Exploring the association between BMI and mortality in Australian women and men with and without diabetes: the AusDiab study

AIMS/HYPOTHESIS: There is conflicting evidence about the obesity paradox—the counterintuitive survival advantage of obesity among certain subpopulations of individuals with chronic conditions. It is believed that results supporting the obesity paradox are due to methodological flaws, such as collider bias. The aim of this study was to examine the association between obesity and mortality in Australian men and women. In addition, we explored whether obesity would appear to be protective if the analysis was restricted to a subpopulation with disease, and to discuss the potential role of collider bias in producing such a result. METHODS: The examined cohort included 10,575 Australian adults (4844 men and 5731 women) aged 25–91 years who were recruited for the AusDiab baseline survey in 1999 and followed-up through 2014. The main predictor variable was BMI categorised as normal weight (18.5 to <25 kg/m(2)), overweight (25 to <30 kg/m(2)) and obese (≥30 kg/m(2)), and the outcome of interest was all-cause mortality. Hazard ratios were estimated from Cox proportional hazards regression models in the entire cohort and then in subpopulations with and without diabetes. RESULTS: A total of 1477 deaths occurred during 145,384 person-years (median 14.6 years) of follow-up. Mortality was higher in obese than in normal-weight individuals for the full population (HR 1.18; 95% CI 1.05, 1.32). When an interaction between diabetes status and BMI category was added to the model, there was no evidence of an interaction between BMI and diabetes status (p = 0.92). When participants with and without diabetes were analysed separately, there was no evidence of an association between obesity and mortality in those with diabetes (HR 0.91; 95% CI 0.62, 1.33). CONCLUSIONS/INTERPRETATION: In the entire AusDiab cohort, we found a significantly higher mortality among obese participants as compared with their normal-weight counterparts. We found no difference in the obesity–mortality association between individuals with and without diabetes. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s00125-019-4830-4) contains peer-reviewed but unedited supplementary material, which is available to authorised users.