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BARONE, BETHANY B., JEANNE M. CLARK, NAEYUH WANG, LUCY A. MEONI, MICHAEL J. KLAG,
AND FREDERICK L. BRANCATI. Lifetime weight
patterns in a cohort of male physicians: an analysis of cohort
effects and selective survival in the Johns Hopkins
Precursors Study. Obesity. 2006;14:902908.
Objective: The natural history of lifetime weight change is
not well understood because of conflicting evidence from
cross-sectional and longitudinal studies. Cross-sectional
analyses find that adult weight is highest at 60 years of
age and lower thereafter. Longitudinal analyses have not
found this pattern. Our objective was to test whether cohort
effects and selective survival may explain the differences
observed between cross-sectional and longitudinal studies.
Research Methods and Procedures: We analyzed data on
white men from the Johns Hopkins Precursors Study (n
1197). Weight and height were measured at enrollment
during medical school. The Precursors Study collected subsequent weight measurements by self-report and follows all
participants for mortality.
Results: In preliminary analyses that ignored cohort and
survival effects, average weight increased 0.16 kg/yr to age
65 (p 0.001) and declined 0.10 kg/yr thereafter (p
0.002). When controlling for differing rates of weight
change by cohort and survival group, the apparent decline
after 65 years of age was mostly explained.
Discussion: These data suggest that, in white men, weight
increases steadily until age 65 and then plateaus. These
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Introduction
Obesity is one of the most significant public health problems facing the United States today (13). High BMI is
associated with greater risk of cardiovascular diseases (2),
type 2 diabetes (4), cancer (5), and all-cause mortality (6,7).
Although reducing obesity was a major goal of Healthy
People 2000 (information regarding Healthy People 2000
is available at http://www.cdc.gov/nchs/about/otheract/
hp2000/hp2k.htm), the prevalence of obesity increased in
every state during the 1990s (3). By 2000, the prevalence of
overweight (BMI 25 kg/m2) in the United States had
reached 64%, and the prevalence of obesity (BMI 30
kg/m2) had reached a staggering 30% (8). Understanding
the natural history of obesity is important for developing
effective treatment and prevention programs.
Cross-sectional evidence from the National Health and
Nutritional Examination Survey (NHANES)1 as well as
other studies has suggested that the natural pattern of weight
change is an increase in weight until the seventh decade of
life followed by a decline in weight thereafter (9 11). This
pattern was also observed when NHANES repeated weight
measurements 10 years after the first weight measurement
(12). However, several longitudinal studies of weight patterns have found sustained weight gain past the seventh
decade of life as opposed to a decline (13,14). We hypothesized that the inverted U trajectory in body weight observed in cross-sectional analyses is not the true lifetime
pattern of weight change but rather the result of several
epidemiological effects. First, increases in the prevalence of
obesity over the past few decades may be creating a birth
1
Nonstandard abbreviation: NHANES, National Health and Nutritional Examination Survey.
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903
Table 1. Selected characteristics of white men in the full study population and by birth cohort in the Johns
Hopkins Precursors Study, Baltimore, MD, 1948 to 2002
Cohort
N
Median birth year*
Mean baseline age (years)*
Mean baseline BMI (kg/m2)
Median number of weight observations
Cumulative mortality by December 2002 (%)*
Overall
1902 to 1927
1928 to 1933
1934 to 1941
1136
1930
23.1 (2.6)
23.1 (2.6)
16 (6)
19
431
1925
24.7 (3.3)
23.2 (2.7)
16 (7)
34
363
1930
22.3 (1.4)
23.1 (2.5)
16 (6)
15
342
1936
21.9 (1.0)
23.1 (2.5)
15 (6)
6
* Characteristic differed significantly (p 0.05) when compared across cohorts using ANOVA.
Values are means (standard deviation).
Results
Selected characteristics of the study population are reported for all participants and by cohort (Table 1). At
enrollment, the mean age was 23 years, and the average
BMI was 23 kg/m2. By December of 2002, approximately
one fifth of the cohort was reported to have died. Median
birth year, age at enrollment, and mortality differed significantly across birth cohorts. There was no statistical difference in number of follow-up observations by cohort. Baseline BMI did not differ significantly by the number of
follow-up observations. Average length of follow-up was
42 11 (standard deviation) years.
Cross-sectional plots of BMI by age in 3 different calendar years showed that average BMI increased and then
decreased as age increased (Figure 1). The average BMI of
the study population at a given age was generally greater in
later calendar years.
In Model 1 (Table 2), we observed the expected result of
a yearly increase in average weight (0.16 kg/yr, p 0.001)
before the spline at age 65 and a yearly decrease in average
weight (0.10 kg/yr, p 0.002) thereafter. This analysis, in
which cohort and survival effects are not considered, shows
a basic longitudinal weight trajectory, the inverted U.
904
Coefficient*
95% confidence
interval
Up to age 65
After age 65
0.16 kg/yr
0.10 kg/yr
0.15,0.18
0.16,0.04
* Age is centered at the median baseline age (22 years), and all
coefficients are adjusted for other covariates in the table and
height2.
p 0.001.
p 0.01.
Discussion
The results observed in the final and best model (Model
3) showed that, contrary to the impression created by crosssectional studies such as NHANES III (9 11), body weight
Table 3. Model 2: rate of weight change by age and weight differences by cohort and survival status in the Johns
Hopkins Precursors Study
Covariate
Age
Up to age 65
After age 65
Birth cohort
1 (1902 to 1927)
2 (1928 to 1933)
3 (1934 to 1941)
Survival status
Alive on December 31, 2002
Deceased before December 31, 2002
* Age
p
p
p
Coefficient*
95% confidence
interval
0.16 kg/yr
0.10 kg/yr
0.15, 0.18
0.16, 0.04
Reference
0.05 kg
0.71 kg
1.19, 1.29
0.65, 2.07
Reference
1.78 kg
0.24, 3.32
is centered at the median baseline age (22 years), and all coefficients are adjusted for other covariates in the table and height2.
0.001.
0.01.
0.05.
905
Table 4. Model 3: rate of weight change by age, weight differences by cohort and survival status, and
age-by-cohort and age-by-survival status interaction terms in the Johns Hopkins Precursors Study
Covariate*
Age
Up to age 65
Age 65 and after
Birth cohort
1 (1902 to 1927)
2 (1928 to 1933)
3 (1934 to 1941)
Survival status
Alive in 2002
Deceased before end of 2002
Age-by-cohort
Up to age 65cohort 1
Up to age 65cohort 2
Up to age 65cohort 3
Age 65 and aftercohort 1
Age 65 and aftercohort 2
Age 65 and aftercohort 3
Age-by-survival status
Up to age 65alive
Up to age 65deceased
Age 65 and afteralive
Age 65 and afterdeceased
Coefficient*
0.14 kg/yr
0.06 kg/yr
0.12, 0.17
0.14, 0.02
Reference
0.01 kg
0.42 kg
1.17, 1.19
1.67, 0.83
Reference
1.36 kg
0.02, 2.74
Reference
0.00 kg/yr
0.05 kg/yr
Reference
0.11 kg/yr
0.39 kg/yr
Reference
0.02 kg/yr
Reference
0.36 kg/yr
0.04, 0.03
0.01, 0.09
0.04, 0.23
0.16, 0.94
0.03, 0.07
0.53, 0.18
* Age is centered at the median baseline age (22 years), and all coefficients are adjusted for other covariates in the table and height2.
p 0.001.
p 0.05.
group and average weight going down as a result. Diseaserelated weight loss may also contribute to this effect. Our
analysis showed the complex nature of the cohort and
survival effects in that they need to be evaluated longitudinally, rather than the cross-sectionally, to truly understand
lifetime weight patterns. Furthermore, we must adjust for
cohort and survival effects as interaction terms with aging
(age-by-cohort, age-by-survival status) and not just simple,
main effect covariates (age, cohort, survival status). Only
when using these interaction terms, as in Model 3, do we see
significant effects by both cohort and survival status, as well
as the attenuation of the weight loss effect after age 65.
The greatest strength of our analysis was the prospective
design of the Johns Hopkins Precursors Study, which has
collected information on weight and has followed all participants for mortality for more than 50 years. This rare
collection of longitudinal data is ideal for analyses of body
weight patterns over time because it allows for the assessment of selective mortality and limits variability by the use
Acknowledgments
This work was supported by NIH Grants AG01760 and
DK02856. F.B. was supported by National Institute of Diabetes & Digestive & Kidney Diseases Grant K24
DK62222-01. The authors thank Drs. Brad Astor, Greta
Bunin, and Lawrence Cheskin for helpful suggestions on
earlier versions of the manuscript.
References
1. Visscher TLS, Seidell JC. The public health impact of obesity. Annu Rev Public Health. 2001;22:35575.
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