Acta Diabetologica

, Volume 56, Issue 1, pp 87–96 | Cite as

Ethnicity-specific association of BMI levels at diagnosis of type 2 diabetes with cardiovascular disease and all-cause mortality risk

  • Ebenezer S. Owusu Adjah
  • Kausik K. Ray
  • Sanjoy K. PaulEmail author
Original Article



To evaluate the risk of CVD and all-cause mortality at different BMI levels in conjunction with weight change prior to diagnosis of T2DM in a multi-ethnic population.


Longitudinal study of 51,455 patients with T2DM and without a history of comorbid diseases at diagnosis. Weight changes prior to diagnosis of T2DM were evaluated, and the risk of CVD and all-cause mortality at different BMI levels among three ethnic groups estimated using treatment effects model.


White Europeans (WE), African-Caribbeans (AC), and South Asians (SA) were mean 52, 49, and 47 years with a mean BMI of 33.0, 32.0, and 30.0 kg/m2 at diagnosis, respectively. Among WE, normal weight patients developed CVD significantly earlier by 0.5 years (95% CI 0.1, 0.9 years; p = 0.018) compared to obese patients. Furthermore, those with normal body weight at diagnosis were significantly more likely to die earlier by 0.6 years (95% CI 0.03, 1.2 years; p = 0.037) among WE and by 2.5 years (95% CI 0.3, 4.6 years; p = 0.023) among SA compared to their respective obese patients. However, BMI at diagnosis was not associated with increased risk of CVD and death among AC.


This study suggests a paradoxical association of BMI with cardiovascular and mortality risks in different ethnic groups, which may partially be driven by different cardiovascular and glycaemic risk profiles at diagnosis.


Body mass index Type 2 diabetes Mortality Ethnicity Weight change pattern 



Melbourne EpiCentre gratefully acknowledges the support from the Australian Government’s National Collaborative Research Infrastructure Strategy (NCRIS) initiative through Therapeutic Innovation Australia.

Author contributions

SKP and ESOA conceived the idea and contributed to the study design. ESOA conducted the data extraction, data manipulation, and statistical analyses and developed the first draft of the manuscript. SKP contributed to the statistical analyses and had full access to all the data in the study and is the guarantor, taking responsibility for the integrity of the data and the accuracy of the data analysis. ESOA, KKR, and SKP were involved in writing the paper and had final approval of the submitted and published versions.


National Health and Medical Research Council of Australia (GNT1063477).

Compliance with ethical standards

Conflict of interest

SKP has acted as a consultant and/or speaker for Novartis, GI Dynamics, Roche, AstraZeneca, Guangzhou Zhongyi Pharmaceutical and Amylin Pharmaceuticals LLC. He has received grants in support of investigator and investigator-initiated clinical studies from Merck, Novo Nordisk, AstraZeneca, Hospira, Amylin Pharmaceuticals, Sanofi Aventis and Pfizer. KKR has acted as a speaker or consultant for Abbvie, Amgen, Pfizer, Astra Zeneca, Sanofi Resverlogix, Regeneron, Esperion, ACKCEA, Medicines Company, BI, Novo Nordisk. ESOA has no conflicts of interest to declare.

Statement of human and animal rights

This article does not contain any studies with human or animal subjects performed by the any of the authors.

Supplementary material

592_2018_1219_MOESM1_ESM.docx (22 kb)
Supplementary material 1 (DOCX 21 KB)


  1. 1.
    Carnethon MR, De Chavez PJD, Biggs ML, Lewis CE, Pankow JS, Bertoni AG, Golden SH, Liu K, Mukamal KJ, Campbell-Jenkins B, Dyer AR (2012) Association of weight status with mortality in adults with incident diabetes. JAMA 308(6):581–590. CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Logue J, Walker JJ, Leese G, Lindsay R, Mcknight J, Morris A, Philip S, Wild S, Sattar N, on behalf of the Scottish Diabetes Research Network Epidemiology Group (2013) Association between BMI measured within a year after diagnosis of type 2 diabetes and mortality. Diabetes Care 36(4):887–893. CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Mulnier HE, Seaman HE, Raleigh VS, Soedamah-Muthu SS, Colhoun HM, Lawrenson RA (2006) Mortality in people with type 2 diabetes in the UK. Diabet Med 23(5):516–521. CrossRefPubMedGoogle Scholar
  4. 4.
    Thomas G, Khunti K, Curcin V, Molokhia M, Millett C, Majeed A, Paul S (2014) Obesity paradox in people newly diagnosed with type 2 diabetes with and without prior cardiovascular disease. Diabetes Obes Metab 16(4):317–325. CrossRefPubMedGoogle Scholar
  5. 5.
    Zhao W, Katzmarzyk PT, Horswell R, Wang Y, Li W, Johnson J, Heymsfield SB, Cefalu WT, Ryan DH, Hu G (2014) Body mass index and the risk of all-cause mortality among patients with type 2 diabetes. Circulation 130(24):2143–2151. CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Banack HR, Kaufman JS (Cambridge (2013) The “Obesity Paradox” explained. Epidemiology (Cambridge, Mass) 24(3):461–462. CrossRefGoogle Scholar
  7. 7.
    Banack HR, Kaufman JS (2015) Does selection bias explain the obesity paradox among individuals with cardiovascular disease? Ann Epidemiol 25(5):342–349. CrossRefPubMedGoogle Scholar
  8. 8.
    Hainer V, Aldhoon-Hainerová I (2013) Obesity paradox does exist. Diabetes Care 36(Supplement 2):S276–S281. CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Owusu Adjah ES, Samanta M, Shaw JE, Majeed A, Khunti K, Paul SK (2018) Weight loss and mortality risk in patients with different adiposity at diagnosis of type 2 diabetes: a longitudinal cohort study. Nutr Diabetes 8(1):37. CrossRefGoogle Scholar
  10. 10.
    Hsu WC, Araneta MRG, Kanaya AM, Chiang JL, Fujimoto W (2015) BMI cut points to identify at-risk asian americans for type 2 diabetes screening. Diabetes Care 38(1):150–158. CrossRefPubMedGoogle Scholar
  11. 11.
    Misra A, Vikram NK, Gupta R, Pandey RM, Wasir JS, Gupta VP (2006) Waist circumference cutoff points and action levels for Asian Indians for identification of abdominal obesity. Int J Obes (2005) 30(1):106–111. CrossRefGoogle Scholar
  12. 12.
    Shai I, Jiang R, Manson JE, Stampfer MJ, Willett WC, Colditz GA, Hu FB (2006) Ethnicity, obesity, and risk of type 2 diabetes in women: a 20-year follow-up study. Diabetes Care 29(7):1585–1590. CrossRefPubMedGoogle Scholar
  13. 13.
    Tillin T, Sattar N, Godsland IF, Hughes AD, Chaturvedi N, Forouhi NG (2015) Ethnicity-specific obesity cut-points in the development of type 2 diabetes—a prospective study including three ethnic groups in the United Kingdom. Diabet Med 32(2):226–234. CrossRefPubMedGoogle Scholar
  14. 14.
    Shah AD, Langenberg C, Rapsomaniki E, Denaxas S, Pujades-Rodriguez M, Gale CP, Deanfield J, Smeeth L, Timmis A, Hemingway H (2015) Type 2 diabetes and incidence of cardiovascular diseases: a cohort study in 1·9 million people. Lancet Diabetes Endocrinol 3(2):105–113. CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    U.K. Prospective Diabetes Study Group (1998) Ethnicity and cardiovascular disease: the incidence of myocardial infarction in white, South Asian, and Afro-Caribbean patients with type 2 diabetes (U.K. Prospective Diabetes Study 32). Diabetes Care 21(8):1271–1277. CrossRefGoogle Scholar
  16. 16.
    Lanting LC, Joung IMA, Mackenbach JP, Lamberts SWJ, Bootsma AH (2005) Ethnic differences in mortality, end-stage complications, and quality of care among diabetic patients: a review. Diabetes Care 28(9):2280–2288. CrossRefPubMedGoogle Scholar
  17. 17.
    Bellary S, O’Hare JP, Raymond NT, Mughal S, Hanif WM, Jones A, Kumar S, Barnett AH (2010) Premature cardiovascular events and mortality in South Asians with type 2 diabetes in the United Kingdom Asian Diabetes Study—effect of ethnicity on risk. Curr Med Res Opin 26(8):1873–1879. CrossRefPubMedGoogle Scholar
  18. 18.
    George J, Mathur R, Shah AD, Pujades-Rodriguez M, Denaxas S, Smeeth L, Timmis A, Hemingway H (2017) Ethnicity and the first diagnosis of a wide range of cardiovascular diseases: associations in a linked electronic health record cohort of 1 million patients. PLoS One 12(6):e0178945. CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Ramezankhani A, Azizi F, Hadaegh F, Momenan AA (2018) Diabetes and number of years of life lost with and without cardiovascular disease: a multi-state homogeneous semi-Markov model. Acta Diabetologica 55(3):253–262CrossRefPubMedGoogle Scholar
  20. 20.
    Lavie CJ, De Schutter A, Patel D, Artham SM, Milani RV (2011) Body composition and coronary heart disease mortality—an obesity or a lean paradox? Mayo Clin Proc 86(9):857–864. CrossRefGoogle Scholar
  21. 21.
    Lavie CJ, Milani RV, Ventura HO (2011) Obesity and the “Obesity Paradox” in cardiovascular diseases. Clin Pharmacol Ther 90(1):23–25. CrossRefPubMedGoogle Scholar
  22. 22.
    Kokkinos P, Myers J, Faselis C, Doumas M, Kheirbek R, Nylen E (2012) BMI–mortality paradox and fitness in African American and Caucasian men with type 2 diabetes. Diabetes Care 35(5):1021–1027. CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Paul SK, Owusu Adjah ES, Samanta M, Patel K, Bellary S, Hanif W, Khunti K (2017) Comparison of body mass index at diagnosis of diabetes in a multi-ethnic population: a case–control study with matched non-diabetic controls. Diabetes Obes Metab 19(7):1014–1023. CrossRefPubMedGoogle Scholar
  24. 24.
    Read J (1991) The read clinical classification (read codes). Br Homoeopath J 80(1):14–20. CrossRefGoogle Scholar
  25. 25.
    Owusu Adjah ES, Montvida O, Agbeve J, Paul SK (2017) Data mining approach to identify disease cohorts from primary care electronic medical records: a case of diabetes mellitus. Open Bioinform J 10:16–27. CrossRefGoogle Scholar
  26. 26.
    WHO Expert Consultation (2004) Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet 363(9403):157CrossRefGoogle Scholar
  27. 27.
    Ho AK, Bartels CM, Thorpe CT, Pandhi N, Smith MA, Johnson HM (2016) achieving weight loss and hypertension control among obese adults: a US Multidisciplinary Group Practice Observational Study. Am J Hypertens 29(8):984–991. CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Rubin DB (1974) Estimating causal effects of treatments in randomized and nonrandomized studies. J Educ Psychol 66(5):688. CrossRefGoogle Scholar
  29. 29.
    Austin PC, Stuart EA (2015) The performance of inverse probability of treatment weighting and full matching on the propensity score in the presence of model misspecification when estimating the effect of treatment on survival outcomes. Stat Methods Med Res 26(4):1654–1670. CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Cattaneo MD (2010) Efficient semiparametric estimation of multi-valued treatment effects under ignorability. J Econom 155(2):138–154. CrossRefGoogle Scholar
  31. 31.
    Lee M-j (2012) Treatment effects in sample selection models and their nonparametric estimation. J Econom 167(2):317–329. CrossRefGoogle Scholar
  32. 32.
    Lavie CJ, McAuley PA, Church TS, Milani RV, Blair SN (2014) Obesity and cardiovascular diseases. J Am Coll Cardiol 63(14):1345–1354. CrossRefPubMedGoogle Scholar
  33. 33.
    Zheng Y, Song M, Manson JE, Giovannucci EL, Hu FB (2017) Group-based trajectory of body shape from ages 5 to 55 years and cardiometabolic disease risk in 2 US cohorts. Am J Epidemiol 186(11):1246–1255. CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Canoy D, Wareham N, Luben R, Welch A, Bingham S, Day N, Khaw KT (2005) Cigarette smoking and fat distribution in 21,828 British men and women: a population-based study. Obes Res 13(8):1466–1475. CrossRefPubMedGoogle Scholar
  35. 35.
    Wright AK, Kontopantelis E, Emsley R, Buchan I, Sattar N, Rutter MK, Ashcroft DM (2016) Life expectancy and cause-specific mortality in type 2 diabetes: a population-based cohort study quantifying relationships in ethnic subgroups. Diabetes Care. PubMedCrossRefGoogle Scholar
  36. 36.
    Penno G, Solini A, Bonora E, Orsi E, Fondelli C, Zerbini G, Trevisan R, Vedovato M, Cavalot F, Laviola L (2018) Defining the contribution of chronic kidney disease to all-cause mortality in patients with type 2 diabetes: the Renal Insufficiency And Cardiovascular Events (RIACE) Italian Multicenter Study. Acta Diabetol 55(6):603–612. CrossRefPubMedGoogle Scholar
  37. 37.
    Owusu Adjah ES, Bellary S, Hanif W, Patel K, Khunti K, Paul SK (2018) Prevalence and incidence of complications at diagnosis of T2DM and during follow-up by BMI and ethnicity: a matched case–control analysis. Cardiovasc Diabetol 17(1):70. CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer-Verlag Italia S.r.l., part of Springer Nature 2018

Authors and Affiliations

  1. 1.QIMR Berghofer Medical Research InstituteBrisbaneAustralia
  2. 2.Faculty of MedicineThe University of QueenslandBrisbaneAustralia
  3. 3.Imperial Centre for Cardiovascular Disease Prevention, Department of Primary Care and Public HealthImperial College LondonLondonUK
  4. 4.Melbourne EpiCentreUniversity of Melbourne and Melbourne HealthMelbourneAustralia

Personalised recommendations