Body mass index and all-cause mortality in a nationwide US cohort

Objective: To investigate whether the nature of the relationship between body mass index (BMI (kg/m(2))) and all-cause mortality is direct, J- or U-shaped, and whether this relationship changes as people age. Design: Prospective nationwide cohort study of US radiologic technologists (USRT). Subjects: Sixty-four thousand seven hundred and thirty-three female and 19 011 male certified radiation technologists. Methods: We prospectively followed participants from the USRT study who completed a mail survey in 1983-1989 through 2000. During an average of 14.7 years of follow-up or 1.23 million person-years, 2278 women and 1495 men died. Using Cox's proportional-hazards regression analyses, we analyzed the relationship between BMI and all-cause mortality by gender and by age group (< 55 years; >= 55 years). We also examined risk in never-smokers after the first 5 years of follow-up to limit bias owing to the confounding effects of smoking and illness-related weight loss on BMI and mortality. Results: Risks were generally J- shaped for both genders and age groups. When we excluded smokers and the first 5 year of follow-up, risks were substantially reduced in those with low BMIs. In never-smoking women under the age of 55 years (excluding the initial 5-year follow-up period), risk rose as BMI increased above 21.0 kg/m(2), whereas in older women, risk increased beginning at a higher BMI (>= 25.0 kg/m(2)). Among younger men who never smoked (excluding the initial 5-year follow-up period), risk began to rise above a BMI of 23.0 kg/m(2), whereas in older men, risk did not begin to increase until exceeding a BMI of 30.0 kg/m(2). Conclusions: In younger/middle-aged, but not older, women and men, mortality risks appear directly related to BMI. The more complicated relationship between BMI and mortality in older subjects suggests the importance of assessing whether other markers of body composition better explain mortality risk in older adults.