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The obesity paradox is mostly driven by decreased noncardiovascular disease mortality in the oldest old in China: a 20-year prospective cohort study

Abstract

National and international recommendations of healthy body mass index (BMI) are primarily based on evidence in young and middle-aged populations, with an insufficient representation of the oldest old (aged ≥80 years). Here, we report associations between BMI and mortality risk in 27,026 community-dwelling oldest old (mean age, 92.7 ± 7.5 years) in China from 1998 to 2018. Nonlinear curves showed reverse J-shaped associations of BMI with cardiovascular disease (CVD), non-CVD and all-cause mortality, with a monotonic decreased risk up to BMIs in the overweight and mild obesity range and flat hazard ratios thereafter. Compared to normal weight, overweight and obesity were significantly associated with decreased non-CVD and all-cause mortality, but not with CVD mortality. Similar associations were found for waist circumference. Our results lend support to the notion that optimal BMI in the oldest old may be around the overweight or mild obesity range and challenge the application of international and national guidelines on optimal BMI in this age group.

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Fig. 1: Associations of BMI with all-cause, CVD and non-CVD mortality in Cox models with penalized splines.
Fig. 2: Association of BMI with all-cause, CVD and non-CVD mortality in the oldest old.
Fig. 3: Association of waist circumference with all-cause, CVD and non-CVD mortality in Cox models with penalized splines for men and women.
Fig. 4: Associations of weight change with all-cause, CVD and non-CVD mortality in the oldest old.

Data availability

The data that support the findings of the study are available from X.S. upon reasonable request.

Code availability

SAS version 9.4 and R version 3.5.0 code used are available from X.S. upon reasonable request.

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Acknowledgements

The Chinese Longitudinal Healthy Longevity Survey, which provided the data analyzed in this article, is jointly supported by National Natural Sciences Foundation of China (82025030, 81941023 and 82003500), the National Key R&D Program of China (2018YFC2000400), the National Institute on Aging (2P01AG031719), the United Nations Fund for Population Activities and the Claude D. Pepper Older Americans Independence Center (National Institute on Aging grant 5P30AG028716 to V.B.K.). The funders had no role in the study design or implementation; data collection, management, analysis and interpretation; manuscript preparation, review or approval; or decision to submit the manuscript for publication. All authors confirm that they had full access to all the data in the study and accept responsibility to submit for publication.

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Authors and Affiliations

Authors

Contributions

X.S. takes responsibility for the integrity of the data and the accuracy of the data analysis. Y.L., C.M., X.G., J.S.J. and J.Y. conducted the data analysis, interpreted the results and drafted the manuscript. Y.Z. and X.S. designed the survey. X.G. helped to conduct data analysis. V.B.K. assisted with data interpretation and drafting of the manuscript. Y.Z., X.S. and V.B.K. provided funding support. V.B.K., Z.Y., H.C., J.S.L., J.Z., Z.L., J.D., W.W. and J.W. helped to implement the survey. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Xiaoming Shi.

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Nature Aging thanks Parminder Raina, Jean Woo and the other, anonymous, reviewer(s) for their contribution to the peer review of this work.

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Extended data figures and tables

Extended Data Fig. 1 Subgroup analyses: association of body mass index with all-cause, CVD and non-CVD mortality in the oldest old.

Two-sided P < 0.05 was defined as statistically significant; multiple comparisons were not adjusted. *<0.05; **<0.01; ***<0.001 † Adjusted for sex, age (continuous and linear), residence, educational background, occupation, source of income, current marital status, living pattern, smoking status, alcohol drinking status, regular exercise, diagnoses of heart disease, cerebrovascular disease, digestive system diseases, respiratory disease, hypertension, cognitive impairment, and disability in activities of daily living. Data are presented as point estimates of effects ±1.96 s.e. (that is, 95% CIs). The Nodes represents the point estimates; the line segment represents the CIs; the solid line is the reference line. Analyses were performed based on the data of 27,026 Chinese oldest old, 17,070 of whom All-cause mortality, 2,389 of whom CVD, and 14,681 of whom non-CVD.

Extended Data Fig. 2 The linear association of age with all-cause mortality in Cox models with penalized splines.

The Cox models with penalized spilnes were used to explore the linear or nonlinear association of age with mortality on the basis of Akaike Information Criterion (AIC), and the linear association was detected.

Supplementary information

43587_2022_201_MOESM1_ESM.pdf

Supplementary study design, Figures 1 and 2, methodological issues in subgroup analyses, Tables 1–13 and Strengthening the Reporting of Observational Studies in Epidemiology statement.

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Lv, Y., Mao, C., Gao, X. et al. The obesity paradox is mostly driven by decreased noncardiovascular disease mortality in the oldest old in China: a 20-year prospective cohort study. Nat Aging 2, 389–396 (2022). https://doi.org/10.1038/s43587-022-00201-3

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