tables. J R Stat Soc B. 1972;34:187-220.
  33. SAS/STAT User's Guide, Version 6. 4th ed. Cary, NC: SAS Institute, Inc; 1990;1-2.
  34. Williamsson DF, Madans J, Anda RF, Kleinman JC, Giovino GA, Byers T. Smoking cessation and severity of weight gain in a national cohort. N Engl J Med. 1991;324:739-745. [Abstract]
  35. The Pooling Project Research Group. Relationship of Blood Pressure, Serum Cholesterol, Smoking Habit, Relative Weight and ECG Abnormalities to Incidence of Major Coronary Events: Final Report of the Pooling Project. Dallas, Tex: American Heart Association; 1978. Monograph No. 60.
  36. Keys A. Seven Countries: A Multivariate Analysis of Death and Coronary Heart Disease. Cambridge, Mass: Harvard University Press; 1980.
  37. Neaton JD, Wentworth D, for the Multiple Risk Factor Intervention Trial Research Group. Serum cholesterol, blood pressure, cigarette smoking and death from coronary heart disease. Arch Intern Med. 1992;152:56-64. [Abstract]
  38. Borkan GA, Sparrow D, Wisniewski C, Vokonas PS. Body weight and coronary disease risk: patterns of risk factor change associated with long-term weight change—the normative aging study. Am J Epidemiol. 1986;124:410-419. [Abstract/Free Full Text]
  39. Barrett-Connor E, Khaw KT. Is hypertension more benign when associated with obesity? Circulation. 1985;72:53-60. [Abstract/Free Full Text]
  40. Phillips A, Shaper AG. Relative weight and major ischaemic heart disease events in hypertensive men. Lancet. 1989;1:1005-1008. [Medline] [Order article via Infotrieve]
  41. Stamler R, Ford CE, Stamler J. Why do lean hypertensives have higher mortality rates than other hypertensives? Findings of the Hypertension Detection and Follow-up Program. Hypertension. 1991;17:553-564. [Abstract/Free Full Text]
  42. Vague P, Raccah D. The syndrome of insulin resistance. Horm Res. 1992;38:28-32.
  43. Hense HW, Döring A, Stieber J, Keil U. The association of antihypertensive treatment patterns and adverse lipid effects in population-based studies. J Clin Epidemiol. 1992;45:1423-1430. [Medline] [Order article via Infotrieve]
  44. Houston MC. The effects of antihypertensive drugs on glucose intolerance in hypertensive nondiabetics and diabetics. Am Heart J. 1988;115:640-656.[Medline] [Order article via Infotrieve]
  45. Pekkanen J, Tervahauta M, Nissinen A, Karvonen MJ. Does the predictive value of baseline coronary risk factors change over a 30-year follow-up? Cardiology. 1993;82:181-190. [Medline] [Order article via Infotrieve]
  46. Despres JP, Moorjani S, Lupien PJ, Tremblay A, Nadeau A, Bouchard C. Genetic aspects of susceptibility to obesity and related dyslipidemias. Mol Cell Biochem. 1992;113:151-169. [Medline] [Order article via Infotrieve]
  47. Higgins M, D'Agostino R, Kannel W, Cobb J. Benefits and adverse effects of weight loss: observations from the Framingham Study. Ann Intern Med. 1993;119:758-763. [Abstract/Free Full Text]
  48. Blair SN, Shaten J, Brownell K, Collins G, Lissner L. Body weight change, all-cause mortality, and cause-specific mortality in the Multiple Risk Factor Intervention Trial. Ann Intern Med. 1993;119:749-757.[Abstract/Free Full Text]
  49. Gillum RF. The association of body fat distribution with hypertension, hypertensive heart disease, coronary heart disease, diabetes and cardiovascular risk factors in men and women aged 18-79 years. J Chron Dis. 1987;40:421-428. [Medline] [Order article via Infotrieve]
  50. Folsom AR, Burke GL, Ballew C, Jacobs DR Jr, Haskell WL, Donahue RP, Liu K, Hilner JE. Relation of body fatness and its distribution to cardiovascular risk factors in young blacks and whites: the role of insulin. Am J Epidemiol. 1989;130:911-924. [Abstract/Free Full Text]
  51. Filipovsky J, Ducimetiere P, Darne B, Richard JL. Abdominal body mass distribution and elevated blood pressure are associated with increased risk of death from cardiovascular diseases and cancer in middle-aged men: the results of a 15- to 20-year follow-up in the Paris prospective study I. Int J Obes. 1993;17:197-203.[Medline] [Order article via Infotrieve]



This article has been cited by other articles:


Home page
 CirculationHome page
S. K. Kumanyika, E. Obarzanek, N. Stettler, R. Bell, A. E. Field, S. P. Fortmann, B. A. Franklin, M. W. Gillman, C. E. Lewis, W. C. Poston II, et al.
Population-Based Prevention of Obesity: The Need for Comprehensive Promotion of Healthful Eating, Physical Activity, and Energy Balance: A Scientific Statement From American Heart Association Council on Epidemiology and Prevention, Interdisciplinary Committee for Prevention (Formerly the Expert Panel on Population and Prevention Science)
Circulation, July 22, 2008; 118(4): 428 - 464.
[Abstract] [Full Text] [PDF]

Home page
 Eur J Public HealthHome page
T. Vlasoff, T. Laatikainen, V. Korpelainen, M. Uhanov, S. Pokusajeva, A. Rogacheva, K. Tossavainen, E. Vartiainen, and P. Puska
Ten year trends in chronic disease risk factors in the Republic of Karelia, Russia
Eur J Public Health, July 15, 2008; (2008) ckn063v1.
[Abstract] [Full Text] [PDF]

Home page
 J. Clin. Endocrinol. Metab.Home page
C. A. Allan, B. J. G. Strauss, H. G. Burger, E. A. Forbes, and R. I. McLachlan
Testosterone Therapy Prevents Gain in Visceral Adipose Tissue and Loss of Skeletal Muscle in Nonobese Aging Men
J. Clin. Endocrinol. Metab., January 1, 2008; 93(1): 139 - 146.
[Abstract] [Full Text] [PDF]

Home page
 Scand J Public HealthHome page
L. L. Haheim, S. Tonstad, I. Hjermann, P. Leren, and I. Holme
Predictiveness of body mass index for fatal coronary heart disease in men according to length of follow-up: A 21-year prospective cohort study
Scand J Public Health, January 1, 2007; 35(1): 4 - 10.
[Abstract] [PDF]

Home page
 J Am Coll CardiolHome page
X. Kang, L. J. Shaw, S. W. Hayes, R. Hachamovitch, A. Abidov, I. Cohen, J. D. Friedman, L. E.J. Thomson, D. Polk, G. Germano, et al.
Impact of Body Mass Index on Cardiac Mortality in Patients With Known or Suspected Coronary Artery Disease Undergoing Myocardial Perfusion Single-Photon Emission Computed Tomography
J. Am. Coll. Cardiol., April 4, 2006; 47(7): 1418 - 1426.
[Abstract] [Full Text] [PDF]

Home page
 Int J EpidemiolHome page
Z. Chen, G. Yang, M. Zhou, M. Smith, A. Offer, J. Ma, L. Wang, H. Pan, G. Whitlock, R. Collins, et al.
Body mass index and mortality from ischaemic heart disease in a lean population: 10 year prospective study of 220 000 adult men
Int. J. Epidemiol., February 1, 2006; 35(1): 141 - 150.
[Abstract] [Full Text] [PDF]

Home page
 Am J EpidemiolHome page
M. S. Blanchard, S. A. Eisen, R. Alpern, J. Karlinsky, R. Toomey, D. J. Reda, F. M. Murphy, L. W. Jackson, and H. K. Kang
Chronic Multisymptom Illness Complex in Gulf War I Veterans 10 Years Later
Am. J. Epidemiol., January 1, 2006; 163(1): 66 - 75.
[Abstract] [Full Text] [PDF]

Home page
 Am J EpidemiolHome page
T. Wilsgaard, B. K. Jacobsen, and E. Arnesen
Determining Lifestyle Correlates of Body Mass Index using Multilevel Analyses: The Tromso Study, 1979-2001
Am. J. Epidemiol., December 15, 2005; 162(12): 1179 - 1188.
[Abstract] [Full Text] [PDF]

Home page
 HeartHome page
Prepared by: British Cardiac Society, British Hype
JBS 2: Joint British Societies' guidelines on prevention of cardiovascular disease in clinical practice
Heart, December 1, 2005; 91(suppl_5): v1 - v52.
[Full Text] [PDF]

Home page
 ANGIOLOGYHome page
E. Tatli, M. Yildiz, C. Gul, A. Birsin, E. Karahasanoglu, F. Ozcelik, and G. Ozbay
Effect of Obesity on Coronary Collateral Vessel Development in Patients with Coronary Artery Disease
Angiology, November 1, 2005; 56(6): 657 - 661.
[Abstract] [PDF]

Home page
 Arch NeurolHome page
M. Kivipelto, T. Ngandu, L. Fratiglioni, M. Viitanen, I. Kareholt, B. Winblad, E.-L. Helkala, J. Tuomilehto, H. Soininen, and A. Nissinen
Obesity and Vascular Risk Factors at Midlife and the Risk of Dementia and Alzheimer Disease
Arch Neurol, October 1, 2005; 62(10): 1556 - 1560.
[Abstract] [Full Text] [PDF]

Home page
 Eur Heart JHome page
J. R. Emberson, P. H. Whincup, R. W. Morris, S. G. Wannamethee, and A. G. Shaper
Lifestyle and cardiovascular disease in middle-aged British men: the effect of adjusting for within-person variation
Eur. Heart J., September 1, 2005; 26(17): 1774 - 1782.
[Abstract] [Full Text] [PDF]

Home page
 HeartHome page
A Rosengren, L Wallentin, M Simoons, A K Gitt, S Behar, A Battler, and D Hasdai
Cardiovascular risk factors and clinical presentation in acute coronary syndromes
Heart, September 1, 2005; 91(9): 1141 - 1147.
[Abstract] [Full Text] [PDF]

Home page
 Psychosom. Med.Home page
A. Kouvonen, M. Kivimaki, S. J. Cox, T. Cox, and J. Vahtera
Relationship Between Work Stress and Body Mass Index Among 45,810 Female and Male Employees
Psychosom Med, July 1, 2005; 67(4): 577 - 583.
[Abstract] [Full Text] [PDF]

Home page
 J. Epidemiol. Community HealthHome page
S G. Wannamethee, A G. Shaper, and M. Walker
Overweight and obesity and weight change in middle aged men: impact on cardiovascular disease and diabetes
J. Epidemiol. Community Health, February 1, 2005; 59(2): 134 - 139.
[Abstract] [Full Text] [PDF]

Home page
 Clin. Chem.Home page
K.-M. Hermann-Arnhof, U. Hanusch-Enserer, T. Kaestenbauer, T. Publig, A. Dunky, H. R. Rosen, R. Prager, and U. Koller
N-Terminal Pro-B-Type Natriuretic Peptide as an Indicator of Possible Cardiovascular Disease in Severely Obese Individuals: Comparison with Patients in Different Stages of Heart Failure
Clin. Chem., January 1, 2005; 51(1): 138 - 143.
[Abstract] [Full Text] [PDF]

Home page
 Eur Heart JHome page
G. Hu, J. Tuomilehto, K. Silventoinen, N. Barengo, and P. Jousilahti
Joint effects of physical activity, body mass index, waist circumference and waist-to-hip ratio with the risk of cardiovascular disease among middle-aged Finnish men and women
Eur. Heart J., December 2, 2004; 25(24): 2212 - 2219.
[Abstract] [Full Text] [PDF]

Home page
 CirculationHome page
I. D. Caterson, V. Hubbard, G. A. Bray, R. Grunstein, B. C. Hansen, Y. Hong, D. Labarthe, J. C. Seidell, and S. C. Smith Jr
Prevention Conference VII: Obesity, a Worldwide Epidemic Related to Heart Disease and Stroke: Group III: Worldwide Comorbidities of Obesity
Circulation, November 2, 2004; 110(18): e476 - e483.
[Full Text] [PDF]

Home page
 Am J EpidemiolHome page
B. J. Nicklas, B. W. J. H. Penninx, M. Cesari, S. B. Kritchevsky, A. B. Newman, A. M. Kanaya, M. Pahor, D. Jingzhong, and T. B. Harris
Association of Visceral Adipose Tissue with Incident Myocardial Infarction in Older Men and Women: The Health, Aging and Body Composition Study
Am. J. Epidemiol., October 15, 2004; 160(8): 741 - 749.