Acta Medica Scandinavica

Supplementurn 679
Height. Weight and Mortality
The Norwegian Experience
Unit for Health Services Research, National Institute of Public Health, Oslo
and
National Mass Radiography Service, Oslo
Hans Th. Waaler
Distributcd bv The Almqvist & Wiksell Periodical Company, Stockholm, Sweden
Preface
What is overweight? How i mportant is it? Is i t a cosmeti c problem or a heal th
problem? What is the opti mal weight?
The exi stence of a l arge fi l e of body hei ght and weight measurements avai l abl e at the
National Mass Radiography Servi ce prompted us to undertake thi s study of the
mortal i ty as a functi on of body build. Such studi es have been carri ed out before, but
not in Norway and not at thi s scale. The study represents the l argest materi al ever
published (1.8 million persons and 18 million observation years) from one of the
smal l est countri es (Norway has 4.1 million inhabitants).
Large fi l es were combined, checked for consistency, and matched with the central
files of deaths. Everybody who has ever undertaken such tasks will appreci ate the
professional data and computer handling required and the skill and effi ci ency with
which thi s has been carri ed out by Hartvi g Opsj@n from the Nati onal I nsti tute of
Public Heal th and Ernst Risan from the National Mass Radiography Service.
A special thank is given to De Norske Livsforsikringsselskapers Forening for thei r
generous financial contribution.
Finally I will thank Randi Hageler and Hel ene Karud for the typing of the manuscript.
Oslo, J une 30 1983
Hans Th. Waaler
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1 Introduction
Background and basic questions. The exi stence of an association between body-
build and health is well documented (5, 7, 1 1 , 17, 19, 20, 23, 25, 33, 36, 37, 39,
47, 48). In affluent communities the overweight problem is given special
attention. The general conclusion is unquestionable: overweight is common and
presents a sizeable problem for the individual as well as for the community. In
spite of an extensive l i terature on the subject, considerable uncertainties remain
as to the exact definition of overweight. At what level is this label reasonable?
A much more exact estimation of the risk function is required as basis for
individual recommendations.
Our interest in this problem started with health education. Here overweight is
presented as a major risk factor for health. However, the scientific basis for this
well-meaning education is not precise: When does overweight change from a
cosmetic problem into a health problem? This is the question that started this
investigation.
Less attenti on has been given to the problem of underweight and health, and
reports are partly conflicting (27, 36, 37). The extent of this problem in the
affluent countries is probably much less. Hence very large materi al s are needed
for such studies.
Observations of excess health risks for under- as well as for overweight
individuals lead to the question of the optimum body-build. Tables on normal
weigth by height are available (I , 25, 361, and some of these pretend to be health
optimal, for example with regard to mortality. Others are named normal, but
present only averages and are useful only as general rules, not necessarily ideals.
In the resulting ocean of uncertainties, myths and vogues are freely developing,
giving us popular ideals from Rubens' femal es to Twiggy-types. Such variations
are typically mostly seen for females, probably reflecting the highly variable and
easily flexible phantasies of the male gender. The popular views on the ideal
body-build of a man seem to be much more constant over ti me and space.
Epidemiological research aims at establishing more objectively the "best" weight
for a given height. Long-term observations of unbiased and unselected material
are necessary, but not enough. The word "best" must be qualified. Best for what?
Mortality and morbidity are two possible variables to be minimized. General
wellbeing is a third possibility (to be maximized), but not necessarily proportion
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a1 to the two former variables. General wellbeing might be the most important
of these, but very difficult to measure and therefore rather useless. Athletic
performance is a fourth possibility (44) but presents other problems. For
instance, a javelin thrower and a marathon runner do not have the same optimal
body-build. A fi fth variable is conceived beauty - important, but highly subjecti-
ve and impossible to measure.
Even the mortality index is not unambiguous. Optimal body-build might differ
from a community with tuberculosis to a community without this disease.
These are considerations to keep in mind during the reading of this report, which
is based upon mortality alone. We have studied both the total mortality and the
most important causes of death in order to elucidate the general association
between body build parameters and mortality.
This report will thus lead to considerations about optimal weight for a given
height and an analysis of mortality pattern along the body-build scale. The
establishment of optimal weights for given heights might be interpreted as ideals
to crave for. However, effects of any individual attempt to approach these
normals are not studied, and normalization of mortality by normalization of the
body weight can therefore not be taken for granted.
Indexes for body-build. The body-build is an expression which combines body
weight and height. Out of the universe of possible mathematical functions we
have selected the body mass index: W/H , also called the Quetelet's index (2, 4,
22, 32) This index has proved it's value in several reports, is widely used and easy
to calculate. Our material might later be used to construct the index with
maximum discriminatory power between the dead and the survivors.
2
Body height. The body-build, as given by the Quetelet's index, is a reflection of
genetics plus the individuals' accumulated energy balance. The body height alone
reflects genetics plus the result of living conditions during the growth phase, i.e.
before the age of 20, minus the height reduction as a normal aging phenomenon,
in some cases also a pathological process. The marked increase in the body
height of military recruits in Norway during the last century (40) is interpreted
to refl ect improvements in the general nutritional status of the population. We
have therefore made a separate analysis of the mortality as a function of the
body height alone.
- 5 -
The interests in possible associations between body height and mortality differ
from the i nterests in the association between health and body weight, because
nothing can be done individually with a body height that indicates an excess
health risk. However, even if possible gradients only refl ect passed history,
connected with the socio-economic living conditions, we believe that such
observations might be of importance since they might give additional informa-
tion about the relationship between socio-economic living conditions and health
(42, 43).
2 Materials and methods
The State Mass Miniature X-ray Examination Organization carried out i ts l ast
compulsory mass examinations for tuberculosis in the years between 1963 and
1975. These examinations covered persons 15 years of age and above.
Thereafter the strategy was changed to a selective case-finding method. I t was
known, in particular from studies in the US (8, 12, 31) that low weight has a
considerable predictive value for tuberculosis. Therefore, measurements of body
weight and height were included in the last mass examinations. These measure-
ments form the basis for the analyses in this report.
The capi tal Oslo had a mass X-ray examination in 1962. At this examination such
measurements were not yet included. The population of Oslo is therefore not
covered by this report.
The files with the measurements of height and weight were matched against the
death registry in the Central Bureau of Statistics. This matching was done by
means of the individual eleven-digit identification number, which is allocated at
birth as well as to immigrants. The county of Buskerud was examined in 1965,
just before the individual numbersystem was adequately established. Buskerud
county is therefore not included. All the other 17 counties were covered. Oslo
and Buskerud counties consti tute 17.5 per cent of the total Norwegian population
of about 4 million.
The second biggest ci ty of Norway, Bergen, which was examined in 1963-64, was
included because the local individual numbering system, used in Bergen for many
years, was transferred to the national personal number system by special
computer treatment.
The Finnmark county was mass examined several times, including measurements
of height and weight. Due to considerable migration between counties, several
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Table I Number of individuals measured under deviating circumstances
N Percentage Percentage
of all measured
With shoes
Invalids
Pregnant
64 981 83.0 3.6
7 549 9.6 0.4
5 761 7.4 0.3
Total 78 291 100 4.4
Table I1 Number of individuals ordinarily measured, hereof dead in the
observation period
Measured Dead
Males Females Total Males Females Total
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80-84
85-89
90
95 830 92 382 188 212
61 595 74 305 135 900
65 794 72019 137813
60 240 67 878 128 118
63 947 71 178 135 125
72 616 79299 151 915
79 598 86 625 166 223
77 376 84 667 162 043
70 954 77 014 147 968
60 133 67 836 127 969
47 436 56 055 103 491
33 252 40 236 73 488
18 078 21 913 39 991
6 944 8 129 15 073
1784 1814 3 598
307 28 1 588
994 252 1246
59 1 257 848
692 370 1062
918 559 I477
1645 914 2559
3 210 1692 4 902
5 484 2 934 8 418
8 462 4 232 12 694
1 1 986 6 365 18 351
15 406 9 416 24 822
17 989 13 328 31 317
16 919 14 892 31 811
I 1 562 I 1 413 22975
5 298 5 439 10 737
I523 1414 2 937
232 186 418
~~
Total 815 884 901 631 1 717 515 102 911 73 663 176 574
individuals from other counties might also have been measured several times.
The report is systematically based on the oldest of several measurements.
Some persons were measured under deviating circumstances: Some refused. to
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take off their shoes, some were invalids, some claimed to be pregnant etc. These
altogether 78 291 individuals are distributed to the various causes in percentages
in Table I and were excluded from the analyses in this report. The final file of
individuals with accepted measurements of height and weight and with accepted
personal number system contain close to 1.8 million individuals.
Table I1 gives sex and age distribution of the population that was ordinarily
measured. The table also gives the number of deaths in the observation period,
i.e. the years 1963-1979 inclusive.
' 10 20 30 40 50 60 70 00 90
AGE ( YEA RS)
Fig. 1 The study population in percentage of the total population 1970
(Oslo and Buskerud counties excluded).
-8-
The attendance at the compulsory mass examination, including the height/weight
measurements, was about 85 per cent. Figure 1 shows the attendance rate
according to age, demonstrating a relatively large non-attendance among the
youngest and particularly among the oldest persons. Non-attendance was mainly
due to "acceptable excuses" at the ti me of examination:
-
- In military service
- In hospital
Already under control or treatment for tuberculosis
Only a negligible number of individuals refused to attend the examination
altogether.
The analysis is thus based on 1 717 515 individuals of which 176 574 died during
the period 1963-1979. Table 111 shows a total observation ti me close to 17 million
person-years, i.e. almost 10 of years observation per person.
Table I11 Years of observation by age and sex
Total Average (years)
Males Females Males Females
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80-84
85-89
90
997 023 973 631
630 523 780 476
659 370 737 713
616 769 705 436
665 162 750 085
751 987 837 180
807 604 901 607
756 655 862 998
670 988 772 819
535 286 659 653
389 313 515 I54
244 302 333 431
114 305 158 041
37 024 48 965
7 748 9 220
1 576 2 065
10.4
10.2
10.0
10.2
10.4
10.4
10.2
9.8
9.5
8.9
8.2
7.4
6.3
5.3
4.4
6.0
10.5
10.5
10.2
10.4
10.5
10.6
10.4
10.2
10.0
9.7
9.2
8.3
7.2
6.0
5.2
?
Total 7 886 035 9 048 474
- 9 -
The measurements. The body weights were measured on scales that were
regularly calibrated. The observations were noted to the nearest decimal. The
persons were asked to undress the upper body because of the X-ray examination,
and they were asked to take off their shoes because of the weight and height
measurements. Only 3.6 per cent were actually measured with shoes (Table 11,
and these individuals are excluded from the analysis. The body height was
measured by standard measures, and the observations were noted to the nearest
centimeter. The staff was instructed in advance on the proper position of the
head and body at the measurements. The observations were di ctated to an
assistant. Extreme observations, that might be due to writing or punching errors,
were checked with l ater measurements and with the X-ray picture itself. But
very few individuals were excluded on this basis.
Deaths and causes of death. Thanks to the eleven-digit identification number,
the matching between our file and the death register in the Central Bureau of
Stati sti cs produced no problems. Before the final matched file was made
available for analysis, the individual numbers were deleted from the tape in
order to exclude identification possibilities in accordance with the legal regu-
lations in Norway.
The deaths were observed between the years 1963 and 1979. Because the
changing from the 7th to the 8th revision of the I nternational Stati sti cal
Classification took place in this period, we have applied a two-digit code for the
whole period. The code for causes of deaths referred to in this report are given
in appendix table. The original four digit codes are of course retained on the
tapes.
This death register is based upon death certi fi cates issued by a doctor according
to international rules. The diagnoses have varying reliability. For the country as
a whole autopsy is performed for 14 per cent. Clinical examination in hospitals
and other health institutions is done for 55 per cent. Medical attenti on before
death in other institutions or outside: 20 per cent (10).
The analysis. Among all known combinations of weight and height which are
available in the literature, we have in this report concentrated the analysis to
W/H (the body mass index, originally called the Quetelet's index (32)) and to the
body height alone.
2
We have chosen the Quetelet's index because it is advocated in most of the
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11.0
10.5
\
4
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$ 9. 5.
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2
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8.5
-
literature. I t also has the stati sti cal advantage of being almost independent of
the average body height in the general population (2, 3). The independence of
body height and other advantages are not necessarily optimal cri teri a for
selection. What we are after, is the most predictive formula, i.e., the one which
gives the most precise prediction of mortality. Our material will l ater be used to
analyse this problem more closely.
AGE IN
YEARS.
4 5 - 4 9 d
50- 54 0-
55- 59. 4
--
-
1
140 I
Death rates. We are not interested in the absolute levels of death rates, only in
differences between death rates as consequences of the body height and weight
properties. We have, therefore, calculated death rates for the whole period by
dividing the number of deaths in the period with the initial population at risk.
This method requires a careful control of the observation time. Table 111 shows,
e.g., that the observation ti me decreases with increasing age. Total mortality
according to age, will therefore give a biased expression of the death probabili-
ties as a function of age. As this function is of no i nterest in our material, we
have disregarded this bias.
BODY HEIGHT (cm)
Fig. 2 Observation ti me by body height. Males aged 45 to 59 years.
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WE1 GH T/ HE1 G HT2( kg/m2 1
Fig. 3 Observation ti me by weight/height2. Males Q5 to 59 years.
However, we have also found (Figures 2 and 3) that the observation ti me is a
function of body height and of W/H2. This is partly due to the effect of what we
are-examining, namely excess mortality as a function of the height and weight
expressions. A real excess mortality for persons with low height will produce
2
shorter observation times f or these persons. The same applies to the W/H .
Different observation times, according to the height and weight parameters,
could also be due to systemati c examinations of counties with varying values for
these parameters. If e.g. Finnmark county was observed early in the period and
this county had shorter body height and higher mortality, an observed positive
relationship between mortality and body height could be an artefact only. We
have approached this problem in three ways.
First, Figure 2 shows that the observation ti me as a function of height does not
represent more than a 10 per cent difference for the extremely short and
extremely long individuals, and this will be shown to be only a minor part of the
total difference in mortality. The crude rates will therefore be given in the
report.
- 12 -
Secondly, we have observed that the association between mortal i ty and body
height i s practi cal l y unchanged if we keep Finnmark county out of the analysis.
Thirdly, we have studied the association by means of a l i fe tabl e method which
el i mi nates the significance of the observation time.
3 Results
3.1 Body height
Figure 4 gives the average body height by age and sex. The decreasi ng hei ght by
age has several causes:
-
A component of aging : decreasi ng height as part of the aging process.
A cohort component: the older cohorts never reached the body hei ght of the
younger cohorts.
-
-
A sel ecti on component in the opposite direction: excess mortal i ty of the
shortest will give tal l er survivors.
20 30
I MALES
. % FEMALES
k
50 60
Fig. 4
AGE ( Y E A R S )
Average body height by sex and age.
- 13 -
MAL ES
I 1
FEMAL ES I
) 160 170 180 190 140 150 160 170 180
BODY HEIGHT (cm)
Fig. 5 Association between body height and mortality by sex and age.
- 14 -
Only longitudinal exami nati ons with repeated measurements can gi ve separate
esti mates of the three factors. This was partl y done by Forsdahl & Waaler (13)
who esti mated that approxi matel y 50 per cent of the reducti on in hei ght by age
is due to the aging process. The rest is a cohort phenomenon.
Figure 5 shows the association between total mortal i ty and body hei ght by age
and sex. For both sexes and for al l ages a cl ear reducti on in mortal i ty by
increased body height is observed, possibly with an excepti on for the very tall.
But by and large: The higher, the better. The contrast is considerable. For
example, for women 40-44 years of age the mortal i ty is halved when the hei ght
is increased from 145-149 cm to 165-169 cm. For mal es aged 55-59 years of age
the mortal i ty is halved when the hei ght is i ncreased from 150-155 cm to 185-189
cm.
I t is well known that the population in Finnmark county in northern Norway on
the average has a lower body hei ght than the rest of the country, and al so that
this county in general has a higher total mortal i ty. Fi gure 6 shows the mortal i ty
risk curves for two age groups of men with and wi thout Finnmark county. The
curves wi thout Finnmark are somewhat fl atter, but the magni tude of the
contrast we have demonstrated is not reduced by excluding Finnmark.
I50 I 60 I70 I80 190 200
BODY HEIGHT (cm 1
Fig. 6 Mortality and body height. Males 50 to 54 and 55 to 59 years of age.
Study population with and without the county of Finnmark.
- 15 -
We have mentioned previously that the observation ti me was partly confounded
with the body height. Some of this might be due to the excess mortality of the
shortest. But even if we assume all of the shorter observation ti me to be a
possible basis for a bias, i t cannot change the major observation, namely that the
body height to a large extent is predictive for the mortality during the next 5-13
years. This becomes quite cl ear from Figure 7, which shows the result of a life
tabl e analysis for one selected age group of men. The difference persists through
the period.
OBSERVATI ON TIME ( YEARS)
Fig. 7 Survival curves by body height. Males aged 50 to 54 years.
Figure 5 shows an exponential development, i.e. close to a log linear relationship.
We have simplified these curves by calculating the relative mortality, i.e. the
mortality by body height in relation to the total mortality for a given age group.
Figures 8 and 9 show the results for the two sexes and three selected age groups.
The curves clearly show a larger excess mortality at low heights for the younger
compared to the older. This is, of course, a result of the method of analysis
because a total mortality of 1 per cent for 20-39 years old might easily be
- 16 -
BODY HEIGHT (cm)
Fig. 8
Fig. 9
Relative mortality by body height. Males aged 40 to 59 years.
BODY HEIGHT (cr n)
Relative mortality by body height. Females aged 40 to 59 years
- 17-
quadrupled, whereas thi s is excl uded for the total mortal i ty of 60-79 years old
which is al ready 35 per cent at the lowest.
The associ ati on between hei ght and mortal i ty looks dramati c. But one should
remember that there are rel ati vel y few individuals who are so short that they
have a marked excess mortal i ty. In Figur 10 we have combi ned the risk curves
with a cumul ati ve frequency distribution for three sel ected age groups 40-59
years. The fi gure shows that 50 per cent excess risk due to low hei ght is observed
for only 2-8 per cent of the population in these age groups, depending upon age
and sex.
BODY HEIGHT (cm)
Fig. 10 Distribution of body hei ght and rel ati ve mortal i ty by body height,
age groups 40 to 59 years.
- 18-
Strength of association. The curves in Figure 5 show that the mortality depends
upon the body height for 5 years age groups. For all age groups, except the oldest
ones, those with the lowest body height in one age group have a mortality which
at least corresponds to the mortality of the tallest individuals in the next age
group. This means that those with lowest body height have a physiological age 5
years higher than their calendar age. In some cases the contrast is even bigger:
males who are 20-24 years and less than 165 cm have a mortality corresponding
to that of 35-39 years old males which are 185-189 cm tal1,i.e. 15 years older.
In chapter 3.4 (page 32) we shall come back to the causes of death at the various
height levels.
A QE ( YEA RS)
2
Fig. 11 Average weightlheight by sex and age.
3.2 Weightlheight
2
Figur I 1 shows the average value of W/H by sex and age, and Figure 12 shows
the distribution for some selected age groups. The index increases by age for
both sexes with a maximum between 60 and 80 years. There is a clear reduction
for the upper age groups. There is also a marked difference between the sexes.
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17 19 21 23 25 27 29 31 33 35 37 39 41 43 45
WEIGHT/ HE IGHT2 (kg /m2)
2
Fig. 13 Mortality by weighttheight for each age group. Males.
- 21 -
20
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I I I I I I I I I
17 19 21 23 25 27 29 31 33 35 37 39 41 43 45
WE I GH T / HElGH T (kg /m2)
Mortality by wei ght/hei ghtL for each age group. Femal es. Fig. 14
- 22 -
Figure 12 shows that the vari ance i ncreases by age, more marked for women
than for men.
Figures 13 and 14 gi ve the mortal i ty rel ated to this index. For al l age groups the
curves have a typi cal U-form, i ystemati cal l y unsymmetri c with a wider form to
the right and with a broad, approxi matel y fl at basis. There is undoubtedly an
opti mal value for the index, but the position of thi s opti mum is very unprecisely
defined. For women aged 45-49 years the l owest val ues are observed for index
values between 26.0 and 27.9, but al l index values between 20 and 30 show
approximately the same mortal i ty.
For age groups below 40 the curves for the femal es are i rregul ar because of
small numbers, but the main resul t is the same.
The U-form is cl ear for both sexes, and the l eft tai l , i.e. those wi th low weight,
is just as cl ear as the ri ght tai l , i.e. those wi th high weight. The curves for the
femal es are fl atter at the bottom, i.e. they have a l arger vari ati on area for
minimal mortal i ty than males. In other words, the femal es seem to tol erate
vari ati ons in overwei ght better than the males. The di fference in mortal i ty
between the opti mal and the extreme values are considerable. The endpoi nts of
the U-curves correspond to an excess mortal i ty of 50-100 per cent, varying with
sex and age. For the ol dest age groups the rel ati ve excess mortal i ty is of course
limited upward because the mortal i ty at optimum is al ready very high.
Figure 15 shows the rel ati ve mortal i ty cal cul ated for three age groups: 50-54,
55-59 and 60-64. There is a wide optimum area for values between 20 and 28,
al most independent of age and sex. One can al so see that the excess mortal i ty
for femal es for higher W/H -values is less pronounced than for males. For
instance, for W/H =34 mal es have an excess mortal i ty of about 30-40 per cent
rel ati ve to the total , whereas the excess mortal i ty for femal es at thi s l evel is
between 20 and 30 per cent.
2
2
2
Early sel ecti ve i mpact of mortal i ty on W/H . One mi ght i nfer from the U-shaped
risk curve that i t refl ects the di rect ef f ect of di seases al ready present at
measurement. This would in parti cul ar apply at the lower tail. Fi gur 16 presents
- for two sel ected age groups - the risk curves separate for those dying during
the whole observati on period and for those dying more than fi ve years af ter the
measurement. The U-shape persists, perhaps even sharpened. The hypothesis that
the U-shape is a product of al ready existing f atal di seases can therefore be
dismissed.
- 23 -
8 0
WE I G H T/ H E I G H T2 ( k g /m2 1
I I 1 I I I
I I I I I I
60-
' )THE WHOLE OBSERVATION PERIOD Do.lc
-
-
Lo 4
40H 2 ) THE FIRST 6 YEARS EXCLUDED
-1
WEIGHT/HEIGHTZ (kg/ m2)
Fig. 16 Mortality according to weight/height 2 . Separate fi gures for the
whole observation periode and the fi rst fi ve years excluded.
- 24 -
Expectancy of l i fe equivalence. One can also express the excess risk in terms of
the age i ncrease to which the excess risk corresponds. We have cal cul ated for an
assumed opti mal index value for femal es of 25 and for mal es of 24 the opti mal
weight with a given average height. Thereafter we have added 30 per cent
respectively to thi s weight. This gi ves index val ues of 32.5 for femal es and 31.2
for males. The corresponding mortal i ty risks for these overvei ght values are
esti mated by visual study of Fi gure 5. From mortal i ty tabl es appl i cabl e to the
general population we have then by i nterpol ati on found the number of added
years which correspond to thi s risk increase. In other words, we have cal cul ated
how much "older" these overwei ght individuals are in terms of mortal i ty risk.
Figure 17 gives the resul ts of these cal cul ati ons in added years by age and sex.
7
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AGE ( Y E A RS )
Fig. 17 Esti mated age i ncrement in years corresponding to a 30 per cent
overweight.
One can see that a 30 per cent weight i ncrease reduces l i fe expectancy for
femal es from one half to two years, decreasi ng by increasing age. For mal es the
values are higher, a 30 per cent weight i ncrease in rel ati on to the opti mum is
equivalent to an increased age of one to fi ve years, falling by age. A man aged
50-54 years with an average hei ght of 175 cm weighing 94.8 kg, i nstead of the
opti mal 79 kg, will have a mortal i ty as if he were 3 years older.
- 25 -
65
Fig. 18
-- ___
I
--
--
I I I I I I I
50 to 54 years.
Fig. 19
2
Survival curves according to weighttheight .
years.
Females 50 to 54
- 26 -
Survival curves. To exclude the possible bias in observati on ti me as a functi on of
W/H (see Fi gure 3), we have studied the survival curves for various W/H -
values. Fi gures 18 and 19 present such curves for i ntermedi ate values as well as
for two extreme values of W/H2, for the age group 50-54 years of age. These
observations cl earl y confirm the previous observation: the i ntermedi ate values
26.0-27.9 i ndi cate low mortal i ty persisting through the observati on period,
whereas both extremes i ndi cate an excess mortality.
2 2
Extent of obesity and underweight in the population. The mortal i ty risk curve
according to W/H looks schemati cal l y as shown in Fi gure 20.
2
1
WEIGHT/ HEIGHT2 (kg/m2)
Fig. 20 Mortality accordi ng to weight/heightL. Schemati c.
There is an opti mal level, and deviation from thi s l evel is associ ated wi th an
increased risk. We have esti mated the percentage of individuals covered by the
hatched areas in the figure, the l eft and the ri ght part separatel y.
Expressed in terms of percentage of al l deaths in the age groups 30-79 years for
males and femal es together we find that the area at the l eft tai l i s 1.7 per cent
(1.9 per cent for femal es and 1.6 per cent for males) and at the ri ght tai l 4.3 per
cent (3.8 per cent for femal es and 5.0 per cent for males) of the total deaths. In
other words, one can say that obesity is responsible for 4.3 per cent of al l deaths
in the age group 30-79 years.
For comparison we mention that lung cancer among mal es and breast cancer
among femal es amount to approxi matel y 4 per cent of al l deaths in the same age
groups.
- 27 -
Opti mum W/HL. I t seems a reasonabl e task to f i t some mathemati cal functi on to
the U-formed curves shown above. We have, however, no theoreti cal basi s f or
the sel ecti on of a proper model. In a paper by Keys (23) a quadrati c functi on has
been used. With the apparent non-symmetry of the observati ons such functi ons
will be biased and will systemati cal l y gi ve mi ni mum val ues of W/H posi ti oned at
hi gher wei ght l evel s than the observati on and i nspecti on of data would i ndi cate.
This is probabl y the reason for the cl ai m that the opti mal wei ght is hi gher than
the average wei ght of Ameri can adul ts (23).
2
There is thus undoubtedl y an opti mal body hei ght as wel l as an opti mal body mass
index. As guide-lines for the popul ati on these findings are, however, too
academi c and of l i ttl e practi cal value. Peopl e would l i ke to know the area f or
thei r personal body-weight, gi ven thei r unchangeabl e body hei ght.
On the basis of Fi gure 15 we have constructed nornogrammes that should be
useful gui des for the individual (Fi gures 21 and 22). In these nomogrammes we
have i ndi cated the posi ti ons for body-weights i ndi cati ng rel ati ve risk of 0.9 - 1.0
- 1.1 - 1.2 and 1.4.
A mal e wi th a body hei ght of 183 cm and a body wei ght of 70 kg has a rel ati ve
excess risk between 0 - 10 per cent.
Si mi l arl y a f emal e wi th a body hei ght of 160 cm and a body wei ght of 85 kg has a
rel ati ve risk (rel ati ve to al l other femal es in her age-group) between 1.1 and 1.2
or an excess mortal i ty risk between 10 and 20 per cent.
I f, however, the mal e i ndi cated is a physically wel l -fi t non-smoker, his ri sk
rel ati ve to all other mal es in his age-group would certai nl y be much less,
probabl y less than 1.0, but mi ght sti l l be 0 - 10 % hi gher than other physically
wel l -fi t non-smokers of his age. And we underl i ne that there is no proof that a
better prognosis would be obtai ned by a del i berate wei ght i ncrease to - say - 80
kg-
For the f emal e menti oned above wei ght reducti on mi ght seem reasonabl e, i.e.
from 85 to 75 kg. However, we don't know whether the observed excess mortal i ty
i s caused only by her over-wei ght, and we cannot assure her that a reduced
wei ght will be accompani ed by a reduced mortal i ty, al though there i s evi dence i n
the l i terature for such an expectati on (9, 29, 34, 35). If she i s physi cal l y under-
trai ned, may be physi cal acti vi ty will i mprove her prognosis. If she i s a smoker,
may be smoke cessati on will i mprove her prognosis even if her wei ght is not
reduced.
- 28 -
Fig. 21 Rel ati ve mortal i ty by weight for given height. Males.
I I I I
I 50 I60 170 I 80 190
BODY HEIGHT (cm)
Fig. 22 Rel ati ve mortal i ty by weight for given height. Femal es.
- 29 -
Table I V
(Deaths: 35 843, under risk: 209 849)
Relative mortality, males 50-64 years
~~~~ ~ ~~
Weight Height (cm)
(kg) 140-149 150-159 160-169 170-179 180-189 190-199
40-49 1.69 2.29 2.34
50-59 1.67 I .47 1.38 1.35 1.80
60-69 1.40 1.11 0.96 0.91
70-79 1.63 1.11 0.91 0.75 0.73
80-89 1.75 1.22 0.95 0.81 0.67
90-99 1.48 1.09 0.93 0.72
100-109 2.01 I .45 1.05 1.25
110-1 19 2.25 1.55 1.23
120-129 1.81 1.36
130-
Table V
(Deaths: 20 01 I , under risk: 229 506)
Relative mortality, females 50-64 years
Weight Height (cm)
(kg) 130-139 140-149 150-159 160-169 170-179 180-189
30-39 4.26
40-49 3.28 1.65 1.51 1.67
50-59 2.29 1.28 1.03 0.89 0.95
60-69 4.13 1.46 I .oo 0.87 0.71
70-79 1.71 1.12 0.87 0.71
80-89 1.95 1.31 1.01 0.85
90-99 2.60 1.58 1.15 0.96
100-109 1.77 1.25 1.18
110-119 2.19 1.48 I .87
120-129 2.31
- 30 -
We will emphasi ze that the nomogrammes should be used wi th cauti on. I t i s
assumed that one's position in the nomogramme is of prognosti c val ue and of
value for action. However, we underline that the nomogrammes do not prescri be
the best acti on to improve prognosis.
3.3 Simultaneous body hei ght and body weight analysis
I nstead of analyzing the associ ati on between mortal i ty and body hei ght and
weight expressed in some form of al gori thm, one can study mortal i ty accordi ng
to weight and hei ght simultaneously. We have, therefore, cal cul ated the total
mortal i ty in correl ati on tabl es of height and weight, and Tabl es IV and V show
these excess mortal i ti es for some sel ected age groups 50-64 years of age,
separatel y for mal es and femal es. The mortal i ty fi gures are given as rel ati ve
fi gures - i.e. in rel ati on to the total mortal i ty for the speci fi c age groups.
The following pattern is evident. Moderate values for wei ght together wi th l arge
body height values give rel ati ve mortal i ty fi gures below the total for the age
group. Graphically thi s can be demonstrated in two ways. Fi rst, for given heights
mortal i ty can be presented as a functi on of weight, and Fi gures 23 and 24
demonstrate cl earl y such U-formed curves stretchi ng out to the ri ght with
increasing body heights. The minima of the curves seem to be shi fted to the ri ght
by increasing body heights. In three dimensions the associ ati on will look like a
valley falling in south east di recti on schemati cal l y given in Figur 25. Secondly,
corresponding to topographic maps, the associ ati on can be demonstrated by a set
of iso-risk curves as given in Fi gures 26 and 27. One such curve is thus defined as
all the points in the correl ati on diagram which have the same mortal i ty risk.
These curves are esti mated by l i near i nterpol ati ons, and we have given separate
curves for 50 per cent excess mortal i ty and 25 per cent reduced mortal i ty.
For mal es one observes that at the height of 150-169 cm one has enhanced
mortal i ty i rrespecti ve of the weight, even having the opti mal wei ght for thi s
height. Fi gure 23 also demonstrates that the man of 50-64 years of age ought to
have a wei ght above 60 kg and under 100 kg, i rrespecti ve of the height, if he
should have a mortal i ty equal to or less than the mortal i ty for the total age
group. The total mortal i ty is of course not i denti cal with the optimal. Lower
than total mortal i ty risks are observed for hei ghts above 185 cm and with
weights between 70 and 90 kg. Corresponding val ues for femal es are shown in
Fi gure 24.
In Fi gures 26 and 27 is added a strai ght line, which marks the "normal" wei ght in
- 31 -
' I MALES AGED 50-64 I I
I 1 I I I I I I
0'4
40- 50- 60- 70- 80- 90- 100- 110- 120.
49 59 69 79 89 99 109 119 129
BODY WEIGHT (kg)
Fig. 23 Rel ati ve mortality by body weight and body height. Males aged 50 to
64 years.
Fig. 24 Relative mortality by body weight and body height. Femal es aged 50
to 64 years.
- 32 -
MORTALITY
I
Fig. 25 Mortality as a function of body height and body weight. Schematical
presentation of the three dimensions.
relation to the height, according to Norwegian standard norms, the socalled
Natvig-tables ( 26) . This curve follows approximately the valley bottom and
represents, as the figure indicates, not only a norm but in f act also the ideal, at
least with regard to mortality.
3.4 Causes of death
Body height. We have demonstrated above a clear association between body
height and total mortality. One would a priori expect the excess risk at low
heights to be due to specific causes. But which causes? Which hypotheses can one
construct on the basis of available knowledge?
In addition to testing possible reasonable hypotheses one might screen the
material for al l causes of mortality and study whether such a method would yield
a pattern of interest. However, we limit this analysis to a few diseases where
one might conceivably construct a reasonable hypothesis.
- 33 -
45
BODY HEIGHT ( cm)
145 155 165 175 185 195 205
1 1 i i i i 1
-
\
b
L
x 65-
75-
2 55-
2
& 85-
0
Q 95-
- r- 1.0
45
\
bl
CI
$ 65-
5 55-
G
s 75-
; 85-
0
Q 95-
I05
115-
Fig. 26 Iso-risk curves according to body height and body weight. Males 50
to 64 years.
-
-
BODY HEIGHT (cm)
135 145 155 165 175 185 195
I 1 1 1 1 1 1
Fig. 27 Iso-risk curves according to body height and body weight. Femal es
50 to 64 years.
- 34 -
The mechanisms behind this association might take at least the following three
paths:
A B C
Disease Living Health
Growth
condition
Genes interaction
Decreased body height
1
I ncreased mortality
Comments:
A.
B.
C.
On
Diseases, for example obstructive lung diseases might lead to shorter body
height via kyfosis and of course also to excess mortality. Other similar
processes are conceivable.
Poverty is often characterized by malnutrition and hence retardation of
body growth. Poverty and poor living conditions also affect health via
several mechanisms resulting in increased incidence of infectious diseases
and possibly of some cardiovascular diseases (14).
J ust as red hair is associated with an excess risk of developing tuberculosis
in an apparantly "meaningless" genetic combination, one cannot exclude that
the genes governing growth and health are linked in a similar way.
this basis we have examined the association between body height and
mortality of obstructive lung diseases and of cardiovascular diseases. We have,
however, also included cancer and accidents in our analyses.
Figure 28 shows for four 5-year age groups the relative mortality of obstructive
lung diseases expressed in per cent. The number of deaths for the two youngest
- 35 -
AGE:
40-44
45 - 49
50- 54
55-59
-.-.-.
- - - - -- --.
- - --
-
P
1
FEMAL ES
I
T
i
L
150 160 170 180
BODY HEIGHT (cm)
Fig. 28 Rel ati ve mortal i ty of obstructi ve lung di seases by sex and age
accordi ng to body height.
- 36 -
160 170 180 190 I50 160 I70 180
BODY HEI GHT (cm)
Fig. 29 Relative mortality of cardiovascular diseases by sex and age
according to body height.
- 37 -
age groups are l i mi ted, but the pattern is very clear. There is a markedly
reduced mortal i ty of these causes with i ncreased body height. Tabl e VI shows the
same for the age groups 50-54 and 55-59 presented in a di fferent way. Here, the
observed i nci dence numbers are compared with the expected numbers if those
dying had had the same hei ght distribution as the enti re age groups. The tabl e
shows a cl ear excess risk of mortal i ty of these di seases for those with low body
height. Those wi th high body hei ghts have reduced mortal i ty from thi s disease.
Forsdahl (14) has demonstrated that cardi ovascul ar mortal i ty in adul ts is
positively associ ated with the living condi ti ons at bi rth expressed as the i nfant
mortal i ty in the municipality of birth. This suggests an associ ati on between
mortal i ty of cardi ovascul ar di seases and body height. Fi gure 29 shows a cl earl y
reduced mortal i ty for those who are tall. For mal es shorter than 160 cm the
mortal i ty of cardi ovascul ar di seases is 50-100 % l arger than the total , and for
mal es 185-189 cm the mortal i ty is only 70-80 per cent of the total mortal i ty of
the age group. There is possibly a decrasi ng advantage for hei ghts above 190 cm,
but the numbers here are very small.
We have also observed a certai n negati ve associ ati on between acci dents and body
height, but the relationship is very weak. For al l cancer cases there is no
association. This convi nces us that the associ ati ons demonstrated above are not
the resul t of stati sti cal artefacts.
2 2
The total mortal i ty in rel ati on to W/H - W/H was for both sexes and al l ages
typically U-formed. This suggests that there must be some typi cal low-weight
di seases and some typi cal high-weight diseases. The l i terature emphasi zes the
i mportance of overweight. Cardi ovascul ar diseases, brain hemorrhage and diabe-
tes are mentioned as i mportant risk di seases for those who are overwei ght (7, 8,
11, 15, 24, 33, 39, 46).
We will i l l ustrate these associ ati ons in two ways. Fi rst, we will show the
di fferent causes of mortal i ty as a functi on of W/HL. Secondly, we will show
fi gures with the average values of W/H2 for individuals who have died of
di fferent causes.
For sorne sel ected causes Fi gures 30 and 31 gi ve the mortal i ty accordi ng to a
given W/H -value. In these fi gures we have sel ected causes that came out of the
anal yses as low-weight diseases, i.e. di seases with higher mortal i ty for l ower
W/H . Among these are 3 groups of lung diseases: lung cancer, tuberculosis and
obstructi ve lung diseases. One other cancer form, stomach cancer, shows a
similar pattern.
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- 39 -
Fig. 30 Mortality of four causes by weight/height2. Males 50 to 64 years.
10
5
2
> I
*
e
0 8 a5
2
L
L,
9 a2
4 01
005
0 02
Ool
I5 17 19 PI 23 25 27 29 31 33 35 37
WEIGHT/HEIGHTe(kg/ me)
Fig. 31 Mortality of four causes by weight/height*. Femal es 50 to 64 years.
- 40 -
On the other hand, we can also sel ect typical high-weight diseases, as shown in
Figures 32 and 33. The following disease groups can be distinguished for both
sexes: cardiovascular diseases, cerebrovascular diseases, and diabetes.
For males colon cancer also shows a gradient of doubling mortality from 18 to 34
in W/H -values. For an average height of 174 cm this range corresponds to a
weight range of 54-103 kg. I t could reasonably be claimed that the excess
mortality of colon cancer for obese men is connected with the surgical
complications, possibly also with a l ate diagnosis. Our material cannot substanti-
ate such hypothesis.
2
The mortality curves for cardiovascular diseases are slightly U-formed with a
minimum at 22-23.9 (average 23) corresponding to a body weight of about 70 kg
for a body height of 174 cm (males). From this level upward the mortality
increases by about 2 per cent for each added kg body weight. For instance at a
minimum level of 70 kg the mortality for the age group 50-64 years for males,
the ten years mortality of cardiovascular diseases is about 0.76 per cent. For the
weight 71 kg the mortality is increased by 2 per cent to 0.774 per cent etc.
.-
MALES 50-64 YEARS
5
2
\ I
s!
u
6 0 5
h
s
a
a2
* 01
005
WEIOHT/HEl GHT' ( kg/m2 1
Fig. 32
Mortality of four causes by weight/height 2 . Males 50 to 64 years.
- 41 -
WEIGHT/HEIGHT* ( k g / m2)
Fig. 33 Mortality of four causes by weight/height*. Femal es 50 to 64 years.
The steepest curve is observed for di abetes. A 3-4 ti mes i ncrease in mortal i ty of
di abetes is seen in the W/H range of 30-34, i.e. a wei ght i ncrease of 90-103 kg
for mal es averagi ng 174 cm in body height. Di abetes is of parti cul ar i nterest.
There are two di fferent kinds of di abetes, one prevailing at young ages and the
other starti ng at increasing age. Fi gures 34-35 show the average W/H -values by
age for al l measured and for those who died of di abetes in the period. The
concept of two di seases comes out in thi s fi gure as the average W/ H -values are
lower than normal at young age and very much higher than normal at higher age.
2
2
2
2
Finally, fi gures 36 and 37 demonstrate marked di fferences in the average W/ H -
values for death of various forms of cancer. Lung cancer is in thi s respect a low-
weight di sease for both sexes. This pi cture is not changed if the deaths during
the fi rst 5 years are excluded.
Al so other cancer forms show i nteresti ng contrasts which will be followed up by
the Cancer Regi stry of Norway.
- 42 -
I
2s
2E
27
\ 2E
4 tn
-s: 25
+
L
X
6 24
X
h 23
X
6
G
g 22
21
20
19
-: TOTAL
I I I I I I I I
MALES
AD I ABE TE
\
k --o
L CANC
2
Fig. 34 Average weightlheight for those who died of various causes by age.
Males.
- 43 -
-: TOTAL
20 30 40 50 60 70 80 90
A GE ( Y E A RS )
2
Fig. 35 Average wei ghtl hei ght for those who died of vari ous causes by age.
Femal es.
- 44 -
MALES
c
LUNG CANCER
: TOTAL
I I I I I 1 I
t
20 30 40 50 60 70 80 90
A GE ( YEA RS)
2
Fig. 36 Average weight/height value for those who died of some selected
cancer forms by age. Males.
- 45 -
31
3c
2s
2E
< b
\ -$ 27
c\r
$
Q 2E
X
X
Q
$ 24
Ci
25
23
22
21
1
z
1
! FEMALES
i
T
x
\ r
d
I
: TOTAL
1 I I I I I
', BR EA ST
\
LUNG CA NCER
20 30 40 50 60 70 80 90
AGE ( Y E AR S )
2
Fig. 37 Average wei ght/hei ght
cancer forms by age. Females.
val ue for those who died of some sel ected
- 46 -
The di seases covered in these Fi gures consti tute about 70 and 60 per cent for
males and femal es, respectively, of al l deaths. If we look at the death risk for
the residual di seases af ter we take away al l those which we have defi ned as high-
or low-weight diseases, we sti l l have an equally marked U-formed mortal i ty
curve. Therefore, also the remaining diseases probably could be divided i nto two
groups. The number of deaths in each group becomes, however, so smal l that a
closer analysis is difficult. The conclusion is that there is a general reducti on of
heal th at both tai l s of the W/H -distribution and that individuals in these tai l s
are hi t by typi cal di seases accordi ng to a systemati c pattern.
2
4 Discussion
We have observed cl ear associ ati ons between mortal i ty and body build. For the
body height the associ ati on is by and l arge uni l ateral with falling mortal i ty by
increasing height. For the body mass index (W/H the associ ati on is U-shaped
for al l ages and both sexes.
2
Body height. The measurements on body hei ght avai l abl e to us were easily
accessible with modern technology, and our anal yses are based on a cheap
expl oi tati on of exi sti ng materi al . The associ ati ons are cl ear and of a si gni fi cant
magnitude, and the resul ts support the few previous observati ons ( 5, 30). A
di fference of 30 cm means a risk rati o of 2:l. The di fference exi sts for al l age-
groups, not only the ol dest cohorts subj ected to poverty in the past. I t is rather
di ffi cul t to accept that Norwegians 20-30 years old to-day have been subj ected
to poverty to an extent that mal nutri ti on has given them reduced body growth.
Maybe a slight excepti on from thi s can be made for age-groups that grew up
during the war. The nutri ti on during the war which has a good reputati on among
cardi ovascul ar experts, mostly because of the shortage of fat and sugar (41),
might have resul ted in growth and heal th reducti ons in the long run. I t is very
cl earl y shown by Brundtland et al. (6) that the generati on which had its growth
phase during the war, is shorter than thei r nabouring cohorts. The associ ati on
between nutrition, poverty and body hei ght has al so been observed by van
Wieringen (42) and VillermC (43). The three al ternati ve mechani sms menti oned
above might therefore gi ve the major expl anati ons of these associations.
No consequences follow for individual behaviour from these observations. The
body height is there, nothing can be done about it. However, the resul ts gi ve
hints for further research and for a real i zati on that the social standard of living
- 47 -
condi ti ons have long term consequences for heal th. I t means that there is room
for great i mprovements in the heal th of the peopl e, as the new cohorts whi ch
have grown up under opti mal nutri ti onal condi ti ons will have better heal th in the
future. This means that many more should be abl e to achi eve the low mortal i ty
fi gures which we have demonstrated for mal es who are 185-189 cm and f or
f emal es who are 170-174 cm. We have shown that these body hei ghts corrrespond
to a total mortal i ty of about 80-85 per cent of the total mortal i ty of the
parti cul ar age group today. A reducti on of the mortal i ty of 15 per cent
corresponds to an i ncrease in the average durati on of l i fe of three years (45).
When i t comes to the causes of death, i t i s rel ati vel y cl ear that the rates for
tubercul osi s, obstructi ve lung di seases and cardi ovascul ar di seases are negati vel y
correl ated wi th the body height. For al l cancer there i s no correl ati on. Forsdahl
has shown, as menti oned above, an associ ati on between cardi ovascul ar mortal i ty
and i nfant mortal i ty in some communi ti es (14). Our observati ons confi rm his
findings.
- W/H2. The i nterpretati on of the associ ati on between W/H2 and mortal i ty i s
di fferent. Thi s concerns the over- and underwei ght among adul ts and the
consequences for the heal th.
We have found very cl ear U-formed curves. These curves are characteri zed by a
very extensi ve f l at bottom, i ndi cati ng a l arge area for mi ni mal mortal i ty where
the exact opti mum is determi ned wi th l i ttl e precision. Thi s can al so be
i nterpreted as a l arge tol erance for wei ght vari ati ons. This i s parti cul arl y so i n
the overwei ght di recti on and for women. For underwei ght the i ncreasi ng
mortal i ty curve i s more dramati c and is cl oser to the mi ni mal mortal i ty point.
The loss of 20-30 kg body wei ght from the average probably affects vi tal body
functi ons, whereas a correspondi ng addi ti on of 20-30 kg above the opti mum only
represents an outsi de fat l ayer wi th rel ati vel y modest effect on heal th. I t seems
also cl ear that middle aged women have a parti cul arl y l arge tol erance for
overwei ght. I t is, of course, possible that di seases wi th l ow fatal i ty prevai l
among the overwei ght. This must be a part of the i nterpretati on of the
observati ons, si nce we are l i mi ti ng our consi derati ons to mortal i ty alone.
Overwei ght does gi ve excess mortal i ty and there i s undoubtedly an opti mal W/HL
rati o and we have suggested practi cal gui del i nes in terms of nomo-grammes.
However, i t i s i mportant to real i ze that our materi al does not say anythi ng about
the reversi bi l i ty, i.e. about the ef f ect of acti vel y reduci ng the rati o by a wei ght
reduction. We don't know whether such a reducti on will normal i ze or even reduce
- 48 -
the mortal i ty allthough i t is reasonabl e to expect (9). One can certai nl y think of
methods for reduci ng the wei ght that gi ve i ncreased mortal i ty. And one cannot
be sure of the exi stence of methods which are abl e to normal i ze the mortal i ty at
all. However, we know for i nstance that the reducti on of overwei ght among
hypertensi ve pati ents has the potenti al of reduci ng the blood pressure (29, 35,
34), and i t is highly likely that thi s will reduce the mortal i ty, but to what extent
i t becomes normal is not known. I t is reasonabl e to state that si mi l ar consi dera-
ti ons are valid for di abetes (29) as wel l and that i n general , the reducti on of
overwei ght will i mprove the physiology and metabol i sm, thereby l oweri ng the
mortal i ty.
Even if the pronounced stati sti cal associ ati on between heal th (in term of
mortal i ty) and rel ati ve wei ght (W/H must be accepted as a fact, there i s no
general agreement on the causal i ty. The detri mental effect on the heal th could
be due to ei ther the non-optimal nutri ti onal composi ti on which al so has l ed to a
concei vabl y rather innocuous overwei ght, or to reduced physi cal exerci se which
itself was promoted by the overwei ght. If so, the assumed heal th i mprovements
caused by e.g. physical acti vi ty (in a sl i mmi ng programme) i s better control l ed
and moni tored via physi cal fi tness, lowering of blood pressure and serum
chol esterol level, than via wei ght reducti on per se.
2
What will be the total gai n if everybody would achi eve the opti mum W/H2? One
mi ght specul ate around the questi on of the ef f ect on the total mortal i ty if
extreme risk val ues were el i mi nated. The fi gures have shown roughly that at
opti mal level of W/H the total mortal i ty is about 85 per cent of the total
mortal i ty. A total reducti on of 15 per cent is therefore the maxi mum yield
attai nabl e correspondi ng to 3 years of added l i fe expectancy. Thi s happens to be
the same as can be gai ned from the opti mal i zati on of the body height. Whether
these effects are addi ti ve remai ns to be answered.
2
2
Such specul ati ons about normal i zati on of W/H etc. are, one must admi t, rather
i uti l e in practi ce because we are not born al i ke wi th respect to heal th, and the
heal th servi ces can only partl y compensate for these di fferences. But it i ndi cates
the potenti al s for a future wi th opti mal living condi ti ons and proper preventi ve
heal th servi ces bei ng appl i ed to all the cohorts.
The nomogrammes give val ues of rel ati ve excess mortal i ty for vari ous devi ati ons
from the opti mal weight. How are such rates to be concei ved and understood?
How frei ghtni ng is a - say - 20 per cent excess mortal i ty?
A femal e aged 35 is in Norway today faced wi th an annual risk of death of 7 per
- 49 -
10 000. Such a low risk is ri ghtl y taken to be too low to occupy the attenti on. A
20 per cent i ncrease would mean an i ncrease to 8.4 per 10 000. Very few will
react di fferentl y to these very low risks. Such consi derati ons should be kept i n
mind in the i nterpretati on of the nomogrammes.
Some will cl ai m that U-formed risk curves are i denti cal wi th i nhomogenei ty.
There must in one way or another be a di fference in causes of death at the l ower
and upper tail. We have shown that there are typi cal high-weight di seases as
cardi ovascul ar di seases, cerebrovascul ar di seases, di abetes and breast cancer and
al so typi cal l y low-weight di seases as tubercul osi s, obstructi ve lung di seases and
some cancer forms. But even the rest of the mortal i ty, compri si ng 30 per cent of
the deaths, i s U-formed. I t seems as if one can look i n vai n f or di seases whi ch
i ncreases mortal i ty but does not depend upon the W/H rati o.
2
I t is well known (18, 38) that overwei ght and hypertensi on are positively
correl ated and i t i s cl ai med or i ndi cated (16, 24, 28) that the associ ai on between
W/H and cardi ovascul ar and cerebrovascul ar di seases as found in thi s report i s
only ef f ected vi a hypertensi on and that obesi ty i s dangerous to the pati ent
mainly because of the hypertensi on that i t produces. We have no addi ti onal
cl i ni cal data and can therefore not confi rm this. The associ ati on remai ns,
however, whether it can be expl ai ned or not.
2
I t should be added that there are well-designed studi es where the associ ati on
between overwei ght and cardi ovascul ar di seases is not very cl ear (21).
The si mul taneous anal ysi s for hei ght and wei ght gi ves a total overvi ew of the
mortal i ty as a functi on of hei ght and weight. I t mi ght be possible to descri be the
associ ati on wi th a mathemati cal formul a. But i t is di ffi cul t to formul ate a
meani ngful mathemati cal model. There i s a pri ori no reason for symmetry i n
these functi ons, whereas there is an a pri ori reason for an evenness in the curves.
This is, however, not a suffi ci ent basi s for the appl i cati on of a mathemati cal
formul a. One can certai nl y fi nd a mathemati cal formul a wi th a good fi t, but one
cannot guarantee an unbiased esti mati on of the mi ni mum poi nts which i s
parti cul arl y i mportant. We have, therefore, only carri ed out an i nterpol ati on
wi thout mathemati cs. The iso-curves seem to i ndi cate the opti mal position,
determi ned threedi mensi onal l y as a "river bed" in the valley. We can also
concl ude that the opti mal wei ght by hei ght i s undistinguishable from the norm
which have been appl i ed in Norway and other Nordic countri es for the l ast 30
years.
- 50 -
Conclusions
1.
2.
3.
4.
5.
6 .
7.
8.
9.
10.
There is a strong negati ve associ ati on between body hei ght and mortal i ty.
2
There is a marked U-shaped associ ati on between body mass i ndex (W/H ) and
mortal i ty.
This associ ati on persi sts unchanged also after the fi ve fi rst years of observati on.
The U-shape of the risk curve for the body mass i ndex (W/H2) i s asymmetri c wi th
the steepest sl ope at the low values.
The minimum poi nt of the U-shaped curves are very unpreci sel y determi ned, a
fact which i ndi cates consi derabl e tol erance to overwei ght parti cul arl y for
2
women. The mi ni mum will be found i n the area of 21 - 25 kg/m .
The low hei ght excess mortal i ty is parti cul arl y cl ear for the fol l owi ng causes of
death: obstructi ve lung di seases, tubercul osi s and stomach and lung cancer.
The mortal i ty associ ated wi th the body mass i ndex is characteri zed by typi cal
low-weight causes (tubercul osi s, lung cancer, obstructi ve lung di seases and
stomach cancer) and typi cal heigh-weight causes (cerebrovascul ar di seases,
cardi ovascul ar di seases, di abetes and col on cancer).
The negati ve associ ati on between body hei ght and mortal i ty may to a l arge
extent be the resul t of a past soci o-economi c hi story and thus a poi nt of i nterest
for the heal th policy as wel l as general economi c policy.
If everybody obtai ned the low mortal i ty of those at the tal l er end of the body
hei ght di stri buti on, the total mortal i ty would be reduced by 15 per cent.
2
I f every body obtai ned the low mortal i ty at the opti mal W/H -l evel the total
mortal i ty would be reduced by an addi ti onal 15 per cent.
The U-shaped associ ati on between rel ati ve body mass index and mortal i ty is a
point of i nterest for heal th educati on, parti cul ary on nutri ti on and physi cal
acti vi ty. However, the wi de range for possible opti mum and the l ack of evi dence
for an effi ci ent reversi bl e mechani sm should l ead to a modest vi ew on moderate
overwei ght.
- 5 1 -
11. The observati on of consi derabl e tol erance towards overwei ght does not mean
that overwei ght persons will not benefi t from nutri ti onal regul ati on and physi cal
fi tness acti vi ti es.
12. As the report i s l i mi ted to mortal i ty, no conclusion can be drawn di rectl y as to
associ ati ons wi th well-being or non-fatal diseases.
- 52 -
Appendix table
Codes according to International Statistical Classification, 7th and 8th revision
for causes of death referred to in this report.
Cause of death
Codes
7th revision 8th revision
- 1968 1969 -
Tuberculosis
Stomach cancer
Colon cancer
Lung cancer
Breast cancer
Cancer corpus uteri
Diabetes
Cerebrovascular diseases
Cardiovascular diseases
Obstructive lung diseases
001-019
151
153
162-163
170
172
260.0
330-334
41 0-468,
782.4, 795.2
241, 470-527
010-019
151
153
162
174
182.0
250
430-438
390-458,
782.4, 795
460-519
- 53 -
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