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Multivariate-adjusted relative risk was calculated using study participants with a body mass index calculated as weight in kilograms divided by square of height in meters of Chen, and Whelton, and Ms C. Context The effect of underweight and obesity on mortality has not been well characterized in Asian populations. De, Setting, and Participants A prospective cohort study in a nationally representative sample of Chinese men and women aged 40 years or older.

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Data on body weight and covariables were obtained at a baseline examination in using a standard protocol. Follow-up evaluation was conducted inwith a response rate of After excluding those participants with missing body weight or height values, adults were included in the analysis. Using those participants with a BMI of The U-shaped association existed even after excluding participants who were current or former smokers, heavy alcohol drinkers, or who had prevalent chronic illness at the baseline examination, or who died during the first 3 years of follow-up.

A similar association was observed between BMI and mortality from cardiovascular disease, cancer, and other causes. Conclusions Our indicate that both underweight and obesity were associated with increased mortality in the Chinese adult population. Furthermore, our findings support the use of a single common recommendation for defining overweight and obesity among all racial and ethnic groups. The prevalence of obesity is increasing to epidemic proportions at an alarming rate around the world. In addition, lifestyle or medical interventions for weight loss are common in Western populations, which might confound any association between body weight and mortality.

Furthermore, self-reported body weight and height were used among many studies. Current definitions of overweight and obesity are based on data from Western populations. In a large prospective cohort study, we examined the relationship between BMI and mortality from all causes and from specific causes in a nationally representative sample of the Chinese adult population.

We also assessed whether the present data support the lower BMI cutoffs for defining overweight and obesity in the Asian populations. In the China National Hypertension Survey, a multistage random cluster sampling de was used to select a representative sample of the general Chinese population aged 15 years or older from all 30 provinces in mainland China.

Of the 30 provinces, 13 were not included in the follow-up study because study participants' contact information was not available.

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However, the sampling process was conducted independently within each province in the China National Hypertension Survey and the 17 provinces that were included in the follow-up study were evenly distributed in different geographic regions representing various economic developing statuses in China. Overall, 83 men and 86 women who were aged 40 years or older at their baseline examination were eligible to participate in the follow-up study. From this population, a total of study participants After excluding those participants with missing body weight or height values, data from study participants were used in our analysis.

Baseline data were collected at a single clinic visit by specially trained physicians and nurses using standardized methods with stringent levels of quality control. Work-related physical activity was assessed because leisure-time physical activity was uncommon. High school education was defined as high school education or higher. Cigarette smokers were defined as having smoked at least 1 cigarette per day for 1 year or more.

The amount and type of alcohol consumed during the past year was collected. Alcohol consumption was defined as drinking alcohol at least 12 times during the last year. Three blood pressure readings were obtained after the study participant had been seated quietly for 5 minutes. Body weight and height were measured in light indoor clothing without shoes, using a standard protocol. Height was measured with the participant standing on a firm, level surface at a right angle to the vertical board of the height measurement device.

Body mass index was then calculated as weight in kilograms divided by height in square meters.

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The follow-up examination, which was conducted between andincluded tracking study participants or their proxies to a current address, performing in-depth interviews to ascertain disease status and vital information, and obtaining hospital records and death certificates.

All deaths reported during the in-person interview were verified by obtaining death Women in China ga looking for sex from the local public health department or police department. If death occurred during a hospitalization, the participant's hospital records, including medical history, physical examination findings, laboratory testautopsy reports, and discharge diagnosis, were abstracted by trained staff using a standard form. In addition, photocopies of selected sections of the participant's inpatient record, discharge summary, electrocardiogram, and pathology reports were obtained.

An end point assessment committee within each province reviewed and confirmed or rejected the hospital discharge diagnosis and cause of death based on the abstracted information using preestablished criteria. A study-wide end point assessment committee at the Chinese Academy of Medical Sciences in Beijing, China, reviewed all death records and determined the final underlying cause of death.

Two committee members independently verified the cause of death and discrepancies were adjudicated by discussion involving additional committee members. All members of the local and study-wide end point assessment committees were blinded to the study participant's baseline risk factor information. Causes of death were coded according to the International Classification of Diseases, Ninth Revision. Written informed consent was obtained from all study participants at their follow-up visit. These were created to allow a detailed examination of the association between body weight and mortality across a wide range of BMI values without a priori assumptions about the shape of the dose-response curve.

Age-standardized mortality was calculated using the 5-year age-specific mortality and the age distribution of the Chinese population from year census data. Cox proportional hazards regression models were used to adjust for baseline age, sex, cigarette smoking, alcohol consumption, physical activity, education, geographic region north vs southand urbanization urban vs rural.

Hypertension was not adjusted for in the primary analyses because it is an intermediate factor in the causal path between BMI and mortality. However, the were similar after adjustment for hypertension in sensitivity analyses. The presence of a linear or U-shaped quadratic term association was tested using the median of BMI in each category as a continuous variable in the Cox proportional hazards regression models.

Methods to estimate variances that take into sample clustering were used in Cox proportional hazards regression models. Baseline characteristics of the study participants are presented according to 10 of BMI in Table 1. Body mass index was inversely related to age. Male sex, cigarette smoking, and alcohol consumption were more common among leaner study participants, and physical inactivity, a high school education high school or higher educationand hypertension were more prevalent among heavier participants.

During a mean follow-up of 8. This U-shaped association between BMI and all-cause mortality remained after multivariate adjustment for important risk factors, including age, sex, cigarette smoking, alcohol consumption, physical activity, education, geographic region north vs southand urbanization urban vs ruraland stratified by sampling clusters.

The association between BMI and all-cause mortality was consistent in men and women. For example, the multivariate-adjusted RRs were 1. The corresponding age-standardized all-cause mortality rate for the 10 of BMI was In addition, the U-shaped association was consistently present among the age groups of 40 to 49, 50 to 59, 60 to 69, and 70 or more years data not shown. The U-shaped association was also present for urban and rural residents. After excluding study participants who died during the first 3 years of follow-up, the multivariate-adjusted RRs for all-cause mortality across BMI were 1.

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During follow-up, deaths from cardiovascular disease, deaths from cancer, and deaths from other causes were documented. The age-standardized mortality rate from cardiovascular disease across BMI was The corresponding age-standardized mortality rate from cancer across BMI was There was a statistically ificant U-shaped association between BMI and mortality from cardiovascular disease, cancer, and other causes after adjustment for important risk factors Table 3.

The relationship between BMI and cause-specific mortality was consistent among men and women. A U-shaped association between BMI and age-standardized all-cause mortality has been observed in several prospective cohort studies conducted in Western populations. A U-shaped association between Women in China ga looking for sex and all-cause mortality was observed among all cohorts, with the lowest mortality for persons with a BMI between In the Cancer Prevention Study II, 13 a prospective study of mortality among 1 men and women in the United States, a U-shaped association between BMI and all-cause mortality was documented for all subgroups, according to smoking status and the presence of a history of disease.

The lowest all-cause mortality was found among study participants with a BMI between In our large population-based, prospective cohort study, the lowest rates of all-cause mortality were found at a BMI of In addition, a BMI of more than We documented 11 deaths during person-years of follow-up among study participants with a BMI of less than As such, we are able to examine the relationship between low body weight and mortality with great precision and statistical power.

Another advantage of our cohort was that it used a nationally representative sample of the general Chinese adult population. Our study also used stringent quality control procedures at the baseline examination and in assessing study outcomes during follow-up.

Unlike other large cohort studies, 913 body weight and height were measured in our study using a standard protocol. A high follow-up rate was achieved in our study. A major limitation was that body weight changes over time were not measured. Therefore, we were not able to evaluate the association between weight change and mortality. Age has been proposed as an effect modifier for the relationship between body weight and all-cause mortality in several epidemiological studies. Our study indicated that the U-shaped association between BMI and all-cause mortality was consistently present for study participants aged 40 to 64 years and 65 years or older.

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Our study does not support the theory that a high mortality rate among elderly persons with a low body weight s for the U-shaped association between BMI and all-cause mortality. In a sensitivity analysis, we excluded individuals who had prevalent cardiovascular disease, stroke, cancer, end-stage renal disease, or chronic obstructive pulmonary disease at the baseline examination, or deaths that occurred during the first 3 years of follow-up. Furthermore, we excluded cigarette smokers and heavy alcohol drinkers in the sensitivity analysis because cigarette smoking and heavy alcohol consumption have been shown to be related to both low body weight and high mortality.

Compared with nonsmokers with a BMI of The study by Zhou 31 reported a meta-analysis of 4 prospective cohorts with a total of 76 Chinese adults. A U-shaped association between BMI and all-cause mortality was identified, even after exclusion of those participants who died during the first 3 years of follow-up and exclusion of cigarette smokers. Age-adjusted all-cause mortality was lowest in persons with a BMI of In conclusion, our study indicates that both obesity and underweight are associated with increased mortality from all causes in the Chinese adult population.

The relationship between BMI and all-cause mortality and mortality from cardiovascular disease, cancer, and other causes was consistent among men and women, those persons who were middle-aged or older, never smokers, and persons who did not have a chronic illness at baseline and who did not die during the first 3 years of follow-up. Our findings are also consistent with observations from Western populations that have identified the lowest all-cause mortality in persons with a BMI between Author Contributions: Drs Gu and He had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Drs Gu and He contributed equally to this work. Analysis and interpretation of data : Gu, He, Reynolds, J. Chen, C. Chen, Whelton. Chen, Huang, C.

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