Mortality Risk Associated with Underweight: a Census-linked Cohort of 31,578 Individuals with Up to 32 Years of Follow-up

Overview

Journal BMC Public Health

Publisher Biomed Central

Specialty Public Health

Date 2014 Apr 18

PMID 24739374

Citations 42

Authors

Lucienne Roh

Julia Braun

Arnaud Chiolero

Matthias Bopp

Sabine Rohrmann

David Faeh

Affiliations

Soon will be listed here.

Abstract

Background: In contrast to obesity, information on the health risks of underweight is sparse. We examined the long-term association between underweight and mortality by considering factors possibly influencing this relationship.

Methods: We included 31,578 individuals aged 25-74 years, who participated in population based health studies between 1977 and 1993 and were followed-up for survival until 2008 by record linkage with the Swiss National Cohort (SNC). Body Mass Index (BMI) was calculated from measured (53% of study population) or self-reported height and weight. Underweight was defined as BMI < 18.5 kg/m2. Cox regression models were used to determine mortality Hazard Ratios (HR) of underweight vs. normal weight (BMI 18.5- < 25.0 kg/m2). Covariates were study, sex, smoking, healthy eating proxy, sports frequency, and educational level.

Results: Underweight individuals represented 3.0% of the total study population (n = 945), and were mostly women (89.9%). Compared to normal weight, underweight was associated with increased all-cause mortality (HR: 1.37; 95% CI: 1.14-1.65). Increased risk was apparent in both sexes, regardless of smoking status, and mainly driven by excess death from external causes (HR: 3.18; 1.96-5.17), but not cancer, cardiovascular or respiratory diseases. The HR were 1.16 (0.88-1.53) in studies with measured BMI and 1.59 (1.24-2.05) with self-reported BMI.

Conclusions: The increased risk of dying of underweight people was mainly due to an increased mortality risk from external causes. Using self-reported BMI may lead to an overestimation of mortality risk associated with underweight.

Citing Articles

Impact of underweight status on mortality in sepsis patients: a meta-analysis.

Chen J, Zhang F, Liang L, Pan X, Zhang J, Jin G Front Med (Lausanne). 2025; 12:1549709.

PMID: 39981083 PMC: 11839434. DOI: 10.3389/fmed.2025.1549709.

Persistent body-weight change on achalasia and peroral endoscopic myotomy: a multicenter cohort study.

Takahashi K, Sato H, Shimamura Y, Abe H, Shiwaku H, Shiota J J Gastroenterol. 2024; .

PMID: 39739029 DOI: 10.1007/s00535-024-02205-9.

TUM4Health, a holistic student health promotion program. Screening of cardiovascular risk factors in university students.

Haggenmuller K, Reiner B, Oberhoffer R, Olson N, Weil J, Schulz T Front Cardiovasc Med. 2024; 11:1428457.

PMID: 39664762 PMC: 11632104. DOI: 10.3389/fcvm.2024.1428457.

Tobacco Use, Food Insecurity, and Low BMI in India's Older Population.

Selvamani Y, Pradhan J, Fong J Nutrients. 2024; 16(21).

PMID: 39519481 PMC: 11547918. DOI: 10.3390/nu16213649.

Clinical and sociodemographic determinants of older breast cancer survivors' reports of receiving advice about exercise.

Wojcik K, Wilson O, Kamil D, Rajagopal P, Schonberg M, Jayasekera J Breast Cancer Res Treat. 2024; 208(3):643-655.

PMID: 39347888 PMC: 11522097. DOI: 10.1007/s10549-024-07460-1.

References

Gutzwiller F, Nater B, Martin J . Community-based primary prevention of cardiovascular disease in Switzerland: methods and results of the National Research Program (NRP 1A). Prev Med. 1985; 14(4):482-91. DOI: 10.1016/0091-7435(85)90008-8. View

Flegal K, Graubard B, Williamson D, Gail M . Impact of smoking and preexisting illness on estimates of the fractions of deaths associated with underweight, overweight, and obesity in the US population. Am J Epidemiol. 2007; 166(8):975-82. DOI: 10.1093/aje/kwm152. View

Tremblay A, Bandi V . Impact of body mass index on outcomes following critical care. Chest. 2003; 123(4):1202-7. DOI: 10.1378/chest.123.4.1202. View

Flegal K, Graubard B, Williamson D, Gail M . Cause-specific excess deaths associated with underweight, overweight, and obesity. JAMA. 2007; 298(17):2028-37. DOI: 10.1001/jama.298.17.2028. View

Calle E, Thun M, Petrelli J, Rodriguez C, Heath Jr C . Body-mass index and mortality in a prospective cohort of U.S. adults. N Engl J Med. 1999; 341(15):1097-105. DOI: 10.1056/NEJM199910073411501. View

Klenk J, Nagel G, Ulmer H, Strasak A, Concin H, Diem G . Body mass index and mortality: results of a cohort of 184,697 adults in Austria. Eur J Epidemiol. 2009; 24(2):83-91. DOI: 10.1007/s10654-009-9312-4. View

De Laet C, Kanis J, Oden A, Johanson H, Johnell O, Delmas P . Body mass index as a predictor of fracture risk: a meta-analysis. Osteoporos Int. 2005; 16(11):1330-8. DOI: 10.1007/s00198-005-1863-y. View

Magnusson P, Rasmussen F, Lawlor D, Tynelius P, Gunnell D . Association of body mass index with suicide mortality: a prospective cohort study of more than one million men. Am J Epidemiol. 2005; 163(1):1-8. DOI: 10.1093/aje/kwj002. View

Allison D, Heo M, Flanders D, Faith M, Carpenter K, Williamson D . Simulation study of the effects of excluding early deaths on risk factor-mortality analyses in the presence of confounding due to occult disease: the example of body mass index. Ann Epidemiol. 1999; 9(2):132-42. DOI: 10.1016/s1047-2797(98)00039-8. View

10.

Shields M, Connor Gorber S, Tremblay M . Estimates of obesity based on self-report versus direct measures. Health Rep. 2008; 19(2):61-76. View

11.

Tamosiunas A, Reklaitiene R, Radisauskas R, Jureniene K . Prognosis of risk factors and trends in mortality from external causes among middle-aged men in Lithuania. Scand J Public Health. 2005; 33(3):190-6. DOI: 10.1080/14034940510005707. View

12.

Willett W, Hu F, Colditz G, Manson J . Underweight, overweight, obesity, and excess deaths. JAMA. 2005; 294(5):551. DOI: 10.1001/jama.294.5.551-a. View

13.

Flegal K, Graubard B, Williamson D, Cooper R . Reverse causation and illness-related weight loss in observational studies of body weight and mortality. Am J Epidemiol. 2010; 173(1):1-9. DOI: 10.1093/aje/kwq341. View

14.

Bopp M, Minder C . Mortality by education in German speaking Switzerland, 1990-1997: results from the Swiss National Cohort. Int J Epidemiol. 2003; 32(3):346-54. DOI: 10.1093/ije/dyg072. View

15.

Whitlock G, Lewington S, Sherliker P, Clarke R, Emberson J, Halsey J . Body-mass index and cause-specific mortality in 900 000 adults: collaborative analyses of 57 prospective studies. Lancet. 2009; 373(9669):1083-96. PMC: 2662372. DOI: 10.1016/S0140-6736(09)60318-4. View

16.

Smith L, Brinton L, Spitz M, Lam T, Park Y, Hollenbeck A . Body mass index and risk of lung cancer among never, former, and current smokers. J Natl Cancer Inst. 2012; 104(10):778-89. PMC: 3352831. DOI: 10.1093/jnci/djs179. View

17.

Manson J, Bassuk S, Hu F, Stampfer M, Colditz G, Willett W . Estimating the number of deaths due to obesity: can the divergent findings be reconciled?. J Womens Health (Larchmt). 2007; 16(2):168-76. DOI: 10.1089/jwh.2006.0080. View

18.

Flegal K, Kit B, Orpana H, Graubard B . Association of all-cause mortality with overweight and obesity using standard body mass index categories: a systematic review and meta-analysis. JAMA. 2013; 309(1):71-82. PMC: 4855514. DOI: 10.1001/jama.2012.113905. View

19.

Flegal K, Graubard B, Williamson D, Gail M . Excess deaths associated with underweight, overweight, and obesity. JAMA. 2005; 293(15):1861-7. DOI: 10.1001/jama.293.15.1861. View

20.

Maag J, Braun J, Bopp M, Faeh D . Direct estimation of death attributable to smoking in Switzerland based on record linkage of routine and observational data. Nicotine Tob Res. 2013; 15(9):1588-97. DOI: 10.1093/ntr/ntt023. View