Body mass index, coronary heart disease and stroke in Swedish women. A prospective 19-year follow-up in the BEDA study

Secular trends in cardiovascular risk factors among women aged 45-54 years in Gothenburg, Sweden, from 1980 to 2014

Background

A declining trend in mean cholesterol levels and smoking has been observed in high-income western countries during the last few decades, whereas obesity rates have increased. Simultaneously, mortality from coronary heart disease has decreased. The aim of the present study was to determine whether the trends in cardiovascular risk factors have continued in successive cohorts of middle-aged women over a period of 34 years.

Methods

Six population-based, cross-sectional samples of women (n = 2294) mean age: 49.8 years (range: 45–54), living in Gothenburg, Sweden, were investigated between 1980 and 2014.

Results

Body mass index (BMI) increased over time, with a mean BMI of 24.7 kg/m² in 1980 to 25.7 kg/m² in 2013–2014, corresponding to a weight gain of 4.5 kg, together with an increase in the proportion of obese individuals (BMI ≥ 30 kg/m²) from 10.4 to 16.6% (p = 0.0012). The proportion of smokers and women with hypertension decreased from 34.5 to 12.8% (p = 0.0006) and from 37.7 to 24.5% (p < 0.0001) respectively. Mean total serum cholesterol levels decreased from 6.23 (SD 1.09) mmol/L in 1980 to 5.43 (SD 0.98) mmol/L in 2013–2014 (p < 0.0001). Self-reported leisure time regular exercise increased from 7.8% in 1980 to 35.6% in 2013–2014 (p < 0.0001). For women born in 1963, the prevalence ratio of not having any of five major cardiovascular risk factors was 1.82 (95% confidence interval (CI) 1.38–2.41), compared with women born in 1925–1934.

Conclusion

The trend towards increasing obesity, more leisure-time physical activity and less smoking remains, while the decrease in serum cholesterol appears to have abated.

The potential health and economic effect of a Body Mass Index decrease in the overweight and obese population in Belgium

OBJECTIVES

The aim of the study was to examine the health and economic consequences of a Body Mass Index decrease in the Belgian overweight and obese population over a 20-year time period.

STUDY DESIGN

Health economic evaluation study.

METHODS

A Markov decision-analytic model using a societal perspective was applied, projecting the one-year results of a one unit Body Mass Index decrease over a time horizon of 20 years. Scenario analysis was applied evaluating the effects on the results of an alternative modelling assumption. One-way sensitivity analysis and probabilistic sensitivity analysis were performed to assess the effects on the findings of varying key input parameters.

RESULTS

A one unit Body Mass Index decrease resulted in improved health outcomes and cost savings/patient (overweight women: 785€, obese women: 1039€, overweight men: 613€, obese men: 864€). For the total overweight and obese population, a cost saving of 2.8 billion euros was estimated. Considering the economic value of the health impact would result in a total economic benefit of about 15.9 billion euros for the Belgian society over a 20 year time period.

CONCLUSIONS

A one unit Body Mass Index reduction in the overweight and obese population in Belgium was found to be associated with improved health outcomes and cost savings. The evidence of such research can assist regulatory bodies in the allocation of healthcare budgets in a more efficient way.

Cost-effectiveness of health promotion targeting physical activity and healthy eating in mental health care

BACKGROUND

There is a higher prevalence of obesity in individuals with mental disorders compared to the general population. The results of several studies suggested that weight reduction in this population is possible following psycho-educational and/or behavioural weight management interventions. Evidence of the effectiveness alone is however inadequate for policy making. The aim of the current study was to evaluate the cost-effectiveness of a health promotion intervention targeting physical activity and healthy eating in individuals with mental disorders.

METHODS

A Markov decision-analytic model using a public payer perspective was applied, projecting the one-year results of a 10-week intervention over a time horizon of 20 years, assuming a repeated yearly implementation of the programme. Scenario analysis was applied evaluating the effects on the results of alternative modelling assumptions. One-way sensitivity analysis was performed to assess the effects on the results of varying key input parameters.

RESULTS

An incremental cost-effectiveness ratio of 27,096€/quality-adjusted life years (QALY) in men, and 40,139€/QALY in women was found in the base case. Scenario analysis assuming an increase in health-related quality of life as a result of the body mass index decrease resulted in much better cost-effectiveness in both men (3,357€/QALY) and women (3,766€/QALY). The uncertainty associated with the intervention effect had the greatest impact on the model.

CONCLUSIONS

As far as is known to the authors, this is the first health economic evaluation of a health promotion intervention targeting physical activity and healthy eating in individuals with mental disorders. Such research is important as it provides payers and governments with better insights how to spend the available resources in the most efficient way. Further research examining the cost-effectiveness of health promotion targeting physical activity and healthy eating in individuals with mental disorders is required.

Cardiovascular disease risk of abdominal obesity vs. metabolic abnormalities

It remains unclear whether abdominal obesity increases cardiovascular disease (CVD) risk independent of the metabolic abnormalities that often accompany it. Therefore, the objective of this study was to evaluate the independent effects of abdominal obesity vs. metabolic syndrome and diabetes on the risk for incident coronary heart disease (CHD) and stroke. The Framingham Offspring, Atherosclerosis Risk in Communities, and Cardiovascular Health studies were pooled to assess the independent effects of abdominal obesity (waist circumference >102 cm for men and >88 cm for women) vs. metabolic syndrome (excluding the waist circumference criterion) and diabetes on risk for incident CHD and stroke in 20,298 men and women aged ≥45 years. The average follow-up was 8.3 (s.d. 1.9) years. There were 1,766 CVD events. After adjustment for demographic factors, smoking, alcohol intake, number of metabolic syndrome components, and diabetes, abdominal obesity was not significantly associated with an increased risk of CVD (hazard ratio (HR) (95% confidence interval): 1.09 (0.98, 1.20)). However, after adjustment for demographics, smoking, alcohol intake, and abdominal obesity, having 1-2 metabolic syndrome components, the metabolic syndrome and diabetes were each associated with a significantly increased risk of CVD (2.12 (1.80, 2.50), 2.82 (1.92, 4.12), and 5.33 (3.37, 8.41), respectively). Although abdominal obesity is an important clinical tool for identification of individuals likely to possess metabolic abnormalities, these data suggest that the metabolic syndrome and diabetes are considerably more important prognostic indicators of CVD risk.

Obesity, smoking and secular trends in cardiovascular risk factors in middle-aged women: data from population studies in Göteborg from 1980 to 2003

BACKGROUND

To study the trends in cardiovascular risk factors in middle-aged city-dwelling Swedish women from 1980 to 2003.

METHODS

Using cross-sectional population-based surveys, five random population samples of a total of 1915 women aged between 45 and 54 years, participating in the BEDA study in 1980, WHO MONICA studies in 1985, 1990 and 1995, and a study of 50-year-old women in 2003 were measured for the following parameters: anthropometry, serum cholesterol and triglyceride levels, smoking habits, blood pressure, physical activity and stress.

RESULTS

Over almost 25 years, middle-aged women gained on average 4.4 kg in weight, with a net increase in body mass index (BMI) from 24.7 to 25.6 kg m⁻². The proportion of participants classified as obese (≥30 kg m⁻²) increased by 50% from 10.4% to 15.1%. Women who were smokers in 2003 did not have lower BMI values than nonsmokers. Mean serum cholesterol concentrations decreased markedly, whereas smoking habits did not significantly change. The prevalence of hypertension decreased by 8%, whereas that of diabetes remained stable at around 2%. Optimal risk factor status - no smoking, normotension and serum cholesterol <5 mmol l⁻¹ - was present in less than one in six women in 2003, and similar across BMI categories.

CONCLUSION

The favourable decline in cholesterol levels and hypertension and the increase in leisure time physical activity were offset by an increase in obesity, triglyceride levels and experience of stress, with only a minority of participants (less than one in six) having an optimal level of risk factors with respect to smoking, serum cholesterol and hypertension in 2003. This applied also to overweight and obese women. In earlier cohorts, subjects with low BMI values were more often smokers, whereas the opposite is observed in recent cohorts. Thus, women who smoke no longer have the advantage of lower weight.

Impact of body mass index and the metabolic syndrome on the risk of cardiovascular disease and death in middle-aged men

BACKGROUND

The purpose of this study was to investigate associations between combinations of body mass index (BMI) categories and metabolic syndrome (MetS) and the risk of cardiovascular disease and death in middle-aged men.

METHODS AND RESULTS

At age 50 years, cardiovascular risk factors were assessed in 1758 participants without diabetes in the community-based Uppsala Longitudinal Study of Adult Men (ULSAM). According to BMI-MetS status, they were categorized as normal weight (BMI <25 kg/m(2)) without MetS (National Cholesterol Education Program criteria; n=891), normal weight with MetS (n=64), overweight (BMI 25 to 30 kg/m(2)) without MetS (n=582), overweight with MetS (n=125), obese (BMI >30 kg/m(2)) without MetS (n=30), or obese with MetS (n=66). During follow-up (median 30 years), 788 participants died, and 681 developed cardiovascular disease (composite of cardiovascular death or hospitalization for myocardial infarction, stroke, or heart failure). In Cox proportional-hazards models that adjusted for age, smoking, and low-density lipoprotein cholesterol, an increased risk for cardiovascular disease was observed in normal-weight participants with MetS (hazard ratio 1.63, 95% confidence interval 1.11 to 2.37), overweight participants without MetS (hazard ratio 1.52, 95% confidence interval 1.28 to 1.80), overweight participants with MetS (hazard ratio 1.74, 95% confidence interval 1.32 to 2.30), obese participants without MetS (hazard ratio 1.95, 95% confidence interval 1.14 to 3.34), and obese participants with MetS (hazard ratio 2.55, 95% confidence interval 1.81 to 3.58) compared with normal-weight individuals without MetS. These BMI-MetS categories significantly predicted total mortality rate in a similar pattern.

CONCLUSIONS

Middle-aged men with MetS had increased risk for cardiovascular events and total death regardless of BMI status during more than 30 years of follow-up. In contrast to previous reports, overweight and obese individuals without MetS also had an increased risk. The present data refute the notion that overweight and obesity without MetS are benign conditions.

Healthy obesity

PURPOSE OF REVIEW

To introduce the healthy obese phenotype, characterized by favorable cardiometabolic risk factors despite excess adipose tissue. The epidemiology of the healthy obese phenotype is presented, including associated risk of cardiovascular disease (CVD), and potential biologic mechanisms which may give rise to the phenotype are discussed.

RECENT FINDINGS

Although it appears that approximately 30% of obese individuals maintain healthy cardiometabolic profiles, little published data exist examining the healthy obese phenotype. The healthy obese do not appear to be at increased risk of incident CVD events compared with at-risk obese, and the location of adipose tissue and the metabolic characteristics of the fat in a given location, including the presence of ectopic fat and associated adipocytokine response, may give rise to the phenotype. Recent data also suggest that weight loss among healthy obese may adversely impact their favorable cardiometabolic profile.

SUMMARY

A high prevalence of the healthy obese phenotype has been reported, and these individuals appear to be at no increased risk of CVD. Further research is needed into the mechanisms that allow these individuals to maintain low risk of CVD despite excess adiposity and appropriate weight loss recommendations for this group.

Gender differences in obesity related cardiovascular risk factors in Spain

BACKGROUND

Obesity and overweight are increasing progressively leading to an increase in cardiovascular risk factors and cardiovascular events.

METHODS

The MESYAS Registry (Metabolic Syndrome in Active Subjects) recruited active workers from their annual health examinations in Spain through 2003. Body mass index was used to diagnose overweight and obesity. Metabolic syndrome (MS) and risk factors were assessed according to the ATP-III definitions.

RESULTS

19,041 subjects were included (80% males), mean age 42.2 (10.7). The prevalence of overweight was 44.6% (44.0-45.2), obesity 17.3% (17.0-17.5) and MS 12.0% (11.8-12.2). Women had lower prevalence of all cardiovascular risk factors. Multivariate analysis showed independent associations between overweight (OR: 2.4; 95% CI 2.2-2.6) or obesity (OR: 5.3; 95% CI 4.7-5.9) and any other two MS criteria. Overweight and obesity were independently associated with all cardiovascular risk factors, except low high-density lipoproteins in women. Significantly higher association was found in women between obesity and diabetes (OR: 13.6; 95% CI 3.8-48.6), MS (OR: 10.6; 7.6-14.8), hypertriglyceridemia (OR: 8.6; 95% CI 5.6-13.1), and impaired fasting glucose (OR: 3.7; 95% CI 2.7-5.3).

CONCLUSIONS

Overweight and obesity are strongly related to classical cardiovascular risk factors, atherogenic dyslipidaemia and MS. Obesity has higher association to insulin-resistance related risk factors in women.

Anthropometric characteristics as predictors of coronary heart disease in women

OBJECTIVES

Obesity and other anthropometric measures are clearly related to risk of coronary heart disease (CHD), although debate remains as to which measures are most important and how the impact of obesity varies over the life course.

AIM

We aimed to investigate these issues in a large cohort of Swedish women. The Women's Lifestyle and Health Cohort Study includes 49 259 women, aged 30-50 years at baseline (1991-1992) when an extensive questionnaire was completed.

METHODS

Women were given standard instructions for self-measurement of anthropometric characteristics. Women were followed through linkages to national registries until December 2003, during which time 256 cases of incident fatal CHD or nonfatal myocardial infarction occurred.

RESULTS

Waist circumference was associated with increased CHD risk after multivariate adjustment for confounders (HR = 1.9; 95% CI:1.1-3.3; highest versus lowest quartile), whereas height, weight and hip circumference were not. Measures of obesity were strongly related to CHD, and after mutual adjustment, waist-hip ratio (HR = 1.9, 95% CI: 1.2-3.2) was more closely related to CHD risk than BMI (HR = 1.5, 95% CI: 1.0-2.4). Risk of CHD was increased in women who remained heavy, those who were heavy at age 18, and those with low birth weight.

CONCLUSIONS

In conclusion, there is strong evidence for supporting control of obesity, in particular avoidance of abdominal obesity, as a strategy to prevent CHD.

The effect of leisure-time physical activity on the risk of acute myocardial infarction depending on body mass index: a population-based case-control study

BACKGROUND

High body mass index (BMI) and lack of physical activity have been recognized as important risk factors for coronary heart disease. The aim of the present study was to evaluate whether leisure-time physical activity compensates for the increased risk of acute myocardial infarction associated with overweight and obesity.

METHODS

Data from the SHEEP (Stockholm Heart Epidemiology Program) study were used. The SHEEP study is a large Swedish population-based case-control study, comprising 1204 male and 550 female cases, and 1538 male and 777 female controls, conducted in Stockholm County, Sweden, during the period 1992-1994. Odds ratios (OR), together with 95 % confidence intervals (95% CI), were calculated using unconditional logistic regression, as estimates of the relative risks.

RESULTS

Regular leisure-time physical activity was associated with a decreased risk of myocardial infarction among lean, normal-weight and overweight subjects, but not among obese subjects. Obese (BMI > or = 30) and physically active persons had an almost twofold risk of myocardial infarction, compared with normal-weight and sedentary persons (OR 1.85, 95% CI 1.07-3.18). The results were similar for men and women.

CONCLUSION

While regular leisure-time physical activity seems to provide protection against myocardial infarction among lean, normal-weight and overweight subjects, this does not appear to be the case in obese subjects.

Prospective study of body size and risk for stroke amongst women below age 60

The relation between obesity, particularly abdominal obesity, and risk of stroke amongst women remains unclear. In 1991-1992, a prospective study was initiated in Sweden amongst women who returned a self-administered questionnaire. Through linkage with nation-wide registries, 45,449 women, free of stroke at entry, were followed up until diagnosis of first incident stroke, death, or the end of follow-up in 2002. We estimated multivariate relative risks (RRs) with 95% confidence intervals (CIs) from Cox proportional hazards regression models. A total of 170 incident stroke cases occurred during an average of 11 years of follow-up. The RR of stroke amongst women in the highest compared with the lowest quintile was 2.4 (95% CI 1.3-4.2; P for trend 0.04) for waist-to-hip ratio, 2.5 (95% CI 1.5-4.3; P for trend 0.01) for waist-to-height ratio and 2.3 (95% CI 1.2-4.3; P for trend 0.02) for waist circumference. Adjustment for hypertension and diabetes attenuated these risk estimates. In contrast, birth weight, body mass index (BMI) at age 18, BMI at entry, weight change in adulthood and adult height were not significantly associated with risk of stroke. This study provides evidence that, in contrast to BMI, several different measures of abdominal obesity are strong predictors of stroke in women.

Interactive relations of central versus total obesity and blood pressure to cognitive function

OBJECTIVE

To examine the potential interactive relations of central versus total obesity and blood pressure (BP) to cognitive function.

METHOD

In all, 90 healthy, stroke, and dementia-free middle-aged and older adults (ages 54-81 years; 63% male; 93% White) underwent biomedical and neuropsychological assessment. Relations of central obesity (assessed by waist circumference (WC)) and systolic or diastolic BP to cognitive function were examined in multiple regression models. Next, body mass index (BMI) was substituted for WC in the models.

RESULTS

After statistical adjustment for age, education, gender, and other potential confounders including components of the metabolic syndrome (depending on the model), significant interactions of WC and systolic (or diastolic) BP were noted for the Grooved Pegboard - Dominant Hand and Stroop Interference scores, with marginally significant results for Grooved Pegboard - Nondominant Hand. In general, individuals with greater WC and higher BP performed most poorly on these measures. Similar results were obtained for BMI.

CONCLUSION

Independent of other confounders including facets of the metabolic syndrome, the combination of greater WC (or BMI) and higher (systolic or diastolic) BP was associated with diminished performance on tests of motor speed and manual dexterity, and executive function (i.e. response inhibition) accounting for 3-13% of the variance in these measures. In healthy older adults, there are similar, negative relations of central and total obesity to cognitive function that are potentiated by higher BP levels.

Differences between coronary disease and stroke in incidence, case fatality, and risk factors, but few differences in risk factors for fatal and non-fatal events

AIMS

To compare incidence and mortality of coronary and stroke events, and risk factors for non-fatal and fatal events, respectively.

METHODS AND RESULTS

Incidence and mortality were compared in all coronary (n=559 341) and stroke (n=530 689) events in Sweden from 1987 to 2001. Data from 28 years of follow-up of a random sample of 7400 men aged 47-55 and free of disease at baseline were used to compare risk factors. Incidence and 28 days of case fatality were considerably higher for coronary disease than for stroke, especially for men. Incidence of coronary disease decreased, especially for men (P=0.0001 for both sexes), and mortality declined for both men and women during 1987-2001 (P=0.0001 for both sexes). Stroke incidence declined slightly (P=0.0001 for both sexes), and there was a decline of mortality (P=0.0001 for both sexes). Out-of-hospital mortality during the first 28 days was higher than in-hospital mortality for coronary events, whereas for stroke, in-hospital mortality was higher (in men) or the same (in women) as out-of-hospital mortality. High serum cholesterol was a strong risk factor for coronary events, but not for stroke. High blood pressure was a stronger risk factor for stroke. About 50% of men with both stroke and coronary disease died from coronary disease.

CONCLUSION

Several differences regarding incidence, mortality, prognosis, and risk factors for stroke and coronary disease point towards different pathologies.