23. Lee HM, Wang G, Englander EW, Kojima M, Greeley
GH Jr. Ghrelin, a new gastrointestinal endocrine pep-
tide that stimulates insulin secretion: enteric distribu-
tion, ontogeny, inuence of endocrine, and dietary
manipulations. Endocrinology. 2002;143:185–190.
24. Broglio F, Arvat E, Benso A, et al. Ghrelin, a natural GH
secretagogue produced by the stomach, induces hy-
perglycemia and reduces insulin secretion in humans.
J Clin Endocrinol Metab. 2001;86:5083–5086.
25. Wren AM, Small CJ, Abbott CR, et al. Ghrelin
causes hyperphagia and obesity in rats. Diabetes.
2001;50:2540 –2547.
26. Lawrence CB, Snape AC, Baudoin FM, Luckman
SM. Acute central ghrelin and GH secretagogues
induce feeding and activate brain appetite centers.
Endocrinology. 2002;143:155 –162.
27. Nagaya N, Uematsu M, Kojima M, et al. Chronic
administration of ghrelin improves left ventricular
dysfunction and attenuates development of cardiac
cachexia in rats with heart failure. Circulation. 2001;
104:1430 –1435.
28. Wren AM, Seal LJ, Cohen MA, et al. Ghrelin en-
hances appetite and increases food intake in hu-
mans. J Clin Endocrinol Metab. 2001;86:5992.
29. Beck B, Musse N, Stricker-Krongrad A. Ghrelin,
macronutrient intake and dietary preferences in
long-evans rats. Biochem Biophys Res Commun.
2002;292:1031 –1035.
30. Mun EC, Blackburn GL, Matthews JB. Current sta-
Body Mass Index and Mortality in Asian Populations:
Implications for Obesity Cut-points
Investigators have questioned whether body
mass index (BMI, kg/m2 ) cut-points for obesity
used in the United States and Europe are appro-
priate for Asian countries. A recent study exam-
ined the association between BMI and mortality
in a population-based cohort of Japanese men
and women. These and other results did not
indicate a need for lower cut-points in Asians.
Key Words: obesity, body mass index, Asians,
mortality, reference standards
© 2003 International Life Sciences Institute
doi: 10.131/nr.2003.marr.104–107
Since the publication of the Metropolitan Life Insurance
Tables,1 standards for body weight have been deŽ ned
This review was prepared by June Stevens, Ph.D.,
Departments of Nutrition and Epidemiology, CB 7461,
and Eric M. Nowicki, M.P.H., R.D., Department of
Epidemiology, University of North Carolina at Chapel
Hill, Chapel Hill, NC 27599, USA.
104
tus of medical and surgical therapy for obesity.
Gastroenterology. 2001;120:669 – 681.
31. Nakagawa E, Nagaya N, Okumura H, et al. Hyper-
glycaemia suppresses the secretion of ghrelin, a
novel growth-hormone-releasing peptide: responses
to the intravenous and oral administration of glu-
cose. Clin Sci (Lond). 2002;103:325 –328.
32. Caixas A, Bashore C, Nash W, Pi-Sunyer F, Lafer-
rere B. Insulin, unlike food intake, does not sup-
press ghrelin in human subjects. J Clin Endocrinol
Metab. 2002;87:1902.
33. Ravussin E, Tschop M, Morales S, Bouchard C,
Heiman ML. Plasma ghrelin concentration and en-
ergy balance: overfeeding and negative energy bal-
ance studies in twins. J Clin Endocrinol Metab.
2001;86:4547 – 4551.
34. Okumura H, Nagaya N, Enomoto M, Nakagawa E,
Oya H, Kangawa K. Vasodilatory effect of ghrelin, an
endogenous peptide from the stomach. J Cardio-
vasc Pharmacol. 2002;39:779 – 883.
35. Nagaya N, Kojima M, Uematsu M, et al. Hemody-
namic and hormonal effects of human ghrelin in
healthy volunteers. Am J Physiol Regul Integr Comp
Physiol. 2001;280:R1483 –R1487.
36. Hinney A, Hoch A, Geller F, et al. Ghrelin gene:
identiŽcation of missense variants and a frameshift
mutation in extremely obese children and adoles-
cents and healthy normal weight students. J Clin
Endocrinol Metab. 2002;87:2716.
by the association between mortality and weight relative
to height. In 1998, cut-points for body mass index (BMI,
kg/m2) were created by the International Obesity Task
Force for the World Health Organization (WHO) to classify
weight status and deŽ ne obesity in adult populations.2
Increases in mortality associated with a BMI $25.0 in
Caucasians were the primary rationale behind the WHO
cut-points for overweight ($25.0) and obesity ($30.0).
Within the past few years, several investigators3–6
and policy-making organizations7 have questioned
whether the cut-points for obesity currently used in the
United States and in most European countries are appro-
priate for use in Asian countries. Studies examining the
association between BMI and mortality in an Asian
population are therefore of great interest. One such study
was recently published by Tsugane et al.8 in a popula-
tion-based cohort of Japanese men and women.
This Japanese cohort was established in 1990 and
was composed of 54,498 men and women, who resided
in 14 administrative districts, and were 40 to 59 years of
age at baseline. Data on height, weight, and several
covariates were collected by questionnaire. Validity of
Nutrition Reviews , Vol. 61, No. 3
self-reported height and weight was assessed in a subset
of approximately 15,000 participants. The mean values
of calculated BMI from the self report versus the mea-
sured data were very similar in both men (23.4 versus
23.5, respectively) and women (23.5 versus 23.7, respec-
tively), and the correlation coefŽ cient between measured
and reported BMI was approximately 0.9.
At baseline, 25.9% of the men were overweight (BMI
25.0–29.9) and only 2.1% were obese (BMI $30.0). In
women, overweight and obesity statistics were 25.9% and
3.2%, respectively. In men, 3.4%, and in women, 4.8%
were in the lowest BMI category (BMI 14.0–18.9). Be-
cause the lower limit of the next-higher BMI category was
19.0, the prevalence of participants that fell into the “nor-
mal” category (18.5–24.9), as deŽ ned by the U.S. National

Figure 2. Relative risk (RR) of all-cause mortality by category of

body mass index (BMI kg/m2 ) at baseline in a cohort of 21,315
Japanese women: JPHC study, 1990–1999. Point estimates and
95% conŽ dence intervals are plotted at the midpoint of each BMI
cagetory and adjusted for study area, age, cigarette smoking,
alcohol consumption, education, and exercise (adapted from Tsu-
gane et al. 2002). BMI categories are 14.0–18.9, 19.0–20.9, 21.0–
22.9, 23.0–24.9 (reference), 25.0–26.9, 27.0–29.9, and 30.0–39.9.

Institutes of Health2 and the International Obesity Task

Figure 1. Relative risk (RR) of all-cause mortality by category of
body mass index (BMI kg/m2 ) at baseline in a cohort of 19,500
Japanese men: JPHC study, 1990–1999. Point estimates and 95%
conŽ dence intervals are plotted at the midpoint of each BMI
category and adjusted for study area, age, cigarette smoking,
alcohol consumption, education, and exercise (adapted from Tsu-
gane et al. 2002). BMI categories are 14.0–18.9, 19.0–20.9, 21.0–
22.9, 23.0–24.9 (reference), 25.0–26.9, 27.0–29.9, and 30.0–39.9.
Force,2 could not be determined. However, 68.6% of men
and 66.1% of women had a BMI between 19.0 and 24.9.
Data on weight change since age 20 were collected
in three categories: lost $5 kg, no change, or gained $5
kg. It is not surprising that the greatest proportion of
participants who had lost 5 kg or more since age 20 were
in the lowest BMI category when they were 40 to 59
years of age. Similarly, those who were in the over-
weight and obesity categories were more likely than
other participants to have gained at least 5 kg. More than
85% of participants in either the overweight or obese
categories had gained a substantial amount of weight
since age 20. The two variables––weight gain and weight
status at baseline––were likely to be highly correlated.
Moreover, because the weight change could occur at any

Nutrition Reviews , Vol. 61, No. 3 105

Figure 3. Relative risk (RR) of all-cause mortality by category of body mass index (BMI kg/m2 ) in other Asian cohorts. Point estimates
and 95% conŽ dence intervals are plotted at the midpoint of each BMI category. (A) is adjusted for age, monthly salary, smoking, alcohol
consumption, and exercise (adapted from Song and Sung, 2001). BMI categories are 18.0, 18.0–19.9, 20.0–21.9, 22.0–23.9 (reference),
24.0–25.9, 26.0–27.9, 28.0–29.9, and #30. (B) is adjusted for age, education, and alcohol consumption (adapted from Yuan et al. 1998).
BMI categories are 18.5, 18.5–20.9, 21.0–23.4, 23.5–25.9, and $26.0. (C, D) are adjusted for age, education, smoking and alcohol
consumption (adapted from Maskarinec et al. 1998). BMI categories for males (C) are 19.6, 19.6–21.3, 21.4–24.8, 24.9–29.2, 29.3–32.5,
and $32.6. BMI categories for females (D) are 18.5, 18.5–19.9, 20.0–23.6, 23.7–30.3, 30.4–35.9, and $36.0.

time since age 20, this variable does not help to ascertain
the participants’ usual weight in adulthood, nor does it
capture subjects with recent weight loss.
Subjects were followed for vital status for 10 years
and cause of death was abstracted from centrally col-
lected death certiŽ cates. The authors analyzed the asso-
ciation between BMI and mortality using Cox propor-
tional hazard regression models and presented results
from several models. Risk ratios from two of the models
were used to examine mortality from all causes. For the
determination of the range of BMI in which there is no
elevation in risk above that of a reference, adjusted
measures of absolute risk or risk difference would yield
results very similar to those assessed using risk ratios.
Figures 1 and 2 were drawn using data reported by the
authors in tables for men and women, respectively. Points
on the graphs are drawn at the midpoint of the BMI
category. All analyses were adjusted for study area, age,
alcohol consumption (non-drinkers, occasional drinkers,
1–149 g/week, 150–299 g/week, 300– 449 g/week, $450
g/week), educational background (junior high or less, high
school, college or more), and sports and physical exercise in
leisure time ( 1 day/month, 1–3 days/month, $1 day/
week). In Figures 1A and 2A, data are shown for all men
and women and smoking is adjusted using covariate anal-
ysis and the following categories: never, former, current. In
Figures 1B and 1C, confounding by smoking is controlled
for by exclusion of former and current smokers from the
analysis. This exclusion resulted in a large reduction in the
sample available for the analysis in men (75.7%), and a
minor reduction in women (7.3%). In Ž gures 1C and 2C,
participants who died in the Ž rst 5 years of follow-up were
excluded in an effort to reduce confounding by illness that
was present at baseline.
Neither the exclusion of smokers nor the exclusion
of participants who died in the Ž rst 5 years of follow-up
eliminated the increase in the risk of mortality seen in the
lowest category of BMI (14.0 –18.9) compared with the
BMI reference group (23.0–24.9). Elimination of smok-
ers did reduce the mortality risk within the range of 19.0
to 22.9 such that there was no increase in the rate of
mortality above the reference level within that range.
Given the current interest in lowering the BMI cut-
point for obesity among Asians, it is important to note that,
among participants with an elevated BMI, a signiŽ cantly
increased risk of mortality was seen only in the highest BMI
category (30 –39.9). Although the trends varied somewhat
depending on the exclusions used, this study provided no
evidence that the range of BMI currently designated as the
lowest risk (18.5–24.9) is set too high among Asians.

106 Nutrition Reviews , Vol. 61, No. 3

 Figure 3 summarizes information on the BMI-mortal-
ity association in earlier studies of Asian men from China,9
Korea,10 and Hawaii,11 and Asian women from Hawaii.11
The Ž gures are all drawn with the points shown at the
midpoints of the BMI categories studied to facilitate com-
parisons among studies. For BMI categories in which the
lower or the upper limit was not speciŽ ed, a lower limit of
14.0 and an upper limit of 40.0 were assumed. Like the
Tsugane study, the results illustrated in Figure 3 provide no
evidence that Asian populations require a lower over-
weight/obesity BMI cut-point that would overlap with the
current normal-weight range of 18.5 to 24.9.
Future evaluations of the effect of BMI on mortality, as
well as studies of morbidity and indices of quality of life,
may indicate that mortality alone is not the optimum out-
come to direct recommendations for population cut-points
of BMI. However, the choice of an outcome or a combi-
nation of outcomes other than mortality to guide public
health policy will need to be done with great care.12 Tsu-
gane et al. note that in the Japanese Ministry of Health,
Labor and Welfare Health Promotion Plan for 2000 to
2010, obesity is deŽ ned as BMI greater than 25.0. This
approach is distinct from that recommended by the WHO
that deŽ nes obesity as a BMI of 30.0 or greater, whereas
overweight is deŽ ned as a BMI of 25.0 or greater.2 There is
potential for confusion as a result of the translation of words
like overweight, obesity, or pre-obesity among languages
and policy-making institutions. Given the results of the
study by Tsugane et al.,8 it seems appropriate that the lower
limit of the BMI cut-point used to deŽ ne the high-risk
group, however named, was not lower than 25.0. In fact,
these data do not support a cut-point below 30.0.
1. Society of Actuaries. Build and Blood Pressure Study,
Volume 1. Chicago, IL: Society of Actuaries; 1959.
2. World Health Organization Consultation on Obesity.
Preventing and managing the global epidemic: re-
Prevalence of Vitamin D InsufŽciency in Canada and the United States:
Importance to Health Status and EfŽ cacy of Current Food FortiŽ cation
and Dietary Supplement Use
Several recent studies have identiŽed a surpris-
ingly high prevalence of vitamin D insufŽciency in
This review was prepared by Mona S. Calvo, Ph.D.,
OfŽce of Applied Research and Safety Assessment,
Center for Food Safety and Applied Nutrition, Food and
Drug Administration, HFS-025, 8301 Muirkirk Road, Lau-
rel, MD, 20708, USA, and Susan J. Whiting, Ph.D., Col-
lege of Pharmacy and Nutrition, University of Saskatche-
wan, 110 Science Place, Saskatoon SK S7N 5C9, Canada.
Nutrition Reviews , Vol. 61, No. 3
port of a WHO consultation on obesity. Geneva, 3–5
June 1997.
3. Moon OR, Kim NS, Jang SM, Yoon TH, Kim OS. The
relationship between body mass index and the
prevalence of obesity-related diseases based on the
1995 National Health Interview Survey in Korea.
Obes Rev. 2002;3:191–196.
4. Li G, Chen X, Jang Y, et al. Obesity, coronary heart
disease risk factors and diabetes in Chinese: an
approach to the criteria of obesity in the Chinese
population. Obes Rev. 2002;3;167–172.
5. Ko GTC, Chan JCN, Cockran CS, Woo J. Prediction
of hypertension, diabetes dyslipidaemia or albumin-
uria using simple anthropometric indexes in Hong
Kong Chinese. Int J Obes Relat Metab Disord. 1999;
23:1136 –1142.
6. Deurenberg-Yap M, Chew SK, Lin VFP, Tan BY, van
Staveren WA, Deurenberg P. Relationships between
indices of obesity and its comorbidities in multi-
ethnic Singapore. Int J Obes Relat Metab Disord.
2001;25:1554 –1562.
7. WHO. The Asia-PaciŽc perspective: redeŽning obe-
sity and its treatment. Victoria: International Diabe-
tes Institute; February 2000.
8. Tsugane S, Sasaki S, Tsubono Y. Under- and over-
weight impact on mortality among middle-aged
Japanese men and women: a 10-y follow-up of
JPHC Study cohort I. Int J Obes Relat Metab Disord.
2002;26:529 –537.
9. Yuan J-M, Ross RK, Gao Y-T, Yu MC. Body weight
and mortality: a prospective evaluation in a cohort of
middle-aged men in Shanghai, China. Int J Epide-
miol. 1998;27:824 – 832.
10. Song Y-M, Sung J. Body mass index and mortality:
a twelve-year prospective study in Korea. Epidemi-
ology. 2001;12:173–179.
11. Maskarinec G, Meng L, Kolonel LN. Alcohol intake,
body weight, and mortality in a multiethnic prospec-
tive cohort. Epidemiology. 1998;9:654 – 661.
12. Stevens J, Juhaeri, Cai J, Jones DW. The effect of
decision rules on the choice of a body mass index
cutoff for obesity: examples from African American
and white women. Am J Clin Nutr. 2002;75:986 –992.
otherwise healthy adults living in Canada and the
United States. Most striking are the effects of
latitude, season, and race. Also noteworthy is
that dietary vitamin D is not reaching the popula-
tion in greatest need, nor is it very protective
against insufŽciency. Fluid milk, as the predomi-
nant vehicle for vitamin D fortiŽcation, is appar-
ently not very effective in staving off vitamin D
insufŽciency in adults in all populations at all
times of the year.
107