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. 2018 May 1;39(17):1514-1520.
doi: 10.1093/eurheartj/ehy057.

The impact of confounding on the associations of different adiposity measures with the incidence of cardiovascular disease: a cohort study of 296 535 adults of white European descent

Stamatina Iliodromiti  1 , Carlos A Celis-Morales  2 , Donald M Lyall  3 , Jana Anderson  3 , Stuart R Gray  2 , Daniel F Mackay  3 , Scott M Nelson  1 , Paul Welsh  2 , Jill P Pell  3 , Jason M R Gill  2 , Naveed Sattar  2
Affiliations

The impact of confounding on the associations of different adiposity measures with the incidence of cardiovascular disease: a cohort study of 296 535 adults of white European descent

Stamatina Iliodromiti et al. Eur Heart J. .

Abstract

Aims: The data regarding the associations of body mass index (BMI) with cardiovascular (CVD) risk, especially for those at the low categories of BMI, are conflicting. The aim of our study was to examine the associations of body composition (assessed by five different measures) with incident CVD outcomes in healthy individuals.

Methods and results: A total of 296 535 participants (57.8% women) of white European descent without CVD at baseline from the UK biobank were included. Exposures were five different measures of adiposity. Fatal and non-fatal CVD events were the primary outcome. Low BMI (≤18.5 kg m-2) was associated with higher incidence of CVD and the lowest CVD risk was exhibited at BMI of 22-23 kg m-2 beyond, which the risk of CVD increased. This J-shaped association attenuated substantially in subgroup analyses, when we excluded participants with comorbidities. In contrast, the associations for the remaining adiposity measures were more linear; 1 SD increase in waist circumference was associated with a hazard ratio of 1.16 [95% confidence interval (CI) 1.13-1.19] for women and 1.10 (95% CI 1.08-1.13) for men with similar magnitude of associations for 1 SD increase in waist-to-hip ratio, waist-to-height ratio, and percentage body fat mass.

Conclusion: Increasing adiposity has a detrimental association with CVD health in middle-aged men and women. The association of BMI with CVD appears more susceptible to confounding due to pre-existing comorbidities when compared with other adiposity measures. Any public misconception of a potential 'protective' effect of fat on CVD risk should be challenged. Take home figureThe obesity paradox is mainly due to the effect of confounding on BMI and disappears on other adiposity measures.

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Figures

Take home figure
Take home figure
The obesity paradox is mainly due to the effect of confounding on BMI and disappears on other adiposity measures.
Figure 1
Figure 1
Hazard ratio of cardiovascular events in men and women in relation to body mass index, waist circumference, waist-to-hip ratio, waist-to-height ratio, and percentage body fat mass referent to the reference category. Hazard ratio (95% confidence intervals) per 1 SD increase in each adiposity marker are presented, for body mass index the hazard ratios correspond to those with a body mass index over 22 kg m−2. The grey line indicates hazard ratio of one at the referent category.
Take home figure
Take home figure
The obesity paradox is mainly due to the effect of confounding on BMI and disappears on other adiposity measures.
See this image and copyright information in PMC

Comment in

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