Body-mass index and cause-specific

mortality in 900 000 adults: collaborative

analyses of 57 prospective studies
Prospective Studies Collaboration
Lancet 2009; 373: 1083-96

Blood pressure, cholesterol and BMI

Blood pressure
160

Cholesterol
M
Non-HDL-C

5
Systolic

M
140

Ratio of means
(non-HDL-C/HDL-C)

F
120

mmol/L
(or ratio)

mm Hg
100

M
80

25

35

HDL-C

F
15

Diastolic

50

M
15

25

35

50

Baseline BMI (kg/m2)

Adjusted for age, smoking and study

Fig 1a & b, Lancet 2009; 373: 1083-96

Ratio non-HDL:HDL cholesterol and BMI

5

M
Mean of ratios
Ratio of means

Ratio

(Mean of ratios
~10% higher than
ratio of means)

15

25

35

50

Baseline BMI (kg/m2)

Adjusted for age, smoking and study

Fig 1b variant, Lancet 2009; 373: 1083-96

Drinking, smoking, diabetes and BMI

Female

Male
100

100

80

80
Drinking

Prevalence
%

60

60

40

40

Drinking

Smoking
20

20

Smoking

Diabetes
0

15

25

35

50

Diabetes
0

15

25

35

50

Baseline BMI (kg/m2)

Adjusted for age, smoking and study

Fig 1c & d, Lancet 2009; 373: 1083-96

All-cause mortality and BMI

64

Annual
deaths
per 1000

Male

32

Female
16

& 95% CI (floated

so matches PSC
rate at ages 35-79)

4
15 20 25 30 35 40

50

Baseline BMI (kg/m2)

Adjusted for age, smoking and study; 1st 5 years of follow-up excluded

Fig 2, Lancet 2009; 373: 1083-96

IHD and stroke mortality and BMI

IHD

Annual
deaths
per 1000

Stroke
2

& 95% CI (floated

so matches PSC
rate at ages 35-79)

05
15 20 25 30 35 40

Baseline BMI
Adjusted for age, sex, smoking and study; 1st 5 years of follow-up excluded

50
(kg/m2)
Fig 3, Lancet 2009; 373: 1083-96

IHD mortality and BMI in the range 2550 kg/m2 only

No. of Mean age
deaths at death

Follow-up period
(years)

Age at risk
(years)
Sex
Smoking at
entry

0-4*
5-9
10-14
15+

2069
3291
3407
4085

35-59
60-69
70-79
80-89

2461
3904
3264
1154

Male
Female

8556
2227

Never smoker
Other/unknown
Current cigarette

2651
3442
4690

All (BMI 25-50 kg/m2, years 5+)

HR & 95% CI

602
629
661
712

126 (116-136)
133 (124-143)
143 (133-153)
142 (134-151)
Trend, 4 groups: c12=66 (p=001)

541
646
740
834

150 (139-162)
140 (132-149)
131 (123-140)
130 (117-145)
Trend, 4 groups: c12=78 (p=0005)

657
724

142 (135-148)
135 (128-143)
Heterogeneity: c12 =14 (p=02)

710
680
641

141 (133-150)
145 (136-154)
133 (125-141)
Heterogeneity: c22 =37 (p=02)

10 783 671

139 (134-144)

10 15 2

Adjusted, when appropriate, for age, sex,

smoking and study, and (except where
marked *) 1st 5 years of follow-up excluded

Hazard ratio (& 95% CI) for

5 kg/m2 higher baseline BMI
Fig 4a, Lancet 2009; 373: 1083-96

Stroke mortality and BMI in the range 2550 kg/m2 only

No. of
deaths

Follow-up period
(years)

Age at risk
(years)
Sex
Smoking at
entry
Stroke
subtype

0-4*
5-9
10-14
15+

583
889
906
1369

35-59
60-69
70-79
80-89

463
997
1152
552

Male
Female

2132
1032

Never smoker
Other/unknown
Current cigarette

1062
921
1181

Never smoker
Other/unknown
Current cigarette
Current cigarette

765
571
242
1586

All (BMI 25-50 kg/m2, years 5+)

Mean age
at death
625
656
690
734

HR & 95% CI
121 (105-141)
136 (120-154)
137 (120-156)
138 (124-153)
Trend, 4 groups: c21 =14 (p=02)

537
649
743
835

176 (152-204)
149 (134-167)
133 (119-148)
110 (094-130)
Trend, 4 groups: c21 =194 (p<00001)

684
732

150 (138-165)
130 (119-142)
Heterogeneity: c21 =54 (p=002)

727
711
665

138 (125-152)
147 (130-165)
134 (120-150)
Heterogeneity: c22 =12 (p=06)

718
662
610
718

138 (123-156)
153 (132-178)
119 (094-152)
140 (128-153)
Heterogeneity: c23 =32 (p=04)

3164

699

139 (131-148)

1 15 2
Adjusted, when appropriate, for age, sex,
smoking and study, and (except where
marked *) 1st 5 years of follow-up excluded

Hazard ratio (& 95% CI) for

5 kg/m2 higher baseline BMI
Fig 4b, Lancet 2009; 373: 1083-96

IHD & stroke mortality and BMI in the range 2550 kg/m2 only
Approximately standardised to overall mean age at IHD, or at stroke, death

IHD
No. of Mean age
deaths at death

Followup
period
(years)

0-4*
5-9
10-14
15+

Stroke
HR & 95% CI

No. of Mean age

deaths at death

2069

602

120 (110-130)

583

625

108 (093-126)

3291

629

129 (121-139)

889

656

127 (112-144)

3407

661

142 (132-152)

906

690

135 (119-154)

4085

712

146 (138-155)

1369

734

145 (131-161)

Trend, 4 groups:
c 2 =173 (p<00001)

Trend, 4 groups:
c21=101 (p=0002)

Sex

Male
Female

8556

657

140 (134-147)

2132

684

147 (134-161)

2227

724

140 (133-149)

1032

732

136 (125-149)

Heterogeneity:
c 21 =00 (p=10)

Smoking
at entry

Never smoker
Other/unknown
Current cigarette

Heterogeneity:
c21 =14 (p=02)

2651

710

145 (136-154)

1062

727

144 (131-159)

3442

680

146 (137-155)

921

711

149 (133-168)

4690

641

130 (123-138)

1181

665

127 (113-143)

Heterogeneity:
c22=81 (p=002)

All (BMI 25-50, years 5+)

10 783

671

139 (134-144)

1 15 2
Adjusted, when appropriate, for age, sex,
smoking and study, and (except where
marked *) 1st 5 years of follow-up excluded

HR & 95% CI

Heterogeneity:
c 2 =42 (p=01)
2
3164

699

139 (131-148)

1 15 2

Hazard ratio (& 95% CI) for

5 kg/m2 higher baseline BMI
Fig 4 variant, Lancet 2009; 373: 1083-96

Main mortality categories and BMI

Male

Female

14

14
Vascular

Annual
deaths
per 1000
& 95% CI (floated
so matches EU rate
at ages 35-79)

12

12

10

10

Vascular

Cancer (other
specified)

Cancer (other
specified)

Cancer (lung,
mouth, pharynx,
larynx, oes.)
2

Respiratory
0
15 20 25 30 35

50

Cancer (lung,
mouth, pharynx,
larynx, oes.)

Resp.

15 20 25 30 35

50

Baseline BMI (kg/m2)

Adjusted for age, smoking and study; 1st 5 years of follow-up excluded

Fig 5, Lancet 2009; 373: 1083-96

All-cause mortality and BMI, by smoking

30
Current
cigarette
smoker

25

Annual
deaths
per 1000

20
Never
smoked
regularly

15
& 95% CI (floated
so matches EU rate
at ages 35-79)

10

(N.B. The vertical separation of the

curves underestimates effects of
lifelong cigarette smoking)

0
15 20 25 30 35

50

Baseline BMI (kg/m2)

Adjusted for age, sex and study; 1st 5 years of follow-up excluded

Fig 6, Lancet 2009; 373: 1083-96

Lifespan and BMI in western Europe, year 2000

Male

Female

100

100
88%
77%

80

%
alive

80

69%

60

84%

60

Yearly dots

40

40
BMI range, kg/m2
22.5-25 (mean 24)
25-30 (mean 27)
30-35 (mean 32)

20
0

40

50

60

20

70

80

90

100

40

50

60

70

80

90

100

Age (years)
Causal PSC relative risks applied to EU mortality rates

Fig 7 variant, Lancet 2009; 373: 1083-96

Lifespan and BMI in western Europe, year 2000

Male

Female

100

100
88%
77%

80

80
72%

%
alive

60

40
20
0

Yearly dots

49%
BMI range, kg/m2
22.5-25 (mean 24)
25-30
30-35 (mean 32)
35-40
40-50 (mean 43)

40

50

60

70

60

40
20

80

90

100

40

50

60

70

80

90

100

Age (years)

Causal PSC relative risks applied to EU mortality rates

Fig 7, Lancet 2009; 373: 1083-96

Comparison with smoking in the British Doctors Study

From figure 3 in Doll, Peto et al., BMJ 2004: 328: 1519-33

All-cause mortality and BMI, by age at risk

Male

Female

512
256

Annual
deaths
per 1000
& 95% CI (floated
so matches PSC
rate at ages 35-89)

Age at
risk:

512

80-89

256

70-79

128
64

60-69

32

Age at
risk:
80-89

128
70-79

64
32

16

35-59

16

15 20 25 30 35

50

60-69

35-59

15 20 25 30 35

50

Baseline BMI (kg/m2)

Adjusted for age, smoking and study; 1st 5 years of follow-up excluded

Webfig 1, Lancet 2009; 373: 1083-96

IHD mortality and BMI in never smokers

16

Annual
deaths
per 1000
& 95% CI (floated
so matches PSC
rate at ages 35-79)

05
15 20 25 30

35 40

50

Baseline BMI (kg/m2)

Adjusted for age, sex and study; 1st 5 years of follow-up excluded

Webfig 2, Lancet 2009; 373: 1083-96

Stroke mortality and BMI in specific subgroups

Excluding:
first 5 years of
followup
Annual
deaths
per 1000

first 10 years of
followup

first 5 years and

ever smokers

& 95% CI (floated

so matches PSC
rate at ages 35-79)

15 20 25 30 35

50

15 20 25 30 35

50 15 20 25 30 35

50

Baseline BMI (kg/m2)

Adjusted for age, sex, study and, when appropriate, smoking

Webfig 3, Lancet 2009; 373: 1083-96

Stroke subtype mortality and BMI

Ischaemic
Annual
deaths
per 1000

Haemorrhagic

Unclassified

1/2

1/2

1/2

1/4

1/4

1/4

& 95% CI (floated

so matches PSC
rate at ages 35-79)

15 20 25 30 35

50

15 20 25 30 35

50 15 20 25 30 35

50

Baseline BMI (kg/m2)

Adjusted for age, sex, smoking and study; 1st 5 years of follow-up excluded

Webfig 4, Lancet 2009; 373: 1083-96

IHD mortality and BMI by study

Study
Finnish Mobile Clinic
Finrisk, Finland
UK HDPP
Israeli IHD
Whitehall, UK
NHEFS, US
Framingham, US
Renfrew/Paisley, UK
Norwegian Counties
BUPA, UK
Oslo, Norway
Midspan, UK
Copenhagen, Denmark
BRHS, UK
Busselton, Australia
Tecumseh, US
Studies with <200 deaths
ALL STUDIES

No. of
deaths
1724
1014
703
571
568
494
481
438
438
362
339
318
231
227
222
215
2438
10 783

2
Test for heterogeneity: c16=225 (p=013)

Adjusted for age, sex and smoking; 1st 5 years of follow-up excluded

08 10

14

20

28

Hazard ratio (& 99% CI) for

5 kg/m2 higher baseline BMI
Webfig 5a, Lancet 2009; 373: 1083-96

Stroke mortality and BMI by study

Study

No. of
deaths

Finnish Mobile Clinic

Finrisk, Finland
Israeli IHD
NHEFS, US
Renfrew/Paisley, UK
Framingham, US
UK HDPP
Honolulu, US
Studies with <100 deaths

556
270
206
148
143
133
122
111
1475

ALL STUDIES

3164

Test for heterogeneity: c28 =61 (p=064)

Adjusted for age, sex and smoking; 1st 5 years of follow-up excluded

08 10

14

20

28

Hazard ratio (& 99% CI) for

5 kg/m2 higher baseline BMI

Webfig 5b, Lancet 2009; 373: 1083-96

COPD mortality and BMI by follow-up period

0-4 years
Annual
deaths
per 1000
& 95% CI (floated
so matches PSC
rate at ages 35-79)

5-9 years

10-14 years

15+ years

1/2

1/2

1/2

1/2

1/4

1/4

1/4

1/4

1/8

1/8

1/8

1/8

15 20 25 30 35

15 20 25 30 35

15 20 25 30 35

15 20 25 30 35

Baseline BMI (kg/m2)

Adjusted for age, sex, smoking and study

Webfig 6, Lancet 2009; 373: 1083-96

All-cause mortality and BMI by smoking

Male (35-69 years)
20

Female (35-69 years)

20

Current
cigarette
smoker

Annual
deaths
per 1000

15

15
Never
smoked
regularly

10

Current
cigarette
smoker

10

& 95% CI (floated

so matches EU rate
at ages 35-69)

Never
smoked
regularly

0
15 20 25 30 35

50

Baseline
Adjusted for age and study; 1st 5 years of follow-up excluded

0
15 20 25 30 35
BMI (kg/m2)

50

Webfig 7a & b, Lancet 2009; 373: 1083-96

All-cause mortality and BMI by smoking

Male (70-79 years)

Female (70-79 years)

100

100
Current
cigarette
smoker

Annual
deaths
per 1000

75

75
Never
smoked
regularly

50

Current
cigarette
smoker

50

& 95% CI (floated

so matches EU rate
at ages 70-79)

25

Never
smoked
regularly

25

0
15 20 25 30 35

50

Baseline
Adjusted for age and study; 1st 5 years of follow-up excluded

0
15 20 25 30 35
BMI (kg/m2)

50

Webfig 7c & d, Lancet 2009; 373: 1083-96

Vascular mortality and BMI by smoking

Male (35-69 years)

Female (35-69 years)

6
Current
cigarette
smoker

Annual
deaths
per 1000
& 95% CI (floated
so matches EU rate
at ages 35-69)

4
Never
smoked
regularly

Current
cigarette
smoker

Never
smoked
regularly
0
15 20 25 30 35

50

Baseline BMI
Adjusted for age and study; 1st 5 years of follow-up excluded

0
15 20 25 30 35
(kg/m2)

50

Webfig 8a & b, Lancet 2009; 373: 1083-96

Vascular mortality and BMI by smoking

Male (70-79 years)

Annual
deaths
per 1000
& 95% CI (floated
so matches EU rate
at ages 35-79)

Female (70-79 years)

30

Current
cigarette
smoker

30

20

Never
smoked
regularly

20
Current
cigarette
smoker

10

10

0
15 20 25 30 35

50

Never
smoked
regularly

0
15 20 25 30 35

50

Baseline BMI (kg/m2)

Adjusted for age and study; 1st 5 years of follow-up excluded

Webfig 8c & d, Lancet 2009; 373: 1083-96