<p class="first" id="d1551858e361">This population-based study calculates lifetime
risk estimates for incident cardiovascular
disease and subtypes of cardiovascular disease and estimates years lived with and
without cardiovascular disease by weight status.
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<h5 class="section-title" id="d1551858e367">Question</h5>
<p id="d1551858e369">What is the association of body mass index with cardiovascular
disease (CVD) morbidity
and mortality?
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<h5 class="section-title" id="d1551858e372">Findings</h5>
<p id="d1551858e374">In this population-based study, overweight and obesity were associated
with significantly
increased risk for CVD. Obesity was associated with shorter longevity and a greater
proportion of life lived with CVD; overweight was associated with similar longevity
as normal weight but at the expense of a greater proportion of life lived with CVD.
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<h5 class="section-title" id="d1551858e377">Meaning</h5>
<p id="d1551858e379">These results provide critical perspective on CVD associated
with overweight and obesity
and challenge both the obesity paradox as well as the view that overweight is associated
with greater longevity.
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<h5 class="section-title" id="d1551858e383">Importance</h5>
<p id="d1551858e385">Prior studies have demonstrated lower all-cause mortality in
individuals who are overweight
compared with those with normal body mass index (BMI), but whether this may come at
the cost of greater burden of cardiovascular disease (CVD) is unknown.
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<h5 class="section-title" id="d1551858e388">Objective</h5>
<p id="d1551858e390">To calculate lifetime risk estimates of incident CVD and subtypes
of CVD and to estimate
years lived with and without CVD by weight status.
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<h5 class="section-title" id="d1551858e393">Design, Setting, and Participants</h5>
<p id="d1551858e395">In this population-based study, we used pooled individual-level
data from adults (baseline
age, 20-39, 40-59, and 60-79 years) across 10 large US prospective cohorts, with 3.2
million person-years of follow-up from 1964 to 2015. All participants were free of
clinical CVD at baseline with available BMI index and CVD outcomes data. Data were
analyzed from October 2016 to July 2017.
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<h5 class="section-title" id="d1551858e398">Exposures</h5>
<p id="d1551858e400">World Health Organization–standardized BMI categories.</p>
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<h5 class="section-title" id="d1551858e403">Main Outcomes and Measures</h5>
<p id="d1551858e405">Total CVD and CVD subtype, including fatal and nonfatal coronary
heart disease, stroke,
congestive heart failure, and other CVD deaths. Heights and weights were measured
directly by investigators in each study, and BMI was calculated as weight in kilograms
divided by height in meters squared. We performed (1) modified Kaplan-Meier analysis
to estimate lifetime risks, (2) adjusted competing Cox models to estimate joint cumulative
risks for CVD or noncardiovascular death, and (3) the Irwin restricted mean to estimate
years lived free of and with CVD.
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<h5 class="section-title" id="d1551858e408">Results</h5>
<p id="d1551858e410">Of the 190 672 in-person examinations included in this study,
the mean (SD) age was
46.0 (15.0) years for men and 58.7 (12.9) years for women, and 140 835 patients (73.9%)
were female. Compared with individuals with a normal BMI (defined as a BMI of 18.5
to 24.9), lifetime risks for incident CVD were higher in middle-aged adults in the
overweight and obese groups. Compared with normal weight, among middle-aged men and
women, competing hazard ratios for incident CVD were 1.21 (95% CI, 1.14-1.28) and
1.32 (95% CI, 1.24-1.40), respectively, for overweight (BMI, 25.0-29.9), 1.67 (95%
CI, 1.55-1.79) and 1.85 (95% CI, 1.72-1.99) for obesity (BMI, 30.0-39.9), and 3.14
(95% CI, 2.48-3.97) and 2.53 (95% CI, 2.20-2.91) for morbid obesity (BMI, ≥40.0).
Higher BMI had the strongest association with incident heart failure among CVD subtypes.
Average years lived with CVD were longer for middle-aged adults in the overweight
and obese groups compared with adults in the normal BMI group. Similar patterns were
observed in younger and older adults.
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<h5 class="section-title" id="d1551858e413">Conclusions and Relevance</h5>
<p id="d1551858e415">In this study, obesity was associated with shorter longevity
and significantly increased
risk of cardiovascular morbidity and mortality compared with normal BMI. Despite similar
longevity compared with normal BMI, overweight was associated with significantly increased
risk of developing CVD at an earlier age, resulting in a greater proportion of life
lived with CVD morbidity.
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