Body-mass index and cause-specific mortality in 900 000 adults: collaborative analyses of 57 prospective studies
Open accessAbstract
Summary Background The main associations of body-mass index (BMI) with overall and cause-specific mortality can best be assessed by long-term prospective follow-up of large numbers of people. The Prospective Studies Collaboration aimed to investigate these associations by sharing data from many studies. Methods Collaborative analyses were undertaken of baseline BMI versus mortality in 57 prospective studies with 894 576 participants, mostly in western Europe and North America (61% [n=541 452] male, mean recruitment age 46 [SD 11] years, median recruitment year 1979 [IQR 1975–85], mean BMI 25 [SD 4] kg/m2). The analyses were adjusted for age, sex, smoking status, and study. To limit reverse causality, the first 5 years of follow-up were excluded, leaving 66 552 deaths of known cause during a mean of 8 (SD 6) further years of follow-up (mean age at death 67 [SD 10] years): 30 416 vascular; 2070 diabetic, renal or hepatic; 22 592 neoplastic; 3770 respiratory; 7704 other. Findings In both sexes, mortality was lowest at about 22·5–25 kg/m2. Above this range, positive associations were recorded for several specific causes and inverse associations for none, the absolute excess risks for higher BMI and smoking were roughly additive, and each 5 kg/m2 higher BMI was on average associated with about 30% higher overall mortality (hazard ratio per 5 kg/m2 [HR] 1·29 [95% CI 1·27–1·32]): 40% for vascular mortality (HR 1·41 [1·37–1·45]); 60–120% for diabetic, renal, and hepatic mortality (HRs 2·16 [1·89–2·46], 1·59 [1·27–1·99], and 1·82 [1·59–2·09], respectively); 10% for neoplastic mortality (HR 1·10 [1·06–1·15]); and 20% for respiratory and for all other mortality (HRs 1·20 [1·07–1·34] and 1·20 [1·16–1·25], respectively). Below the range 22·5–25 kg/m2, BMI was associated inversely with overall mortality, mainly because of strong inverse associations with respiratory disease and lung cancer. These inverse associations were much stronger for smokers than for non-smokers, despite cigarette consumption per smoker varying little with BMI. Interpretation Although other anthropometric measures (eg, waist circumference, waist-to-hip ratio) could well add extra information to BMI, and BMI to them, BMI is in itself a strong predictor of overall mortality both above and below the apparent optimum of about 22·5–25 kg/m2. The progressive excess mortality above this range is due mainly to vascular disease and is probably largely causal. At 30–35 kg/m2, median survival is reduced by 2–4 years; at 40–45 kg/m2, it is reduced by 8–10 years (which is comparable with the effects of smoking). The definite excess mortality below 22·5 kg/m2 is due mainly to smoking-related diseases, and is not fully explained. Funding UK Medical Research Council, British Heart Foundation, Cancer Research UK, EU BIOMED programme, US National Institute on Aging, and Clinical Trial Service Unit (Oxford, UK).
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The impact of serious mental illness on life expectancy is marked and generally higher than similarly calculated impacts of well-recognised adverse exposures such as smoking, diabetes and obesity.
“The impact of serious mental illness on life expectancy is marked and generally higher than similarly calculated impacts of well-recognised adverse exposures such as smoking, diabetes and obesity.”
From Life Expectancy at Birth for People with Serious Mental Illness and Other Major Disorders from a Secondary Mental Health Care Case Register in London (2011) · cites this paper as [35]
The Discussion estimates that obesity reduces median survival by 2–4 years, or 8–10 years for morbid obesity, and compares the latter with smoking. It does not assess serious mental illness or establish that its effect on life expectancy is generally greater than the effects of smoking, diabetes, and obesity. Page numbers are not available in our copy. (LLM, conf=0.84)
Experimental — accuracy not yet measuredObservational studies of body-mass index effect sizes have controlled for some potential confounders.
“Observational studies of the effect sizes for body-mass index have controlled for some potential confounders.75–77”
Overweight and obesity are associated with risk of death in CVD.
“Both overweight and obesity are associated with a risk of death in CVD.363 -365”
From European Guidelines on cardiovascular disease prevention in clinical practice (version 2012) (2012) · cites this paper as [363]
Risk of death is elevated with BMI higher or lower than optimal ranges, with a U-shaped association.
“The risk was elevated with BMI levels either higher or lower than these ranges, with a U-shaped association.”
From European Guidelines on cardiovascular disease prevention in clinical practice (version 2012) (2012) · cites this paper as [363]
All-cause mortality is lowest with a BMI of 20-25 kg/m2.
“All-cause mortality is lowest with a BMI of 20 -25 kg/m 2 .363 -365”
From European Guidelines on cardiovascular disease prevention in clinical practice (version 2012) (2012) · cites this paper as [363]
The same optimal weight range in Asian and European studies argues against race- or ethnicity-specific BMI cut-offs for overweight and obesity.
“The finding that the same optimal weight range is associated with the lowest risk of death both in this study and in previous studies of European origin argues against the use of race-or ethnicity-specific BMI cut-off points to define overweight and obesity.363”
From European Guidelines on cardiovascular disease prevention in clinical practice (version 2012) (2012) · cites this paper as [363]
BMI has a positive linear association with all-cause mortality.
“There is a positive linear association of BMI with all-cause mortality.363”
From European Guidelines on cardiovascular disease prevention in clinical practice (version 2012) (2012) · cites this paper as [363]
Prospective Studies Collaboration found positive linear associations of BMI from 22.5 to 25.0 with all-cause mortality.
“Recent findings from the Prospective Studies Collaboration, 363 involving .900000 participants, found positive linear associations of BMI from 22.5 to 25.0 with all-cause mortality.”
From European Guidelines on cardiovascular disease prevention in clinical practice (version 2012) (2012) · cites this paper as [363]
Recent studies have shown an association between overweight or obesity and a lower risk of CVD or CVD-associated death, whereas being underweight is associated with an increased risk of CVD, a phenomenon known as the obesity paradox.
“Likewise, recent studies have shown an association between overweight or obesity and a lower risk of CVD or CVD-associated death, whereas being underweight is associated with an increased risk of CVD, a phenomenon known as the obesity paradox (71, 72).”
From Health Consequences of Sarcopenic Obesity: A Narrative Review (2020) · cites this paper as [72]
A reduction of 11 to 20 years in life expectancy is higher than what is associated with most other risk factors for premature death such as diabetes (up to 2 years), smoking (10 years), and severe obesity (10 years).
“A reduction of 11 to 20 years in life expectancy is higher than what is associated with most other risk factors for premature death such as diabetes (up to 2 years) [45], smoking (10 years) [46], and severe obesity (10 years) [47].”
From Life expectancy and death by diseases of the circulatory system in patients with bipolar disorder or schizophrenia in the Nordic countries. (2013) · cites this paper as [47]
In healthy people in youth and middle age, there is obesity risk, not an Obesity Paradox.
“And the final important point to make is this: in healthy people in youth and middle age, there is obesity risk, not an Obesity Paradox.115”
From Obesity Paradox in Hypertension: Is This Because Sympathetic Activation in Obesity-Hypertension Takes a Benign Form? (2018) · cites this paper as [115]
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- Authors
- Prospective Studies Collaboration
- Affiliations
- University of Oxford (GB)
- Corresponding author
- Prospective Studies Collaboration
- Venue
- The Lancet
- Publisher
- Elsevier BV
- Published
- 2009-03
- Volume
- 373
- Issue
- 9669
- Pages
- 1083-1096
- ISSN
- 0099-5355 (ISSN-L)
- 0140-6736
- PMC
- PMC2662372
- OpenAlex
- W2142170772
- Semantic Scholar
- 361c5dcd41aee7110e253f884a767df43651ce71
- Cited by
- 4,807
- References
- 37
- Citations by year
- 2026: 128 · 2025: 224 · 2024: 282 · 2023: 267 · 2022: 282 · 2021: 332 · 2020: 301 · 2019: 268 · 2018: 293 · 2017: 328 · 2016: 300 · 2015: 333 · 2014: 344 · 2013: 312 · 2012: 282
- FWCI
- 269.25
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- The Lancet (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Socio-Environmental Systems Modeling (acceptedVersion)
- LSHTM Research Online (London School of Hygiene and Tropical Medicine) (acceptedVersion)
- Lirias (KU Leuven) (submittedVersion, other-oa)
- Research Portal (Queen's University Belfast) (submittedVersion, other-oa)
- Ghent University Academic Bibliography (Ghent University) (submittedVersion)
- Adelaide Research & Scholarship (AR&S) (University of Adelaide) (submittedVersion)
- UCL Discovery (University College London) (submittedVersion)
- Institutional Repositories DataBase (IRDB) (submittedVersion, cc-by-nc-nd)
- STM:n Hallinnonalan avoin julkaisuarkisto (Julkari) (submittedVersion)
- Data Archiving and Networked Services (DANS) (submittedVersion)
- Funders
- Health Research Council of New Zealand
- Medical Research Council
- British Heart Foundation
- National Institute on Aging (P01 AG17625-01)
- Cancer Research UK
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Obesity, Physical Activity, Diet
- Health Sciences › Medicine › Oncology › Cancer Risks and Factors
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes, Cardiovascular Risks, and Lipoproteins
- Keywords
- body mass index, obesity, cause-specific mortality, all-cause mortality, vascular death, diabetes mortality, renal mortality, respiratory mortality, smoking, excess risk, data sharing, collaborative analysis, reverse causality, cardiovascular disease, cancer risk, respiratory disease risk, liver disease risk, diabetes risk, renal disease risk
- MeSH terms
- Adult, Aged, Aged, 80 and over, Cause of Death, Female, Humans, Male, Middle Aged, Mortality, Prospective Studies, Respiratory Tract Diseases, Body Mass Index, Myocardial Ischemia, Stroke
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