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Acta Medica Scandinavica

Supplementurn 679

Height. Weight and MortalityTh e Norwegian Experience

Un it for H ealth Services Research, National Institute of Public H ealth, OsloandNational Mass Radiography Service, Oslo

Hans Th. Waaler

Distributcd bv The Almqvist & Wiksell Periodical Company, Stockholm, Sweden

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Preface

What is overweight? How important is i t? Is i t a c o s m e t i c p r o b l e m or a h e a l t h

problem? What is the op t imal weigh t?

The ex i s tence of a l a rg e f i l e of body he igh t and weigh t m easurem ents ava i lab lea t t h e

Nat ional Mass Radiography Ser v ice p rompte d us to u n d e r t a k e t h i s s t u d y of t h e

m o r t a l i t y as a func t ion of body bui ld . Such s tud ies have been ca r r i ed o u t be fore , bu t

not in Norway and not at t h i s s c al e . T h e s t u d y r e p r e s e n ts t h e l a rg e s t m a t e r i a l e v e r

published 1.8 million persons and 18 mil l ion observa t ion years ) f rom oneof t h esmal les t cou nt r ies (Norway has4.1 million inh abitants).

L a rg e f i l e s w e r e c o m b i n ed , c h e c k e d f o r c o n si st e nc y, a n d m a t c h e d w i th t h e c e n t r a lf i les of deaths . Everybody who has ev er under taken such task s will app rec iat e t h e

profess iona l da ta and compute r hand l ing requ i red and the sk i l l and e ff i c iency wi th

which th i s has been ca r r i ed ou t by Har tv ig Opsj@n f rom the Nat ion a l Ins t i t u teof

Publ ic Hea l th and Erns t Risan f rom t he Nat iona lMass Radiography Service .

A special thank is given t o De Norske Livsforsikringsselskapers Foren ing fo r the i r

generous f inancial contr ibut ion.

Final ly I wil l thank Randi Hage le r and Helene Karud fo r t he typ ing of th e manuscr ip t.

Oslo, u n e 30 1983

Han s Th. Waaler

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1 Introduction

Background and basic quest ions . The exis tenceof an associat ion between body-bui ld and heal th is wel l documented 5 , 7 , 1 1 17, 19, 20, 23, 25 33, 36, 37, 39,

47, 48). In a ff luen t communi t i es th e overweigh t p rob lem i s g iven spec ia l

a t t en t ion . The genera l conc lus ion i s unques t ionab le : overweigh t i s common and

presen ts a s izeable problem for the individual as well as fo r t he communi ty. In

sp i te of an ex tens ive l i t e r a tu re on th e sub jec t , cons iderab le uncer ta in t i es remain

as t o t h e e x a c t d e fi ni ti o nof overweigh t . At wha t l eve l is th i s l abe l reasonab le?A much more ex ac t es t imat ion of t he r i sk func t ionis requ i red as bas i s fo r

individual recom menda t ions .

Our in te res t in th i s p rob lem s ta r ted w i th hea l th educa t ion . H ere overweigh tis

presen ted as a major ri sk fa c to r fo r hea l th . However, th e sc ien t i f i c bas i s fo r th i s

wel l -meaning educ at ion is not precise: When does overweig ht cha nge froma

cosmet ic p rob lem in to a hea l th p rob lem? This i s the ques t ion th a t s t a r t ed th i s

invest igat ion.

Less a t t en t ion has been g iven to the problem of underweight and heal th , and

repor t s a re par t ly conf l i c t ing 27, 36, 37). The ex ten t o f th i s p rob lem in th e

aff luen t count r ies i s p robab ly much less. H ence very l a rge ma te r i a l sare needed

fo r such s tudies .

Observa t ions of excess hea l th r i sks fo r under- as well as fo r overweigh t

individuals lead to th e quest ion of t h e opt imu m body-build. Tables on normal

weig th by he igh t a re ava i lab le( I , 25, 361, and some of thes e p re tend to b e h e a l t h

op t imal , fo r examp le wi th regard to morta l i ty. Oth ers a re named normal , bu t

prese nt only aver ages and a r e useful onlyas gene ral rules , not necessar i ly ideals.

In the resul t ing ocean of uncer ta in ti es , myths and vogues a r e f ree ly deve lop ing,giving u s popular ideals f rom Rubens ' fem ale s to Twiggy-types. Such var ia t ions

ar e typical ly most ly seen for females , probably ref lect ing t h e highly var iable and

easi ly f lexible phantasies of th e m ale gender. The popula r v iews on the idea l

body-build of a man seem t o b e much mo re cons tan t over t im e and space .

Epidemiolog ica l research a imsat es tab l i sh ing more ob jec t ive ly th e bes t we igh tfor a given height . Long-term observat ion s of unbiased and unselected mate r ia l

a r e necessary, but not enough. The word best must b e qual i f ied. Best for what?

Mortal i ty and morbidi ty a re tw o possible var iablesto be min imized . Genera l

wellbeing is a th i rd possibi li ty ( to be maximized) , but not nece ssar i ly proport ion

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a1 to t h e t w o f o r m e r v a r ia b l es . G e n e r a l w e l lb e in g m i g h t b e t h e m o s t i m p o r t a n t

of these , bu t ve ry d i ff i cu l t to me asure and the re for e ra the r use less. Ath le t i c

per fo rmance i s a four th possibi l i ty (44) but presents other problems. For

ins tance , a j ave l in th rower and a m a r a t h o n r u n n er d o n o t h a v e t h esame o p t i m a lbody-build. A f i f th va r iab le i s conce ived beau ty- impo r tan t , bu t h igh ly sub jec t i -ve and impossible t o measure .

Even the mo rta l i ty index is not unambiguous. O pt im al body-build mig ht di ff er

f rom a comm uni ty wi th tubercu los i sto a comm uni ty wi thou t th i s d i sease .

T h e s e a r e c o n s i d e r a ti o n s t o k e e p i n m i nd d u r i n g t h e r e a d in gof th is repor t , whichis based upon m orta li ty alone. W e h a v e s t u d i e d b o t h t h e t o t a l m o r t a l i t y a n d t h e

m o s t i m p o r t a n t c a u s e s of d e a t h i n o r d e r t o e l u c i d a t e t h e g e n e r a l a s s o c i a t i o n

be tween body bu ild pa ram ete r s and mor ta l i ty.

This repor t wi l l thus lead to c o n s i d e r a t i o n s a b o u t o p t i m a l w e i g h t f o ra given

he igh t and an ana lys i s o f mo r ta l i ty pa t t e r n a long th e body-bu ild sca le . The

es tab l i shment o f op t imal we igh t s fo r g iven he igh t s migh t be in te rp re tedas idea l s

to c r a v e fo r. H o w e v e r, e f f e c t s of a n y in d iv id u al a t t e m p tto a p p r o a c h t h e s e

n o r m a l s a r e not s tud ied , and normal iza t ion o f mor ta l i ty by normal iza t ion of t he

body weigh t can the re fo re no t be t aken fo r g ran ted .

Index es fo r body-build. Th e body-build is an express ion which combines body

weigh t and he igh t . Out o f th e un iverse o f possib le math ema t ica l func t ions we

have selected the body mass index: W/H, l so ca l led t he Q ue te le t ' s index 2, 4,22, 32) This index has proved i t ' s value in sev era l repo r ts , i s widely used an d easy

to ca lcu la te . Our mate r ia l m igh t l a t e r be used to cons t ruc t t he index wi th

maximum d i sc r imina to ry power b e twee n th e dead and th e surv ivors .

2

Body height. The body-build, as given by t h e Quetele t ' s index, i sa r e f l e c t i o n of

gene t i cs p lus th e indiv idua ls ' accumula ted energy ba lance . The body he igh t a lone

ref le cts g en et ics plus th e resul t of l iv ing condi t ions dur ing the grow th phase, i .e.

b e f o r e t h e a g e of 20, minus th e he igh t r educ t ionas a normal ag ing phenomenon ,

in some cases a l so a pa tho log ica l p rocess . The m arked inc reas e in t h e body

height of mil i t a ry rec ru i t s in Norway dur ing the l a s t cen tu ry (40) i s in te rp re tedto re f l ec t improv ements in the genera l nu t r it iona l s t a t us of th e popu la t ion .W e

h a ve t h e r e f o r e m a d e a s e p a r a t e a n a l y si s o f t h e m o r t a l i t yas a func t ion o f the

body he ight a lone.

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Table I Number o f ind ividua l s measured under dev ia t ing c i rcumsta nces

N P e r c e n t a g e P e r c e n t a g e

of a l l m e a s u r e dWith shoes

Invalids

Pregnan t

64 981 83.0 3.6

7 549 9.6 0.4

5 761 7.4 0.3

Tota l 78 291 100 4.4

Table I1 Num ber of individuals ordinar i ly measured, hereof d ead in th e

observat ion per iod

Measured Dead

Males Fem ales To ta l Males Fem ales To ta l

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 79 299 151 915

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 914 255 9

3 210 16 92 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~~

To t a l 815 884 901 631 717 515 102 911 73 663 176 574

ind iv idua l s f rom o ther coun t ies migh t a l so have been measured severa l t imes .

The repor t i s sys temat ica l ly based on th e o ldes tof s e v e r a l m e a s u r e m e n t s .

Some persons were measured under dev ia t ing c i rcumstances : Some re fused . to

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t a k e off thei r shoes , some were inva lids, som e c la imed to b e p r e g n a n t etc. T h e s ea l t o g e t h e r 78 291 individuals a r e dis t r ibu tedto t h e v a ri o u s c a u s e s in p e r c e n t a g e s

in Tab le I and w ere exc luded f rom th e ana lyses in th i s r epor t . The f ina l f i l e o f

indiv idua ls wi th acc ep ted measure men tsof h e i g h t a n d w e i g h t a n d w i t h a c c e p t e dp e r s o n a l n u m b e r s y s t e m c o n t a i n c l o s eto 1.8 million individuals.

Tab le I1 g i v e s s e x a n d a g e d i s t r i b u t i o n of t h e p o p u l a t i o n t h a t w a s o r d i n a r i l y

measured . The t ab le also g i v e s t h e n u m b e r of dea ths in the obse rva t ion pe r iod ,

i .e. the years 1963-1979 inclusive.

'10 2 0 30 40 50 6 7 90AGE ( Y E A R S )

Fig. 1 T h e s t u d y p o p u l a t i o n i n p e r c e n t a g eof t h e t o t a l p o p u l a t i o n 1970(Oslo nd Buskerud c oun t ies excluded) .

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T h e a t t e n d a n c e at th e compulsory mass examina t ion , inc lud ing th e he igh t /weigh tmeasurements , was about 85 per cen t . F igure 1 s h o w s t h e a t t e n d a n c e r a t e

accord ing to age , demons t ra t ing a re la t ive ly l a rge non-a t t endance among the

youngest and par t icular ly am ong th e oldest persons. Non-a t tendance was m ainlydue to acceptable excuses at t h e t i m e of examinat ion:

-

- In mil i tary service- In hospital

Al ready under con t ro l o r t r ea t me nt fo r tubercu losi s

Only a negligible number of individuals refused to a t t e n d t h e e x a m i n a t i o n

al together.

The analysis is thus based on 1 717 515 individuals of which 176 574 died during

th e per iod 1963-1979. Table 111 shows a to ta l observa t ion t ime c lose to 17 million

person-years, i.e. almost 10 of year s observat ion per person.

Table I11 Years of observat ion by age and sex

Tota l 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

85-8990

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 2201 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

4.46.0

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?

To t a l 7 886 035 9 048 474

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The measurements. T h e b o dy w e i g h t s w e r e m e a s u r e d o n s c a l e s t h a t w e r e

regu la r ly ca l ib ra ted . The obse rva t ionswere noted to t h e nearest d e c i m a l . T h epersons were asked to undress the upper body beca useof th e X-ray ex amina t ion ,

a n d t h e y w e r e a s k e d to take off the i r sho es because o f t h e we igh t and he igh tmeasurem ents . Only 3 .6 pe r ce n t w ere ac tua l ly measu red wi th shoes (Tab le11,

and these individuals are exc luded f rom th e ana lys is . The body he igh t w as

measured by s tandard measures , and th e obse rva t ions were no tedto t h e n e a r e st

c e n t i m e t e r. T h e s t a f f w a s i n s t ru c t e d in a d v a n c e o n t h e p r o p e r p o s i ti o nof t h e

head and body at t h e m e a s u r e m e n t s . T h e o b s e r v a t i o n s w e r e d i c t a t e dto ana s s i st a n t . E x t r e m e o b s e rv a t i o n s, t h a t m i g h t b e d u e t o w r i ti n g o r p u nc h in g e r r o r s ,

w e r e c h e c k e d w i t h l a t e r m e a s u r e m e n t s a n d w i th t h e X- ra y p i c t u r e i t s e lf . B u t

very fe w individuals w er e excluded on th is basis.

Dea ths and causes o f dea th . Thanksto th e e leven-d ig i t iden t i f i ca t ion numb er,

t h e m a t c h in g b e t w e e n o u r f i l e an d t h e d e a t h r e g i s te r in t h e C e n t r a l B u r e a u o f

S t a t i s t i c s p r o d uc e d n o p r ob le m s. B e f o r e t h e f i n a l m a t c h e d f i l e w a s m a d e

ava i l ab le fo r ana lys i s , the ind iv idua l numbers were de le ted f rom the t ape in

order to exc lude iden t i f i ca t ion poss ib i l i t i e s in accordance wi th the l ega l r egu-

la t ions in Norway.

T h e d e a t h s w e r e o b s e rv e d b e t w e e n t h e y e a r s 1 9 6 3 a n d 1 97 9. B e c a u s e t h e

c h a n g in g f r o m t h e 7 t h to the 8 th rev i s ion of t h e I n t e rn a t i o n al S t a t i s t i c a l

Class i f i ca t ion took p lac e in th i s pe riod , we h ave app l ieda t w o -d i g it c o d e f o r t h e

whole pe riod. The code fo r causes of de a th s re fe r redto in t h i s r e p o r t a r e g iv e n

in append ix t ab le . Th e o r ig ina l four d ig i t codes a reof c o u r s e r e t a i n e d o n t h e

tapes .

Th is de a th reg i s te r i s based upon dea th ce r t i f i c a te s is sued bya doc to r accord ingto in te rna t iona l ru les . The d iagnoses have va ry ing re l i ab i l ity. For th e coun t ryas

a whole au topsy i s pe r fo rmed fo r 14 per cen t . C l in ica l examina t ion in hosp i t a l s

and o the r hea l th ins t i tu t ions i s done fo r5 5 p e r c e n t . M e d i ca l a t t e n t i o n b e f o r e

death in other ins t i tu t ions or outs ide:20 p er c e n t (10).

The analysis. Among al l known combin at ionsof w e i g h t a n d h e i g h t w h i c h a r e

a v a i la b l e in t h e l i t e r a tu r e , w e h a v e i n t h i s r e p o r t c o n c e n t r a t e d t h e a n a ly s is t oW/H ( the body mass index , o r ig ina l ly ca l l ed th e Que te le t ' s index(32)) and to t h e

body heigh t a lone.

2

W e have chosen the Que te le t ' s index because i t i s advoca ted in mos tof t h e

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11.0

10.5

\

4

9 . 5 .

2

9.0

8.5

l i tera ture . I t a l so has the s t a t i s t i c a l adva n tage o f be ing a lmos t independen t of

the average body he igh t in the genera l popu la t ion(2, 3). The independence o f

body he igh t and o the r ad van ta ges a re no t necessa r ily op t imal c r i t e r i a fo r

se lec tion . What we a r e a f t e r, i s th e mos t p red ic t ive fo rmula , i.e., th eone whichg ives the mos t p rec i se p red ic t ionof mor ta l i ty. Our m ate r ia l wi l l l a t e r b e usedto

analyse th is problem mo re c losely.

AGE INYEARS.

4 5 - 4 9 d

5 0 - 5 4 0

5 5 - 5 9 . 4

--

140 I

Death ra tes . We are no t in te res ted in the abso lu te l eve l sof dea th ra tes , on ly ind i f f e r e n c e s b e t w e e n d e a t h r a t e sas c o n s e q u e n c e sof th e body h e igh t and weigh t

proper t ies . W e have , the re fo re , ca lcu la ted d ea th ra te s fo r th e whole pe riod by

dividing the number of dea th s in th e pe riod wi th th e in i t i a l popu la t ionat risk.

This method requires a c a r e f u l c o n t r o l of the obse rva t ion t ime . Tab le111 shows,

e.g., th a t th e obse rva t ion t im e decreases wi th inc reas ing age . To ta l m or ta l i ty

a c c o rd i n g t o a g e , w il l t h e r e f o r e g i v ea biased express ion of th e d ea th p robab i li -

t i e s as a func t ion of age. As th i s func t ion is o f no in te res t in our mate r ia l , we

have d isregarded this b ias.

B O D Y H E I G H T(cm)

Fig. 2 Ob serva t ion t i m e by body height. Males aged45 to 59 years .

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WE1GHT / HE1GHT2(k g / m 2 1

Fig. 3 O b s e r v a t io n t i m e by w e i g h t /h e i g h t 2 .Males Q5 t o 59 years .

However, we have also found (F igures 2 and 3) t h a t t h e o b s e r v a ti o n t i m e i sa

funct ion of body height andof W/H2. This is par t ly d ue to t h e effect of w h a t w e

a r e - e x a m in i n g , n a m e l y e x c e s s m o r t a l i tyas a func t ion of t h e h e i g h t a n d w e i g h t

express ions . A rea l excess mor ta l i ty fo r pe r sons wi th low he igh t wi l l p roduce

2s h o r t e r o b s e r v a t i o n t im e s f o r t h e s e p e rs on s. T h e s a m e a p p l ie sto t h e W / H .Diffe ren t obse rva t ion t imes , accord ing to t h e h e i g h t a n d w e i g h t p a r a m e t e r s ,

cou ld a lso be due to s y s t e m a t i c e x a m i n a ti o n s o f c o u n t i e s w i th v a r yi n g v a l u es f o r

the se pa ram ete r s . If e.g . F innmark cou n ty was obse rved ea r ly in th e per iod and

th i s coun ty had sh or te r body he igh t and h igher mor ta l i ty, an obse rved pos i t ive

re la t ionsh ip be tween mor ta l i ty and body he igh t cou ld be an a r t e f ac t on ly.W e

have approached th i s p rob lem in th r ee ways .

F i r s t , F igure 2 s h ow s t h a t t h e o b s e rv a ti o n t i m eas a func t ion o f he igh t do es no tr e p r e s e n t m o r e t h a n a 10 p e r c e n t d i f f e re n c e f o r t h e e x t r e m e l y s h o r t a n d

ext rem ely long individuals , and this wi ll be shown to be onlya minor pa r t of th e

t o t a l d i f f e r e n c e in m o r t a l it y. T h e c r u d e r a t e s w i ll t h e r e f o r e b e g i v e n i n t h e

repor t .

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Second ly, we have obse rved tha t the a s soc ia t ion be tween mor ta l i ty and body

he igh t i s p rac t i ca l ly unchangedif w e k e e p F i n n m a r k c o u n t y o u tof t h e ana lys i s.

Th i rd ly, we hav e s tud ied th e as soc ia t ion by m ean s ofa l i f e t a b l e m e t h o d w h ic he l imin a tes the s ign i f i cance o f th e obse rva t ion time .

3 Results

3.1 Body height

F igure 4 g ives the av e ra ge body he igh t by a ge and sex . Th e dec rea s ing he ig h t by

a g e h a s s e v e r a l c a u s es :

- A componen t of aging : e c r e a s i n g h e i g h t as p a r t of t he ag ing p rocess .

A c o h o r t c o m p o n e n t: t h e o l d e r c o h o r t s n ev e r r e a c h e d t h e b od y h e i g h tof t h e

younger cohor t s .

-

- A se lec t ion componen t in the oppos i t e d i rec t ion : ex cess mo r ta l i ty o f thesho r tes t wi ll g ive t a l l e r su rv ivors .

20 30

I M A L E S

.% F E M A L E S

k60Fig. 4 A G E ( Y E A R S )A ve rag e body height by sex and age.

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M A L E SI

F E M A L E S

) 160 170 180 190 140 150 160 170 180B O D Y H E I G H T ( c m )

Fig. 5 Assoc ia t ion be twe en body he igh t and mor ta l i ty by sex and age .

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O nly l o ng i tu d in a l e x a m i n a t io n s w i t h r e p e a t e d m e a s u r e m e n t s c a n g i v e s e p a r a t e

e s t i m a t e s of t h e th re e f ac to r s . Th i s was pa r t ly done by Forsdah l& Waaler (13)

who es t ima ted th a t app rox imate ly 50 pe r ce n t of the r educ t ion in he igh t by ag e

i s due to th e ag ing p rocess . The res tis a cohor t phenomenon.

F igure 5 shows th e assoc ia t ion be tween to t a l mor ta l i ty and body he igh t by age

and sex. For bo th sexe s and fo r a l l a g e s a c lea r r educ t ion in mor ta l i ty by

increased body height i s observed, poss ibly wi th an excep t ion for t h e very ta l l .

But by and large: The higher, th e bet te r. T h e c o n t r a s t is considerable . For

example, fo r women 40-44 yea r s o f ag e the mor ta l i tyis ha lved when the he igh t

is increased f rom 145-149 cm to 165-169 cm. For males aged 55-59 yearsof a g e

the mor ta l i ty i s ha lved when t he he igh t i s inc reased f rom 150-155 c m t o 185-189

c m .

I t i s wel l known th at th e popula t ion in Finnmark c oun ty in nor th ern Norway on

t h e a v e r a g e h a s a l ower body he igh t than th e re s t o f t he coun t ry, and a l so tha t

th i s coun ty in gener a l hasa h igher to ta l mor ta l i ty. F igure 6 shows the mor ta l i ty

r isk cu rves fo r two age g roups of men w i th and wi tho u t F innmark coun ty. The

c u r v e s w i th o u t F in n m a rk a r e s o m e w h a t f l a t t e r, b u t t h e m a g n i t u d eof t h e

con t ras t w e have demon s t ra ted is no t r educed by exc lud ing F innmark .

I 5 0 I 6 0 I70 I80 190 2 0 0B O D Y HEIGHT ( c m 1

Fig. 6 Morta li ty and body height. Males 50to 54 and 55 to 5 9 y e a r s of age.

S tudy popu la t ion wi th and w i thou t th e coun tyof Finnmark.

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We have m ent ioned prev iously th a t t he observa t ion t im e was par t ly confounded

with the body height . Som eof t h i s m i g h t b e d u e t o t h e excess morta l i ty of t h eshortes t . But even if we assume al l of th e short er observat ion t im eto b e a

possible basis for a bias, i t cannot change the major observa t ion , namely tha t t hebody height to a l a rge ex te n t i s p red ic t ive fo r the m or ta l i ty dur ing th e nex t5-13

years . Th is becomes qu i te c lea r f rom Figure7, which shows the resu l t of a l i fe

table analysis for one selected age group of men. The difference pers is ts through

th e per iod.

O B S E RVAT I O N TIME ( Y E A R S )

Fig. 7 Surviv al cu rve s by body height. Males aged50 to 54 years .

F igure 5 shows an exponent ia l developm ent , i.e. c lose toa log linear relationship.

W e have s impli f ied these cur ves by calculat ing th e re la t ive m ortal i ty, i .e. th e

mortali ty by body height in relationto t h e t o t a l m o r t a l i t y for a given a ge group.F igures 8 and 9 show t he resu l t s fo r th e two sexes and th re e se lec ted ag e g roups.

The curves c lea r ly showa l a rger excess mor ta l i ty at low he igh ts fo r t he younger

compared to the older. This is , of course , a resul t of the method of analysis

because a to ta l mo r ta l i ty o f 1 per ce nt fo r 20-39 years old might easi ly be

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- 1 7 -

quadrup led , whereas th i s is e x c l u d e d f o r t h e t o t a l m o r t a l i t y o f 60-79 years o ld

which is a l ready 35 p e r c e n t at t h e lowes t.

The assoc ia t ion be tween he igh t and mor ta l i ty looks d ramat ic . Bu t one shou ldr e m e m b e r t h a t t h e r e a r e r e l a t i v e l y f e w i n d i v i d u a l s w h o a r eso s h o r t t h a t t h e y

h a v e a marked excess mor ta l i ty. In F igur 10 w e h a v e c o m b i n e d t h e r i s k c u r v e s

with a c u m u l a t i v e f r e q u e n c y d i s t r i b u t i o n f o r t h r e e s e l e c t e d a g e g r o u p s40-59

years. The f igure shows th a t50 p e r c e n t e x c e s s r i sk d u e t o l o w h e i g h tis observed

for only 2-8 per ce n t o f th e popula t ion in the se age g roups , depend ing upon ag e

and sex.

B O D Y HEIGHT( c m )

Fig. 10 Distr ibut ion of body height and re la t ive morta l i ty by body height ,

a g e g r o u p s 40 t o 59 years .

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35

30

2

20 1

M LES

FEM LES

3

WEG

H

G

k

m2

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17 19 21 23 25 27 29 31 33 35 37 39 41 43 45

W EIGHT / HE IGH T2k g m2)2Fig. 13 Mortality by weight theight for each age group. Males.

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Figure 12 shows tha t the va r i anc e inc reases by ag e , more marke dfor women

than for men.

Figures 13 and 14 g ive the mor ta l i ty r e l a t ed to th i s index. For a l l ag e g roups th ecurves have a typ ica l U-fo rm, iys tem at ica l ly unsymm et r i c wi tha w i d e r f o r m t o

the r igh t and wi th a broad , approx imate ly f l a t bas i s . There i s undoub ted ly anop t ima l va lue fo r th e index , bu t t he pos i tion o f th i s op t imu m i s ve ry unprec ise ly

def ined. For w omen aged 45-49 yea rs the lowest valu esare observed for index

values bet we en 26.0 and 27.9, bu t a l l i ndex va lues be tween 20 and 30 show

a p p ro x im a t el y t h e s a m e m o r t a l it y.

F o r a g e g r o u p s b e l o w 4 0 t h e c u r v e s f o r t h e f e m a l e s a r e i r r e g u l a r b e c a u s e o f

smal l numbers , bu t t he ma in res u l t i s the same .

The U-form is c le a r fo r bo th sexes , and the l e f t t a i l , i.e. t hose wi th low weigh t,

is just as c l e a r as t h e r igh t t a i l, i.e. t hose wi th high we ight . The curve s fo r th e

f e m a l e s a r e f l a t t e r at th e bot to m, i .e. they have a l a rg e r v a r i a t i o n a r e a f o r

min imal mor ta l i ty than males . In o the r words , the f emales seemto t o l e r a t e

v a r i a t i o n s i n o v e r w e i g h t b e t t e r t h a n t h e m a l e s . T h e d i f f e r e n c e i n m o r t a l i t y

b e t w e e n t h e o p t i m a l a nd t h e e x t r e m e v a l u es a r e c o n s id e ra b le . T h e e n d p o i n t s of

th e U-curves correspond to a n e x c e s s m o r t a l i ty of 50-100 per c en t , varying wi th

s e x an d a g e . F o r t h e o l d e s t a g e g ro u p s t h e r e l a t i v e e x c e s s m o r t a l i t y i s of c o u r s e

l imited upward bec ause th e mor ta l i tyat opt imum is alrea dy v ery high.

Figure 15 s h o w s t h e r e l a t i v e m o r t a l i t y c a l c u l a t e d for th re e ag e groups: 50-54,

55-59 and 60-64. T he re is a wide op t imum area fo r va lues be tween 20 and28,

a lmos t independen t of a g e a n d s e x. O n e c a n a l s osee t h a t t h e e x c e s s m o r t a l i t yfor females for h igher W/H -values is less pronounced than for males . For

instance, for W/H = 34 males have an excess mor ta l i tyof abou t 30-40 pe r c en tr e l a t iv e t o t h e t o t a l , w h e r e a s t h e e x c e s s m o r ta l i t y f o r f e m a l e sa t t h i s l ev e l i s

b e t w e e n 20 a n d 30 p e r c e n t .

2

2

2Early se lec t ive imp act of mo rta l i ty on W/H .On e migh t in fe r f rom th e U-shapedr is k c u r v e t h a t i t r e f l e c t s t h e d i r e c t e f f e c t of d i s e a s e s a l r e a d y p r e s e n tat

measurement . This would in par t icular applyat t h e lower t a il . F igu r 16 p resen t s

- fo r two se lec ted age g roups - t h e r is k c u r v e s s e p a r a t e f o r t h o s e d y in g d u r in gt h e w h o le o b s e r v a t i o n pe r io d a n d f o r t h o s e d y in g m o r e t h a n f i v e y e a r s a f t e r t h emeasurem ent . T he U-shape pe r s is t s , pe rhaps even sha rpened . The hypo thes is th a t

the U-shape is a produc t o f a l r eady ex i s t ing fa t a l d i seases can the re fo re be

dismissed.

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8 0

WE IGH T/ HE G HT2 ( k g /m2 1

I

I I I I60

) T H E WHOL E OBSERVATION PERIOD Do.lco40H) T H E F I R ST 6 YEARS EXCLUDED -1

W E I G H T / H E I G H T Z ( k g / m 2 )

Fig. 16 Morta l i ty accord ing to weigh t /he igh t 2. S e p a r a t e f i g u r e s for t h ewhole obse rva t ion pe r iode and th e f i r s t f ive yea r s exc luded .

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6 5

Fig. 18

__I

----I I I I I

50 to 54 years.

Fig. 19 2Survival curves according to weighttheight .years.

Females 50 to 54

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- 26 -

Survival curves. To exc lude th e poss ib le b ias in obse rva t ion t im eas a f u n c t i o n of

W/H (see Figure 3), we have s tudied th e survival cur ves for var ious W/H-values. F igures 18 and 19 p resen t suc h curves fo r in te rmed ia te va luesas w e l l a s

fo r two ex t re me va lues of W/H2, fo r th e age g roup 50-54 yea r sof age . Theseobse rvat ions c l ea r ly conf i rm th e p revious obse rva t ion : th e in te rm edia te va lues

26.0-27.9 indic ate low mor ta l i ty pers is t ing through t h e observ at ion period,

w h e r e a s b o t h e x t r e m e s i n d i c a t e a n e x c e s s m o r t al it y.

2 2

Ext ent of obesi ty and underweight in th e popula tion. T he m orta l i t y r i sk cur ve

according t o W/H looks schemat ical ly as shown in Fig ure 20.

EIGHT/ HEIGHT2( k g / m 2 )

Fig. 20 Morta l i ty acco rding t o weight /heightL. Sch ema t ic .

There i s an op t ima l leve l, and dev ia tion f rom th i s l eve l i s a s soc ia ted wi th a n

increased risk. We h a v e e s t i m a t e d t h e p e r c e n t a g e of individuals covered by the

h a t c h e d a r e a s in t h e f i g ur e , t h e l e f t a n d t h e r i g h t p a r t s e p a r a t e l y.

Expressed in t e rms of p e r c e n t a g e of a l l dea ths in the ag e g roups 30-79 yea r s fo r

m a le s a n d f e m a l e s to g e t h e r w e f i n d t h a t t h e a r e aat t h e l e f t t a i l i s 1.7 p e r c e n t

(1 .9 per ce nt for fem ale s and 1.6 per cen t fo r ma les ) and at t h e r igh t t a i l 4.3 pe r

ce n t (3.8 p e r c en t fo r f em ales and 5.0 pe r ce n t fo r ma les )of t h e t o t a l d e a t h s. In

o the r words , one can say th a t obes i ty i s r e spons ib lefor 4.3 per ce nt of a l l d e a t h s

in the ag e group 30-79 years .

For compar i son we ment ion tha t lung cancer among males and b reas t cancer

a m o n g f e m a l e s a m o u n t to a p p r o x i m a t e l y 4 p e r c e n tof a l l d e a t h s in t h e s a m e a g e

groups.

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O p t i m u m W / H L . I t s e e m sa r e a s o n a b l e t a s k to f i t s o m e m a t h e m a t i c a l f u n c t io nto

t h e U - f o r m e d c u r v e s s h o wn a b o ve . W e h a v e , h o w e ve r, n o t h e o r e t i c a l b a s i s f o r

t h e s e l e c ti o n of a proper model . In a paper by Keys (23) a q u a d r a t i c f u n c t i o n h a s

been used. With the app are n t non-symme t ry of t h e o b s e r v a t i o n s s u c h fu n c t i o n swi ll be b ia sed and wi ll sys t em at i ca l ly g ive min imum va luesof W/H posi t ioned a t

h i g h e r w e i g h t l e v e l s t h a n t h e o b s e r v a t i o n a n d i n s p e c ti o nof d a t a w o u l d i n d i c a t e .

This is p r ob a b ly t h e r e a s on f o r t h e c l a i m t h a t t h e o p t i m a l w e i g h tis h i g h e r t h a n

t h e a v e r a g e w e i g h tof Ame r ican adu l t s (23) .

2

T h e r e i s t h u s u n d o u b t e dl y a n o p t i m a l bo d y h e i g h tas wel l as a n o p t i m a l bo dy m a s s

index . As gu ide - l ines fo r th e popu la t ion the se f ind ings a r e , however,too

a c a d e m i c a n d of l i t t l e p r a c t i c a l va l ue . P e o p l e w o ul d l i keto k no w t h e a r e a f o rthe i r pe r sona l body-we igh t , g iven the i r unchangeab le body he igh t .

O n t h e b a s i s of F i g u re 1 5 w e h a v e c o n s t r u c t e d n o r no g r a m m e s t h a t s h ou ld b e

u s e f u l g u i d e s fo r t h e i n di v id u al ( F i g u r e s 2 1 a n d 22). In t h e s e n o m o g r a m m e s w e

have ind ica ted t he pos i t ions fo r body-we ight s ind ica t ing r e l a t i ve r i sk o f 0 .9- 1.0- 1 1 - 1.2 and 1.4.

A m a l e w i t h a body height of 1 8 3 c m a nd a body we igh t of 7 0 k g h a s a r e l a t i v e

e x c e s s r i sk b e t w e e n 0 - 10 pe r cen t .

S imi la r ly a f e m a l e w i th a body height of 160 c m a n d a body we ig h t of 85 k g h a s a

r e l a t i v e r i sk ( r e l a t i v e to a l l o t h e r f e m a l e s i n h e r a g e - gr ou p ) b e t w e e n1.1 and 1.2

or a n e x c e s s m o r t a l i t y r is k b e t w e e n10 and 20 pe r cen t .

I f, h o w e v e r, t h e m a l e i n d i c a t e d i s a physica l ly wel l - f i t non-smoker, h is r i sk

r e l a t i v e to all o th e r ma le s in h i s age -g roup would ce r t a in l y be muc h l es s ,

p robab ly less t h a n 1.0, b u t m i g h t s t i l l b e 0 - 10 h igher than o the r phys ica l lywel l - f i t non-smokers of his age. A nd w e u nd e r li n e t h a t t h e r e is n o p r oo f t h a t a

be t t e r p rognosi s wou ld be ob t a ined bya d e l i b e r a t e w e i g ht i n c r e a s et o - s a y - 8 0

kg-

F o r t h e f e m a l e m e n t i o n e d a b o v e w e i gh t r e d u c t i o n m i g h t s e e m r e a s o na b l e , i .e.

f r o m 85 to 7 5 kg . H o w e v e r, w e d o n ' t k no w w h e t h e r t h e o b s e r v e d e x c e s s m o r t a l i t y

i s c a u s e d o n ly by h e r o v e r - w e ig h t , a n d w e c a n n o t a s s u r e h e r t h a ta r e d u c e d

weigh t wi l l be accom pan ied bya r e d u c e d m o r t a l i t y, a l t h o u g h t h e r e i s e v i d e n c e i nth e l i t e ra tu r e fo r such an ex pec ta t ion (9, 29, 34, 35). If sh e i s phys ica l ly under-

t r a ined , may b e phys ica l ac t iv i ty wil l improve he r p rognos is . If sh e i sa s m o k e r,

may b e sm oke cessa t ion wil l improve he r p rognos i s ev en if he r we igh t i s no t

reduced.

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Fig. 21 Rela t ive mor ta l i ty by we igh tfor given height. Males.

I I I

I 5 0 I60 170 I 8 0 190

BODY HEIGHT ( c m )

Fig. 22 Rela t ive mor ta l i ty by we igh tfor given height . Females .

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- 29 -

Table I V

Deaths: 35 843, under risk: 209 849)

Relative mortality, males 50-64 years

~~~~ ~~

Weight Height ( c m )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 1.25110-1 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 ( c m )

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 0.9560-69 4.13 1.46 I .oo 0.87 0.7170-79 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

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We wi ll emp has iz e tha t th e nom ogramm es shou ld be used wi th cau t ion . I t i s

a s sumed tha t one' s pos it ion in t he n omogra mme i sof prognos t i c va lue and o f

v a lu e f o r a c t io n . H o w e v er, w e u n d er li n e t h a t t h e n o m o g r a m m e s d o n o t p r e s c r i b e

th e be s t ac t ion to improve p rognos is .

3.3 Simul taneous body heigh t and body weight analys is

Ins tead of ana lyzing th e assoc ia t ion be tween mor ta l i ty and body h e igh t and

weigh t expressed in some fo rmof a l g o r i th m , o n e c a n s tu d y m o r t a l i t y a c c o r d i n g

to weight and height s imul taneously. We h a v e, t h e r e f o r e , c a l c u l a t e d t h e t o t a l

mor ta l i ty in co r re la t ion t ab les of he igh t and we igh t , and Tab lesIV a n d V show

t h e s e e x c e s s m o r t a l i t i e s f o r s o m e s e l e c t e d a g e g ro u p s50-64 y e a r s of a g e ,

s e p a r a t e ly f o r m a l e s an d f e m a l e s . T h e m o r t a l i ty f i g u r e s a r e g iv e nas r e l a t i v e

f igures - i.e. in rel atio n to t h e t o t a l m o r t a l i t y f o r t h e s p e c i f i c a g e g ro u ps .

The fo l lowing pa t t e r n is ev iden t . Mode ra te va lues fo r w e igh t toge th e r w i th l a rge

body he igh t va lues g ive re l a t iv e mor ta l i ty f igure s be low th e to ta l fo r th e ag e

group . Graph ica l ly th i s can b e dem ons t ra ted in two ways . F i r s t , fo r g iven he igh ts

m o r t a l i t y c a n b e p r e s e n t e d as a func t ion of weigh t , and F igures 23 a n d 24

dem ons t ra te c l ea r ly such U-fo rmed curves s t r e t ch ing ou tto t h e r i g h t w i t h

inc reas ing body he igh ts . The min ima o f t he cu rves seemto be sh i f t ed to t h e r i gh t

by increas ing body heights . In th re e dimensions th e ass ocia t ion wil l look l ikea

valley fall ing in south east d i rec t ion schemat ica l ly g iven in F igur 25. Secondly,

corresponding to t o po g ra p h ic m a p s, t h e a s s o c i a t i o n c a n b e d e m o n s t r a t e d b ya set

of iso-risk curvesas given in Figures 26 and 27. O n e s u c h c u r v e is t hus de f ined as

a l l the po in t s in the co r re la t ion d iagram which h ave the sa me mo r ta l i ty r isk.

T h e s e c u r v e s a r e e s t i m a t e d by l i n e a r i n te r p o l a t io n s , a n d w e h a v e g i ve n s e p a r a t e

c u r v e s f o r 50 p e r c e n t e x c e s s m o r t a l i ty a n d25 p e r c e n t r e d u c e d m o r t a l i t y.

F o r m a l e s o n e o b s e r v e s t h a t at the height of 150-169 c m o n e h a s e n h a n c e d

mor ta l i ty i r r e spec t ive of t he we igh t , even hav ing the op t ima l we igh t fo r th i s

height . Figure 23 a ls o d e m o n s t ra t e s t h a t t h e m a nof 50-64 y e a r s of a g e o u g h t to

have a w e i g h t a b o v e 60 kg and under 100 kg , i r r e spec t ive of th e height , if h e

should have a mor ta l i ty equa l to or l es s th a n t h e m o r t a l i ty f o r t h e t o t a l a g e

group . The to ta l mor ta l i ty is of course no t iden t i ca l wi th the op t imal . Low er

than to t a l mor ta l i ty r i sks a r e obse rved fo r he igh t s above185 c m a n d w i t h

weigh t s be tween 70 a n d 90 kg. Cor respond ing va lues fo r f em ale s a re shown in

F i g u r e 24.

In Figures 26 and 27 s added a s t r a igh t l ine , which marks the normal we igh t in

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I MALES AGED 50-64 I I

I I I I I I I

0 440- 50- 60- 70- 80- 90- 100- 110- 120.49 59 69 79 89 99 109 119 129

BODY WEIGHT k g )

Fig. 23 Relative mortali ty by body weight and body height. Males aged 50 to

64 years.

Fig. 24 Relative mortali ty by body weigh t and body height. Fem ale s aged 50

to 64 years.

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M O RTA L I T Y

Fig. 25 Mortal i ty as a function of body height and body weight. Schematical

presentat ion of t he th re e dimensions.

re la t ion to the he igh t , accord ing to Norwegian s tan dard norm s, th e socal led

Natvig- tables 26 ) . This curve fo l lows approx imate ly t he va l ley bo t tom and

represents , as the f igure indicates , not onlya norm bu t in fa c t a l so the idea l ,at

l eas t wi th regard to mortal i ty.

3.4 Causes of de ath

Body height. We have demons t ra ted above a clear associat ion between body

height and total mortal i ty. One would a pr io r i expec t the excess r i sk at low

h e i g ht s t o b e d u e to specif ic causes . But which causes? Which hypothe ses ca n onecons t ruc t on th e basi sof available knowledge?

In addition to t e s t ing poss ib le reasonab le hypotheses one migh t sc reen themate r ia l fo r a l l causesof morta l i ty and s tudy whether sucha method would yield

a pat tern of interes t . However, we l imit th is analysisto a few d i seases where

one might conceivably constructa reaso nab le hypothesis.

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45

BODY H E I G H T ( c m )145 155 165 175 185 195 205

i i i i 1

-\

b

L

x 65-

75-

55-

2

& 85-Q 9 5 -

- - 1.0

45\

bl

I

6 5 -

5 55-

s 75-5 -

Q 9 5 -

I05

115-

Fig. 26 Iso-risk cu rve s accord ing to body height and body weight . Males50

to 64 years .

-

-

B O D Y H E I G H T ( c m )135 145 155 165 175 185 195

1

Fig. 27 Iso-risk cu rve s accord ing to body height and body weight . F em al es

50 t o 6 4 years .

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The mecha n isms beh ind th i s a ssoc ia tion m igh t t ak ea t l e a s t t h e f o l l o w i n g t h r e e

paths:

A B C

Disease Living Hea l th

G r o w t hondi t ionG e n e s i n t e r a c t i o n

Decreased body height Inc reased mor ta l i ty

Comments :

A.

B.

C.

On

Diseases , fo r example obs t ruc t ive lung d i seases migh t l eadto shor ter bodyheight v ia kyfosis and of co urse a lso to e x c e s s m o r t a l i t y. O t h e r s i m i l a r

p rocesses a re conce ivab le .

Pover ty i s o f t en charac te r i zed by malnu t r i t ion and hence re ta rda t ionof

body growth. Pover ty and poor l iv ing condi t ions a lsoaffect h e a l t h v i a

severa l mechan i sms resu l t ing in inc reased inc idenceof in fec t ious d i seasesand possibly of some ca rd iovascu la r d i seases(14).

J u s t as red h a i r i s a s soc ia ted wi th an exce ss ri sk o f deve lop ing tubercu los i s

in an apparan t ly mean ing less gene t i c combina t ion , one cann o t exc lude tha t

th e genes govern ing g rowth and hea l th a re l inked ina similar way.

th i s bas is we have examine d th e assoc ia t ion be tween body h e igh t and

mo rta l i ty of ob st ru ct iv e lung disea ses andof card iovascu la r d i seases. W e have,

however, a l so inc luded cancer and acc iden t s in our ana lyses .

Figure 28 shows fo r four 5-year a ge g roups th e re la t ive mo r ta l i ty of obs t ruc t ive

lung diseases expressed in per cen t . T he number of d eat hsfor t h e t w o y o u ng e st

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A G E :40 4445 4950 455 59

-.-.-.--------.- - --

P

F E M A L E SI

T

50 160 170 180

B O D Y H E I G H T ( cm)Fig. 28 R e l a t i v e m o r t a l i t y of obs t ruc t ive lung d i seases by sex and age

accord ing to body he igh t.

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160 170 180 190 I50 160 I70 180

BODY H E I G H T (cm)Fig. 29 Relative mortality of cardiovascular diseases by sex and age

according to body height.

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- 37 -

a g e g ro u p s a r e l i m i t e d , b u t t h e p a t t e r n i s v e ry c l ea r. T h e r e i sa markedly

reduced mor ta l i ty o f th ese causes wi th inc reased body he igh t. Tab leV I s h o w s t h e

same fo r th e ag e g roups 50-54 and 55-59 p resen ted ina d i ffe ren t way. Here , the

o b se r ve d i n c i d e n c e n u m b er s a r e c o m p a r e d w i t h t h e e x p e c t e d n u m b e r s if t h o s edy ing had had the same he igh t d i s t r ibu t ion as t h e e n t i r e a g e g r ou p s. T h e t a b l e

shows a c lea r excess r i sk of mor ta l i ty of t hese d i seases fo r thos e wi th low body

he igh t. Those wi th h igh body he igh t s have reduced mor ta l i ty f ro m th i s d i sease .

Forsdah l (14) has demons t ra ted tha t ca rd iovascu la r mor ta l i ty in adu l t sis

pos it ive ly as soc ia ted wi th t he l iv ing cond i t ionsa t b i r th expressed as t h e i n f a n t

morta l i ty in the municipal i ty of b i r th . Th i s sugges t s an assoc ia t ion be tween

mor ta l i ty of ca rd iovascu la r d i seases and body he igh t. F igure 29 showsa c lea r lyreduced mor ta l i ty for t h o s e w h o a r e t a ll . F o r m a l e s s h o r t e r t h a n 1 6 0 c m t h e

mor ta l i ty of ca rd iovascu la r d i seases is 50-100 l a rg e r t h a n t h e t o t a l , a n d f o r

males 185-189 cm the mor ta l i ty i s on ly70-80 p e r c e n t of t h e t o t a l m o r t a l i t y of

t h e a g e g ro u p. T h e r e is possibly a d e c r a s i n g a d v a n t a g e f o r h e i g h t s a b o v e 1 9 0 c m ,

b u t t h e n u m b e r s h e r e a r e v e ry s m al l.

W e have a lso observed a c e r t a i n n e g a t i v e a s s o c i a t io n b e t w e e n a c c i d e n t s a n d b od y

he igh t, bu t th e r e l a t ionsh ip i s ve ry weak . For a l l canc e rcases t h e r e i s n o

a s so c ia t io n . T h i s c o n v in c e s u s t h a t t h e a s s o c i a t io n s d e m o n s t r a t e d a b o v e a r e n o t

t h e r e s u l t of s t a t i s t i c a l a r t e f a c t s .

2 2The to ta l mor ta l i ty in r e l a t ion to W/H/H was for b o th s e x e s a n d a l l a g e s

typ ica l ly U- fo rmed . Th i s sugges t s th a t th e r e mus t be some typ ica l low-weigh t

d i s e a s e s an d s o m e t y p i c a l h i g h- w e ig h t d i se a se s . T h e l i t e r a t u r e e m p h a s i z e s t h e

impor tance o f overwe igh t . Card iova scu la r d iseases , b ra in hemo r rhag e and d iabe-

tes a r e m e n ti o ne d as i m p o r t a n t r is k d i s e a s e s f o r t h o s e w h o a r e o v e r w e i g h t7, 8,

11, 15, 24, 33, 39, 46).

W e wil l i l lu s t r a t e these a s soc ia t ions in two ways. F i r s t , w e wil l show the

d i f f e r e n t c a u s e s o f m o r t a l it y as a f u n c t i o n of W/HL. Secondly, we will show

f igures wi th the ave rage va lues of W/H2 for individuals who have died of

d i ffe re n t causes .

For sorne s e l e c t e d c a u s e s F i g u r e s 3 0 a n d 3 1 g i v e t h e m o r t a l i t y a c c o r d i n gto a

g iv e n W /H - va lu e. In t h e s e f i g u re s w e h a v e s e l e c t e d c a u s e s t h a t c a m e o u tof t h e

a n a l y s e s as low-weight d iseases , i.e. d isea ses wi th higher mo rta l i tyfor l o w e r

W/H . A m on g t h e s e a r e 3 groups of lung diseases : lung cancer, tuberculos is andobs t ruc t ive lung d i seases . O ne o the r canc er fo rm , s toma ch canc er, showsa

s imilar pat tern .

2

2

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T

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lu

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- 39 -

Fig. 30 Morta li ty of four ca use s by weight /he ight2 . Males 50 to 64 years.

10

5

2

> I*e0 8 a5

2L

9 a24 1

005

0 02

Ool I5 17 19 P I 23 25 27 2 9 31 33 35 37

WEIGHT/HEIGHTe(kg/ me)

Fig. 31 Mortali ty of four causes by we igh t /heigh t* . Fem ales 50 t o 64 years.

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- 40 -

On the o th e r hand , we can a l so se lec t typ ica l h igh-weigh t d i seases ,as shown in

Figures 32 and 33. The fo l lowing d i sease g roups can be d i s t ingu i shed fo r bo th

sexes : ca rd iovascu la r d i seases , ce rebrovascu la r d i seases , and d iabe tes .

For ma les co lon cance r a l so showsa grad ie n t o f doubl ing mor ta l i ty f ro m18 to 34

in W/H -va lues . For an average he igh tof 174 c m t h i s r a n g e c o r r e s p o n d s t oa

weigh t r ange of 54-103 kg. I t c o u ld r e a so n a b ly b e c l a i m e d t h a t t h e e x c e s s

mor ta l i ty o f co lon cance r fo r obese men is c o n n e c t e d w i t h t h e s u rg i c a l

comp licat ions , possibly a lso wi tha l a t e d iagnos is . Our mate r ia l can no t subs tan t i -

ate such hypothesis.

2

The m or ta l i ty cur ves fo r ca rd iovascu la r d i seases a re s l igh tly U- formed wi tha

minimum at 22-23.9 (average 23) cor responding to a body weight of a b o u t 70 kg

for a body height of 174 cm (males ) . F rom th i s l eve l upward the mor ta l i ty

inc reases by ab ou t 2 per cen t fo r each added kg body weigh t . For ins tance a ta

minimum level of 70 k g t h e m o r t a l it y f o r t h e a g e g r o up50-64 years fo r males ,

the t en yea rs mor ta l i ty of ca rd iovasc u la r d i seases i s abou t 0 .76 pe r cen t . For th e

weigh t 71 kg the morta l i ty is increased by2 p e r c e n t t o 0.774 p e r c e n t etc.

.-M A L E S 50-64 YEARS

5

2

\ Isu

5

hs

aa2

01

005

WEIOHT/HElGHT ( kg/m2 1

Fig. 32 Mortal i ty of four causes by we igh t /he igh t2 Males 50 to 64 years .

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- 41 -

WEIGHT/HEIGHT*( k g / m 2 )

Fig. 33 Mortal i ty of four cau ses by weight /height* . Fe ma les50 to 64 years .

The s t eepes t cu rve i s obse rved fo r d iabe tes .A 3-4 t imes inc rease in mor ta l i ty o f

d i a b e t e s is s e e n i n t h e W/H range of 30-34, i.e. a weigh t inc rease o f 90-103 k g

for ma les ave rag ing 174 cm in body height . Dia betes i s of par t icu lar in tere s t .

T h e r e a r e t w o d i f f e r e n t k i n d s of d iabe tes , one p reva i l ing a t y o un g a g e s a n d t h eo t h e r s t a r t i n g at increas ing age. Figures34-35 s h o w t h e a v e r a g e W/H -values by

ag e fo r a l l measured and fo r tho se who d iedof d iabe tes in th e per iod. Th e

c o n c e p t of t w o d i s e a s e s c o m e s o u t i n t h i s f i g u r eas t h e a v e r a g e W / H -va lues a re

lower than norm al a t young ag e and ve ry much h igher than normalat higher age.

2

2

2

2Final ly, f igures 36 and 37 d e m o n s t r a t e m a r k e d d i f f e r e n c e s in t h e a v e r a g eW / H -va lues fo r dea t h of va r ious fo rmsof cancer. Lung canc er i s in th i s r e spec ta low-

weigh t d i sease fo r bo th sexes . Th i s p ic tu re i s no t changed if th e de a th s dur ing

t h e f i r st 5 y e a r s a r e e x c l ud e d .

Also o the r canc er fo rms show in te res t ing con t ra s t s which wil l be fo l lowed up byt h e C a n c e r R e g i s t ry of Norway.

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- 42 -

I

2s

2E

27

\ 2E

4n-s: 25

LX6 24

Xh 23X6

g 2221

20

19

- TOTAL

I I I

M A L E S

ADA B E TE

\

-o

LANC

2Fig. 34 Average weightlheight for those who died of various causes by age.

Males.

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- 4 3 -

:TOTAL

20 30 40 50 6 7 8 90A G E ( Y E A R S )

2Fig. 35 Av e r a g e w e i g h t l h e i g h t fo r those who died of v a r i o u s c a u s e s by age.

F e m a l e s .

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M A L E S

LUNG C A N C E R

: T O TA L

I I I I

20 30 40 50 6 0 7 80 90

A G E ( Y E A R S )

2Fig. 36 Average weight/height value for those who died of some selected

cancer fo rms by age. Males.

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- 5 -

31

3c

2s

2E