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European Heart Journal Advance Access originally published online on September 23, 2005
European Heart Journal 2006 27(1):96-106; doi:10.1093/eurheartj/ehi506
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© The European Society of Cardiology 2005. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org

Long-term cardiovascular consequences of obesity: 20-year follow-up of more than 15 000 middle-aged men and women (the Renfrew–Paisley study)

N.F. Murphy1, K. MacIntyre2, S. Stewart3, C.L. Hart2, D. Hole2 and J.J.V. McMurray1,*

1Department of Cardiology, Western Infirmary, Glasgow G12 8QQ, UK
2Public Health and Health Policy, University of Glasgow, Scotland, UK
3Division of Health Sciences, University of South Australia, Adelaide, Australia

Received 11 May 2005; revised 26 August 2005; accepted 2 September 2005; online publish-ahead-of-print 23 September 2005.

* Corresponding author. Tel: +44 141 2111838; fax: +44 141 2112252. E-mail address: j.mcmurray{at}bio.gla.ac.uk


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 Acknowledgements
 References
 
Aims To examine the long-term cardiovascular consequences of obesity and project the cardiovascular consequences of the recent increase in prevalence of obesity.

Methods and results Between 1972 and 1976, 15 402 individuals aged 45–64, living in two towns in the west of Scotland underwent comprehensive cardiovascular screening. We analysed all deaths and hospitalizations for cardiovascular reasons occurring over the subsequent 20 years according to baseline body mass index (BMI) category. Compared with normal weight individuals (BMI 18.5–24.9), obesity (BMI ≥30) was associated with an increased adjusted risk of coronary heart disease (hazard ratio for death or hospital admission: 1.60, 95% CI 1.45–1.78), heart failure (2.09, 1.68–2.59), stroke (1.41, 1.21–1.65), venous thrombo-embolism (2.29, 1.60–3.30), and atrial fibrillation (1.75, 1.17–2.65). Obesity was associated with nine additional cardiovascular deaths and 36 additional cardiovascular hospital admissions for every 100 affected middle-aged men over the subsequent 20 years (seven deaths and 28 admissions in women). Assuming no change in cardiovascular risk profile and outcomes related to obesity, the increase in prevalence in 1998, when compared with 1972, is projected to lead to an additional four cardiovascular deaths and 14 admissions per 100 middle-aged men and women over the next 20 years.

Conclusion Obesity is associated with an increase in a broad range of fatal and non-fatal cardiovascular events. Consideration of only coronary, only fatal, and only first events greatly underestimates the cardiovascular consequences of obesity.

Key Words: Obesity • Coronary heart disease • Heart failure • Atrial fibrillation • Stroke • Thromboembolism


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 Acknowledgements
 References
 
The prevalence of obesity has reached unprecedented proportions.1 Nearly one-third of Americans are obese.2,3 It is estimated that there are up to 200 million obese citizens in the recently expanded European Union. The obesity epidemic also afflicts developing countries.1 There is appropriate concern that this alarming trend will have major public health consequences globally, with evidence linking obesity to an increased risk of more than 30 medical conditions.4

One of the first medical consequences of obesity to be recognized was coronary heart disease.5–8 Obesity, however, carries a broader cardiovascular risk though this has not been fully explored in any society. Neither the full range of cardiovascular problems related to obesity nor the complete burden, as measured by both fatal and non-fatal events, has been quantified in detail. In particular, the whole spectrum of cardiovascular problems related to obesity has not been evaluated in a single population-based cohort, in order to compare the relative effect of obesity on different outcomes.

Between 1972 and 1976, the Renfrew–Paisley Study enrolled 7048 men and 8354 women, representing 80% of individuals aged 45–64 residing in these two towns in the west of Scotland.9–11 Because of the large number of events over 20 years (3028 cardiovascular deaths and 11 028 hospital admissions), this cohort provides the opportunity to quantify the full cardiovascular burden of obesity in the long-term. In addition, when combined with monitored trends in body mass index (BMI) in Scotland,12 this information enables projection of the future cardiovascular consequences likely to result from recent increases in the population prevalence of obesity.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 Acknowledgements
 References
 
Sample and baseline data
Between 1972 and 1976, 7048 men and 8354 women, representing 80% of subjects aged 45–64 residing in the towns of Renfrew and Paisley, in the west of Scotland, took part in this epidemiological study. Written consent was given at this time for hospital records to be looked at. Ethical permission was obtained from Argyll & Clyde LREC for linkage with the Scottish Morbidity Records system. The study was approved by the Privacy Advisory Committee of the Information and Statistics Division, Scotland. Each subject's demographic profile and cardio-respiratory health status were documented. Social class was determined by regular occupation at baseline screening according to the Registrar General's classification.13 Angina pectoris (classified as definite by the Rose angina questionnaire) and chronic bronchitis (determined by the Medical Research Council's chronic bronchitis questionnaire) were noted.10,14,15 Past and current medical history and risk factors for cardio-respiratory disease were documented. Blood pressure, height, and weight (used to calculate BMI in kg/m2) were measured. The cardiothoracic ratio (based on chest radiographs) and forced expiratory volume in 1 s (FEV1) were measured. Cardiomegaly was defined as a cardiothoracic ratio ≥0.55. An adjusted FEV1 was calculated as a percentage of the ‘expected’ FEV1 (derived from a linear regression equation of age and height for men and women separately from a healthy subset of the sample who were non-smokers and had no respiratory symptoms) and the actual FEV1.16 Plasma cholesterol and glucose concentrations were measured in a non-fasting blood sample. Glucose concentration was not measured during the whole screening period and was, therefore, only available for 69% of the total cohort. A six-lead electrocardiograph (ECG) was also obtained and coded.17 These ECGs were used to identify all subjects with atrial fibrillation and, within the constraints of interpreting data from only six leads, other abnormalities indicative of past myocardial infarction, ST-segment changes (possibly indicating myocardial ischaemia), and left bundle branch block.

Overweight and obesity criteria
According to baseline BMI, subjects in the Renfrew/Paisley Study were categorized into underweight (BMI <18.5 kg/m2), normal (BMI 18.5–24.9 kg/m2), overweight (BMI 25.0–29.9 kg/m2), and obese (BMI ≥30 kg/m2).1 The underweight group (n=243) was excluded from this analysis.

Study follow-up
Electronic linkage to hospital and death records is possible for all residents of Scotland as previously described.10,18 The Scottish Morbidity Record Scheme was used to retrieve details of all hospital discharges [according to the eighth (a small number of initial episodes) and ninth revisions of the World Health Organization International Classification of Diseases] during the 20 years after initial screening.19 We followed-up all individuals until date of death or censorship. Date of censorship was 20 years from the date of each person's initial screening visit. We noted the occurrence and timing of admissions for coronary heart disease (ICD9 410–414), acute myocardial infarction (ICD9 410), heart failure (ICD9 425.4, 425.5, 428, 402), deep venous thrombosis (ICD9 451.1), pulmonary embolism (ICD9 415) (collectively referred to as venous thrombo-embolism), atrial fibrillation (ICD9 427.3), and stroke (ICD9 430–438). These diagnoses, in combination with a number of other less commonly recorded diagnoses are collectively called cardiovascular hospitalizations (ICD9 390–459). Audits have shown that these data are approximately 90% accurate in identifying the correct discharge diagnosis.20 Emergency, transfers, and elective admissions were included in total hospital admission. Deaths and their certified causes were obtained from the National Health Service Central Register for the same period. Rates were calculated using official age and sex-specific population estimates for 1972 and 1998.21

Statistical analysis
Baseline characteristics in different weight categories were compared using {chi}2 tests for trend for categorical data and one-way analysis of variance for continuous data. The expected number of hospital admissions or cardiovascular deaths in the overweight and obese groups was calculated by applying the mean admission rate or cardiovascular case-fatality rate per person in the normal weight group to the obese and overweight group. We estimated the projected burden of obesity by applying age- and sex-specific rates of cardiovascular events to the obese Scottish population in 1998 using the prevalence of obesity as estimated from the 1998 Scottish Health Survey.12 Case-fatality and event rates were calculated over the 20-year follow-up period using the actuarial life-table method.

We used Cox proportional-hazards regression models to examine the relation between BMI and outcome. BMI was modelled as a continuous and a categorical variable. The assumption of proportional hazards was tested by inspection of the log minus log survival plots and this was satisfied. The linearity assumption for BMI as a continuous variable was assessed by fitting the models with added quadratic terms. Quadratic terms were significant for death. In all other cases, the linearity assumption was satisfied. We excluded 17 (0.1%) patients (one subject in the obese category) from the survival analyses as they had emigrated and their vital status was unknown. As elevated BMI can mediate its effect on cardiovascular risk by promoting atherogenic traits such as hypertension, diabetes, and dyslipidaemia, we therefore ran two separate multi-variable analysis, the first adjusting for age, sex, adjusted FEV1, number of cigarettes smoked per day, social class and the second in addition also adjusting for systolic blood pressure, past history of diabetes, and cholesterol. Data were missing for social class in 409 (2.7%) cases and cholesterol in 124 (0.8%) cases. Missing values for social class were replaced with the most common social class in each sex and missing values for cholesterol were replaced with the sex-specific mean cholesterol. Data were missing in a small number of cases for systolic blood pressure (n=7) and adjusted FEV1 (n=11), however, the availability of other variables was complete. All analyses were undertaken using SPSS (version 11.0).


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 Acknowledgements
 References
 
Baseline characteristics
The baseline characteristics of the Renfrew–Paisley cohort, divided into the different BMI categories, are shown in Table 1 When compared with individuals with a normal BMI, obese men and women had more risk factors for cardiovascular disease (with the notable exception of smoking), more clinical evidence of cardiovascular disease, and more ECG abnormalities. Of particular note, the prevalence of diabetes was two-fold higher in obese subjects and systolic blood pressure was on an average more than 15 mmHg higher. Individuals who were ‘overweight’ had a profile intermediate between that of those who were obese and men and women with a normal BMI.


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  		Table 1 Characteristics of the Renfrew/Paisley cohort, by body mass index category at baseline
 
Death from any cause over 20 years of follow-up
When compared with 48.9% of men with a normal BMI (P-value for BMI as a continuous variable=0.285, Table 2), 51.2% of obese men died within 20 years of screening. The corresponding figures for women were 29.8 and 39.2%, respectively (P=0.015). The adjusted HR (95% CI) of death (compared with those with a normal BMI) was 1.16 (1.03–1.30) in obese men and 1.23 (1.11–1.37) in obese women. The proportion of ‘overweight’ men who died was 45.5% (1.00, 0.93–1.08) and in women this proportion was 29.3% (0.95, 0.87–1.04). There was evidence of a quadratic trend for death in men (P-value for BMI squared=0.001) and women (P<0.001).


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  		Table 2 Principal cause of death according to BMI category
 
Death from cardiovascular causes over 20 years of follow-up
When compared with individuals with a normal BMI, a significantly higher proportion of obese men and women died from a cardiovascular cause (men 35.6% compared with 23.2%, P<0.001; women 25.5% compared with 15.6%, P<0.001) (Figure 1 and Table 2). The adjusted HR of cardiovascular death was 1.49 (1.28–1.72) in obese men and 1.45 (1.25–1.67) in obese women, compared with individuals with a normal BMI. The risk of death from a cardiovascular cause was increased in men in the overweight category (1.14, 1.03–1.26) but not in women (0.92, 0.81–1.05).



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  		Figure 1 Age adjusted event-free survival in men and women for CV death.

 
Death from coronary heart disease over 20 years of follow-up
Obese men (HR 1.60, 1.35–1.90) and women (HR 1.44, 1.19–1.74) were more likely to die from coronary heart disease. Again, the risk of death from coronary heart disease was increased in men in the overweight category (1.19, 1.06–1.35) but not in women (0.99, 0.83–1.16) (Table 2). Examination of deaths attributed to acute myocardial infarction showed similar findings.

Death from non-coronary cardiovascular causes over 20 years of follow-up
There were many fewer deaths from stroke than from coronary heart disease and only a small number of deaths from heart failure, venous thrombo-embolism, and atrial fibrillation, making assessment of their risk related to obesity unreliable. Examination of combined fatal and non-fatal outcomes gives a more reliable estimate of risk (see subsequently).

Hospitalization for cardiovascular causes over 20 years of follow-up
The excess risk of cardiovascular admissions associated with obesity was broadly similar to the increased risk of cardiovascular death (Table 3). Table 4 shows the total number of admissions for different cardiovascular reasons over 20 years of follow-up. Obesity was associated not only with more subjects requiring at least one admission for a cardiovascular reason but also more admissions per patient. Overweight patients were at intermediate risk. Obesity accounted for an ‘extra’ 600 (95% CI 530–670) admissions (difference between the observed and expected number of admissions) for cardiovascular reasons (an increase of 47%) among the 2010 individuals in this BMI category, i.e. 30 per 100 extra admissions. Heart failure accounted for the greatest proportional increase (138%) in hospital episodes related to obesity [i.e. 139 (95% CI 119–159) extra heart failure admissions].


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  		Table 3 Patients with at least one hospital admission for a cardiovascular cause (coded as principal discharge diagnosis) according to BMI category
 

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  		Table 4 Total number of hospital admissions (mean admissions per patient) for each cardiovascular event (coded as principal discharge diagnosis) according to BMI category
 
This was because of a two-fold increase in the rate of two admissions (P=0.001) and a four-fold increase in the rate of three or more admissions (P<0.001) in obese compared with normal weight individuals.

The prevalence of ‘overweight’ was much greater than that of obesity. Consequently, though the relative risk related to ‘overweight’ was less, the absolute number of events attributable to overweight was greater. Overweight accounted for an additional 884 (95% CI 759–1009) cardiovascular hospitalizations (an increase of 22%) among the 6493 individuals in this BMI category, i.e. 14 per 100 extra admissions.

Death or hospitalization for cardiovascular causes over 20 years of follow-up
When compared with 47.9% of men in the normal BMI category (P<0.001), 58.6% of obese men died from, or were admitted to hospital for a cardiovascular reason (Table 5 and Figure 2). The risk for overweight men (50.6%) was intermediate. The adjusted HR was 1.44 (1.29–1.61) for obese men and 1.15 (1.06–1.24) for overweight men.


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  		Table 5 Fatal or non-fatal cardiovascular events (death or hospital admission) according to BMI category
 


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  		Figure 2 Age adjusted event-free survival in men and women for CV death or hospital admission.

 
The picture for women was similar; 45.6% of obese women died or were admitted to hospital (HR 1.44, 1.30–1.60) compared with 34.0% of overweight women (HR 1.06, 0.97–1.15) and 32.0% of women with a normal BMI. The pattern for deaths and admissions related to coronary heart disease were similar.

Examination of the composite of hospital admission or death doubled the number of individuals experiencing a stroke (n=1288). The proportion of men and women admitted to hospital with a stroke was increased in obese subjects. The adjusted HR was 1.33 (1.03–1.73) for obese men and 1.47 (1.20–1.80) for obese women.

The addition of hospital admissions to deaths increased the total number of patients experiencing a heart failure-related event seven-fold (n=641). Obesity increased the adjusted risk of heart failure in men (2.61, 1.92–3.56) and women (1.70, 1.26–2.30).

Obesity also increased the risk of fatal and non-fatal episodes of venous thrombo-embolism in men (1.89, 1.13–3.17) and women (2.91, 1.72–4.94). Patients in the overweight category had an intermediate risk. There was no increase in the adjusted risk of atrial fibrillation in men though this risk was increased in obese women (2.18, 1.31–3.56) (Table 5).

For every 1 kg/m2 increase in BMI there was a 4% increased risk of myocardial infarction (1.04, 1.03–1.05), a 3% increased risk of stroke (1.03, 1.01–1.04), a 6% increased risk of heart failure (1.06, 1.04–1.08), a 8% increased risk of venous thrombo-embolism (1.08, 1.05–1.11), and a 5% increased risk of atrial fibrillation (1.05, 1.01–1.08).

Fully adjusted risk of death or hospitalization for cardiovascular causes over 20 years of follow-up
When we included diabetes, cholesterol, and hypertension in the multi-variable analysis, obesity remained an independent risk factor for any cardiovascular hospitalization or death in men (1.21, 1.08–1.36) and women (1.22, 1.10–1.36) and for a coronary heart disease event in men (1.32, 1.14–1.53) and women (1.30, 1.11–1.51). Obesity also increased the risk of heart failure (men 2.16, 1.57–2.97; women 1.37, 1.00–1.88), venous thrombo- embolism (men 1.92, 1.13–3.26; women 2.90, 1.67–5.01), and atrial fibrillation in women (1.76, 1.04–2.98), although it was no longer an independent risk factor for stroke (men 1.04, 0.79–1.35; women 1.17, 0.95–1.44).

Potential consequences of increase in obesity
Using the previous data, it is possible to estimate the cardiovascular consequences of the increase in prevalence of obesity from the time of the initial Renfrew–Paisley study screening (1972–76) to the present day. A recent survey showed that the prevalence of obesity in Scotland has risen to 28.8% in men and 26.0% in women aged 45–54 and 23% in men and 31.5% in women aged 55–64 in 1998. We applied the rate of cardiovascular events seen in the Renfrew–Paisley cohort to the Scottish obese population in 1972 and 1998. The number of obese Scots aged 45–64 in 1972 and 1998 was calculated using age-specific population estimates and the obesity prevalence for each year. The difference between the numbers of obese men and women experiencing a cardiovascular event in both years was expressed per 100 men and women in Scotland in 1998. Assuming that the cardiovascular risk profile and outcomes associated with obesity have remained unchanged, the increase in prevalence of obesity between 1976 and 1998 is expected to lead to an additional nine (95% CI 8.7–9.9) per 100 men and an additional five (5.5–6.2) per 100 women experiencing a cardiovascular event (death or hospital admission) between 1998 and 2018. The increase in obesity is also projected to lead to an extra 18 (17.7–18.6) hospital admissions for cardiovascular disease per 100 men and 10 (10.0–10.6) per 100 women over this period.

The increased prevalence of men and women in the overweight category is expected to result in an additional one (1.0–1.1) per 100 cardiovascular events and an additional 1.9 (1.9–1.9) per 100 cardiovascular hospital episodes in men [the corresponding figures for women would be 0.04 (0.4–0.4) per 100 and 0.07 (0.07–0.07) per 100].


   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
Acknowledgements
 References
 
We have been able to examine the association between obesity and a broad spectrum of cardiovascular events in a single, large, population-based cohort followed for 20 years and examine the rates and rankings of these outcomes. The principal finding of this study is that the harmful cardiovascular effects of obesity extend beyond coronary heart disease though, numerically, coronary events account for the greatest proportion of all cardiovascular events.

In the Renfrew–Paisley cohort, obesity was also associated with an increased, long-term risk of fatal and non-fatal (and recurrent) heart failure, venous thrombo-embolism, atrial fibrillation (in women), and, probably, stroke. Consideration of only coronary events, only fatal events, and only first events, therefore, greatly underestimates the cardiovascular burden of obesity.

Stroke and heart failure were, numerically, the two next most frequent adverse cardiovascular outcomes after coronary heart disease. The comparative risk of these two outcomes differed between men and women across the range of BMI.

Heart failure was relatively more common in men, but there was a clear association between obesity and an increased risk of heart failure in both sexes. Indeed, the relative risk of a heart failure event was greater than that for any other type of cardiovascular event, including coronary events, with the exception of the much less common problem of venous thrombo-embolism (see subsequently). Obesity was also particularly associated with multiple hospital admissions for heart failure, which is important given the huge symptom burden and cost related to heart failure. Other studies have shown that obesity increases the risk of heart failure.22–25 In the Framingham study, the risk for heart failure in obese persons was approximately double that in persons with a normal BMI.22

Another equally dreaded and expensive cardiovascular complication is stroke. This was relatively more common in women but, unlike heart failure, the fully adjusted relative risk of this outcome was not increased, statistically significantly, in relation to obesity. There has also been no consistent relationship between obesity and stroke in prior studies.6,26–32 There seem to be a number of explanations for this. The risk of stroke related to obesity may be different in men and women and for ischaemic compared with haemorrhagic stroke.27,28 More contentious is the completeness of adjustment for baseline co-variates. We report two separate multi-variable analysis, one excluding and one including blood pressure, cholesterol, and diabetes. There has been much debate as to whether these obesity-related variables should be adjusted for. Clearly, doing so attenuates the strength of the relationship between obesity and stroke (and other cardiovascular outcomes).

Venous thrombo-embolic events were infrequent compared with heart failure or stroke. However, the adjusted risk for thrombo-embolism was increased relatively more than for any other adverse cardiovascular outcome. Increased risk of thrombo-embolism has been reported before, but no comparison with the rate and risk of other cardiovascular events has been provided.33–35

Lastly, we also looked at the relationship between obesity and atrial fibrillation, which was also infrequent and relatively more common in women. The adjusted relative risk for the composite of death or hospital admission was increased, significantly, in women but not in men though this apparent difference may not be real and may simply reflect low power due to small numbers. The few prior reports on the relation between obesity and atrial fibrillation have given inconsistent results.36–39

Overall, obesity was associated with nine additional cardiovascular deaths and 36 additional cardiovascular hospital admissions for every 100 affected middle-aged men over the subsequent 20 years; for women these numbers were seven and 28, respectively. Clearly, the rise in prevalence of obesity may result in a rise in cardiovascular events, although the calculated number of these events given in the ‘results’ section may be excessive, as newer preventive treatments such as blood pressure and cholesterol lowering, as well as a fall in smoking prevalence, are likely to have reduced the risk related to obesity in more recent times.

Our study has several limitations. A small proportion of individuals had heart disease at initial screening and this was not adjusted for in the analysis. Our main analysis did not adjust for cholesterol, diabetes, and hypertension as it is impossible to disentangle the effect of these different factors from each other and they are important mediators in the risk between obesity and cardiovascular disease; we did, however, include these factors in a separate analysis to determine the independent effects of obesity.

These figures have, of course, only quantified the cardiovascular burden of obesity as reflected by death and hospital admission. Clearly, there was also a potentially huge additional symptom burden related to cardiovascular disease, which may not have led to admission or death, e.g. angina, peripheral arterial disease, atrial fibrillation, and heart failure. Hypertension was another cardiovascular consequence of obesity not directly measured in this study. Our analysis may also have underestimated the true risk of obesity as BMI was only measured at baseline and may increase beyond middle-age, i.e. some of our ‘normal’ BMI group may have become obese during the follow-up period. There is also the possibility of unmeasured confounding factors contributing to the findings. There is a possible lack of applicability to other populations, as this is a cohort from Scotland and because the inception of the cohort occurred 30 years ago. By design, we also did not attempt to quantify the non-cardiovascular effects of obesity.

In summary, obesity is associated with an increased long-term risk of cardiovascular death and hospital admission from a wide range of cardiovascular problems in addition to coronary heart disease. There are three to four times as many admissions as deaths related to obesity. The rising prevalence of obesity will have a potentially huge impact not only on individual health but on the hospital sector.


   Acknowledgements
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Acknowledgements
References
 
N.M. is funded by the British Heart Foundation, S.S. is supported by the NH & MRC and the NHF of Australia. The funding source had no involvement in the study design or in the collection, analysis, and interpretation of data or in the preparation, review, or approval of the manuscript.

Conflict of interest: none declared.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Acknowledgements
 References
 

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