General and Abdominal Adiposity and Mortality in Mexico City: A Prospective Study of 150 000 Adults
Publication: Annals of Internal Medicine
Volume 171, Number 6
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Visual Abstract. Adiposity and Mortality in Mexico City
Conflicting evidence exists as to whether overweight and obesity are associated with mortality among Hispanic populations. This study followed more than 150 000 adults aged 35 to 89 years in Mexico City for up to 14 years to examine the relationship between 3 measures of adiposity (body mass index, waist circumference, and waist-to-hip-ratio) and mortality.
Abstract
Background:
Some reports suggest that body mass index (BMI) is not strongly associated with mortality in Hispanic populations.
Objective:
To assess the causal relevance of adiposity to mortality in Mexican adults, avoiding reverse causality biases.
Design:
Prospective study.
Setting:
2 Mexico City districts.
Participants:
159 755 adults aged 35 years and older at recruitment, followed for up to 14 years. Participants with a hemoglobin A1c level of 7% or greater, diabetes, or other chronic diseases were excluded.
Measurements:
BMI, waist-to-hip ratio, waist circumference, and cause-specific mortality. Cox regression, adjusted for confounders, yielded mortality hazard ratios (HRs) after at least 5 years of follow-up and before age 75 years.
Results:
Among 115 400 participants aged 35 to <75 years at recruitment, mean BMI was 28.0 kg/m2 (SD, 4.1 kg/m2) in men and 29.6 kg/m2 (SD, 5.1 kg/m2) in women. The association of BMI at recruitment with all-cause mortality was J-shaped, with the minimum at 25 to <27.5 kg/m2. Above 25 kg/m2, each 5-kg/m2 increase in BMI was associated with a 30% increase in all-cause mortality (HR, 1.30 [95% CI, 1.24 to 1.36]). This association was stronger at ages 40 to <60 years (HR, 1.40 [CI, 1.30 to 1.49]) than at ages 60 to <75 years (HR, 1.24 [CI, 1.17 to 1.31]) but was not materially affected by sex, smoking, or other confounders. The associations of mortality with BMI and waist-to-hip ratio were similarly strong, and each was weakened only slightly by adjustment for the other. Waist circumference was strongly related to mortality and remained so even after adjustment for BMI and hip circumference.
Limitation:
Analyses were limited to mortality.
Conclusion:
General, and particularly abdominal, adiposity were strongly associated with mortality in this Mexican population.
Primary Funding Source:
Mexican Health Ministry, Mexican National Council of Science and Technology, Wellcome Trust, Medical Research Council, and Kidney Research UK.
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Published In
Annals of Internal Medicine
Volume 171 • Number 6 • 17 September 2019
Pages: 397 - 405
History
Published online: 13 August 2019
Published in issue: 17 September 2019
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Copyright
© 2019 American College of Physicians.
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General and Abdominal Adiposity and Mortality in Mexico City: A Prospective Study of 150 000 Adults. Ann Intern Med.2019;171:397-405. [Epub 13 August 2019]. doi:10.7326/M18-3502
General and Abdominal Adiposity and Mortality in Mexico City: A Prospective Study of 150 000 Adults. Ann Intern Med.2019;171:397-405. [Epub 13 August 2019]. doi:10.7326/M18-3502
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Regarding General and Abdominal Adiposity and Mortality in Mexico City
We read with interest and nostalgia the paper by Gnatiuc et al (1) that reported a link between abdominal adiposity and mortality in Mexicans. We reported an enhanced cardiovascular risk profile linked to visceral fat estimated by computerized tomography in this journal in 1989 (2). The enhanced morbidity and mortality linked to abdominal obesity, however, dates back several decades to Jean Vague, a French physician. There is little doubt that abdominal adiposity with its increased visceral fat and frequent steatosis identifies individuals of both genders at very high risk of metabolic and cardiovascular complications including early death. Even individuals of near normal weight with increased abdominal adiposity may be at such risk. Studies have confirmed this association across many different cultures and countries. Abdominal obesity has reached pandemic proportions. In order to address this pressing public health issue and to contain soaring costs it behooves researchers to consider the pathogenesis of abdominal adiposity.
Further, we would like to submit the following evolutionary hypothesis for the development of abdominal adiposity. A high carbohydrate diet is experienced in Asian and Hispanic cultures. As well, an increase in refined carbohydrate intake has extended to all cultures in the last few decades. This increase has been documented by the Centers for Disease control (CDC) and independent entities such as PEW research. Physicians have warned about the dangers of a high fat diet but largely ignored the potential dangers of the excessive intake of refined carbohydrates. The PURE study, a global initiative confirmed that high carbohydrate intake was linked closely to mortality, and a high fat intake had an inverse relationship to mortality (3). When low calorie diets are compared in obese diabetic patients – a low carbohydrate diet is clearly superior to a high carbohydrate diet in improving metabolic parameters and reducing visceral fat (4). Moreover, satiety may be better induced on a low carbohydrate diet than a low-fat diet. We do not discount that a plant based high carbohydrate low fat diet may also have metabolic benefits. However, since a reduction in vascular endothelial dysfunction in obesity is related to a reduction in visceral adiposity (5) additional studies addressing the benefits of a low refined carbohydrate diet are urgently needed. It is possible that physicians need a paradigm shift from the dangers of a high fat diet to the dangers of a processed-food carbohydrate diet. We look forward to the authors’ response.
References:
(1) Gnatiuc L, Alegre-Díaz J, Wade R, et al. General and Abdominal Adiposity and Mortality in Mexico City: Prospective Study of 150 000 Adults. Ann Intern Med. [Epub ahead of print 13 August 2019] doi: 10.7326/M18-3502
(2) Peiris AN, Sothmann MS, Hoffmann RG, et al. Adiposity, fat distribution, and cardiovascular risk. Ann Intern Med. 1989 Jun 1;110(11):867-72
(3) Dehghan M, Mente A, Zhang X, et al. Associations of fats and carbohydrate intake with cardiovascular disease and mortality in 18 countries from five continents (PURE): a prospective cohort study. Lancet. 2017 Nov 4;390(10107):2050-2062. doi: 10.1016/S0140-6736(17)32252-3.
(4) Miyashita Y, Koide N, Ohtsuka M, et al. Beneficial effect of low carbohydrate in low calorie diets on visceral fat reduction in type 2 diabetic patients with obesity. Diabetes Res Clin Pract. 2004 Sep;65(3):235-41.
(5) Park SH, Shim KW. Reduction in Visceral Adiposity is Highly Related to Improvement in Vascular Endothelial Dysfunction among Obese Women: An Assessment of Endothelial Function by Radial Artery Pulse Wave Analysis. Yonsei Med J. 2005 Aug 31; 46(4): 511–518. doi: 10.3349/ymj.2005.46.4.511.