Legend: Estimated years lived free of cardiovascular disease (CVD) and with CVD at age 50, by sex and adiposity categories defined by combining BMI and WC thresholds (low, increased, high and very high). Final models were adjusted for age, household composition, education, physical activity, DHD-15 index, smoking (including cigarettes/day in current smokers), alcohol consumption and COPD. Created in https://BioRender.com.
Abbreviations: BMI, body-mass index; COPD, chronic obstructive pulmonary disease; CPAI, Cambridge Physical Activity Index; CVD, cardiovascular disease; LE, life expectancy; DHD, Dutch healthy diet; WC, waist circumference.
Figure 1
Flowchart of study participant selection.
Figure 2
Definition of adiposity categories based on body mass index and waist circumference thresholds.
Legend: Adiposity categories were defined based on AACE/ ACE guidelines, combining BMI thresholds: normal weight <25 kg/m2, overweight 25 to <30 kg/m2, and obesity ≥30 kg/m2; and WC thresholds: healthy WC <94 cm and <80 cm, abdominal overweight 94≤–<102 cm and 80≤–<88 cm, and abdominal obesity ≥102 cm and ≥88 cm, for men and women, respectively.
Abbreviations: BMI, body mass index; WC, waist circumference; AACE, American Association of Clinical Endocrinologists; ACE, American College of Endocrinology.
Table 1
Baseline characteristics of the study population.
| CHARACTERISTICS | MEN (n = 1,166) | WOMEN (n = 1,157) |
|---|---|---|
| Population | ||
| Age at baseline, y | 57.9 [53.9, 63.7] | 57.7 [53.3, 63.2] |
| Age, 10y | ||
| 50–59 | 689 (59.1) | 688 (59.5) |
| 60–69 | 463 (39.7) | 447 (38.6) |
| 70–79 | 14 (1.2) | 22 (1.9) |
| Anthropometry | ||
| Adiposity categoriesa | ||
| Low | 208 (17.9) | 153 (13.4) |
| Increased | 483 (41.7) | 291 (25.5) |
| High | 282 (24.3) | 450 (39.4) |
| Very high | 186 (16.0) | 247 (21.6) |
| WC categoriesb | ||
| Healthy WC | 308 (26.5) | 167 (14.5) |
| Abdominal overweight | 390 (33.6) | 286 (24.9) |
| Abdominal obesity | 464 (39.9) | 695 (60.5) |
| BMI categoriesc | ||
| Normal | 293 (25.3) | 389 (34.1) |
| Overweight | 677 (58.4) | 502 (44.0) |
| Obesity | 190 (16.4) | 250 (21.9) |
| Social and economic status | ||
| House composition, living with others | 1,084 (93.3) | 979 (85.0) |
| Education | ||
| Lower | 127 (10.9) | 147 (12.8) |
| Medium | 739 (63.6) | 821 (74.3) |
| High | 296 (25.5) | 184 (16.0) |
| Employment, employed and self-employed | 627 (51.7) | 359 (30.7) |
| Lifestyle variables | ||
| Physical activityd | ||
| Inactive | 166 (14.2) | 138 (11.9) |
| Moderately inactive | 338 (29.0) | 362 (31.3) |
| Moderately active | 302 (25.9) | 342 (29.6) |
| Active | 360 (30.9) | 315 (27.2) |
| Health perception | ||
| Good/excellent | 276 (23.7) | 279 (24.1) |
| Intermediate | 728 (62.6) | 728 (62.9) |
| Reasonably/poor | 159 (13.7) | 150 (13.0) |
| Number of hours of sleep per day | ||
| ≤6 hours | 230 (19.8) | 215 (18.7) |
| 7 hours | 454 (39.1) | 402 (35.0) |
| ≥8 hours | 478 (41.1) | 533 (46.3) |
| Smoking | ||
| Never | 266 (22.8) | 522 (45.2) |
| Current | 275 (23.6) | 250 (21.6) |
| Former | 625 (53.6) | 384 (33.2) |
| Cigarette use in current smokers, no./day | 15.0 [10.0, 20.0] | 12.0 [8.0, 20.0] |
| Dutch Healthy Diet index 2015 | 64.0 [54.3, 72.4] | 70.1 [60.8, 78.6] |
| Alcohol consumption, glasses/weeke | ||
| No, never/no, used to | 101 (8.7) | 226 (19.7) |
| Occasionally, less than 1 | 154 (13.2) | 268 (23.3) |
| Yes, 1 or 2 | 38 (3.3) | 83 (7.2) |
| Yes, 3–14; 3–7 | 514 (44.1) | 265 (23.0) |
| Yes, ≥15; ≥8 | 359 (30.8) | 308 (26.8) |
| Alcohol consumption in drinkers, glass/week | 8.0 [2.0, 16.0] | 2.0 [0.0, 8.0] |
| Comorbidities and treatmentf | ||
| Hypertension, yes | 576 (49.5) | 514 (44.8) |
| Hypertension treatment, yes | 165 (19.2) | 203 (21.2) |
| Diabetes, yes | 56 (4.8) | 41 (3.5) |
| Diabetes treatment, yes | 48 (4.0) | 35 (3.0) |
| Hypercholesterolaemia, yes | 256 (22.0) | 392 (34.2) |
| Hypercholesterolaemia treatment, yes | 12 (1.3) | 12 (1.5) |
| Low-HDL, yes | 171 (14.7) | 46 (4.0) |
| COPD, yesg | 186 (16.0) | 188 (16.2) |
| Biomarkers | ||
| Serum lipids (mmol/L) | ||
| Total cholesterol | 5.8 [5.1, 6.4] | 6.1 [5.4, 6.8] |
| HDL | 1.2 [1.0, 1.4] | 1.5 [1.2, 1.7] |
[i] Median [IQR] values for continuous variables and within-category proportions (%) were reported for categorical variables.
aAdiposity categories (AACE/ACE guidelines (30)) combining BMI and WC thresholds, as low, moderate, high and very high.
bWC categories (WHO (31)); healthy WC <94 cm and <80, abdominal overweight 94≤–<102 cm and 80≤–<88 cm, and abdominal obesity ≥102 cm and ≥88 cm, for men and women, respectively.
cBMI categories (WHO (32)); normal weight <25 kg/m2, overweight 25 to <30 kg/m2, and obesity ≥30 kg/m2.
dPhysical activity based on the Cambridge Physical Activity Index (37).
eSex-specific categories of alcohol consumption in drinkers (glasses/week). In men: yes, 1 or 2 g/wk; yes, 3–14 g/wk; yes, ≥15 g/wk. In women: yes, 1 or 2 g/wk; yes, 3–7 g/wk; yes, ≥7 g/wk.
fTreatment for hypertension, diabetes and hypercholesterolaemia were self-reported.
gCOPD based on self-reported symptoms/complaints: attacks of shortness of breath when walking, almost daily cough (3 months/year), and giving up mucus daily (3 months/year).
Abbreviations: IQR, interquartile range; BMI, body mass index; WC, waist circumference; HDL, high-density lipoprotein; COPD, chronic obstructive pulmonary disease.
Figure 3
Adjusted HRs for incident CVD and all-cause mortality by adiposity categories, stratified by sex.
Legend: HRs and 95% CIs for (i) incident CVD and (ii) all-cause mortality among participants with and without CVD, comparing moderate, high and very high versus low category of adiposity. Adiposity categories were defined by combining BMI and WC thresholds: low, moderate, high and very high. Models adjusted for age, household composition, education, physical activity, DHD-15 index, smoking (status and cigarettes/day in current smokers), alcohol consumption and COPD.
Abbreviations: BMI, body mass index; CI, confidence interval; COPD, chronic obstructive pulmonary disease; CVD, cardiovascular disease; HRs, hazard ratios; WC, waist circumference.
Table 2
Adjusted HRs for incident CVD and all-cause mortality by adiposity category and sex.
| TRANSITION | ADIPOSITY CATEGORYd | MEN | WOMEN |
|---|---|---|---|
| HR (95% CI)¶ | HR (95% CI)¶ | ||
| Incident CVDa | Low | 1.0 | 1.0 |
| Increased | 1.07 (0.88, 1.31) | 0.77 (0.58, 1.01) | |
| High | 1.14 (0.92, 1.41) | 1.03 (0.81, 1.32) | |
| Very high | 1.66 (1.33, 2.08) | 1.02 (0.78, 1.34) | |
| Mortality among those without CVDb | Low | 1.0 | 1.0 |
| Increased | 0.90 (0.67, 1.21) | 1.13 (0.76, 1.67) | |
| High | 1.23 (0.92, 1.66) | 1.30 (0.90, 1.88) | |
| Very high | 1.25 (0.89, 1.75) | 0.98 (0.66, 1.47) | |
| Mortality among those with CVDc | Low | 1.0 | 1.0 |
| Increased | 1.21 (0.84, 1.74) | 0.69 (0.44, 1.09) | |
| High | 1.45 (1.00, 2.12) | 0.91 (0.60, 1.37) | |
| Very high | 1.84 (1.23, 2.75) | 0.81 (0.53, 1.27) |
[i] aCalculations made with 1,044 men and 1,092 women.
bCalculations made with 1,044 men and 1,092 women.
cCalculations made with 1,044 men and 1,092 women.
dAdiposity categories (AACE/ACE guidelines), combining BMI and WC thresholds: low, increased, high and very high.
¶Models adjusted for age, household composition, education, physical activity, DHD-15 index, smoking (status and cigarettes/day in current smokers), alcohol consumption and COPD. Significant associations in bold.
Abbreviations: BMI, body mass index; CI, confidence interval; CVD, cardiovascular disease; HR, hazard ratio; WC, waist circumference.
Figure 4
Effect of adiposity on sex-specific LE with and without CVD at age 50 years.
Legend: Total LE at age 50 divided into CVD-free LE and LE with CVD, by sex and adiposity categories (low, increased, high, very high) defined by combining BMI and WC thresholds.
Abbreviations: BMI, body mass index; CVD, cardiovascular disease; LE, life expectancy; WC, waist circumference.