H B Hubert, M Feinleib, P M McNamara and W P Castelli

participants in the Framingham Heart Study.

Obesity as an independent risk factor for cardiovascular disease: a 26-year follow-up of
Print ISSN: 0009-7322. Online ISSN: 1524-4539
Copyright 1983 American Heart Association, Inc. All rights reserved.
is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Circulation
doi: 10.1161/01.CIR.67.5.968
1983;67:968-977 Circulation.
http://circ.ahajournals.org/content/67/5/968
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O b e s i t y as an I nd e p e nd e nt R i s k F ac t o r
f o r C ar d i o v as c u l ar D i s e as e : A 2 6 - y e ar F o l l o w - u p
o f P ar t i c i p ant s i n t h e F r ami ngh am H e ar t S t u d y
H E L E N B . H U B E R T , M. P . H . , P H . D . , MAN N I N G F E I N L E I B , M. D . , D R . P . H . ,
P AT R I C I A M. MC N AMAR A, AN D W I L L I AM P . C AS T E L L I , M. D .
S U MMAR Y T h e r e l at i o ns h i p b e t w e e n t h e d e gr e e o f o b e s i t y and t h e i nc i d e nc e o f c ar d i o v as c u l ar d i s e as e
( C V D ) w as r e e x ami ne d i n t h e 5 2 0 9 me n and w o me n o f t h e o r i gi nal F r ami ngh am c o h o r t . R e c e nt o b s e r v a-
t i o ns o f d i s e as e o c c u r r e nc e o v e r 2 6 y e ar s i nd i c at e t h at o b e s i t y , me as u r e d b y Me t r o p o l i t an R e l at i v e W e i gh t ,
w as a s i gni f i c ant i nd e p e nd e nt p r e d i c t o r o f C V D , p ar t i c u l ar l y amo ng w o me n. Mu l t i p l e l o gi s t i c r e gr e s s i o n
anal y s e s s h o w e d t h at Me t r o p o l i t an R e l at i v e W e i gh t , o r p e r c e nt age o f d e s i r ab l e w e i gh t , o n i ni t i al e x ami na-
t i o n p r e d i c t e d 2 6 - y e ar i nc i d e nc e o f c o r o nar y d i s e as e ( b o t h angi na and c o r o nar y d i s e as e o t h e r t h an angi na) ,
c o r o nar y d e at h and c o nge s t i v e h e ar t f ai l u r e i n me n i nd e p e nd e nt o f age , c h o l e s t e r o l , s y s t o l i c b l o o d p r e s s u r e ,
c i gar e t t e s , l e f t v e nt r i c u l ar h y p e r t r o p h y and gl u c o s e i nt o l e r anc e . R e l at i v e w e i gh t i n w o me n w as al s o p o s i -
t i v e l y and i nd e p e nd e nt l y as s o c i at e d w i t h c o r o nar y d i s e as e , s t r o k e , c o nge s t i v e f ai l u r e , and c o r o nar y and
C V D d e at h . T h e s e d at a f u r t h e r s h o w t h at w e i gh t gai n af t e r t h e y o u ng ad u l t y e ar s c o nv e y e d an i nc r e as e d
r i s k o f C V D i n b o t h s e x e s t h at c o u l d no t b e at t r i b u t e d e i t h e r t o t h e i ni t i al w e i gh t o r t h e l e v e l s o f t h e r i s k
f ac t o r s t h at may h av e r e s u l t e d f r o m w e i gh t gai n. I nt e r v e nt i o n i n o b e s i t y , i n ad d i t i o n t o t h e w e l l e s t ab l i s h e d
r i s k f ac t o r s , ap p e ar s t o b e an ad v i s ab l e go al i n t h e p r i mar y p r e v e nt i o n o f C V D .
T H E I MP O R T AN C E o f b o d y w e i gh t , b o d y mas s and
o t h e r me as u r e s o f ad i p o s i t y i n t h e p r e d i c t i o n o f c ar d i o -
v as c u l ar d i s e as e ( C V D ) h as b e e n t h e s u b j e c t o f l o ng-
s t and i ng d e b at e . Many s t u d i e s h av e s h o w n t h at t h e
i nc i d e nc e o f c e r t ai n t y p e s o f C V D , p ar t i c u l ar l y c o r o -
nar y h e ar t d i s e as e and s t r o k e , i s gr e at e r i n h e av i e r
p e r s o ns , ' ` b u t o nl y a f e w s u gge s t t h at any o b e s i t y
i nd e x mak e s an ad d i t i o nal c o nt r i b u t i o n t o r i s k o nc e t h e
l e v e l s o f c o e x i s t i ng r i s k f ac t o r s ar e t ak e n i nt o ac -
c o u nt . ' . 2 ' 4 O b e s i t y i s as s o c i at e d w i t h e l e v at e d b l o o d
p r e s s u r e , b l o o d l i p i d s and b l o o d gl u c o s e , 7 1 and
c h ange s i n b o d y w e i gh t ar e c o i nc i d e nt w i t h c h ange s i n
t h e s e r i s k f ac t o r s f o r d i s e as e . " , 1 1 3 T h u s , t h e c o ns e ns u s
h as b e e n t h at t h e i nc r e as e d r i s k amo ng h e av i e r p e r s o ns
i s d u e p r i mar i l y t o t h e i nf l u e nc e o f t h e as s o c i at e d r i s k
f ac t o r p r o f i l e and no t t o t h e d e gr e e o f o b e s i t y p e r s e .
T h e e x i s t i ng d at a h av e al s o b e e n i nt e r p r e t e d t o s u gge s t
t h at o b e s i t y i s b e ni gn w h e n i t e x i s t s w i t h o u t o t h e r
maj o r r i s k f ac t o r s f o r C V D .
I n t h i s r e p o r t , w e r e e x ami ne t h e o b e s i t y q u e s t i o n
and d e s c r i b e t h e i nf l u e nc e o f r e l at i v e w e i gh t o n t h e 2 6 -
y e ar i nc i d e nc e o f C V D i n F r ami ngh am me n and w o m-
e n. E ar l i e r r e s u l t s f r o m t h i s s t u d y s u gge s t e d t h at t h e
d e gr e e o f o b e s i t y i s no t a p o t e nt i nd e p e nd e nt r i s k f ac t o r
f o r C V D i n ge ne r al , p ar t i c u l ar l y amo ng w o me n.
1 4 , 1 5
H o w e v e r , t h e s e c o nc l u s i o ns w e r e b as e d o n anal y s e s o f
t h e i nf l u e nc e o f r e l at i v e w e i gh t o v e r s h o r t e r p e r i o d s o f
f o l l o w - u p and may no t h av e c o nv e y e d t h e t r u e i mp ac t
o f d i s e as e r i s k .
S u c h a r e e v al u at i o n ap p e ar s t i me l y i n v i e w o f t h e
c u r r e nt r e v i s i o ns t o t h e o r i gi nal Me t r o p o l i t an L i f e I n-
F r o m t h e E p i d e mi o l o gy and B i o me t r y P r o gr am, N at i o nal H e ar t ,
L u ng, and B l o o d I ns t i t u t e , B e t h e s d a, Mar y l and , and t h e F r ami ngh am
H e ar t S t u d y , F r ami ngh am, Mas s ac h u s e t t s .
P r e s e nt e d i n p ar t at t h e 2 2 nd Annu al C o nf e r e nc e o n C ar d i o v as c u l ar
D i s e as e E p i d e mi o l o gy , S an Ant o ni o , T e x as , Mar c h 1 9 8 2 .
Ad d r e s s f o r c o r r e s p o nd e nc e : H e l e n H u b e r t , P h . D . , N H L B I , F e d e r al
B u i l d i ng, R o o m 3 0 0 , B e t h e s d a, Mar y l and 2 0 2 0 5 .
R e c e i v e d J u l y 2 9 , 1 9 8 2 ; r e v i s i o n ac c e p t e d D e c e mb e r 2 0 , 1 9 8 2 .
C i r c u l at i o n 6 7 , N o . 5 , 1 9 8 3 .
s u r anc e C o mp any d e s i r ab l e w e i gh t t ab l e s . 1 6 T h e s e
d e s i r ab l e w e i gh t s , d e r i v e d f r o m t h e mo r t al i t y e x p e r i -
e nc e s o f s u b s c r i b e r s , h av e b e e n r e v i s e d u p w ar d b e -
c au s e ne w d at a o n i ns u r e d l i v e s ' 7 s u gge s t t h at i t i s
h e al t h i e r t o b e h e av i e r t h an o nc e t h o u gh t . R e c e nt anal -
y s e s o f l o ng- t e r m mo r t al i t y i n F r ami ngh am i nd i c at e ,
h o w e v e r , t h at t h i s may no t b e s o ; mi ni mal mo r t al i t y
o c c u r s at p r e v i o u s l y p u b l i s h e d l e v e l s o f d e s i r ab l e
w e i gh t . ' 8 Al t h o u gh r e c e nt s t at i s t i c s i nd i c at e t h at t h e
ge ne r al U . S . p o p u l at i o n, p ar t i c u l ar l y me n, h as b e e n
ge t t i ng h e av i e r o v e r t h e l as t f e w d e c ad e s , 1 9 2 0 c o ns i d e r -
ab l y mo r e d at a ar e ne e d e d t o e v al u at e t h e i mp l i c at i o ns
o f t h i s t r e nd . L i k e w i s e , r e v i s i o ns t o t h e d e s i r ab l e
w e i gh t t ab l e s s e e m p r e mat u r e , b e c au s e t h e c o mp l e x
r e l at i o ns h i p s b e t w e e n b o d y w e i gh t and h e al t h o r d i s -
e as e ar e s o p o o r l y u nd e r s t o o d . T h i s r e ap p r ai s al o f t h e
i mp ac t o f r e l at i v e w e i gh t o n c ar d i o v as c u l ar mo r b i d i t y
i n F r ami ngh am f u r t h e r e mp h as i z e s t h e ne e d f o r c au -
t i o n, b e c au s e h e al t h - r e l at e d i s s u e s . o t h e r t h an t o t al
mo r t al i t y s h o u l d b e c o ns i d e r e d i n ar r i v i ng at ac c e p t -
ab l e l e v e l s o f d e s i r ab l e w e i gh t .
Me t h o d s
T h e F r ami ngh am H e ar t S t u d y p o p u l at i o n h as b e e n
e x ami ne d and f o l l o w e d b i e nni al l y f o r t h e d e v e l o p me nt
o f C V D s i nc e 1 9 4 8 . 2 1 I n t h i s r e p o r t w e p r e s e nt t h e
mo r b i d i t y e x p e r i e nc e o f 2 2 5 2 me n and 2 8 1 8 w o me n,
age s 2 8 - 6 2 y e ar s , w h o w e r e f r e e o f c l i ni c al l y r e c o g-
ni z ab l e C V D at t h e f i r s t s t u d y e x ami nat i o n, w h i c h t o o k
p l ac e b e t w e e n 1 9 4 9 and 1 9 5 0 . Mani f e s t at i o ns o f C V D
i nc l u d e d c o r o nar y h e ar t d i s e as e , c o nge s t i v e h e ar t f ai l -
u r e , s t r o k e and i nt e r mi t t e nt c l au d i c at i o n.
F o r t h e p u r p o s e s o f t h i s r e p o r t , t h e s u b j e c t s w e r e
c l as s i f i e d b y w e i gh t and o t h e r r i s k at t r i b u t e s at t h e
i ni t i al e x ami nat i o n o nl y and o b s e r v e d o v e r 2 6 y e ar s f o r
t h e d e v e l o p me nt o f C V D . T h e o b e s i t y i nd e x c h o s e n t o
c h ar ac t e r i z e t h e p o p u l at i o n w as Me t r o p o l i t an R e l at i v e
W e i gh t ( MR W ) , o r p e r c e nt age o f d e s i r ab l e w e i gh t ( t h e
r at i o o f ac t u al w e i gh t t o d e s i r ab l e w e i gh t x 1 0 0 ) .
D e s i r ab l e w e i gh t f o r e ac h s e x w as d e r i v e d f r o m t h e
9 6 8
by guest on June 23, 2014 http://circ.ahajournals.org/ Downloaded from
O B E S I T Y AN D C AR D I O V AS C U L AR D I S E AS E / H u b e r t e t al .
1 9 5 9 Me t r o p o l i t an L i f e I ns u r anc e C o mp any t ab l e s ' 6 b y
t ak i ng t h e mi d p o i nt o f t h e w e i gh t r ange f o r t h e me d i u m
b u i l d at a s p e c i f i e d h e i gh t . S i nc e d e s i r ab l e w e i gh t s
w e r e r e p o r t e d f o r s u b j e c t s w e ar i ng b o t h c l o t h e s and
s h o e s , t h e s e f i gu r e s w e r e ad j u s t e d i n o r d e r t o ap p l y
t h e m t o F r ami ngh am s u b j e c t s , w h o w e r e w e i gh e d
and me as u r e d i n a d r e s s i ng go w n and w i t h o u t s h o e s
( t ab l e 1 ) .
O t h e r c h ar ac t e r i s t i c s o f i nt e r e s t at t h e i ni t i al e x -
ami nat i o n w e r e s y s t o l i c b l o o d p r e s s u r e , me as u r e d i n
t h e l e f t ar m o f t h e s e at e d s u b j e c t s w i t h a me r c u r y
s p h y gmo mano me t e r and a 1 4 - c m c u f f l o ng e no u gh
t o f i t t h e mo s t o b e s e ar m; s e r u m c h o l e s t e r o l c o nc e n-
t r at i o n, d e t e r mi ne d b y t h e me t h o d o f S p e r r y ; 2 2 t h e
nu mb e r o f c i gar e t t e s s mo k e d p e r d ay , as s e s s e d b y a
p h y s i c i an- ad mi ni s t e r e d me d i c al h i s t o r y q u e s t i o nnai r e ;
gl u c o s e i nt o l e r anc e , d e f i ne d b y a c as u al b l o o d gl u c o s e
l e v e l o f at l e as t 1 2 0 mg%, t h e p r e s e nc e o f gl y c o s u r i a o r
a d e f i ni t e h i s t o r y o f d i ab e t e s ; and l e f t v e nt r i c u l ar h y -
p e r t r o p h y o n a 1 3 - l e ad E C G.
C r i t e r i a f o r e ac h c ar d i o v as c u l ar o u t c o me d u r i ng f o l -
l o w - u p w e r e s t and ar d i z e d , 2 3 and d e c i s i o ns r e gar d i ng
d i agno s i s w e r e mad e b y a p ane l o f F r ami ngh am i nv e s -
t i gat o r s . C o r o nar y h e ar t d i s e as e i nc l u d e d d i agno s e s o f
( 1 ) angi na p e c t o r i s , e v i d e nc e d b y a t y p i c al h i s t o r y o f
c h e s t p ai n o n a p h y s i c i an- ad mi ni s t e r e d q u e s t i o nnai r e ;
( 2 ) my o c ar d i al i nf ar c t i o n, d e t e r mi ne d b y s p e c i f i e d
e l e c t r o c ar d i o gr ap h i c c h ange s , d i agno s t i c e l e v at i o n o f
s e r u m e nz y me s w i t h p r o l o nge d i s c h e mi c c h e s t p ai n, o r
au t o p s y ; ( 3 ) c o r o nar y i ns u f f i c i e nc y , d e f i ne d as p r o -
l o nge d i s c h e mi c c h e s t p ai n ac c o mp ani e d b y t r ans i e nt
i s c h e mi c ab no r mal i t i e s o n t h e E C G; and ( 4 ) s u d d e n ( i n
T AB L E 1 . Ad j u s t e d D e s i r ab l e W e i gh t s f o r t h e F r ami ngh am H e ar t
S t u d y P ar t i c i p ant s
H e i gh t
W e i gh t ( l b )
( i nc h e s ) Me n W o me n
5 5 9 4
5 6
5 7
5 8
5 9
6 0
6 1
6 2
6 3
6 4
6 5
6 6
6 7
6 8
6 9
7 0
7 1
7 2
7 3
7 4
1 1 6
1 1 9
1 2 2
1 2 5
1 2 8
1 3 1
1 3 5
1 4 0
1 4 4
1 4 8
1 5 2
1 5 7
1 6 1
1 6 6
1 7 0
9 7
1 0 0
1 0 3
1 0 6
1 0 9
1 1 2
1 1 6
1 2 0
1 2 4
1 2 8
1 3 2
1 3 6
1 4 0
l e s s t h an 1 h o u r ) o r no ns u d d e n c o r o nar y d e at h . C o n-
ge s t i v e h e ar t f ai l u r e w as i nd i c at e d w h e n at l e as t t w o
maj o r o r o ne maj o r and t w o mi no r d i agno s t i c c o nd i -
t i o ns e x i s t e d c o nc u r r e nt l y u p o n e x ami nat i o n. 2 3 T h e
maj o r s t r o k e e nd p o i nt o f i nt e r e s t w as at h e r o t h r o m-
b o t i c b r ai n i nf ar c t i o n, d e f i ne d as t h e s u d d e n o ns e t o f a
l o c al i z i ng ne u r o l o gi c d e f i c i t l as t i ng o v e r 2 4 h o u r s
w i t h o u t e v i d e nc e o f e mb o l i s m o r h e mo r r h age . I nt e r -
mi t t e nt c l au d i c at i o n w as d i agno s e d f r o m s u b j e c t i v e
r e s p o ns e s t o q u e s t i o ns o n c al f c r amp i ng d u r i ng e x -
e r t i o n.
P r e l i mi nar y anal y s e s o f t h e d at a c o ns i s t e d o f c al c u -
l at i ng c r u d e i nc i d e nc e r at e s o f d i s e as e b y l e v e l o f
MR W . Mo r e f o r mal s t at i s t i c al me t h o d s u s e d t o as s e s s
t h e i nf l u e nc e o f MR W i nd e p e nd e nt l y o f t h e c o e x i s t i ng
l e v e l s o f t h e maj o r c ar d i o v as c u l ar r i s k f ac t o r s r e l i e d
u p o n mu l t i v ar i at e l o gi s t i c r e gr e s s i o n p r o c e d u r e s 2 4 i n
w h i c h t h e p r o b ab i l i t y o f an e v e nt w as d e s c r i b e d as a
f u nc t i o n o f s e v e r al at t r i b u t e s me as u r e d at e nt r y t o t h e
F r ami ngh am S t u d y . R e gr e s s i o n c o e f f i c i e nt s ge ne r at e d
b y t h e l o gi s t i c mo d e l me as u r e d t h e s t r e ngt h o f t h e
as s o c i at i o n b e t w e e n ad i p o s i t y and t h e p r o b ab i l i t y o f
d i s e as e af t e r ad j u s t me nt f o r age and t h e o t h e r r i s k
f ac t o r s . T h e c o e f f i c i e nt s d i v i d e d b y t h e i r s t and ar d e r -
r o r s p r o v i d e d t e s t s o f s i gni f i c anc e t o i nd i c at e w h e t h e r
t h e s e r e l at i o ns h i p s w e r e s i gni f i c ant l y d i f f e r e nt f r o m
z e r o ( p
-
0 . 0 5 w h e n z 1 . 9 6 ) . S t and ar d i z e d c o e f f i -
c i e nt s t h at ad j u s t f o r d i f f e r e nc e s i n me as u r e me nt u ni t s
b e t w e e n v ar i ab l e s w e r e al s o c al c u l at e d t o s h o w t h e
i mp ac t o f w e i gh t r e l at i v e t o t h e o t h e r r i s k f ac t o r s f o r
d i s e as e .
R e s u l t s
D u r i ng t h e 2 6 - y e ar f o l l o w - u p , 8 7 0 me n and 6 8 8
w o me n d e v e l o p e d c l i ni c al l y r e c o gni z ab l e C V D . Al -
t h o u gh s o me s u b j e c t s h ad mo r e t h an o ne mani f e s t at i o n
o f d i s e as e , c o r o nar y h e ar t d i s e as e ac c o u nt e d f o r a l ar ge
p r o p o r t i o n o f t h e e v e nt s , 7 5 % and 6 6 % i n me n and
w o me n, r e s p e c t i v e l y . C o nge s t i v e f ai l u r e o c c u r r e d i n
1 8 3 me n and 1 6 5 w o me n and at h e r o t h r o mb o t i c s t r o k e
i n 1 0 6 me n and 1 0 3 w o me n. I nt e r mi t t e nt c l au d i c at i o n
w as d i agno s e d mo r e o f t e n i n mal e s t h an i n f e mal e s
( 1 7 1 v s 1 1 2 ) .
At e nt r y t o t h e s t u d y , t h e d i s e as e - f r e e F r ami ngh am
c o h o r t ap p e ar e d t o b e c o ns i d e r ab l y o v e r w e i gh t . O n t h e
av e r age , me n w e r e 1 8 . 9 % and w o me n 2 0 . 5 % ab o v e
d e s i r ab l e w e i gh t . Al t h o u gh t h e d i s t r i b u t i o ns o f i ni t i al
r e l at i v e w e i gh t s w e r e v e r y s i mi l ar i n me n y o u nge r t h an
4 0 y e ar s , 4 0 - 4 9 y e ar s and 5 0 y e ar s o r o l d e r , w o me n
ap p e ar e d t o b e h e av i e r i n e ac h s u b s e q u e nt age gr o u p
( f i g. 1 ) . C l e ar l y , a l ar ge r p r o p o r t i o n o f f e mal e s t h an
mal e s w e r e at t h e u p p e r e nd o f t h e w e i gh t d i s t r i b u t i o n,
p ar t i c u l ar l y amo ng t h e 5 0 - 6 2 - y e ar - o l d s .
F i gu r e 2 s h o w s s e x - and age - s p e c i f i c c r u d e i nc i -
d e nc e r at e s f o r t o t al C V D o v e r 2 6 y e ar s b y
MR W at
e nt r y t o t h e s t u d y . F o r t h i s p u r p o s e o nl y ,
r e l at i v e
w e i gh t w as c at e go r i z e d as l e s s t h an 1 1 0 , 1 1 0 - 1 2 9 ,
and
1 3 0 o r o v e r ; t h e mi d d l e c at e go r y s p anne d e v e nl y o v e r
t h e me an w e i gh t s f o r me n and w o me n. T h e r i s k o f
C V D i nc r e as e d i n b o t h me n and w o me n w i t h i nc r e as -
i ng MR W . H o w e v e r , t h e as s o c i at i o n o f w e i gh t
t o i nc i -
9 6 9
by guest on June 23, 2014 http://circ.ahajournals.org/ Downloaded from
V O L 6 7 , N o 5 , MAY 1 9 8 3
U
z
U 1 1
L U
0 -
1 0 l
3 0
z
L U
C )
a:
L U
a-
ME N
W O ME N
<8 0 9 0 9 - 9 1 1 0 - 1 1 9 1 3 0 - 1 3 9 1 5 0 - 1 5 9 1 7 0 -
8 0 - 8 9 1 0 0 - 1 0 9 1 2 0 - 1 2 9 1 4 0 - 1 4 9 1 6 0 - 1 6 9 1 8 0 +
ME T R O P O L I T AN R E L AT I V E W E I GH T ( %)
F I GU R E 1 . Age - and s e x - s p e c i f i c d i s t r i b u t i o ns o f Me t r o p o l i -
t an R e l at i v e W e i gh t at t h e i ni t i al F r ami ngh am e x ami nat i o n.
d e nc e w as mo s t p r o no u nc e d i n t h o s e y o u nge r t h an 5 0
y e ar s . T h i s o b s e r v at i o n w as b o r ne o u t i n l o gi s t i c r e -
gr e s s i o n anal y s e s b y s e x and age gr o u p , w h e r e t h e
i mp ac t o f w e i gh t w as s i mi l ar i n t h o s e y o u nge r t h an 4 0
y e ar s and 4 0 - 4 9 y e ar s , b u t gr e at e r i n t h e s e t w o age
gr o u p s c o mb i ne d t h an i n t h e o l d e r s e gme nt o f t h e
c o h o r t .
ME N
6 0 0 r
<5 0
5 0 0
F
4 0 0 -
w
C - )
z
L U
u
z
3 0 0 F
2 0 0 V
1 0 0
0
( N )
1 1 0 - 1 2 9
( 4 9 8 ) ( 7 0 7 ) ( 3 8 6 )
S i mi l ar r e l at i o ns h i p s w e r e e v i d e nt b e t w e e n MR W
and c o r o nar y d i s e as e , t h e mo s t f r e q u e nt mani f e s t at i o n
o f C V D ( f i g. 3 ) . I nc i d e nc e al s o i nc r e as e d w i t h i nc r e as -
i ng MR W , and t h e gr ad i e nt o f r i s k w as s t e e p e r i n t h e
y o u nge r me n and w o me n. Amo ng me n y o u nge r t h an
5 0 y e ar s , t h e h e av i e s t gr o u p e x p e r i e nc e d t w i c e t h e r i s k
o f c o r o nar y d i s e as e c o mp ar e d w i t h t h e l e ane s t gr o u p .
T h e r i s k w as i nc r e as e d 2 . 4 - f o l d amo ng o b e s e w o me n
o f s i mi l ar age . T h e r e l at i o ns h i p s f o r r i s k o f my o c ar d i al
i nf ar c t i o n w e r e s i mi l ar t o t h o s e f o r t o t al c o r o nar y d i s -
e as e ( f i g. 4 ) . H o w e v e r , t h e r e w as a mu c h s t r o nge r
gr ad i e nt o f r i s k f o r s u d d e n d e at h w i t h i nc r e as i ng MR W
i n e ac h age gr o u p i n b o t h s e x e s ( f i g. 5 ) . I n f ac t , t h e s e
c r u d e r at e s s u gge s t t h at t h e i mp ac t o f w e i gh t o n r i s k
may b e mo s t p r o no u nc e d f o r t h i s o u t c o me . F i gu r e 6
s h o w s t h at t h e 2 6 - y e ar i nc i d e nc e o f c o nge s t i v e h e ar t
f ai l u r e i n t h e y o u nge r me n and w o me n i nc r e as e d 2 . 5 -
t o 3 - f o l d f r o m t h e l e ane s t t o t h e h e av i e s t s u b j e c t s .
U nl i k e c o r o nar y d i s e as e , i t ap p e ar e d t h at t h e r i s k o f
c o nge s t i v e f ai l u r e i n w o me n w as e l e v at e d o nl y i n t h e
mo s t o b e s e gr o u p . MR W h ad a gr e at e r i mp ac t o n t h e
i nc i d e nc e o f at h e r o t h r o mb o t i c s t r o k e i n w o me n t h an i n
me n ( f i g. 7 ) . W o me n y o u nge r t h an 7 0 y e ar s w h o w e r e
3 0 % o r mo r e o v e r d e s i r ab l e w e i gh t e x p e r i e nc e d o v e r
f o u r t i me s t h e s t r o k e r at e o f t h e l e ane s t gr o u p .
H o w e v e r , no t e v e r y c ar d i o v as c u l ar e nd p o i nt w as
c o ns i s t e nt l y r e l at e d t o MR W . T h e 2 6 - y e ar i nc i d e nc e o f
i nt e r mi t t e nt c l au d i c at i o n, i nd i c at i v e o f p e r i p h e r al v as -
c u l ar d i s e as e , d i d no t ap p e ar t o b e c l e ar l y r e l at e d t o t h e
d e gr e e o f o v e r w e i gh t i n e i t h e r me n o r w o me n ( f i g. 8 ) .
Mu l t i v ar i at e l o gi s t i c r e gr e s s i o n anal y s e s w e r e u n-
d e r t ak e n t o as c e r t ai n w h e t h e r t h e s t r o ng r e l at i o ns h i p s
b e t w e e n w e i gh t and d i s e as e w o u l d p e r s i s t u p o n ad j u s t -
me nt f o r t h e i nf l u e nc e o f t h e c o e x i s t i ng l e v e l s o f t h e
maj o r C V D r i s k f ac t o r s . T h e s e i nc l u d e d age , s y s t o l i c
b l o o d p r e s s u r e , s e r u m c h o l e s t e r o l , c i gar e t t e s p e r d ay ,
W O ME N
5 0 + 5 8 9
4 8 5
5 1 9
<1 1 0 1 3 0 +
1 1 0 - 1 2 9
( 1 7 1 ) ( 3 1 4 ) ( 1 7 5 )
<5 0
1 1 0 - 1 2 9
( 7 9 2 ) ( 7 6 4 ) ( 4 2 4 )
3 8 2
5 0 +
3 7 6
4 5 2
F I GU R E 2 . T w e nt y - s i x - y e ar i nc i d e nc e o f c ar -
d i o v as c u l ar d i s e as e b y Me t r o p o l i t an R e l at i v e
W e i gh t at e nt r y amo ng F r ami ngh am me n and
w o me n y o u nge r t h an age 5 0 y e ar s and age 5 0
y e ar s o r o l d e r . N
=
t h e nu mb e r at r i s k f o r an
e v e nt . N u mb e r s ab o v e t h e b ar s gi v e t h e ac t u al
i nc i d e nc e r at e s p e r 1 0 0 0 .
< 1 1 0 1 3 0 +
1 1 0 - 1 2 9
( 1 5 7 ) ( 3 1 4 ) ( 3 6 3 )
ME T R O P O L I T AN R E L AT I V E W E I GH T ( %)
9 7 0 C I R C U L AT I O N
by guest on June 23, 2014 http://circ.ahajournals.org/ Downloaded from
O B E S I T Y AN D C AR D I O V AS C U L AR D I S E AS E / H u b e r t e t al .
W O ME N
F I GU R E 3 . T w e nt y - s i x - y e ar i nc i d e nc e o f c o r o -
nar y h e ar t d i s e as e b y Me t r o p o l i t an R e l at i v e
W e i gh t at e nt r y amo ng F r ami ngh am me n and
w o me n y o u nge r t h an age 5 0 y e ar s and age 5 0
y e ar s o r o l d e r . N
=
t h e nu mb e r at r i s k f o r an
e v e nt . N u mb e r s ab o v e t h e b ar s gi v e t h e ac t u al
i nc i d e nc e r at e s p e r 1 0 0 0 .
ME T R O P O L I T AN R E L AT I V E W E I GH T ( %)
gl u c o s e i nt o l e r anc e ( no , y e s ) , and e l e c t r o c ar d i o gr ap h -
i c l e f t v e nt r i c u l ar h y p e r t r o p h y ( no , p o s s i b l e , d e f i ni t e ) .
I n al l r e gr e s s i o n p r o c e d u r e s , MR W and age w e r e e n-
t e r e d as c o nt i nu o u s r at h e r t h an c at e go r i c al v ar i ab l e s .
T h e r e s u l t s i n t ab l e 2 i nd i c at e t h at MR W w as a s i gni f i -
c ant p r e d i c t o r o f t o t al C V D i n b o t h me n and w o me n
af t e r ad j u s t me nt f o r r i s k f ac t o r s . Al t h o u gh i nd e p e nd -
e nt r e l at i o ns h i p s w e r e ap p ar e nt f o r angi na, c o r o nar y
d i s e as e o t h e r t h an angi na, c o nge s t i v e f ai l u r e , and
c o r o nar y d e at h i n b o t h s e x e s , t h e p r o b ab i l i t i e s o f my o -
c ar d i al i nf ar c t i o n, at h e r o t h r o mb o t i c s t r o k e , and c ar -
d i o v as c u l ar d e at h w e r e as s o c i at e d w i t h t h e d e gr e e o f
o b e s i t y i n w o me n o nl y . ( T h e r e gr e s s i o ns t h at ad j u s t e d
f o r age al o ne y i e l d e d s t at i s t i c al l y s i gni f i c ant as s o c i -
ME N
2 5 0
2 0 0
* 1 5 0
0
z
c ] 0
Z 1 0 0
5 0
0
<5 0 5 0 +
W O ME N
<5 0 5 0 +
<1 1 0 1 3 0 + <1 1 0 1 3 0 + <1 1 0 1 3 0 + <1 1 0 1 3 0 +
1 1 0 - 1 2 9 1 1 0 - 1 2 9 1 1 0 - 1 2 9 1 1 0 - 1 2 9
( N ) ( 4 9 8 ) ) 7 0 7 ) ( 3 8 6 ) ( 1 7 1 ) ( 3 1 4 ) ( 1 7 5 ) ( 7 9 2 ) ( 7 6 4 ) ( 4 2 4 ) ( 1 5 7 ) ( 3 1 4 ) ( 3 6 3 )
at i o ns b e t w e e n al l e nd p o i nt s and o b e s i t y i n b o t h
s e x e s . ) MR W w as c l e ar l y a s t r o ng p r e d i c t o r o f s u d d e n
d e at h i n mal e s . T h e f ac t t h at MR W w as no t s i gni f i -
c ant l y as s o c i at e d w i t h s u d d e n d e at h i n f e mal e s c o u l d
b e at t r i b u t e d t o t h e s mal l nu mb e r o f e v e nt s i n t h i s
gr o u p . T h e c o e f f i c i e nt s i n t ab l e 2 s u gge s t t h at t h e
s t r e ngt h o f t h e as s o c i at i o n w as gr e at e s t f o r s u d d e n
d e at h i n me n and c o nge s t i v e f ai l u r e i n w o me n and t h at
t h e r e l at i o ns h i p b e t w e e n MR W and c o r o nar y d i s e as e
w as s t r o nge r i n mal e s t h an i n f e mal e s b e c au s e o f t h e
gr e at e r i nf l u e nc e o f t h i s c h ar ac t e r i s t i c o n t h e d e v e l o p -
me nt o f angi na i n me n. I nc l u s i o n o f ad d i t i o nal r i s k
f ac t o r s ( c ar d i ac e nl ar ge me nt , h e ar t r at e and v i t al c a-
p ac i t y ) i n t h e r e gr e s s i o n f o r c o nge s t i v e f ai l u r e d i d no t
al t e r t h e r e l at i o ns h i p b e t w e e n w e i gh t and d i s e as e . Al -
t h o u gh i t h as b e e n s u gge s t e d t h at l e an c o mp ar e d t o
o b e s e h y p e r t e ns i v e s may b e at i nc r e as e d r i s k o f d e at h
o v e r 8 y e ar s o f f o l l o w - u p i n F r ami ngh am ( u np u b l i s h e d
d at a) , f u r t h e r anal y s e s o f 2 6 - y e ar i nc i d e nc e o f C V D
and c o r o nar y d e at h p r e s e nt e d no e v i d e nc e t o i nd i c at e
ME N W O ME N
<5 0 5 0 + < 5 0 5 0 +
<1 1 0 1 3 0 + <1 1 0 1 3 0 + <1 1 0 1 3 0 + <1 1 0 1 3 0 +
1 1 0 - 1 2 9 1 1 0 - 1 2 9 1 1 0 - 1 2 9 1 1 0 - 1 2 9
( N ) ( 4 9 8 ) ( 7 0 7 ) 1 3 8 6 ) ( 1 7 1 ) ( 3 1 4 ) ) 1 7 5 ) ( 7 9 2 ) ( 7 6 4 ) ) 4 2 4 ) ( 1 5 7 ) ) 3 1 4 ) ) 3 6 3 )
ME T R O P O L I T AN R E L AT I V E W E I GH T ( %)
F I GU R E 4 . T w e nt y - s i x - y e ar i nc i d e nc e o f my o c ar d i al i nf ar c -
t i o n b y Me t r o p o l i t an R e l at i v e W e i gh t at e nt r y amo ng F r a-
mi ngh am me n and w o me n y o u nge r t h an age 5 0 y e ar s and age 5 0
y e ar s o r o l d e r . N = t h e nu mb e r at r i s k f o r an e v e nt . N u mb e r s
ab o v e t h e b ar s gi v e t h e ac t u al i nc i d e nc e r at e s p e r 1 0 0 0 .
ME T R O P O L I T AN R E L AT I V E W E I GH T ( %)
F I GU R E 5 . T w e nt y - s i x - y e ar i nc i d e nc e o f s u d d e n d e at h b y Me t -
r o p o l i t an R e l at i v e W e i gh t at e nt r y amo ng F r ami ngh am me n and
w o me n y o u nge r t h an age 5 0 y e ar s and age 5 0 y e ar s o r o l d e r . N
= t h e nu mb e r at r i s k f o r an e v e nt . N u mb e r s ab o v e t h e b ar s gi v e
t h e ac t u al i nc i d e nc e r at e s p e r 1 0 0 0 .
5 0 0
ME N
4 0 0 k
3 0 0 F
w
zC X
w
0
z
2 0 0 k
1 0 0 1
n
<1 1 0 1 3 0 + <1 1 0 1 3 0 + <1 1 0 1 3 0 + <1 1 0 1 3 0 +
1 1 0 - 1 2 9 1 1 0 - 1 2 9 1 1 0 - 1 2 9 1 1 0 - 1 2 9
( N ) ( 4 9 8 ) ( 7 0 7 ) ( 3 8 6 ) ( 1 7 1 ) ( 3 1 4 ) ( 1 7 5 ) ( 7 9 2 ) ( 7 6 4 ) ( 4 2 4 ) ( 1 5 7 ) ( 3 1 4 ) ( 3 6 3 )
9 7 1
by guest on June 23, 2014 http://circ.ahajournals.org/ Downloaded from
V O L
6 7 , N o 5 ,
MAY 1 9 8 3
ME N W O ME N
F I GU R E 6 . T w e nt y - s i x - y e ar i nc i d e nc e o f c o n-
ge s t i v e h e ar t f ai l u r e b y Me t r o p o l i t an R e l at i v e
W e i gh t at e nt r y amo ng F r ami ngh am me n and
w o me n y o u nge r t h an age 5 0 y e ar s and age 5 0
y e ar s o r o l d e r . N = t h e nu mb e r at r i s k f o r an
e v e nt . N u mb e r s ab o v e t h e b ar s gi v e t h e ac t u al
i nc i d e nc e r at e s p e r 1 0 0 0 .
w
C )
z
z
<1 1 0 1 3 0 + <1 1 0 1 3 0 + <1 1 0 1 3 0 + <1 1 0 1 3 0 +
1 1 0 - 1 2 9 1 1 0 - 1 2 9 1 1 0 - 1 2 9 1 1 0 - 1 2 9
( N ) ( 4 9 8 ( 7 0 7 ) ( 3 8 6 ) ( 1 7 1 ) ( 3 1 4 ) ( 1 7 5 ) ( 7 9 2 ) 7 6 4 ) ( 4 2 4 ) ( 1 5 7 ) ( 3 1 4 ) ( 3 6 3 )
ME T R O P O L I T AN R E L AT I V E W E I GH T ( %)
t h at t h e r e w as s u c h an i nt e r ac t i o n e f f e c t b e t w e e n
w e i gh t and i t s s t r o nge s t c o r r e l at e , b l o o d p r e s s u r e .
T h e magni t u d e o f t h e s t and ar d i z e d r e gr e s s i o n c o e f -
f i c i e nt s i nd i c at e d t h at d e gr e e o f o b e s i t y w as o ne o f t h e
b e s t p r e d i c t o r s o f t o t al C V D i n w o me n ( t ab l e 3 ) . I n t h i s
gr o u p , w e i gh t r ank e d o nl y b e h i nd age and b l o o d p r e s -
s u r e , w h i l e i n me n i t r ank e d b e h i nd al l t h e o t h e r r i s k
f ac t o r s . MR W amo ng mal e s w as a b e t t e r p r e d i c t o r o f
mani f e s t at i o ns o f c o r o nar y h e ar t d i s e as e t h an b l o o d
p r e s s u r e , c i gar e t t e s mo k i ng, gl u c o s e i nt o l e r anc e o r
e l e c t r o c ar d i o gr ap h i c l e f t v e nt r i c u l ar h y p e r t r o p h y .
I t h as b e e n ar gu e d t h at o b e s i t y d o e s no t c o nv e y an
i nc r e as e d r i s k o f d i s e as e u nl e s s i t i s ac c o mp ani e d b y
e l e v at i o ns i n s u c h c h ar ac t e r i s t i c s as b l o o d p r e s s u r e o r
b l o o d l i p i d s . T h i s h y p o t h e s i s w as e x ami ne d b y c al c u -
l at i ng C V D i nc i d e nc e r at e s b y l e v e l o f MR W i n me n
and w o me n y o u nge r t h an 5 0 y e ar s o f age w h o w e r e
f r e e o f r i s k f ac t o r s at e nt r y i nt o t h e s t u d y ( f i g. 9 ) . T h at
i s , t h e y w e r e no r mo t e ns i v e , h ad s e r u m c h o l e s t e r o l l e v -
e l s l e s s t h an 2 5 0 mg/ d l , d i d no t s mo k e c i gar e t t e s , and
h ad no e v i d e nc e o f gl u c o s e i nt o l e r anc e o r l e f t v e nt r i c u -
l ar h y p e r t r o p h y o n t h e E C G. I t i s no t s u r p r i s i ng t h at
o nl y 8 % o f t h e me n and 1 8 % o f t h e w o me n i n t h e
h i gh e s t w e i gh t c l as s w e r e f r e e o f r i s k f ac t o r s . I n t h e
s u b p o p u l at i o n w i t h o u t maj o r r i s k f ac t o r s f o r d i s e as e ,
C V D i nc i d e nc e r o s e w i t h i nc r e as i ng w e i gh t i n b o t h
me n and w o me n, al t h o u gh t h e gr ad i e nt o f r i s k w as
c l e ar l y s t e e p e r i n mal e s t h an f e mal e s . Mo r e o v e r , l o gi s -
ME N W O ME
1 5 0
-
<5 0 5 0 + <5 0
&1 0 0
_ 9 2
w 8 0
O
7 0
z
2 5 0 -
0 ~~~~0 3
z
F / I
< 1 1 0 1 3 0 + <1 1 0 1 3 0 +
1 1 0 - 1 2 9 1 1 0 - 1 2 9
( N ) ( 4 9 8 ) ( 7 0 7 ) ( 3 8 6 ) ( 1 7 1 ) ( 3 1 4 ) ( 1 7 5 )
E N
t i c r e gr e s s i o n anal y s i s i n t h i s gr o u p s h o w e d t h at t h e
s t r e ngt h o f t h e as s o c i at i o n b e t w e e n MR W and d i s e as e
i n b o t h s e x e s w as at l e as t as gr e at as t h at f o r me n and
w o me n i n t h e t o t al c o h o r t . T h e MR W c o e f f i c i e nt s f o r
t h e s e mal e s and f e mal e s w e r e 0 . 0 1 6 and 0 . 0 1 0 , r e s p e c -
t i v e l y , c o mp ar e d w i t h a c o e f f i c i e nt o f 0 . 0 0 9 f o r t h e
t o t al p o p u l at i o n s h o w n i n t ab l e 2 . T h u s , t h e e f f e c t s o f
o b e s i t y c o u l d b e d e mo ns t r at e d e v e n i n t h o s e w i t h o u t
maj o r r i s k f ac t o r s f o r d i s e as e .
T h e r e l at i o ns h i p o f w e i gh t c h ange t o C V D i nc i d e nc e
w as e x ami ne d b y c o mp ar i ng s e l f - r e p o r t e d w e i gh t at
age 2 5 w i t h w e i gh t s at t h e i ni t i al F r ami ngh am e x ami -
nat i o n. Al t h o u gh r e c al l may b e s u b j e c t t o s o me d e gr e e
o f b i as , t h e r e i s e v i d e nc e f r o m t h e N H L B I T w i n
S t u d y 2 5 and t h e H o no l u l u H e ar t P r o gr am ( p e r s o nal
c o mmu ni c at i o n) t h at w e i gh t s r e p o r t e d many y e ar s
af t e r age 2 5 y e ar s c o r r e l at e f ai r l y w e l l w i t h ac t u al
w e i gh t s o r w e i gh t s r e p o r t e d c l o s e t o t h at age . I n t h i s
s t u d y , w e i gh t c h ange w as d e f i ne d as t h e d i f f e r e nc e
b e t w e e n MR W at e x am 1 and MR W at age 2 5 y e ar s .
L o gi s t i c r e gr e s s i o n anal y s e s s h o w e d t h at c h ange i n
MR W w as p o s i t i v e l y and s i gni f i c ant l y r e l at e d t o r i s k
o f C V D o v e r 2 6 y e ar s i n b o t h s e x e s e v e n af t e r ad j u s t -
me nt f o r t h e e f f e c t s o f MR W at age 2 5 , age at e x am 1 ,
and r i s k f ac t o r l e v e l s . T h e r e l at i v e o d d s o f d e v e l o p i ng
d i s e as e c o r r e s p o nd i ng t o d e gr e e s o f c h ange i n r e l at i v e
w e i gh t w e r e c al c u l at e d f r o m t h e mu l t i v ar i at e r e gr e s -
s i o n e q u at i o n. Al t h o u gh w o me n, o n t h e av e r age ,
5 0 +
1 2 1
F I GU R E 7 . T w e nt y - s i x - y e ar i nc i d e nc e o f at h -
e r o t h r o mb o t i c b r ai n i nf ar c t i o n b y Me t r o p o l i -
6 4 t an R e l at i v e W e i gh t at e nt r y amo ng F r a-
mi ngh am me n and w o me n y o u nge r t h an age 5 0
y e ar s and age 5 0 y e ar s o r o l d e r . N = t h e
nu mb e r at r i s k f o r an e v e nt . N u mb e r s ab o v e t h e
b ar s gi v e t h e ac t u al i nc i d e nc e r at e s p e r 1 0 0 0 .
<1 1 0 1 3 0 + <1 1 0 1 3 0 +
1 1 0 - 1 2 9 1 1 0 - 1 2 9
( 7 9 2 ) ( 7 6 4 ) ( 4 2 4 ( ( 1 5 7 ) ( 3 1 4 ) ( 3 6 3 )
ME T R O P O L I T AN R E L AT I V E W E I GH T ( %)
C I R C U L AT I O N
9 7 2
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by guest on June 23, 2014 http://circ.ahajournals.org/ Downloaded from
O B E S I T Y AN D C AR D I O V AS C U L AR D I S E AS E / H u b e r t e t al .
W O ME N
l 5 O r
<5 0
1 0 0 -
5 0 1 -
0
1 1 0 - 1 2 9
( N ) ( 4 9 8 ) ( 7 0 7 ) ( 3 8 6 )
5 0 +
<1 1 0 1 3 0 +
1 1 0 - 1 2 9
( 1 7 1 ) ( 3 1 4 ) ( 1 7 5 )
<5 0 5 0 +
<l 1 0 1 3 0 + <1 1 0 1 3 0 +
1 1 0 - 1 2 9 1 1 0 - 1 2 9
( 7 9 2 ) ( 7 6 4 ) ( 4 2 4 ) ( 1 5 7 ) ( 3 1 4 ) ( 3 6 3 )
F I GU R E 8 . T w e nt y - s i x - y e ar i nc i d e nc e o f i n-
t e r mi t t e nt c l au d i c at i o n b y Me t r o p o l i t an R e l a-
t i v e W e i gh t at e nt r y amo ng F r ami ngh am me n
and w o me n y o u nge r t h an age 5 0 y e ar s and age
5 0
y e ar s o r o l d e r . N = t h e nu mb e r at r i s k f o r
an e v e nt . N u mb e r s ab o v e t h e b ar s gi v e t h e ac -
t u al i nc i d e nc e r at e s p e r 1 0 0 0 .
ME T R O P O L I T AN R E L AT I V E W E I GH T M%)
gai ne d mo r e w e i gh t t h an me n b e t w e e n age 2 5 and
e nt r y , f i gu r e 1 0 s h o w s t h at t h e ne t e f f e c t o f w e i gh t
c h ange w as gr e at e r i n mal e s t h an f e mal e s . N o ne t h e -
l e s s , o ne c o u l d c o nc l u d e f r o m t h e s e d at a t h at w e i gh t
gai n i nt o t h e mi d d l e and o l d e r age s c o nv e y e d an i n-
c r e as e d r i s k o f d i s e as e and w e i gh t l o s s a d e c r e as e d r i s k
o f d i s e as e t h at c o u l d no t b e at t r i b u t e d e i t h e r t o MR W at
age 2 5 y e ar s o r t h e l e v e l s o f t h e r i s k f ac t o r s t h at may
h av e r e s u l t e d f r o m w e i gh t c h ange .
D i s c u s s i o n
T h e s e d at a c l e ar l y s h o w t h at t h e d e gr e e o f o b e s i t y i n
F r ami ngh am me n and w o me n w as an i mp o r t ant l o ng-
t e r m p r e d i c t o r o f C V D i nc i d e nc e , p ar t i c u l ar l y amo ng
t h e y o u nge r me mb e r s o f t h e c o h o r t . Mo r e o v e r , o b e s i t y
i n b o t h s e x e s d i d no t e x e r t i t s i nf l u e nc e o n t h e r i s k o f
T AB L E 2 . T h e As s o c i at i o n B e t w e e n Me t r o p o l i t an R e l at i v e W e i gh t
at E nt r y and C ar d i o v as c u l ar D i s e as e I nc i d e nc e O v e r 2 6 Ye ar s i n
F r ami ngh am Me n and W o me n
Mu l t i v ar i at e l o gi s t i c
r e gr e s s i o n c o e f f i c i e nt s
f o r MR W
Me n W o me n
E v e nt ( n =
2 1 9 7 ) ( n =
2 7 1 4 )
C H D 0 . 0 1 2 t ( 6 3 6 ) 0 . 0 0 8 t ( 4 3 7 )
AP 0 . 0 1 4 t ( 3 3 6 ) 0 . 0 0 7 * ( 2 7 6 )
C H D o t h e r t h an AP 0 . 0 0 9 t ( 5 1 4 ) 0 . 0 1 0 t ( 2 6 1 )
MI 0 . 0 0 6 ( 3 7 2 ) O . l O t ( 1 6 1 )
D e at h f r o m C H D 0 . 0 0 9 * ( 2 6 6 ) 0 . 0 1 0 t ( 1 3 2 )
S u d d e n d e at h f r o m C H D 0 . 0 1 6 t ( 1 2 0 ) 0 . 0 1 0 ( 4 5 )
C o nge s t i v e h e ar t f ai l u r e 0 . 0 1 4 t ( 1 7 7 ) 0 . 0 1 5 : ( 1 6 1 )
At h e r o t h r o mb o t i c s t r o k e 0 . 0 0 4 ( 1 0 5 ) 0 . 0 1 2 t ( 1 0 0 )
D e at h f r o m C V D 0 . 0 0 6 ( 3 9 5 ) 0 . 0 0 8 t ( 2 6 3 )
T o t al C V D 0 . 0 0 9 t ( 8 4 9 ) 0 . 0 0 9 t ( 6 6 7 )
R e gr e s s i o ns i nc l u d e ad j u s t me nt s f o r age , s y s t o l i c b l o o d p r e s s u r e ,
s e r u m c h o l e s t e r o l , c i gar e t t e s / d ay , gl u c o s e i nt o l e r anc e , and e l e c t r o -
c ar d i o gr ap h i c l e f t v e nt r i c u l ar h y p e r t r o p h y at e x am 1 .
T h e nu mb e r o f e v e nt s i s gi v e n i n p ar e nt h e s e s .
* C o e f f i c i e nt i s s i gni f i c ant l y d i f f e r e nt f r o m z e r o , p < 0 . 0 5 .
t C o e f f i c i e nt i s
s i gni f i c ant l y d i f f e r e nt f r o m
z e r o , p
< 0 . 0 1 .
t C o e f f i c i e nt i s s i gni f i c ant l y d i f f e r e nt f r o m z e r o , p < 0 . 0 0 1 .
Ab b r e v i at i o ns : MR W =
Me t r o p o l i t an R e l at i v e W e i gh t ; C H D =
c o r o nar y h e ar t d i s e as e ; AP =
angi na p e c t o r i s ; MI =
my o c ar d i al
i nf ar c t i o n; C V D = c ar d i o v as c u l ar d i s e as e ; n = nu mb e r at r i s k .
c o r o nar y d i s e as e o r c o nge s t i v e f ai l u r e s o l e l y t h r o u gh
i t s as s o c i at i o n w i t h t h e c o e x i s t i ng r i s k f ac t o r s . I n w o m-
e n, s i gni f i c ant i nd e p e nd e nt r e l at i o ns h i p s w e r e e v i d e nt
f o r at h e r o t h r o mb o t i c s t r o k e as w e l l . T h e l ac k o f as s o c i -
at i o n b e t w e e n w e i gh t and i nc i d e nc e o f i nt e r mi t t e nt
c l au d i c at i o n, o n t h e o t h e r h and , s u gge s t s t h at t h e c au s e
o f t h i s d i s o r d e r may b e s o me w h at d i f f e r e nt f r o m t h at o f
t h e o t h e r c ar d i o v as c u l ar d i s e as e s . T h e s e r e s u l t s mi gh t
al s o b e at t r i b u t e d t o u nd e r d i agno s i s o f i nt e r mi t t e nt
c l au d i c at i o n i n h e av i e r s u b j e c t s w h o may no t w al k o r
e x e r c i s e t o e l i c i t s y mp t o ms w i t h t h e s ame f r e q u e nc y as
l e ane r s u b j e c t s .
I t al s o ap p e ar s t h at o b e s i t y p r e d i s p o s e d t o p r e mat u r e
C V D i n F r ami ngh am. P l o t s o f t h e ac t u ar i al l i f e t ab l e s
f o r t h e y o u nge r me mb e r s o f t h e c o h o r t ( t h o s e y o u nge r
t h an 5 0 y e ar s o f age at e nt r y t o t h e s t u d y ) s h o w h i gh e r
r i s k s f o r t h e h e av i e s t c o mp ar e d w i t h t h e l e ane s t gr o u p
t h r o u gh o u t t h e 2 6 - y e ar f o l l o w - u p p e r i o d ( f i g. 1 ) .
H o w e v e r , d i f f e r e nc e s w e r e mo r e p r o no u nc e d i n t h e
y o u nge r me n t h an w o me n.
W e i gh t w as a r e l at i v e l y p o t e nt r i s k f ac t o r f o r t o t al
C V D i n w o me n. O nl y age and b l o o d p r e s s u r e w e r e
mo r e p o w e r f u l p r e d i c t o r s i n t h i s gr o u p . Mal e - f e mal e
d i f f e r e nc e s r e gar d i ng t h e i mp ac t o f o b e s i t y o n d i s e as e
T AB L E 3 . T h e As s o c i at i o n B e t w e e n t h e Maj o r R i s k F ac t o r s and
D i s e as e I nc i d e nc e O v e r 2 6 Ye ar s i n F r ami ngh am Me n and W o me n
S t and ar d i z e d l o gi s t i c
r e gr e s s i o n c o e f f i c i e nt s
Me n ( n =
2 1 9 7 ) W o me n ( n
=
2 7 1 4 )
R i s k f ac t o r s C H D C V D C H D C V D
Age 0 . 3 2 5 0 . 4 6 9 0 . 3 3 9 0 . 3 9 0
S y s t o l i c b l o o d
p r e s s u r e 0 . 1 7 6 0 . 3 1 1 0 . 2 8 1 0 . 3 3 2
MR W 0 . 2 0 0 0 . 1 4 3 0 . 1 7 5 0 . 1 9 9
S e r u m c h o l e s t e r o l 0 . 3 4 5 0 . 3 0 9 0 . 2 6 6 0 . 1 9 7
C i gar e t t e s / d ay 0 . 1 7 0 0 . 2 3 2 0 . 0 3 5 * 0 . 1 3 9
Gl u c o s e
i nt o l e r anc e 0 . 1 1 1 0 . 2 2 0 0 . 1 0 9 0 . 1 0 0
E C G- L V H 0 . 0 9 8 0 . 2 1 5 0 . 0 1 6 * 0 . 0 8 4 *
* C o e f f i c i e nt s no t s i gni f i c ant l y d i f f e r e nt f r o m
z e r o , p > 0 . 0 5 .
Ab b r e v i at i o ns : C H D =
c o r o nar y h e ar t d i s e as e ; C V D = c ar d i o -
v as c u l ar d i s e as e ; MR W = Me t r o p o l i t an R e l at i v e W e i gh t ; E C G-
L V H =
e l e c t r o c ar d i o gr ap h i c l e f t v e nt r i c u l ar h y p e r t r o p h y ; n =
nu mb e r at r i s k .
ME N
w
0
z
z
9 7 3
by guest on June 23, 2014 http://circ.ahajournals.org/ Downloaded from
V O L 6 7 , N o 5 , MAY 1 9 8 3
ME N
3 0 0
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2 5 0
2 0 0
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0
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1 5 0
1 0 0
5 0
L
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1 2 5
2 0 0
2 6 7
W O ME N
1 0 5
1 2 1
1 2 8
<1 1 0 1 1 0 - 1 2 9 1 3 0 + <1 1 0 1 1 0 - 1 2 9 1 3 0 +
( 5 6 ) ( 7 5 ) ( 3 0 ) ( 1 9 1 ) ( 1 9 9 ) ( 7 8 )
ME T R O P O L I T AN R E L AT I V E W E I GH T ( %)
F I GU R E 9 . T w e nt y - s i x - y e ar i nc i d e nc e o f c ar d i o v as c u l ar d i s -
e as e b y Me t r o p o l i t an R e l at i v e W e i gh t at e nt r y amo ng F r a-
mi ngh am me n and w o me n y o u nge r t h an 5 0 y e ar s o f age w h o
w e r e no r mo t e ns i v e , h ad c h o l e s t e r o l l e v e l s l e s s t h an 2 5 0 mgl d l ,
d i d no t s mo k e c i gar e t t e s , and h ad no e v i d e nc e o f gl u c o s e i nt o l -
e r anc e o r e l e c t r o c ar d i o gr ap h i c l e f t v e nt r i c u l ar h y p e r t r o p h y . N
t h e nu mb e r at r i s k f o r an e v e nt . N u mb e r s ab o v e t h e b ar s gi v e
t h e ac t u al i nc i d e nc e r at e s p e r 1 0 0 0 .
mi gh t b e e x p l ai ne d b y d i f f e r e nc e s i n t h e o p e r at i o n o f
t h e r i s k f ac t o r s o r i n t h e c au s al p at h w ay s l e ad i ng t o
d i s e as e . T h e s e h y p o t h e s e s h av e b e e n s u gge s t e d b y o t h -
e r d at a, 2 6 ' 2 7 b u t ad d i t i o nal f ac t o r s may b e r e s p o ns i b l e
f o r t h e d i f f e r e nc e s o b s e r v e d h e r e . I t i s p o s s i b l e t h at t h e
d i s p ar i t y i n t h e w e i gh t d i s t r i b u t i o ns ( t h at i s , p r o p o r -
t i o nat e l y mo r e w o me n t h an me n w e r e e x t r e me l y o v e r -
w e i gh t ) i nf l u e nc e d t h e r e s u l t s t o a c e r t ai n d e gr e e . R e l a-
t i v e w e i gh t al s o may h av e r e p r e s e nt e d a s o me w h at
d i f f e r e nt me as u r e o f b o d y mas s i n e ac h s e x , s i nc e
e x c e s s w e i gh t r e s u l t e d f r o m mu s c u l ar i t y mo r e o f t e n i n
mal e s t h an f e mal e s . T h i s p o i nt may b e i l l u s t r at e d b y
ad d i t i o nal anal y s e s t h at d e s c r i b e t h e i nf l u e nc e o f o t h e r
me as u r e s o f o b e s i t y o n r i s k . T h e s e s h o w t h at w h i l e
MR W w as no t an i nd e p e nd e nt p r e d i c t o r o f my o c ar d i al
ME N W O ME N
1 . 5
- 1 . 4 6
1 . 1 3
1 . 0 8
l o
v z 0 0 1 . 0
I n
1 0
- - -
1 . 0 0 . - 9 3
- -
. 8 8
i nf ar c t i o n i n F r ami ngh am me n, s u b s c ap u l ar s k i nf o l d
me as u r e me nt s w e r e s i gni f i c ant l y and i nd e p e nd e nt l y
as s o c i at e d w i t h t h i s o u t c o me . T h u s , i t may b e mi s l e ad -
i ng t o s u gge s t t h at o b e s i t y i n me n d i d no t p l ay an
i mp o r t ant r o l e as a p r e c u r s o r t o i nf ar c t i o n.
Age d i f f e r e nc e s i n t h e c o nt r i b u t i o n o f o b e s i t y t o r i s k
h av e al s o b e e n no t e d b y o t h e r s . 1 4 S i mi l ar l y , o t h e r r i s k
f ac t o r s f o r d i s e as e d o no t p r e d i c t as w e l l at o l d e r age s
as at y o u nge r age s . 4 ' 2 8 S e l e c t i o n h as b e e n s u gge s t e d as
an e x p l anat i o n f o r s u c h f i nd i ngs . H e r e , t h e o l d e r ,
h e av i e r s u b j e c t s may h av e b e e n a s e l e c t i v e gr o u p , b e -
c au s e t h e y r e mai ne d r e s i s t ant t o t h e i nf l u e nc e o f o b e s i -
t y d u r i ng e ar l i e r y e ar s . H o w e v e r , w e i gh t s at o l d e r age s
may b e l e s s t y p i c al o f t h e l i f e t i me e x p o s u r e t o o b e s i t y ,
w h i c h may b e i mp o r t ant i n d e t e r mi ni ng r i s k . I f , as
s u s p e c t e d , age at o ns e t and d u r at i o n o f o b e s i t y p l ay a
p ar t i n e x p l ai ni ng t h e o b s e r v e d as s o c i at i o ns w i t h d i s -
e as e , t h e n e ar l i e r me as u r e me nt s may mo r e ac c u r at e l y
c l as s i f y i nd i v i d u al s i nt o r i s k c at e go r i e s t h an t h o s e
mad e i n l at e r y e ar s . T h e f ac t t h at c e r t ai n r i s k f ac t o r s
c o r r e l at e d mo r e s t r o ngl y w i t h r e l at i v e w e i gh t at y o u n-
ge r t h an o l d e r age s al s o s u p p o r t s t h e l at t e r t h e o r y .
P o p u l at i o n s t u d i e s h av e s h o w n t h at t h e e x t r e me l y
l e an as w e l l as t h e mo s t o b e s e ar e at i nc r e as e d r i s k o f
d y i ng o v e r a s p e c i f i e d t i me . 2 9 S u c h o b s e r v at i o ns s u g-
ge s t t h at t h e r e l at i o ns h i p s f o u nd i n t h i s s t u d y mi gh t b e
o v e r s t at e d and at t r i b u t ab l e t o t h e p h e no me no n o f c o m-
p e t i ng r i s k s . T h at i s , t h e l e ane r s u b j e c t s may h av e
ap p e ar e d t o b e at l o w e r r i s k d u e t o t h e f ac t t h at t h e y
d i e d f r o m o t h e r c au s e s b e f o r e t h e y c o u l d d e v e l o p
C V D . A f e w s i mp l e ap p r o ac h e s t o e v al u at i ng t h e p l au -
s i b i l i t y o f s u c h an e x p l anat i o n i nd i c at e d t h at c o mp e t -
i ng r i s k s c o u l d no t ac c o u nt f o r t h e w e i gh t - d i s e as e r e l a-
t i o ns h i p s f o u nd i n F r ami ngh am me n and w o me n. T h e
f i r s t ap p r o ac h e nt ai l e d e s t i mat i ng t h e p r o p o r t i o n o f
s u b j e c t s w h o d i e d o f o t h e r c au s e s b u t w h o w o u l d h av e
b e e n e x p e c t e d t o d e v e l o p C V D i f t h e y h ad l i v e d l o ng
e no u gh . 3 0 T h e c al c u l at i o n o f ne w i nc i d e nc e r at e s b y
l e v e l o f MR W s h o w e d r i s k s as s o c i at e d w i t h i nc r e as e d
MR W t h at w e r e d i mi ni s h e d , b u t o nl y ne gl i gi b l y . As -
s u mi ng t h at t h e l e ane s t s u b j e c t s mi gh t al r e ad y b e i l l
and d i e o f c au s e s o t h e r t h an C V D , r e anal y s i s o f t h e
d at a al s o w as u nd e r t ak e n i nc l u d i ng o nl y s u b j e c t s w i t h
MR W o f 1 0 0 o r mo r e . T h e r e s u l t s s h o w e d as s o c i at i o ns
w i t h C V D t h at w e r e at l e as t as s t r o ng as t h o s e o r i gi -
nal l y o b t ai ne d .
N o t o nl y w as t h e r e a p o w e r f u l r e l at i o ns h i p o f MR W
t o d i s e as e r i s k i n F r ami ngh am, b u t al s o , t h e c h ange i n
F I GU R E 1 0 . T h e r e l at i v e o d d s o f d e v e l o p i ng
1 . 2 6
c ar d i o v as c u l ar d i s e as e c o r r e s p o nd i ng t o d e -
gr e e s o f c h ange i n Me t r o p o l i t an R e l at i v e
W e i gh t b e t w e e n age 2 5 y e ar s and e nt r y i nt o t h e
F r ami ngh am S t u d y . T h e o d d s r at i o s r e f l e c t ad -
j u s t me nt s f o r
t h e
e f f e c t s o f
r e l at i v e
w e i gh t
at
age 2 5 y e ar s and age and r i s k f ac t o r l e v e l s at
e x am 1 .
V . u . I
I
- 1 0 0 1 0 2 0 3 0 - 1 0 0 1 0 2 0 3 0
U N I T C H AN GE I N ME T R O P O L I T AN R E L AT I V E W E I GH T ( %)
.
9 7 4 C I R C U L AT I O N
by guest on June 23, 2014 http://circ.ahajournals.org/ Downloaded from
O B E S I T Y AN D C AR D I O V AS C U L AR D I S E AS E / H u b e r t e t al .
1 . 0
W e MR W
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e at v e
7
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c h ange r i b u i n t h e p r e s e nt i s t u d y s u gge s t s e v e r , o
t h W atme ay ge mo r y e as ge ne r al l s e ans i i e t h an w o mi i e ny
t o t e e f f e c t s o f w e i gh t c h nu t ange , b e au e b e e i t s i mp ac t go n
d i e au s E no t b e a t r i o b u e d s o l e l at i o nt h e s u i n
t h ar d i s e ae n
p at r ac f l l o w s u p
p e x ai ai o u s l yr e p o r t e d o f i nd i ng R e l -
l e v e l s o f e R i ah ate nt r y t o
c h eF r i ngh anm t T h e
p r e S t u d y
afb t p e s d i t o r o e v e f
h nMR W at
age
2 5
y e ar s , w i gt h angw al s e p s i nd i c ae l
t h at i e s w as r emo s t p nu nc e r ae
amo ngy
t h e w h o s t me na
t h e f f e c t s o f w e i gh t c l as s b e t w e e ns t h e i t s i mep w e r t
t anu c e i o f
o f e i y o b e s i t y r o nge
i nc ai d e nc e h o f C V D . e
T h e ae ad i t o nal o ne at r i b u t i o d o s o b e s i y t o t h er s l o i ng-
t e r m p r me d c i n o f al e ' may e b e o i s l r e o l t e d as nd i a p r c r o r
t o e t h e rd e v l o e nt e o f t h e i maj o r r i s k f ac t o r s o r t h o u gh
mt ah b o l i nc and p h
c at u d y
w sr e s t s o w b e i e
i l u e t h e r i s k d e v l t o p mea o w a o r s s
c t h y a
t h y e r e s o . E t y MW i
F r ami ngh amS t d
w as a r e i t o f V
ni f i ant r i nd e p e nd e ns t
p r e d i u c t o r
ao f nh p e t h o e ns i o n o v ae r d 2
i n t h e h e av i e s t
w e i gh t
c l as s b e t w e e n t h e t w o t i me
p e r i -
o d s . T h e s e
f i nd i ngs
l e nd f u r t h e r
s u p p o r t
t o t h e
i mp o r -
t anc e o f d u r at i o n o f
o b e s i t y o n i nc i d e nc e o f C V D .
T h e ad d i t i o nal c o nt r i b u t i o n o f
o b e s i t y
t o t h e
l o ng-
t e r m
p r e d i c t i o n
o f C V D
may
b e i t s r o l e as a
p r e c u r s o r
t o t h e '
d e v e l o p me nt
o f t h e
maj o r
r i s k f ac t o r s o r
t h r o u gh
me t ab o l i c and
p h y s i o l o gi c me c h anl i s ms y e t t o b e i d e n-
t i f i e d . I t s e e ms t h at t h e
d e gr e e o f o b e s i t y may ,
i n f ac t ,
i nf l u e nc e t h e l at e r
d e v e l o p me nt
o f r i s k f ac t o r s s u c h as
h y p e r t e ns i o n. E nt r y
MR W i n
F r ami ' ngh am
w as a
s i g-
ni f i c ant
i nd e p e nd e nt p r e d i c t o r
o f
h y p e r t e ns i o n
o v e r 2 6
y e ar s
i n w o me n, b u t no t i n me n. E x c e s s w e i gh t
i n t h i s
p o p u l at i o n i h ay
al s o h av e b e e n as s o c i at e d w i t h o t h e r
l i f e s t y l e
o r b e h av i o r al c h ar ac t e r i s t i c s w h i c h , o v e r
t i me , may
h av e i nf l u e nc e d C V D r i s k . W h i l e no d at a at
e nt r y
w e r e av ai l ab l e o n
p h y s i c al ac t i v i t y ,
d i e t o r
p e r -
s o nal i t y t y p e , anal y s e s
t h at i nc l u d e d an i nd e x o f s o c i al
c l as s d i d no t
ap ' p e ar
t o h av e
any i mp ac t
o n t h e r e l at i o n-
s h i p s
b e t w e e n
w e i gh t
and d i s e as e .
O t h e r d i r e c t e f f e c t s o f
o v e r w e i gh t may e x p l ai n
i t s
u ni q u e
c o nt r i b u t i o n t o C V D r i s k . R e c e nt d at a
s u gge s t
t h at o b e s i t y i s as s o c i at e d w i t h f i b r i no l y t i c ac t i v i t y and
p l as ma f i b r i no ge n c o nc e nt r at i o ns , w h i c h h av e b e e n
i mp l i c at e d i n t h e o ns e t and c o u r s e o f i s c h e mi c h e ar t
d i s e as e . 3 ' Mo r e o v e r , o b e s i t y ap p e ar s t o i nc r e as e c ar d i -
ac w o r k l o ad and i nt r av as c u l ar v o l u me 3 2 and t o al t e r
gl u c o s e and l i p i d me t ab o l i s m. 3 3 I nc r e as e d c ar d i ac
w o r k l o ad i n a h e av i e r p e r s o n may p r e c i p i t at e an ac u t e
e v e nt o r e l i c i t s y mp t o ms i f t h e c o r o nar y c i r c u l at i o n i s
al r e ad y c o mp r o mi s e d . T h e b u r d e n o f e x c e s s w e i gh t o n
t h e h e ar t al s o h as b e e n s h o w n i n au t o p s y s t u d i e s i n
w h i c h r e l at i v e w e i gh t w as i nd e p e nd e nt l y r e l at e d t o
h e ar t s i z e . 3 4 3 5 O b e s i t y h as al s o b e e n as s o c i at e d w i t h
t h e e x t e nt o f c o r o nar y at h e r o s c l e r o s i s at au t o p s y . 3 4
D e s p i t e t h e f i nd i ngs f r o m c l i ni c al and e x p e r i me nt al
s t u d i e s , t h e r e i s s t i l l mu c h c o nf u s i o n o v e r t h e c o mp l e x
r e l at i o ns h i p b e t w e e n o b e s i t y and C V D r i s k . Mo s t e p i -
d e mi o l o gi c s t u d i e s h av e b e e n c o nc e r ne d w i t h t h e i m-
p ac t o f o v e r w e i gh t o n c o r o nar y h e ar t d i s e as e i n me n.
T h e s e s t u d i e s c an b e u s e d t o h i gh l i gh t s o me o f t h e
d i f f i c u l t i e s i n i nt e r p r e t i ng and c o mp ar i ng r e s u l t s . F o r
e x amp l e , t h e S e v e n C o u nt r i e s S t u d y s h o w e d no s i g-
ni f i c ant as s o c i at i o n b e t w e e n b o d y mas s i nd e x i n mo s t
r e gi o ns and c o r o nar y d i s e as e i nc i d e nc e o v e r 1 0
y e ar s . H o w e v e r , many o f t h e p o p u l at i o ns o b s e r v e d
w e r e c o ns i d e r ab l y l e ane r t h an t h e F r ami ngh am c o h o r t ,
w h o s e w e i gh t s c o mp ar e d f av o r ab l y w i t h t h o s e i n t h e
ge ne r al U . S . p o p u l at i o n. ' 9 T h e l ac k o f s u f f i c i e nt h e t -
e r o ge ne i t y i n ad i p o s i t y , and t h e d i f f e r e nt c u l t u r al and
ge ne t i c c o nt e x t i n w h i c h t h i s c h ar ac t e r i s t i c may h av e
o p e r at e d , mak e c o mp ar ab i l i t y b e t w e e n t h e s e t w o s t u d -
i e s d i f f i c u l t .
D i f f e r e nt i nd e x e s o f o b e s i t y c an b e d i f f e r e nt i al l y
r e l at e d t o d i s e as e r i s k , 3 7 w h i c h may e x p l ai n s o me v ar i -
ab i l i t y i n s t u d y r e s u l t s . W h i l e b o d y mas s i nd e x ( w e i gh t /
h e i gh t 2 ) h as b e e n s u gge s t e d as t h e p r e f e r r e d me as u r e o f
ad i p o s i t y , i n F r ami ngh am i t w as v e r y h i gh l y c o r r e l at e d
w i t h MR W ( r = 0 . 9 9 ) and h ad no gr e at e r p r e d i c t i v e
p o w e r . H o w e v e r , s k i nf o l d me as u r e me nt s o f s u b c u t a-
ne o u s f at ac c u mu l at i o n c o r r e l at e d w i t h MR W t o a l e s s -
e r d e gr e e ( r = 0 . 4 0 - 0 . 6 5 ) , and p r e l i mi nar y r e s u l t s
s u gge s t t h at t h e s e me as u r e s w e r e as s o c i at e d s o me w h at
d i f f e r e nt l y w i t h d i s e as e r i s k i n F r ami ngh am. F u r t h e r -
mo r e , i f i nd e x e s o f o b e s i t y ar e mo r e p o w e r f u l p r e d i c -
t o r s o f d i s e as e i n y o u nge r t h an o l d e r p e r s o ns , d i f f e r -
e nc e s i n t h e age d i s t r i b u t i o ns o f s t u d y p o p u l at i o ns may
al s o s e r v e t o e x p l ai n w h at ap p e ar t o b e c o nf l i c t i ng
r e s u l t s .
T h e l e ngt h o f f o l l o w - u p f o r e v e nt s i n e ac h p o p u l a-
t i o n c an al s o af f e c t t h e c o nc l u s i o ns d r aw n f r o m v ar i o u s
s t u d i e s . S o me e f f e c t s o f o v e r w e i gh t may b e e v i d e nt
o nl y af t e r f o l l o w - u p o v e r l o ng p e r i o d s o f t i me , as s u g-
ge s t e d b y t h e i mp o r t anc e o f d u r at i o n o f o b e s i t y o n
d i s e as e . B o t h t h e F r ami ngh am and Mani t o b a s t u d i e s '
f o u nd o b e s i t y t o b e an i nd e p e nd e nt p r e d i c t o r o f d i s e as e
o n l o ng- t e r m o b s e r v at i o n o nl y . T ab l e 4 s h o w s h o w
o b s e r v at i o n o v e r d i f f e r e nt p e r i o d s o f t i me may r e s u l t i n
d i f f e r e nt i nt e r p r e t at i o ns o f t h e s ame d at a. I n F r a-
mi ngh am me n, a s t r o ng and s i gni f i c ant as s o c i at i o n
b e t w e e n MR W and c o r o nar y d i s e as e i nc i d e nc e d i d no t
e me r ge u nt i l t h e 8 - y e ar f o l l o w - u p , at w h i c h p o i nt t h e
s t r e ngt h o f t h e r e l at i o ns h i p r e mai ne d f ai r l y
c o ns t ant f o r
9 7 5
by guest on June 23, 2014 http://circ.ahajournals.org/ Downloaded from
9 7 6 C I R C U L AT I O N
T AB L E 4 . T h e As s o c i at i o n B e t w e e n Me t r o p o l i t an R e l at i v e W e i gh t
at E nt r y and C o r o nar y H e ar t D i s e as e I nc i d e nc e b y L e ngt h o f F o l -
l o w - u p i n F r ami ngh am Me n and W o me n
Mu l t i v ar i at e l o gi s t i c r e gr e s s i o n
c o e f f i c i e nt s f o r MR W
L e ngt h o f
f o l l o w - u p Me n ( n
=
2 1 9 7 ) W o me n ( n = 2 7 1 4 )
6 y e ar s 0 . 0 0 6 ( 1 1 4 ) 0 . 0 1 1 ( 5 6 )
8 y e ar s 0 . 0 1 4 * ( 1 5 4 ) 0 . 0 0 8 ( 7 8 )
1 4 y e ar s 0 . 0 1 2 t ( 3 1 4 ) 0 . 0 0 8 * ( 1 6 6 )
2 0 y e ar s 0 . 0 1 2 : ( 4 8 0 ) 0 . 0 0 7 * ( 3 0 1 )
2 6 y e ar s 0 . 0 1 2 t ( 6 3 6 ) 0 . 0 0 8 t ( 4 3 7 )
R e gr e s s i o ns i nc l u d e ad j u s t me nt s f o r age , s y s t o l i c b l o o d p r e s s u r e ,
s e r u m c h o l e s t e r o l , c i gar e t t e s / d ay , gl u c o s e i nt o l e r anc e , and e l e c t r o -
c ar d i o gr ap h i c l e f t v e nt r i c u l ar h y p e r t r o p h y at e x am 1 .
T h e nu mb e r o f e v e nt s at d i f f e r e nt f o l l o w - u p t i me s i s gi v e n i n
p ar e nt h e s e s .
* C o e f f i c i e nt i s s i gni f i c ant l y d i f f e r e nt f r o m z e r o , p < 0 . 0 5 .
t C o e f f i c i e nt i s s i gni f i c ant l y d i f f e r e nt f r o m z e r o , p < 0 . 0 1 .
t C o e f f i c i e nt i s s i gni f i c ant l y d i f f e r e nt f r o m z e r o , p
< 0 . 0 0 1 .
Ab b r e v i at i o ns : MR W =
Me t r o p o l i t an R e l at i v e W e i gh t ; n -
nu mb e r at r i s k .
t h e d u r at i o n o f t h e s t u d y . Amo ng w o me n, t h e l o gi s t i c
c o e f f i c i e nt s w e r e f ai r l y s t r o ng and c o ns i s t e nt i n al l
o b s e r v at i o n p e r i o d s . H o w e v e r , s t at i s t i c al s i gni f i c anc e
w as no t ac h i e v e d u nt i l ne ar l y 1 4 y e ar s o f f o l l o w - u p ,
f o r t h e s mal l nu mb e r o f e v e nt s i n t h i s gr o u p r e s u l t e d
i n i ns u f f i c i e nt p o w e r t o t e s t as s u mp t i o ns . P r e v i o u s
anal y s e s , b as e d o n s h o r t e r p e r i o d s o f o b s e r v at i o n,
h av e s u gge s t e d t h at t h e r e i s no i nd e p e nd e nt r e l at i o n-
s h i p b e t w e e n MR W and c o r o nar y r i s k i n F r ami ng-
h am w o me n. ' 4 T h e s e i l l u s t r at i o ns c l e ar l y s h o w t h at
t h e ac c u mu l at e d e v i d e nc e d e s c r i b i ng t h e nat u r e o f
t h e w e i gh t - d i s e as e r e l at i o ns h i p s h o u l d b e i nt e r p r e t e d
c au t i o u s l y .
T h e i s s u e o f i nd e p e nd e nc e c an b e r e s o l v e d o nl y b y
f u r t h e r s t u d y , b u t w e c o nc l u d e f r o m t h e e x i s t i ng d at a
t h at l e anne s s and av o i d anc e o f w e i gh t gai n b e f o r e mi d -
d l e age ar e ad v i s ab l e go al s i n t h e p r e v e nt i o n o f C V D
f o r mo s t Ame r i c an me n and w o me n. T h e s e d at a f u r -
t h e r - i nd i c at e t h at i nt e r v e nt i o n o n t h e w e l l - e s t ab l i s h e d
r i s k f ac t o r s f o r d i s e as e s h o u l d b e ac c o mp ani e d b y
w e i gh t l o s s i n t h e o v e r w e i gh t i nd i v i d u al . L i k e w i s e ,
r e v i s i o ns t o t h e ac t u ar i al d e s i r ab l e w e i gh t t ab l e s ar e
p r e mat u r e , b e c au s e s u c h c h ange s s u gge s t t h at mai nt e -
nanc e o f h e av i e r w e i gh t s w i l l no t d i mi ni s h h e al t h s t at -
u s . T h i s as s u mp t i o n ap p e ar s t o b e u ns u b s t ant i at e d b y
t h e s e as w e l l as o t h e r d at a c o nc e r ne d w i t h t h e i mp ac t o f
o b e s i t y o n mo r b i d i t y and mo r t al i t y . ' 2 ' 4 ' 1 8
Ac k no w l e d gme nt s
T h e au t h o r s t h ank F e l i c i a C ar r and D o r i s S c h e r b ak f o r t h e i r as s i s t anc e
i n p r e p ar i ng t h i s manu s c r i p t .
R e f e r e nc e s
1 . R ab k i n S W , Mat h e w s o n F A, H s u P H : R e l at i o n o f b o d y w e i gh t t o
d e v e l o p me nt o f i s c h e mi c h e ar t d i s e as e i n a c o h o r t o f y o u ng N o r t h
Ame r i c an me n af t e r a 2 6 y e ar o b s e r v at i o n p e r i o d . T h e Mani t o b a
S t u d y . Am J C ar d i o l 3 9 : 4 5 2 , 1 9 7 7
2 . R o b e r t s o n T L , K at o H , Go r d o n T , K agan A, R h o ad s GG, L and
C E , W o r t h R M, B e l s k y J L , D o c k D S , Mi y ani s h i M, K aw amo t o S :
E p i d e mi o l o gi c s t u d i e s o f c o r o nar y h e ar t d i s e as e and s t r o k e i n J ap a-
V O L 6 7 , N o 5 , MAY 1 9 8 3
ne s e me n l i v i ng i n J ap an, H aw ai i and C al i f o r ni a. Am J C ar d i o l 3 9 :
2 4 4 , 1 9 7 7
3 . P au l 0 , L e p p e r MH , P h e l an W H , D u p e r t u i s GW , Mac Mi l l an A,
Mc K e an H , P ar k H : A l o ngi t u d i nal s t u d y o f c o r o nar y h e ar t d i s e as e .
C i r c u l at i o n 2 8 : 2 0 , 1 9 6 3
4 . C h ap man J M, . C o u l s o n AH , C l ar k V A, B o r u n E R : T h e d i f f e r e nt i al
e f f e c t o f s e r u m c h o l e s t e r o l , b l o o d p r e s s u r e and w e i gh t o n t h e i nc i -
d e nc e o f my o c ar d i al i nf ar c t i o n and angi na p e c t o r i s . J C h r o ni c D i s
2 3 : 6 3 1 , 1 9 7 1
5 . P e t i t t i D B , W i nge r d J , P e l l e gr i n F , R amc h ar an S : R i s k o f v as c u l ar
d i s e as e i n w o me n. S mo k i ng, o r al c o nt r ac e p t i v e s , no nc o nt r ac e p t i v e
e s t r o ge ns , and o t h e r f ac t o r s . J AMA 2 4 2 : 1 1 5 0 , 1 9 7 9
6 . H e y man A, K ar p H R , H e y d e n S , B ar t e l A, C as s e l J C , T y r o l e r H A,
H ame s C G: C e r e b r o v as c u l ar d i s e as e i n t h e b i r ac i al p o p u l at i o n o f
E v ans C o u nt y , Ge o r gi a. Ar c h I nt e r n Me d 1 2 8 : 9 4 9 , 1 9 7 1
7 . C h i ang B N , P e r l man L V , E p s t e i n F H : O v e r w e i gh t and h y p e r t e n-
s i o n. A r e v i e w . C i r c u l at i o n 3 9 : 4 0 3 , 1 9 6 9
8 . K anne l W B , Go r d o n T , C as t e l l i W P : O b e s i t y , l i p i d s , and gl u c o s e
i nt o l e r anc e . T h e F r ami ngh am S t u d y . Am J C l i n N u t r 3 2 : 1 2 3 8 ,
1 9 7 9
9 . Gar r i s o n R J , W i l s o n P W , C as t e l l i W P , F e i nl e i b M, K anne l W B ,
Mc N amar a P M: O b e s i t y and l i p o p r o t e i n c h o l e s t e r o l i n t h e F r a-
mi ngh am O f f s p r i ng S t u d y . Me t ab o l i s m 2 9 : 1 0 5 3 , 1 9 8 0
1 0 . N o p p a H , B e ngt s s o n C , B j o r nt o r p P , S mi t h U , T i b b l i n E : O v e r -
w e i gh t i n w o me n me t ab o l i c as p e c t s . T h e p o p u l at i o n s t u d y o f
w o me n i n Go t e b o r g 1 9 6 8 - 1 9 6 9 . Ac t a Me d S c and 2 0 3 : 1 3 5 , 1 9 7 8
1 1 . L e r e n P , As k e v o l d E M, F o s s O P , F r o i l i A, Gr y my r D , H e l ge l and
A, H j e r mann I , H o l me 1 , L u nd - L ar s e n P G, N o r u m K R : T h e O s l o
S t u d y . C ar d i o v as c u l ar d i s e as e i n mi d d l e - age d and y o u ng O s l o
me n. Ac t a Me d S c and ( s u p p l 5 8 8 ) : 1 9 7 7
1 2 . N o p p a H : B o d y w e i gh t c h ange i n r e l at i o n t o i nc i d e nc e o f i s c h e mi c
h e ar t d i s e as e and c h ange i n r i s k f ac t o r s f o r i s c h e mi c h e ar t d i s e as e .
Am J E p i d e mi o l 1 1 1 : 6 9 3 , 1 9 8 0
1 3 . As h l e y F W , K anne l W B : R e l at i o n o f w e i gh t c h ange t o c h ange s i n
at h e r o ge ni c t r ai t s : t h e F r ami ngh am S t u d y . J C h r o ni c D i s 2 7 : 1 0 3 ,
1 9 7 4
1 4 . T r u e t t J , C o r nf i e l d J , K anne l W : A mu l t i v ar i at e anal y s i s o f t h e r i s k
o f c o r o nar y h e ar t d i s e as e i n F r ami ngh am. J C h r o ni c D i s 2 0 : 5 1 1 ,
1 9 6 7
1 5 . K anne l W B , Go r d o n T : O b e s i t y and c ar d i o v as c u l ar d i s e as e . T h e
F r ami ngh am S t u d y . I n O b e s i t y S y mp o s i u m. P r o c e e d i ngs o f a S e r -
v i e r R e s e ar c h I ns t i t u t e S y mp o s i u m, e d i t e d b y B u r l and W L , S am-
u e l P D , Yu d k i n J . E d i nb u r gh , C h u r c h i l l - L i v i ngs t o ne , 1 9 7 4 , p 2 4
1 6 . Me t r o p o l i t an L i f e I ns u r anc e C o mp any : N e w w e i gh t s t and ar d s f o r
me n and w o me n. S t at B u l l Me t r o p o l L i f e I ns u r C o 4 0 : 1 , 1 9 5 9
1 7 . S o c i e t y o f Ac t u ar i e s and As s o c i at i o n o f L i f e I ns u r anc e Me d i c al
D i r e c t o r s o f Ame r i c a: B u i l d S t u d y 1 9 7 9 . S o c i e t y o f Ac t u ar i e s ,
1 9 8 0
1 8 . Gar r i s o n R J , F e i nl e i b M, C as t e l l i W P , Mc N amar a P M: C i gar e t t e
s mo k i ng as a c o nf o u nd e r o f t h e r e l at i o ns h i p b e t w e e n r e l at i v e
w e i gh t and l o ng- t e r m mo r t al i t y i n t h e F r ami ngh am H e ar t S t u d y .
J AMA. I n p r e s s
1 9 . U ni t e d S t at e s D H E W : V i t al and H e al t h S t at i s t i c s . W e i gh t b y
H e i gh t and Age f o r Ad u l t s 1 8 - 7 4 Ye ar s . U ni t e d S t at e s , 1 9 7 1 - 7 4 .
N at i o nal C e nt e r f o r H e al t h S t at i s t i c s , s e r i e s 1 1 , no . 2 0 8
2 0 . U ni t e d S t at e s D H E W : Ad v anc e d D at a f r o m V i t al and H e al t h S t at i s -
t i c s , no . 3 , N o v e mb e r 1 9 , 1 9 7 6
2 1 . D aw b e r T R , Me ad o r s GF , Mo o r e F E : E p i d e mi o l o gi c al ap p r o ac h e s
t o h e ar t d i s e as e : t h e F r ami ngh am S t u d y . Am J P u b l i c H e al t h 4 1 :
2 7 9 , 1 9 5 1
2 2 . S p e r r y W J : A mi c r o me t h o d f o r t h e d e t e r mi nat i o n o f t o t al and f r e e
c h o l e s t e r o l . Am J C l i n P at h o l ( s u p p l 2 ) : 9 1 , 1 9 3 8
2 3 . S h u r t l e f f D : S o me c h ar ac t e r i s t i c s r e l at e d t o t h e i nc i d e nc e o f c ar d i o -
v as c u l ar d i s e as e and d e at h : F r ami ngh am S t u d y , 1 8 - y e ar f o l l o w - u p .
I n T h e F r ami ngh am S t u d y : An E p i d e mi o l o gi c al I nv e s t i gat i o n o f
C ar d i o v as c u l ar D i s e as e , e d i t e d b y K anne l W B , Go r d o n T . W as h -
i ngt o n, D C , U . S . D H E W , 1 9 7 4
2 4 . W al k e r S H , D u nc an D B : E s t i mat i o n o f t h e p r o b ab i l i t y o f an e v e nt
as a f u nc t i o n o f s e v e r al i nd e p e nd e nt v ar i ab l e s . B i o me t r i k a 5 4 : 1 6 7 ,
1 9 6 7
2 5 . F ab s i t z R , F e i nl e i b M, H r u b e c Z: W e i gh t c h ange s i n ad u l t t w i ns .
Ac t a Ge ne t Me d Ge me l l o l 2 9 : 2 7 3 , 1 9 8 0
2 6 . W al d r o n I : S e x d i f f e r e nc e s i n l o nge v i t y . I n S e c o nd C o nf e r e nc e o n
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O B E S I T Y AN D C AR D I O V AS C U L AR D I S E AS E / H u b e r t e t al .
t h e E p i d e mi o l o gy o f Agi ng, e d i t e d b y H ay ne s S G, F e i nl e i b M.
W as h i ngt o n, D C , D H H S , 1 9 8 0 , p 1 6 3
2 7 . B e ngt s s o n C : I s c h ae mi c h e ar t d i s e as e i n w o me n: a s t u d y b as e d o n a
r and o mi z e d p o p u l at i o n s amp l e o f w o me n and w o me n w i t h my o c ar -
d i al i nf ar c t i o n i n Go t e b o r g, S w e d e n. Ac t a Me d S c and ( s u p p l 5 4 9 ) :
1 9 7 3
2 8 . K anne l W B , Go r d o n T : C ar d i o v as c u l ar r i s k f ac t o r s i n t h e age d : t h e
F r ami ngh am S t u d y . I n S e c o nd C o nf e r e nc e o n t h e E p i d e mi o l o gy o f
Agi ng, e d i t e d b y H ay ne s S G, F e i nl e i b M. W as h i ngt o n, D C ,
D H H S , 1 9 8 0 , p 6 5
2 9 . D y e r AR , S t aml e r J , B e r k s o n D M, L i nd b e r g H A: R e l at i o ns h i p o f
r e l at i v e w e i gh t and b o d y mas s i nd e x t o 1 4 - y e ar mo r t al i t y i n t h e
C h i c ago P e o p l e s Gas C o mp any . J C h r o ni c D i s 2 8 : 1 0 9 , 1 9 7 5
3 0 . Gar c i a- P al mi e r i MR , S o r l i e P D , C o s t as R , H av l i k R J : An ap p ar e nt
i nv e r s e r e l at i o ns h i p b e t w e e n s e r u m c h o l e s t e r o l and c anc e r mo r t al -
i t y i n P u e r t o R i c o . Am J E p i d e mi o l 1 1 4 : 2 9 , 1 9 8 1
3 1 . Me ad e T W , C h ak r ab ar t i R , H ai ne s AP , N o r t h W R S , S t i r l i ng Y:
C h ar ac t e r i s t i c s af f e c t i ng f i b r i no l y t i c ac t i v i t y and p l as ma f i b r i no ge n
c o nc e nt r at i o ns . B r Me d J 1 : 1 5 2 , 1 9 7 9
3 2 . Al e x and e r J K : O b e s i t y and c ar d i ac p e r f o r manc e . Am J C ar d i o l 1 4 :
8 6 0 , 1 9 6 4
3 3 . Go r d o n E S : Me t ab o l i c as p e c t s o f o b e s i t y . Ad v Me t ab D i s o r d 4 :
2 2 9 , 1 9 7 0
3 4 . R h o ad s GG, B l ac k w e l d e r W C , S t e mme r mann GN , H ay as k i T ,
K agan A: C o r o nar y r i s k f ac t o r s and au t o p s y f i nd i ngs i n J ap ane s e -
Ame r i c an me n. L ab I nv e s t 3 8 : 3 0 4 , 1 9 7 8
3 5 . F e i nl e i b M, K anne l W B , T e d e s c h i C G, L and au T K , Gar r i s o n R J :
T h e r e l at i o n o f ant e mo r t e m c h ar ac t e r i s t i c s t o c ar d i o v as c u l ar f i nd -
i ngs at ne c r o p s y . At h e r o s c l e r o s i s 3 4 : 1 4 5 , 1 9 7 9
3 6 . K e y s A: S e v e n C o u nt r i e s . A Mu l t i v ar i at e Anal y s i s o f D e at h and
C o r o nar y H e ar t D i s e as e . C amb r i d ge , MA, H ar v ar d U ni v e r s i t y
P r e s s , 1 9 8 0
3 7 . S and e r s K : C o r o nar y - ar t e r y d i s e as e and o b e s i t y . L anc e t 2 : 4 3 2 ,
1 9 5 9
As s o c i at i o n B e t w e e n C o r o nar y H e ar t D i s e as e
R i s k F ac t o r s and P h y s i c al F i t ne s s
i n H e al t h y Ad u l t W o me n
L AR R Y W . GI B B O N S , M. D . , M. P . H . , S T E V E N N . B L AI R , P . E . D . ,
K E N N E T H H . C O O P E R , M. D . , M. P . H . , AN D MI K E S MI T H , M. S .
S U MMAR Y W e e x ami ne d as s o c i at i o ns b e t w e e n p h y s i c al f i t ne s s and r i s k f ac t o r s f o r c o r o nar y h e ar t
d i s e as e i n h e al t h y w o me n age s 1 8 - 6 5 y e ar s . P h y s i c al f i t ne s s w as o b j e c t i v e l y d e t e r mi ne d b y t h e d u r at i o n o f a
max i mal t r e ad mi l l e x e r c i s e t e s t . S i x p h y s i c al f i t ne s s c at e go r i e s ( v e r y p o o r t o s u p e r i o r ) , s p e c i f i c w i t h i n 1 0 -
y e ar age i nc r e me nt s , w e r e e s t ab l i s h e d . Me an r i s k f ac t o r l e v e l s v ar i e d ac r o s s c at e go r i e s , b u t s o d i d p o t e nt i al
c o nf o u nd e r s s u c h as age and w e i gh t . Mu l t i p l e l i ne ar r e gr e s s i o n mo d e l i ng w as u s e d t o c o nt r o l f o r t h e e f f e c t s
o f age , w e i gh t and y e ar o f e x am o n c o r o nar y r i s k f ac t o r s . Af t e r ad j u s t me nt , p h y s i c al f i t ne s s w as i nd e p e nd -
e nt l y as s o c i at e d w i t h t r i gl y c e r i d e s ( p < 0 . 0 0 1 ) , h i gh - d e ns i t y l i p o p r o t e i n c h o l e s t e r o l ( H D L - C ) ( p
-
0 . 0 0 1 ) ,
t o t al c h o l e s t e r o l / H D L - C r at i o ( p S 0 . 0 0 1 ) , b l o o d p r e s s u r e ( p s i 0 . 0 0 1 ) and c i gar e t t e s mo k i ng ( p
-
0 . 0 0 1 ) .
I T I S W E L L E S T AB L I S H E D t h at me n h av e a h i gh e r
i nc i d e nc e o f c ar d i o v as c u l ar d i s e as e t h an w o me n.
N o ne t h e l e s s , c o r o nar y h e ar t d i s e as e ( C H D ) i s t h e l e ad -
i ng c au s e o f d e at h i n w o me n ( 2 5 9 d e at h s / 1 0 0 , 0 0 0 p e r
y e ar ) , w i t h w o me n i n t h e U ni t e d S t at e s h av i ng h i gh
r at e s c o mp ar e d w i t h t h e r e s t o f t h e w o r l d . ' T h e s e s t a-
t i s t i c s b e l i e t h e r e l at i v e p au c i t y o f r e s e ar c h i n C H D
e p i d e mi o l o gy i n w o me n. Av ai l ab l e d at a, no t ab l y f r o m
t h e F r ami ngh am s t u d y , s u p p o r t t h e c l as s i c r i s k f ac t o r
h y p o t h e s i s f o r C H D i n w o me n. W o me n w i t h h i gh e r
l e v e l s o f b l o o d c h o l e s t e r o l , h i gh b l o o d p r e s s u r e , and
w h o s mo k e c i gar e t t e s ar e mo r e l i k e l y t o d e v e l o p C H D
t h an w o me n w i t h o u t t h e s e r i s k f ac t o r s . 2 O t h e r p r e -
s u me d C H D r i s k f ac t o r s h av e b e e n l e s s t h o r o u gh l y
s t u d i e d i n w o me n. F o r e x amp l e , s e v e r al s t u d i e s as s o -
c i at i ng s e d e nt ar y l i v i ng h ab i t s w i t h t h e i nc i d e nc e o f
C H D i n me n h av e b e e n p u b l i s h e d , 3 - 5
b u t w e ar e u n-
F r o m t h e C o o p e r C l i ni c and I ns t i t u t e f o r Ae r o b i c s R e s e ar c h , D al l as ,
T e x as , and t h e S c h o o l o f P u b l i c H e al t h , U ni v e r s i t y o f S o u t h C ar o l i na,
C o l u mb i a, S o u t h C ar o l i na.
Ad d r e s s f o r c o r r e s p o nd e nc e : L ar r y W . Gi b b o ns , M. D . , C o o p e r C l i n-
i c , 1 2 2 0 0 P r e s t o n R o ad , D al l as , T e x as 7 5 2 3 0 .
R e c e i v e d J u l y 6 , 1 9 8 2 ; r e v i s i o n ac c e p t e d J anu ar y 1 8 ,
1 9 8 3 .
C i r c u l at i o n 6 7 , N o . 5 , 1 9 8 3 .
aw ar e o f any s u c h s t u d i e s i n w o me n. Al t h o u gh t h e
p r e c i s e r o l e o f p h y s i c al ac t i v i t y i n t h e p r e v e nt i o n o f
C H D i s no t k no w n, a t e nab l e h y p o t h e s i s i s t h at mo r e
ac t i v e p e r s o ns h av e l o w e r l e v e l s o f e s t ab l i s h e d - r i s k
f ac t o r s . W e p r e v i o u s l y s h o w e d t h at me n w h o w e r e
mo r e p h y s i c al l y f i t h ad l o w e r l e v e l s o f C H D r i s k t h an
t h e i r l e s s p h y s i c al l y f i t p e e r s . 6
T h e p u r p o s e o f t h i s p ap e r i s t o e x ami ne t h e as s o c i -
at i o n b e t w e e n p h y s i c al f i t ne s s and C H D r i s k f ac t o r s i n
w o me n. W e h y p o t h e s i z e d t h at w o me n w i t h h i gh e r l e v -
e l s o f p h y s i c al f i t ne s s h av e a l o w e r C H D r i s k .
Me t h o d s
Mo r e t h an 3 9 0 0 ad u l t w o me n, age s 1 8 - 6 5 y e ar s ,
w e r e e x ami ne d f r o m 1 9 7 1 t o 1 9 8 0 . S o me w o me n r e -
c e i v e d o nl y a t r e ad mi l l t e s t , b u t 2 8 5 4 r e c e i v e d a c o m-
p l e t e p h y s i c al e x ami nat i o n, i nc l u d i ng C H D r i s k f ac t o r
me as u r e me nt s . Mo s t o f t h e s e w o me n w e r e s e l f - r e -
f e r r e d f o r t h e p u r p o s e o f p h y s i c al f i t ne s s e v al u at i o n,
p e r i o d i c h e al t h e x ami nat i o n o r r e c e i v i ng p r e v e nt i v e
me d i c al ad v i c e . T h e s e p at i e nt s t e nd e d t o b e w e l l e d u -
c at e d and f r o m mi d d l e t o u p p e r s o c i o e c o no mi c s t r at a.
Mo r e t h an 9 9 % o f t h e w o me n w e r e w h i t e . D at a r e p o r t -
e d i n t h i s p ap e r ar e f r o m t h e f i r s t c l i ni c v i s i t f o r t h e s e
9 7 7
by guest on June 23, 2014 http://circ.ahajournals.org/ Downloaded from