Synergistic Assessment of Mortality Risk According to Body Mass Index and Exercise Ability and Capacity in Patients Referred for Radionuclide Stress Testing

The relationship between Body Mass Index (BMI) and acute heart failure (HF) remains ill-defined. This study aimed to compare the influence of BMI on in-hospital mortality between patients with acute HF with preserved ejection fraction (HFpEF) and those with acute HF with reduced ejection fraction (HFrEF) and to examine the specific phenotypes of HFpEF/HFrEF according to BMI. This multicenter retrospective study included 5313 and 6332 consecutive patients with acute HFpEF and HFrEF, respectively. Low, normal, and high BMIs were defined as BMI <18.5, 18.5 ≤BMI <25.0, and BMI ≥25.0, respectively. Overweight/obesity was defined as BMI ≥25.0. Kaplan-Meier survival curves and log-rank tests were used for between-group comparisons of in-hospital mortality. Univariable and multivariable Cox regression analyses were performed to identify significant prognostic factors. A paradoxical association between overweight/obesity and survival benefits, the so-called obesity paradox exists in HFpEF (log-rank P<0.05 in low BMI vs. normal BMI, low BMI vs. high BMI, and normal BMI vs. high BMI). In HFrEF, a trend towards lower in-hospital mortality was observed in patients with higher BMI. However, the obesity paradox in patients with HFrEF was not as evident as that in patients with HFpEF. Significant differences in the clinical characteristics and prognostic factors for in-hospital mortality were observed among the groups according to BMI. The obesity paradox was more evident in patients with HFpEF than in those with HFrEF. Specific phenotypes of HFpEF and HFrEF according to BMI were revealed.

To investigate the association between body mass index (BMI) and ectopic pregnancy (EP) following embryo transfer (ET). Retrospective cohort study. University-affiliated hospital. A total of 16378 pregnancies derived from either fresh ET or frozen-thawed ET between January 2008 and December 2017. We used the generalised estimating equation (GEE) to analyse the association between BMI categories and EP, as one woman may contribute to more than one pregnancy. Generalised additive models were also used to demonstrate the non-linear association. Models were adjusted for age, parity, gravidity, previous history of ectopic pregnancy, duration of infertility, polycystic ovary syndrome, endometriosis, diagnosis of tubal problems, ovarian reserve markers, ovarian stimulation parameters, insemination protocol, endometrial thickness and embryo transfer policies. Ectopic pregnancy. According to the WHO criteria, the number of cycles with low (<18.5kg/m2 ), normal (18.5-24.9kg/m2 ) and high (≥25kg/m2 ) BMI were 2155, 13447 and 776, respectively. In comparison with the normal BMI group, the rate of EP was significantly increased in the low BMI group (2.92% versus 2.02%, relative risk 1.45, 95% CI 1.11-1.90), but not in the high BMI group (2.84%, relative risk 1.41, 95% CI 0.92-2.20). Adjusted for confounding factors, the odds ratio for EP comparing low BMI versus normal BMI was 1.61 (95% CI 1.19-2.16) and that comparing high BMI versus normal BMI was 1.12 (95% CI 0.72-1.76). Low BMI is associated with an increased risk of EP. The ectopic pregnancy rate after embryo transfer for lean women is higher than that for women of normal weight.

&lt;p dir="ltr"&gt;As global populations age and the prevalence of obesity and metabolic disorders rises, understanding the complex relationships between body mass index (BMI), metabolic health, and aging becomes increasingly critical. This thesis sought to unravel these connections, focusing on how BMI and metabolic health are associated with biological aging and all-cause mortality while considering the nonlinear effects of BMI and age differences. By employing measures of biological aging - encompassing functional (functional aging Index, FAI), physiological (frailty index - FI), and cellular (epigenetic age acceleration - EAA) levels - we aimed to provide a comprehensive examination of the BMI, metabolic health, and biological aging connections.&lt;/p&gt;&lt;p dir="ltr"&gt;&lt;b&gt;Study I &lt;/b&gt;examined the independent and joint associations of midlife and late-life BMI and metabolic health status (MHS) assessments with risk of all-cause mortality. Data from 6,252 Swedish twins in midlife (65 years and below) and 6,215 in late life (over 65 years) were analyzed using Cox proportional hazards models. In the joint models, being metabolically unhealthy (MU) was consistently associated with increased mortality risk robust to BMI adjustments, while the mortality risk associated with BMI categories attenuated. In the interaction models, MU with obesity in midlife and across all BMI categories in late life was associated with higher mortality risk than metabolically healthy normal weight (MHN). Conversely, metabolically healthy with overweight (MHOw) or obesity in midlife and late life was not associated with higher mortality risks. In fact, late-life MHOw was associated with a lower mortality risk compared to MHN. These findings suggest that MHS plays a more significant role than BMI in predicting mortality risk.&lt;/p&gt;&lt;p dir="ltr"&gt;&lt;b&gt;Study II&lt;/b&gt; investigated how BMI and MHS jointly associate with biological aging, measured by FAI and FI, and whether these associations varied by chronological age. A cross-sectional analysis of 1,825 Swedish twins using mixed-effects linear models revealed a U-shaped association between BMI and FAI, where low and high BMI were associated with higher biological aging. MU was also associated with higher FAI. Significant three-way interactions between BMI, MHS, and chronological age on FI prompted the stratification of the analysis by age: below 65, 65 to 85, and over 85 years. In these groups, low BMI, high BMI and MU were consistently associated with greater FI, with significant modifications by MU and chronological age in the 65 to 85 and over 85 groups, respectively. This study highlights a complex interplay between BMI, MHS, and chronological age. Low BMI, high BMI, and MU were associated with higher biological aging, indicating their potential contribution to age acceleration.&lt;/p&gt;&lt;p dir="ltr"&gt;&lt;b&gt;Study III&lt;/b&gt; explored if biological aging, measured by EAA, mediates the BMI- mortality relationship. Using data from 3,840 participants in the U.S. Health and Retirement Study, a nonlinear association was found: both low and high BMI were associated with increased EAA and shorter life expectancy. Mediation analysis showed that high BMI's association with shorter life expectancy was strongly mediated by EAA, supporting the hypothesis that obesity accelerates biological aging. In contrast, the association of low BMI with shorter life expectancy was mainly driven by direct effects rather than mediation through biological aging.&lt;/p&gt;&lt;p dir="ltr"&gt;&lt;b&gt;Study IV &lt;/b&gt;analyzed the bidirectional relationship between change in BMI and biological aging, measured by FAI and FI, in 1,902-1,976 Swedish twins aged 60 to 91.9, using dual change score models. The age trajectory of BMI followed an almost linear, declining pattern, whereas FAI and FI exhibited exponentially increasing trends. The study found a unidirectional relationship where higher FAI predicted a steeper BMI decline. In contrast, the BMI-FI relationship was bidirectional - higher BMI predicted increased FI and higher FI contributed to a steeper BMI decline.&lt;/p&gt;&lt;p dir="ltr"&gt;These findings underscore the complex nature of the relationships between BMI, metabolic health, and aging, revealing the distinct influences of high BMI, low BMI, and metabolic health on biological aging and life expectancy. Together, these results emphasized the importance of integrating BMI, metabolic health, and biological aging into the assessment of late-life health, offering new insights into how these factors may converge to potentially shape the aging process and survival.&lt;/p&gt;&lt;p dir="ltr"&gt;&lt;b&gt;Keywords&lt;/b&gt;: aging, all-cause mortality, biological aging, body mass index, frailty, epigenetic age, metabolic health, obesity, mediation analysis, dual change score models&lt;/p&gt;&lt;h3&gt;List of scientific papers&lt;/h3&gt;&lt;p dir="ltr"&gt;I. &lt;b&gt;Ler P,&lt;/b&gt; Li X, Hassing LB, Reynolds CA, Finkel D, Karlsson IK, Dahl Aslan AK. Independent and joint effects of body mass index and metabolic health in mid- and late-life on all-cause mortality: a cohort study from the Swedish Twin Registry with a mean follow-up of 13 years. BMC Public Health. 2022;22(1):718. &lt;a href="https://doi.org/10.1186/s12889-022-13082-3" rel="noreferrer" target="_blank"&gt;https://doi.org/10.1186/s12889-022-13082-3&lt;/a&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;II. &lt;b&gt;Ler P,&lt;/b&gt; Ploner A, Finkel D, Reynolds CA, Zhan Y, Jylhävä J, Dahl Aslan AK, Karlsson IK. Interplay of body mass index and metabolic syndrome: association with physiological age from midlife to late- life. Geroscience. 2024;46(2):2605 - 2617. &lt;a href="https://doi.org/10.1007/s11357-023-01032-9" rel="noreferrer" target="_blank"&gt;https://doi.org/10.1007/s11357-023-01032-9&lt;/a&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;III. &lt;b&gt;Ler P,&lt;/b&gt; Jylhava J, Finkel D, Aslan Dahl AK, Ploner A, Karlsson IK. Does biological aging mediate the association between body mass index and survival among older adults? [Manuscript]&lt;/p&gt;&lt;p dir="ltr"&gt;IV. &lt;b&gt;Ler P,&lt;/b&gt; Mak JKL, Reynolds CA, Ploner A, Pedersen NL, Jylhävä J, Aslan Dahl AK, Finkel D, Karlsson IK. Longitudinal study of body mass index and biological aging: investigating the temporal dynamics. [Submitted]&lt;/p&gt;&lt;p dir="ltr"&gt;Paper I @ Ler et al., 2022. Published by Springer Nature. This is an open-access article under the terms of CC BY-NC-CD or CC BY 4.0.&lt;/p&gt;&lt;p dir="ltr"&gt;Paper II @ Ler et al., 2022. Published by Springer Nature. This is an open-access article under the terms of CC BY 4.0.&lt;/p&gt;

BackgroundThe association between body mass index (BMI) and clinical outcomes of gastric cancer were still under debate. The aim of the present study was to investigate the impact of BMI on intraoperative conditions, postoperative complications and prognosis of gastric cancer.MethodsFrom October 2008 to March 2015, 1210 gastric cancer patients treated with D2 gastrectomy were enrolled in the present study. Patients were divided into three groups: low BMI group (BMI < 18.5 Kg/m2), normal BMI group (18.5 Kg/m2 ≤ BMI < 25.0 Kg/m2) and high BMI group (BMI ≥ 25.0 Kg/m2). Clinicopathological characteristics and prognosis of patients were recorded and analyzed. Propensity score matching was used to match patients in the three groups.ResultsThere were 107 patients in low BMI group (8.9%), 862 patients in normal BMI group (71.2%) and 241 patients in high BMI group (19.95%). Before matching, BMI was inversely associated with tumor size, tumor depth, lymph node metastasis (LNM) and tumor stage (all P < 0.05). After matching, the clinicopathological features were all comparable among the three groups (all P > 0.05). High BMI was associated with increased blood loss and operation time, and deceased number of retrieved lymph nodes (all P < 0.05). For postoperative complications, low BMI was associated with decreased rate of postoperative fever (P = 0.025). Age, BMI, tumor size, Borrmann type, pathological type, type of gastrectomy, tumor depth, LNM and tumor stage were risk factors for the prognosis of gastric cancer. Multivariate analysis showed that only BMI, tumor size, tumor depth and LNM were independent prognostic factors. The overall survival of patients with low BMI was significantly worse than patients with normal (P < 0.05) or high BMI (P < 0.05). However, the overall survival was comparable between patients with normal and high BMI (P > 0.05).ConclusionsBMI was inversely associated with tumor size, tumor depth, LNM and tumor stage. High BMI was associated with increased blood loss and operation time, and deceased number of retrieved lymph nodes. Low BMI was associated with decreased rate of postoperative fever and decreased survival.

Excess body weight is associated with increased mortality, low physical fitness and low levels of physical activity. The objective this study to verify the linear and nonlinear (quadratic) relationships between Body Mass Index (BMI) and lower limb strength in children and adolescents of both sexes in a region of Chile. A descriptive (cross-sectional) study was carried out in children and adolescents of school age (6 to 17 years) of both sexes. The sample size was 863 schoolchildren (500 males and 363 females). Weight, height and the Horizontal Jump test (HJ) were evaluated. BMI and BMI z -score were calculated according to age and sex. In males, the explanatory power in the linear model [R= 0.15, R2= 0.02, Root Mean Square Error (RMSE)= 39.6] is lower than the non-linear quadratic model (R= 0.22, R2= 0.05, RMSE= 39.0). In females, the explanatory power in the linear model (R= 0.12, R2= 0.02, RMSE= 23.2) is lower than the quadratic nonlinear model (R= 0.19, R2= 0.04, RMSE= 22.9). In the BMI z-score scale, males presented HJ values of: [Low BMI 145.4±39.5cm, normal 164.2±33.6cm, and high BMI 109.0±23.2cm]. In females it was: [Low BMI 108.0±23.0cm, normal 113.5±36.3cm, and elevated BMI 91.5±30.4cm]. The study verified a curvilinear relationship in the form of a parabola (quadratic) between BMI and the HJ test in children and adolescents of both sexes. Schoolchildren in the extreme BMI categories (low and high BMI) reflected low performance in the HJ in relation to school-children with normal BMI.

Background The relationship between body mass index (BMI) and cardiovascular diseases (CVD) is well known, highlighting that a high BMI (&amp;gt;24.9 kg/m²) is associated with an increased risk of developing these conditions. However, a low BMI (&amp;lt;18.5 kg/m²) has also been linked to the development of CVD, particularly concerning heart failure, arrhythmias, vascular diseases, and an increased mortality rate following acute myocardial infarction, due to factors such as sarcopenia and reduced cardiac reserve. In addition, it has been shown that BMI correlates directly with early outcomes such as mediastinal hemorrhage, hypovolemia, arrhythmias, and perioperative mortality in patients undergoing cardiac surgery. Purpose The aim of this study was to describe the association between BMI and the development of perioperative and postoperative complications in patients undergoing cardiac surgery, regardless of preoperative diagnosis. Methods A descriptive retrospective observational study was conducted on patients over 18 years old who underwent cardiac surgery with cardiopulmonary bypass. The study evaluated BMI and the development of cardiovascular diseases (CVD), comparing four groups: low BMI (&amp;lt;18.5 kg/m²), normal BMI (18.5 to 24.9 kg/m²), overweight (24.9 to 29.9 kg/m²), and obesity (&amp;gt;30 kg/m²). The patients were admitted to the cardiovascular intensive care unit from June 1, 2022, to December 31, 2023. The study included demographic, surgical, hemodynamic variables, outcomes, and intrahospital mortality. Results A sample of 555 patients was included, of which 56.8% were men and 43.2% were women. 61% had a high BMI, 2.7% had a low BMI, and the rest had a normal BMI. We identified that patients with a low BMI had a higher likelihood of developing various immediate postoperative complications, including mediastinal hemorrhage (OR 1.73; 95% CI 0.47-6.30), postcardiotomy low cardiac output syndrome (OR 3.35; 95% CI 1.11-10.11), acute liver failure (OR 1.95; 95% CI 0.53-7.12), and postoperative atrial fibrillation (OR 2.59; 95% CI 0.86-7.76), which increased the need for blood product transfusions (OR 1.81; 95% CI 0.61-5.38). In contrast, patients with a high BMI had a lower incidence of perioperative and postoperative complications. Conclusion This retrospective analysis showed that BMI directly affects the development of early outcomes in patients undergoing cardiac surgery. Also, patients with a low BMI had a higher likelihood of developing these complications compared to patients with a high BMI.Description postoperative outcomes

Objectives Although the association between obesity and bronchial asthma (BA) has been gaining more attention, few studies have been conducted concerning the relationship between body mass index (BMI) and other allergic diseases. The purpose of this study is to determine the relationship between allergic rhinitis (AR) and BMI. Materials and methods This was a retrospective study. Two hundred and ten patients of AR (138 males and 72 females) and 424 healthy controls were included in the study. The BMI of patients and controls were calculated and correlated. Results The percentage of AR patients with a low BMI was 9.5%, whereas 57.6% had a normal BMI; 21% were preobese and 9.5% were obese. In the control group, 48.6% subjects had normal BMI range followed by preobese 21.2%, underweight 20.3%, and obese 9.9%. Among the overweight (preobese+ obese) category, the maximum number of subjects belonged to cases, i.e., 32.8% with an odds ratio (OR) of 0.95 (95% confidence interval (CI) 0.91-1.07). Thus, AR was not associated with high BMI. Among the underweight, the maximum number of subjects belonged to the control group, i.e., 20.3% with an OR of 2.13 (95% CI 1.24-3.68). Thus, AR had no relationship with lower BMI also. It was also observed that more of the female patients (18, 29.1, and 12.5% were underweight, preobese, and obese respectively) had deranged BMI than male patients (5.3, 20.2, and 7.9% were underweight, preobese, and obese respectively). A relative risk of 1.124 (95% CI 1.01-1.23) and 1.04 (95% CI 0.95-1.13) was present in female patients with low and high BMI respectively, which is statistically significant (p = 0.0008). Conclusion It was concluded that BMI was not associated with increased prevalence of AR. Among the underweight and overweight, AR was more common in females than in males. Thus, BMI had a significant association with AR among female patients. Overall, BMI had no significant association with AR. How to cite this article Kala H, Bhagat S, Varshney S, Bist SS. A Clinical Study of Relationship of Body Mass Index with Allergic Rhinitis. Clin Rhinol An Int J 2016;9(1):33-36.

Gonadotropin and body mass index: high FSH levels in lean, normally cycling women

This study aims to investigate the relationship between body mass index (BMI) and all-cause mortality among older adults with type 2 diabetes mellitus (T2DM) in Shanghai, seeking to determine the optimal BMI threshold and safe range, as well as to analyze the asymmetric effects of low and high BMI on mortality risk. This large-scale community cohort study is based on the diabetes management cohort from the Shanghai Municipal Center for Disease Control and Prevention. A total of 372,829 T2DM patients age ≥ 60 were included, with a follow-up period from May 1, 2020, to Dec 31, 2024, and a median follow-up of 19 months. BMI was calculated using standardized measurements and self-reported height and weight (kg/m2). All-cause mortality data were matched from the Shanghai Death Registry System. Covariates included sex, age, marital status, education level, smoking, alcohol, and physical activity. Statistical analysis utilized Restricted Cubic Spline (RCS) analysis to explore the dose–response relationship between BMI and mortality risk, identifying the optimal cutoff point. BMI groups were further compared using Cox regression and Kaplan–Meier (KM) survival curves to assess risk differences. BMI intervals of ± 5% and ± 10% were used to verify risk gradients, with adjustments for covariates. The significance level was set at α = 0.05. The RCS curve revealed a U-shaped relationship between BMI and all-cause mortality, identifying a BMI of 22.68 as the point of lowest mortality risk (covariates adjusted model, P for nonlinear < 0.001). The risk was asymmetric: a low BMI (22.68) significantly increased mortality risk (HR = 0.86, 95%CI: 0.82 ~ 0.88, P < 0.001), while high BMI was positively correlated with mortality risk (HR = 1.01, 95%CI: 1.01 ~ 1.02, P < 0.001) but with a weaker effect size. Stratified analysis showed that BMI < 21.55 (-5% interval) was associated with significantly lower survival probability compared to the reference group (21.55 ~ 23.81) (P < 0.001), whereas BMI > 23.81 (+ 5% interval) had survival probabilities that were not significantly different from those of the reference group on the KM curve. Similarly, BMI < 20.41 (-10% interval) had significantly lower survival probability than the reference group (20.41 ~ 24.95) (P < 0.001), while BMI > 24.95 (+ 10% interval) showed no statistically significant difference compared to the reference group on the KM curve. There is an obesity survival paradox among T2DM older adults, with low BMI significantly increasing mortality risk, while the protective effects of high BMI may partially counterbalance its metabolic harms, resulting in a lower effect size of risk. These findings suggest that weight management strategies for older adults with T2DM should prioritize the avoidance of low BMI over aggressive weight reduction.

Background Cardiac amyloidosis (CA) is a severe condition characterized by infiltrative cardiomyopathy and heart failure, primarily with preserved ejection fraction (HFpEF), resulting from the deposition of amyloid fibrils in the myocardial extracellular space. While obesity generally linked with increased health risks, studies in chronic cardiac conditions have shown a relationship between body mass index (BMI) and patient’s outcomes. Aim We therefore sought to investigate the association of BMI and clinical outcomes in patients with diagnosed CA, focusing on whether lower BMI serves as a marker for increased risk in this patient population. Methods In this study, we conducted a retrospectively analysis of CA patients enrolled in a clinical registry. Patients were categorized by baseline BMI into underweight (BMI &amp;lt; 18.5), normal weight (BMI 18.5–24.9), overweight (BMI 25.0–29.9), and obese (BMI ≥ 30.0) groups. We used Kaplan-Meier survival analysis to examine the relationship between BMI categories and patient outcomes over a 10 year follow-up period. Results A total of 418 patients were included, with a median age of 75.5 years, interquartile range (IQR): 33.6 – 94.0. Of these, 77.5 % were male, and 39.7% were classified as NYHA functional class. Kaplan-Meier curves demonstrated that patients with a lower BMI had a significantly higher risk of both all-cause mortality and/or heart-failure related hospitalizations compared to those in the overweight and obese categories (p &amp;lt; 0.05). Conclusions These findings underscore that lower BMI is associated with poorer outcomes in patients with CA. This observed "obesity paradox", where higher BMI appears protective, highlights the need for individualized management strategies in CA patients, especially those with lower BMI who may be at elevated risk for adverse outcomes.

CA: A Cancer Journal for Clinicians publishes information about the prevention, early detection, and treatment of cancer, as well as nutrition, palliative care, survivorship, and additional topics of interest related to cancer care.

Addressing the Complex Synergy Between Exercise Capacity and BMI and Its Relationship to All-Cause Mortality

This study examined the relationship between body mass index (BMI) and the risk of pneumonia in Aboriginal Australians. A total of 677 adults aged 20-60 years were followed up from the baseline examination during 1992-1995 to June 2012. The pneumonia events were identified through hospital records. Pneumonia incident rates were calculated according to BMI groups. Hazard ratios were computed using Cox regression adjusting for age, smoking and alcohol consumption status. The incident rate of pneumonia was 13.3/1000 person-years, and this rate was significantly higher in females than males (hazard ratio = 1.5). Compared to males with normal BMI (18.5-24.9 kg/m²), the adjusted hazard ratio was 3.5 for males with lowest BMI (P < 0.01). Low BMI was significantly associated with a higher risk of hospitalized pneumonia for Aboriginal males. However, the U-shaped trend of this association indicates that the risk of pneumonia is likely to be associated with both low and high BMI.

Objective: The positive relation between body mass index (BMI) and risk of incident hypertension (HT) has been reported mainly in the Western subjects with high BMI. However, there are a few reports in the Asian with relatively lower BMI. This study investigated the relation of BMI with risk of incident HT in the population-based prospective cohort study of Japan, the Suita study. Methods: Participants who had no HT at baseline (1,591 men and 1,973 women) aged 30-84 years were included in this study. BMI categories were defined as following: underweight (BMI&lt;18.5), normal (18.5≤BMI&lt;25.0), and overweight (BMI ≥ 25.0). The Cox proportional hazards model was used to estimate hazard ratios (HRs) of BMI categories for incident HT by sex. HRs were adjusted for age, cigarette smoking and alcohol drinking. The HRs according to quartiles of BMI were also estimated, using the lowest quartile of BMI as a reference. Results: During median follow-up of 7.2 years, 1,325 participants (640 men and 685 women) developed HT. The HR (95% CI) of 1kg/m2 increment of BMI for HT in men and women was 1.08 (1.05-1.11) and 1.10 (1.07-1.12), respectively. When we set a normal BMI as a reference, HR of overweight BMI in men and women was 1.37 (1.13-1.67) and 1.45 (1.18-1.77), whereas HR of underweight BMI in men and women was 0.63 (0.45-0.90) and 0.60 (0.45-0.80), respectively. In addition, compared to the lowest quartile, HR of the highest quartile of BMI in men and women was 1.67 (1.33-2.10, trend p&lt;0.001) and 2.10 (1.67-2.64, trend p&lt;0.001), respectively. Conclusion: In this study, we showed that higher BMI was associated with increased risk of hypertension in both Japanese men and women.

BackgroundThe association between metabolic syndrome and increased cardiovascular disease (CVD) risk is well‐established. However, in patients with incident CVD, the relationship between obesity, metabolic health, and subsequent CVD and mortality outcomes are less well‐established. This study investigated the association between body mass index (BMI), metabolic health and the risk of subsequent cardiovascular mortality and morbidity outcomes in patients with incident CVD events.MethodsThis cohort study identified 130 685 patients from the nationwide Clinical Practice Research Datalink (CPRD GOLD) and Hospital Episode Statistics (HES) databases in the United Kingdom. Patients were ≥18 years with incident CVD [coronary heart disease (CHD), stroke, or peripheral vascular disease (PVD)] between 1 January 1998 and 31 December 2017. BMI (in kg/m2) was categorized as underweight (<18.5), normal (18.5–24.9), overweight (25.0–29.9) and obese (≥30). Within each BMI category, patients were grouped by increasing count of 1, 2 or 3 metabolic risk factors [RF] (dyslipidaemia, diabetes mellitus and hypertension) and were regarded as metabolically unhealthy while absence of these factors was considered metabolically healthy (MH). Multivariable Cox regression was used to assess the risk (hazard ratio with 95% confidence interval) of subsequent outcomes (non‐fatal CHD, stroke, PVD, incident heart failure, CVD‐mortality and all‐cause mortality) in BMI subgroups with incremental count of metabolic RFs.ResultsDuring a median follow‐up of 13.0 years, a higher BMI was associated with reduced risk for stroke, PVD, CVD‐mortality and all‐cause mortality within each metabolic risk category, while increasing metabolic RFs within each BMI subgroup accounted for increasing risks. When compared with patients with normal BMI and no RF, CVD‐mortality risk in overweight patients with no RF was 0.76 (0.70–0.84), and in obese patients with no RF was 0.85 (0.76–0.96). The respective risk for all‐cause mortality in patients with overweight and no RF was 0.69 (0.65–0.72), and in obese patients with no RF was 0.75 (0.70–0.79). Subsequent outcomes of stroke and PVD showed similar trends. In contrast, the risk of subsequent non‐fatal CHD events and incident HF increased with higher BMI and with incremental metabolic risk factors within each BMI category. Underweight was constantly associated with increased risk for all outcomes regardless of the presence of metabolic RFs except for non‐fatal CHD events.ConclusionsIn patients with incident CVD, overweight and obesity were related to a more favourable prognosis for subsequent stroke, PVD and mortality (CVD‐related and all‐cause) irrespective of the presence of other metabolic risk factors.