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Epidemiology and Population Health

Early mortality and cardiovascular disease, varied association with body mass index and its changes in insulin-treated diabetes: a nationwide study



We investigated the hazards of cardiovascular diseases (CVDs) and all-cause death during follow-up according to baseline body mass index (BMI) and percent change in BMI among adults with insulin-treated diabetes.


Using the Korean National Health Insurance Service datasets (2002–2017), the hazards of myocardial infarction (MI), stroke, and all-cause mortality during follow-up were analyzed according to baseline BMI and percent change in BMI among adults with insulin-treated diabetes and without baseline CVD and/or malignancy (N = 44,055).


At baseline, 67.3% of total subjects were either obese or overweight. During a mean 3.8 years, 1,081 MI and 1,562 stroke cases developed; 2,847 deaths occurred over a mean 3.9 years. Compared with normal weight, overweight and obesity were associated with lower hazards of outcomes [hazard ratio (95% CI): 0.836 (0.712–0.981), 0.794 (0.687–0.917) for MI; 0.829 (0.726–0.946), 0.772 (0.684–0.870) for stroke; 0.740 (0.672–0.816), 0.666 (0.609–0.728) for death, respectively]. Underweight was associated with a higher hazard of all-cause death during follow-up [hazard ratio (95% CI): 2.035 (1.695–2.443)]. When the group with minimum absolute value for percent change in BMI was set as a reference, the relative reduction in BMI was associated with increased hazards of MI, stroke, and all-cause death, and relative increase in BMI was associated with increased hazards of stroke and all-cause death during follow-up.


Among adults with insulin-treated diabetes, a high prevalence of overweight and obesity was observed, and baseline BMI category was inversely associated with CVD incidence and all-cause death during follow-up. Both weight loss and gain were associated with increased CVD incidence and all-cause death during follow-up, showing a U-shaped relationship between weight change and outcome. Stable body weight might be a predictor of a lower risk of CVDs and premature death among individuals with insulin-treated diabetes.

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Fig. 1
Fig. 2: Adjusted hazard ratios and 95% confidence intervals for incidence of myocardial infarction, stroke, and all-cause death during follow-up according to percent change in body mass index.


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This work was performed using the database from the Korean National Health Insurance Service (KNHIS). This study used the National Health Information Database constructed by the KNHIS, and the study results do not necessarily represent the opinion of the KNHIS.

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Y-BL drafted the manuscript. Y-BL, KH, GK, and JHK contributed to the study design. BK and KH participated in the data analysis planning and statistical analysis. JP, MK, MSC, SMJ, and KYH performed literature searches and contributed to conception of the hypothesis. JHK critically edited the manuscript. All authors read and approved the final version of the manuscript. JHK and KH are the guarantors of this work and, as such, had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

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Correspondence to Kyungdo Han or Jae Hyeon Kim.

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Lee, YB., Kim, B., Park, J. et al. Early mortality and cardiovascular disease, varied association with body mass index and its changes in insulin-treated diabetes: a nationwide study. Int J Obes 45, 2482–2489 (2021).

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