Elsevier

Surgery

Volume 137, Issue 1, January 2005, Pages 16-25
Surgery

Surgical outcomes research
Effect of diabetes and hypertension on obesity-related mortality

https://doi.org/10.1016/j.surg.2004.05.049Get rights and content

Background

Obesity is increasing and, along with it, greater mortality resulting from the overweight condition. Weight-reduction surgery is recommended for many obese patients based on a perceived risk of greater obesity-related mortality. However, many of the studies cited to justify this have aggregated patient groups together, making it difficult to apply their findings to individual patients.

Methods

The combined National Health Interview Survey database from the years 1986-1994 that has been linked to the National Death Index was analyzed. Patients were stratified for their body mass index (BMI) category, the presence or absence of diabetes and hypertension, gender, and race. The contribution of hypertension and diabetes to mortality was determined by Cox proportional hazards modeling. The absolute magnitude that the effect gender, race, BMI, hypertension, and diabetes had on mortality was determined by examination of stratified age-adjusted death rates.

Results

We analyzed 662,443 records from individuals interviewed between 1986 and 1994. Of these, 49,391 had died in the follow-up period (mean follow-up, 7.2 years; range, 1-14 years). Cox proportional hazards modeling—adjusting for age, race, and gender—revealed that hypertension (hazard ratio = 1.35 [95% CI 1.34-1.35], P < .0001) and diabetes (hazard ratio = 2.29 [95% CI 2.28-2.29], P < .0001) increased mortality independent of body weight. Serious obesity was associated with an increased mortality by Cox modeling (hazard ratio = 1.72 [95% CI 1.71-1.73], P < .0001); however, when assessed by stratified age-adjusted mortality rates, this increase was numerically small because of the relatively low mortality rate for those without hypertension or diabetes. The presence of hypertension or diabetes substantially increased age-adjusted mortality rates. Much of the increased mortality observed in diabetic patients was attributable to complications of diabetes and not necessarily from atherosclerosis.

Conclusion

Because weight-loss surgery successfully cures hypertension or diabetes in most obese patients, it should be considered for obese patients having these diseases. Based on the greatly elevated mortality associated with diabetes, surgery may be justified for obese diabetic patients with BMIs lower than the currently accepted criteria. In contrast, for the morbidly obese without diabetes or hypertension, mortality is only slightly increased from obesity alone. In terms of mortality, the benefits of weight reduction resulting from weight-loss surgery are less clear if there is no coexistent diabetes or hypertension.

Section snippets

National Health Interview Survey database

The National Health Interview Survey (NHIS) is a population-based survey that is the principal device used by the US government to track disease prevalence. In continuous operation since 1957, the NHIS uses a complex multiscale design with oversampling of black and Hispanic individuals to acquire population-representative health-related information. Probability samples that are socioeconomically and racially representative of the entire US population are determined from the US census. Once

Results

The completed database, after ineligible cases were excluded, contained 662,443 records. Of these, there were 49,391 deaths in a patient cohort having a mean follow-up period of 74 months and ranging from 1 to 144 months, totaling 4,060,524 person-years.

Hazard ratios for age-adjusted mortality as a function of BMI and stratified for gender and race are presented in the Figure. BMI = 25.0-29.9 was associated with the lowest mortality. Compared with individuals with BMIs ranging from 18.5 to 25.0,

Discussion

Obesity unquestionably increases mortality; however, with two thirds of the American population being overweight or obese, it is impractical to provide treatment for all individuals at risk for early mortality. Current guidelines recommend maintenance of a healthy weight by dietary control and exercise.3., 31. For the extremely obese, pharmacological or surgical therapy may be used. Medical treatment of severe obesity generally results in modest, transient weight loss,32 with greater and more

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