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Obesity paradox

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associated with the overweight and obese categories of BMI among non-smokers. In an analysis of 1.46 million individuals, restriction to never-smoking participants greatly reduced the mortality estimates in the underweight group, as well as strengthening the estimates in the overweight and obese groups. This study concluded that, for non-Hispanic white adults who have never smoked, the BMI range of 20.0 to 24.9 was associated with the lowest mortality rates. A similar 2016 study found that, of the BMI ranges studied (which ranged from 18.5 to >30), the "normal" 18.5–22.4 BMI range combined with healthy eating, high levels of physical activity, not smoking, and no more than moderate alcohol consumption was associated with the lowest risk of premature death.
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Terminally ill individuals often undergo weight loss before death, and classifying those individuals as lean greatly inflates the mortality rate in the normal and underweight categories of BMI, while lowering the risk in the higher BMI categories. Studies that employ strategies to reduce reverse causation such as excluding sick individuals at baseline and introducing time lag to exclude deaths at the beginning of follow-up have yielded estimates of increased risk for body mass indices above 25 kg/m.
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patients don't get cardiovascular disease at all up until later in life. In fact, the obese have shorter lifespans because they get cardiovascular disease at an early age and have to live a longer proportion of their life with it. This also shows a misunderstanding regarding the paradox: While survival rate once sick is indeed higher for those with obesity than for those few non-obese that have cardiovascular disease, people without obesity usually do not get cardiovascular disease in the first place.
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obesity is the collider, the outcome is cardiovascular disease, and the unmeasured variables are environmental and genetic factors – given that obesity and cardiovascular disorders are often associated with each other, medical professionals may be reluctant to consider both other causes of cardiovascular disease or other causes of protection against said diseases.
684:). Similar findings have been made in other types of heart disease. Among people with heart disease, those with class I obesity do not have greater rates of further heart problems than people of normal weight. In people with greater degrees of obesity, however, risk of further events is increased. Even after 768:
A study from 2018 found that the reason why overweight or obese patients supposedly live longer with cardiovascular disease than people of normal weight is simply because overweight / obese patients get cardiovascular disease at an earlier age, meaning while they survive more years with it, non-obese
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Berrington de Gonzalez A, Hartge P, Cerhan JR, Flint AJ, Hannan L, MacInnis RJ, Moore SC, Tobias GS, Anton-Culver H, Freeman LB, Beeson WL, Clipp SL, English DR, Folsom AR, Freedman DM, Giles G, Hakansson N, Henderson KD, Hoffman-Bolton J, Hoppin JA, Koenig KL, Lee IM, Linet MS, Park Y, Pocobelli G,
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Padwal, R; McAlister, F A; McMurray, J J V; Cowie, M R; Rich, M; Pocock, S; Swedberg, K; Maggioni, A; Gamble, G; Ariti, C; Earle, N; Whalley, G; Poppe, K K; Doughty, R N; Bayes-Genis, A (31 October 2013). "The obesity paradox in heart failure patients with preserved versus reduced ejection fraction:
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Another concern is reverse causation due to illness-induced weight loss. That is, it may not be low BMI that is causing death (and thereby making obesity seem protective) but rather imminent death causing low BMI. Indeed, unintentional weight loss is an extremely significant predictor of mortality.
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While obese people have twice the risk of developing heart failure compared to individuals with a normal BMI, once a person experiences heart failure, those with a BMI between 30.0 and 34.9 had lower mortality than those with a normal BMI. This has been attributed to the fact that people often lose
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Romero-Corral, Abel; Montori, Victor M; Somers, Virend K; Korinek, Josef; Thomas, Randal J; Allison, Thomas G; Mookadam, Farouk; Lopez-Jimenez, Francisco (2006). "Association of bodyweight with total mortality and with cardiovascular events in coronary artery disease: A systematic review of cohort
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Veronese, N; Cereda, E; Solmi, M; Fowler, SA; Manzato, E; Maggi, S; Manu, P; Abe, E; Hayashi, K; Allard, JP; Arendt, BM; Beck, A; Chan, M; Audrey, YJ; Lin, WY; Hsu, HS; Lin, CC; Diekmann, R; Kimyagarov, S; Miller, M; Cameron, ID; Pitkälä, KH; Lee, J; Woo, J; Nakamura, K; Smiley, D; Umpierrez, G;
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have proposed that a paradox does not actually exist, as people can be healthy at a range of sizes. As one study puts it, "There is no 'obesity paradox' to explain, if we accept the premise that varying ideal weight ranges apply to individuals over different stages of the life span, accordingly
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bias, which commonly emerges when one restricts or stratifies on a factor (the "collider") that is caused by both the exposure (or its descendants) of an unmeasured variable and the outcome (or its ancestors / risk factors). In the example of the obesity-cardiovascular disease relationship, the
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Diercks, Deborah B.; Roe, Matthew T.; Mulgund, Jyotsna; Pollack, Charles V.; Kirk, J. Douglas; Gibler, W. Brian; Ohman, E. Magnus; Smith, Sidney C.; et al. (2006). "The obesity paradox in non–ST-segment elevation acute coronary syndromes: Results from the Can Rapid risk stratification of
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has been noted by several researchers, although others have suggested that smoking does not account for the observed patterns. Since smokers, who are subject to higher mortality rates, also tend to be leaner, inadequate adjustment for smoking would lead to underestimations of the risk ratios
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Critics of the paradox have also argued that studies supporting its existence almost always use BMI as the only measure of obesity. However, because BMI is an imperfect method of measuring obesity, critics argue that studies using other measures of obesity in addition to BMI, such as
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and protein energy wasting in advanced CKD seems to a large extent to account for this paradoxical association between traditional risk factors and CV outcomes in this patient population." Other research has proposed that the paradox also may be explained by
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Veronese, Nicola; Li, Yanping; Manson, JoAnn E; Willett, Walter C; Fontana, Luigi; Hu, Frank B. (2016) "Combined associations of body weight and lifestyle factors with all cause and cause specific mortality in men and women: prospective cohort study",
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and cancer. Explanations for the paradox range from excess weight being protective to the statistical association being caused by methodological flaws such as confounding, detection bias, reverse causality, or selection bias.
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Wang, L; Liu, W; He, X; Chen, Y; Lu, J; Liu, K; Cao, K; Yin, P (4 September 2015). "Association of overweight and obesity with patient mortality after acute myocardial infarction: A meta-analysis of prospective studies".
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as a preventative health measure – weight-cycling (a repeated pattern of losing and then regaining weight) is more common in obese people, and has health effects commonly assumed to be caused by obesity, such as
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Unstable angina patients Suppress ADverse outcomes with Early implementation of the American College of Cardiology/American Heart Association Guidelines Quality Improvement Initiative".
816:(Low birth-weight babies born to smokers have a lower mortality than low birth-weight babies born to non-smokers, because other causes of low birth-weight are more harmful than smoking.) 2560:
Dixon, J.B.; Egger, G.J.; Finkelstein, E.A.; Kral, J.G.; Lambert, G.W. (January 2015). "'Obesity paradox' misunderstands the biology of optimal weight throughout the life cycle".
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Carnethon, Mercedes R.; De Chavez, Peter John D.; Biggs, Mary L.; Lewis, Cora E.; Pankow, James S.; Bertoni, Alain G.; Golden, Sherita H.; Liu, Kiang; et al. (2012-08-12).
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Naghavi, Morteza; Falk, Erling; Hecht, Harvey S.; Shah, Prediman K.; Shape Task Force (2006). "The First SHAPE (Screening for Heart Attack Prevention and Education) Guideline".
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The obesity paradox may therefore result from people becoming lean due to smoking, sedentary lifestyles, and unhealthy diets – all factors which also negatively impact health.
1199:"The association between obesity and mortality in the elderly differs by serum concentrations of persistent organic pollutants: a possible explanation for the obesity paradox" 2410:
Banack, Hailey R.; Kaufman, Jay S. (May 2014). "The obesity paradox: Understanding the effect of obesity on mortality among individuals with cardiovascular disease".
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is the finding in some studies of a lower mortality rate for overweight or obese people within certain subpopulations. The paradox has been observed in people with
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Rondanelli, M; Sund-Levander, M; Valentini, L; Schindler, K; Törmä, J; Volpato, S; Zuliani, G; Wong, M; Lok, K; Kane, JM; Sergi, G; Correll, CU (November 2015).
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Schmidt, Darren S.; Salahudeen, Abdulla K. (2007). "CARDIOVASCULAR AND SURVIVAL PARADOXES IN DIALYSIS PATIENTS: Obesity-Survival Paradox-Still a Controversy?".
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has promoted the hypothesis and funded researchers who agree with the hypothesis, which has raised questions about what research the company supports and why.
2118:"Impact of Smoking and Preexisting Illness on Estimates of the Fractions of Deaths Associated with Underweight, Overweight, and Obesity in the US Population" 2324:
Chrysant, Steven G.; Chrysant, George S. (January 2013). "New insights into the true nature of the obesity paradox and the lower cardiovascular risk".
1283:"Meta-analysis of the relation of body mass index to all-cause and cardiovascular mortality and hospitalization in patients with chronic heart failure" 2396: 1411:
Niedziela, J; Hudzik, B; Niedziela, N; Gąsior, M; Gierlotka, M; Wasilewski, J; Myrda, K; Lekston, A; Poloński, L; Rozentryt, P (November 2014).
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Sharma, A; Lavie, CJ; Borer, JS; Vallakati, A; Goel, S; Lopez-Jimenez, F; Arbab-Zadeh, A; Mukherjee, D; Lazar, JM (15 May 2015).
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Oreopoulos, Antigone; Padwal, Raj; Kalantar-Zadeh, Kamyar; Fonarow, Gregg C.; Norris, Colleen M.; McAlister, Finlay A. (2008).
2077:"Commentary: selection bias as an explanation for the obesity paradox: just because it's possible doesn't mean it's plausible" 1830:
Mariscalco, G; Wozniak, MJ; Dawson, AG; Serraino, GF; Porter, R; Nath, M; Klersy, C; Kumar, T; Murphy, GJ (28 February 2017).
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The obesity paradox (excluding the cholesterol paradox) was first described in 1999 in overweight and obese people undergoing
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allowing us to abandon the rigid biologically implausible concept of a single 'ideal weight' (for height) or weight range."
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Florez, Hermes; Castillo-Florez, Sumaya (2012). "Beyond the Obesity Paradox in Diabetes: Fitness, Fatness, and Mortality".
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Oreopoulos, Antigone; Padwal, Raj; Norris, Colleen M; Mullen, John C; Pretorius, Victor; Kalantar-Zadeh, Kamyar (2008).
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Cao, Chao; Wang, Ran; Wang, Jianmiao; Bunjhoo, Hansvin; Xu, Yongjian; Xiong, Weining; Simpson, Colin (24 August 2012).
147: 2368: 104: 2363:. Greenland, Sander, 1951–, Lash, Timothy L. (3rd edition, thoroughly revised and updated ed.). Philadelphia. 761: 2277:"Body-mass index and cause-specific mortality in 900 000 adults: collaborative analyses of 57 prospective studies" 556: 332: 685: 520: 153: 2161:
Schatzkin A, Sesso HD, Weiderpass E, Willcox BJ, Wolk A, Zeleniuch-Jacquotte A, Willett WC, Thun MJ (2010).
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One probable methodological explanation for the obesity paradox in regards to cardiovascular disease is
2028:"Obesity Paradox: Conditioning on Disease Enhances Biases in Estimating the Mortality Risks of Obesity" 628:
The mechanism responsible for this reversed association is unknown, but it has been theorized that, in
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Habbu, Amit; Lakkis, Nasser M.; Dokainish, Hisham (2006). "The Obesity Paradox: Fact or Fiction?".
1180:"Article: Vascular disease and chronic renal failure: new insights (abstract) - January 2010 - NJM" 824: 813: 525: 1282: 1179: 758: 692:, the benefit of obesity no longer exists. The obesity paradox is also relevant in discussion of 661: 485: 392: 80: 49: 629: 614: 581: 479: 1197:
Hong, N-S; Kim, K-S; Lee, I-K; Lind, P M; Lind, L; Jacobs, D R; Lee, D-H (27 September 2011).
2688: 657: 594: 510: 385: 261: 221: 2534:"The obesity paradox: Why Coke is promoting a theory that being fat won't hurt your health" 1473: 599: 495: 447: 181: 1566: 8: 2693: 1521:"Obesity and pulmonary embolism: The mounting evidence of risk and the mortality paradox" 1462:"Body Mass Index and Mortality in Chronic Obstructive Pulmonary Disease: A Meta-Analysis" 747: 727: 515: 426: 327: 291: 216: 191: 138: 2506:"The obesity paradox debunked: People with extra pounds do not live longer, study shows" 1914: 1477: 2633: 2608: 2585: 2481: 2454: 2386: 2301: 2276: 2187: 2162: 2052: 2027: 2003: 1978: 1954: 1927: 1861: 1771: 1724: 1604: 1496: 1461: 1437: 1412: 1393: 1349: 1263: 1116: 1085: 1033: 979: 954: 930: 905: 881: 848: 751: 702: 669: 352: 143: 2292: 1848: 1831: 1712: 1004:"Reverse epidemiology of cardiovascular risk factors in maintenance dialysis patients" 1002:
Kalantar-Zadeh, Kamyar; Block, Gladys; Humphreys, Michael H.; Kopple, Joel D. (2003).
2667: 2638: 2577: 2510: 2486: 2435: 2427: 2374: 2364: 2341: 2306: 2257: 2236:"A review and meta-analysis of the effect of weight loss on all-cause mortality risk" 2192: 2139: 2098: 2057: 2008: 1959: 1897: 1865: 1853: 1812: 1763: 1716: 1680: 1645: 1596: 1540: 1501: 1442: 1385: 1353: 1341: 1305: 1255: 1251: 1220: 1161: 1120: 1077: 1025: 1020: 1003: 984: 935: 886: 868: 402: 211: 100: 90: 31: 1775: 1728: 1608: 1397: 1267: 1089: 1037: 2698: 2659: 2628: 2620: 2589: 2569: 2476: 2466: 2419: 2333: 2296: 2288: 2247: 2182: 2174: 2129: 2088: 2047: 2039: 1998: 1990: 1979:"Smoking and reverse causation create an obesity paradox in cardiovascular disease" 1949: 1939: 1889: 1843: 1802: 1755: 1708: 1672: 1635: 1586: 1578: 1536: 1532: 1491: 1481: 1432: 1424: 1377: 1333: 1297: 1247: 1210: 1151: 1112: 1067: 1015: 974: 966: 925: 917: 876: 860: 819: 719: 442: 437: 317: 201: 196: 163: 133: 85: 1676: 1301: 2471: 2116:
Flegal, Katherine M.; Graubard, Barry; Williamson, David; Gail, Mitchell (2007).
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Kalantar-Zadeh, Kamyar; Block, Gladys; Horwich, Tamara; Fonarow, Gregg C (2004).
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people has been and is controversial in the medical community for several years.
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in 2004. It is a contradiction to prevailing medical concepts of prevention of
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Lennon, Hannah; Sperrin, Matthew; Badrick, Ellena; Renehan, Andrew G. (2016).
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Sadiya S. Kahn; Hongyan Ning; John T. Wilkins; et al. (April 2018).
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Carnethon, Mercedes; De Chaves, Peter John; Biggs, Mary (8 August 2012).
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weight when they have severe and chronic illness (a syndrome called
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The obesity paradox has been criticized on the grounds of being an
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Flegal, Katherine; Kit, Brian; Orpana, Heather (2 January 2013).
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The terminology "reverse epidemiology" was first proposed by
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Harrington, Mary; Gibson, Sigrid; Cottrell, Richard (2009).
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chemicals that would otherwise be toxic to the body.
1662: 1102: 754:, render the existence of the paradox questionable. 1925: 2074: 1459: 1518: 1237: 1049: 1047: 2680: 2323: 1519:Stein, Paul; Matta, Fadi; Goldman, Jose (2011). 652:, and has subsequently been found in those with 2326:Journal of the American Society of Hypertension 2208: 2206: 903: 632:patients, "The common occurrence of persistent 1196: 1044: 2409: 2025: 1366: 1324:a meta-analysis of individual patient data". 1060:Journal of the American College of Cardiology 606:Journal of the American College of Cardiology 557: 2531: 2503: 2203: 1919: 2395:) CS1 maint: multiple names: authors list ( 1231: 959:Journal of the American Medical Association 910:Journal of the American Medical Association 2391:: CS1 maint: location missing publisher ( 2275:Prospective Studies Collaboration (2009). 564: 550: 2632: 2480: 2470: 2300: 2251: 2186: 2133: 2092: 2051: 2002: 1953: 1943: 1847: 1806: 1656: 1639: 1621: 1590: 1495: 1485: 1436: 1214: 1155: 1071: 1019: 978: 929: 880: 849:"The Obesity Paradox in Cancer: a Review" 2155: 2153: 2026:Preston, Samuel; Stokes, Andrew (2014). 842: 840: 2268: 1624:"Obesity and the risk of heart failure" 1137: 621:of heart disease in otherwise healthy, 2681: 1976: 1131: 1096: 2150: 837: 666:chronic obstructive pulmonary disease 784: 772: 2167:The New England Journal of Medicine 13: 2600: 2504:Karen Kaplan (February 28, 2018). 2403: 2358: 1665:The American Journal of Cardiology 1290:The American Journal of Cardiology 1117:10.1097/01.hpc.0000249784.29151.54 148:Epidemiology of metabolic syndrome 14: 2715: 2532:Julia Belluz (October 20, 2015). 1849:10.1161/CIRCULATIONAHA.116.022840 1622:Kenchaiah, Satish (Aug 1, 2002). 2562:International Journal of Obesity 2122:American Journal of Epidemiology 1417:European Journal of Epidemiology 1370:International Journal of Obesity 1326:International Journal of Obesity 1252:10.1111/j.1525-139X.2007.00349.x 1203:International Journal of Obesity 1021:10.1046/j.1523-1755.2003.00803.x 2553: 2525: 2497: 2446: 2352: 2317: 2227: 2109: 2068: 2019: 1970: 1908: 1872: 1823: 1782: 1735: 1691: 1628:New England Journal of Medicine 1557: 1512: 1453: 1404: 1360: 1316: 1274: 1105:Critical Pathways in Cardiology 705:, and cardiovascular diseases. 1537:10.1016/j.thromres.2011.10.019 1190: 1172: 995: 946: 897: 713: 588: 521:Social determinants of obesity 1: 2359:J., Rothman, Kenneth (2008). 2293:10.1016/S0140-6736(09)60318-4 2075:Glymour; Vittinghoff (2014). 1713:10.1016/S0140-6736(06)69251-9 1677:10.1016/j.amjcard.2006.04.039 1302:10.1016/j.amjcard.2015.02.024 830: 708: 154:Metabolically healthy obesity 2472:10.1001/jamacardio.2018.0022 2094:10.1097/EDE.0000000000000013 2044:10.1097/EDE.0000000000000075 1926:Bacon L, Aphramor L (2011). 1487:10.1371/journal.pone.0043892 777:It has also been noted that 311:Obesity-associated morbidity 7: 2424:10.1016/j.ypmed.2014.02.003 797: 506:Obesity and the environment 10: 2720: 2338:10.1016/j.jash.2012.11.008 1073:10.1016/j.jacc.2003.11.039 2253:10.1017/S0954422409990035 1894:10.1016/j.ahj.2005.09.024 1760:10.1016/j.ahj.2008.02.014 1429:10.1007/s10654-014-9961-9 865:10.1007/s11912-016-0539-4 690:peripheral artery disease 129:Classification of obesity 922:10.1001/jama.2012.113905 853:Current Oncology Reports 825:Social stigma of obesity 814:Low birth-weight paradox 730:. 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(2007). 662:acute coronary syndrome 486:Fat acceptance movement 393:Anti-obesity medication 81:Gestational weight gain 2664:10.1001/jama.2012.9776 2625:10.1001/jama.2012.9282 1945:10.1186/1475-2891-10-9 1882:American Heart Journal 1748:American Heart Journal 971:10.1001/jama.2012.9282 686:cardiac bypass surgery 630:chronic kidney disease 619:prophylactic treatment 615:cardiovascular disease 582:cardiovascular disease 2179:10.1056/NEJMoa1000367 728:observational studies 658:myocardial infarction 595:Kamyar Kalantar-Zadeh 511:Obesity and sexuality 386:Management of obesity 262:Binge eating disorder 222:Waist-to-height ratio 1641:10.1056/NEJMoa020245 1382:10.1038/ijo.2015.176 1338:10.1038/ijo.2013.203 1240:Seminars in Dialysis 1216:10.1038/ijo.2011.187 1008:Kidney International 600:Kidney International 496:Health at Every Size 448:Weight loss coaching 182:Body adiposity index 2574:10.1038/ijo.2014.59 2412:Preventive Medicine 2361:Modern epidemiology 2287:(9669): 1083–1096. 1808:10.1038/oby.2007.36 1525:Thrombosis Research 1478:2012PLoSO...743892C 748:waist circumference 670:pulmonary embolisms 603:in 2003 and in the 516:Sedentary lifestyle 328:Fatty liver disease 292:Starvation response 192:Body fat percentage 139:Genetics of obesity 2135:10.1093/aje/kwm152 752:waist to hip ratio 703:insulin resistance 617:; however, active 353:Obesity and cancer 234:Related conditions 144:Metabolic syndrome 16:Medical hypothesis 2511:Los Angeles Times 1995:10.1002/oby.21239 1932:Nutrition Journal 1583:10.1111/obr.12309 785:Weight relativism 773:Ties to Coca-Cola 574: 573: 403:Bariatric surgery 212:Relative Fat Mass 101:Childhood obesity 91:Weight management 32:Human body weight 2711: 2704:Health paradoxes 2675: 2646: 2636: 2619:(8): 9000–9001. 2594: 2593: 2557: 2551: 2550: 2548: 2546: 2529: 2523: 2522: 2520: 2518: 2501: 2495: 2494: 2484: 2474: 2450: 2444: 2443: 2407: 2401: 2400: 2390: 2382: 2356: 2350: 2349: 2321: 2315: 2314: 2304: 2272: 2266: 2265: 2255: 2231: 2225: 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Index

a series
Human body weight
Obesity
Epidemiology
Overweight
Underweight
Body shape
Weight gain
Weight loss
Gestational weight gain
Diet (nutrition)
Weight management
Overnutrition
Childhood obesity
Epidemiology
Adipose tissue
Classification of obesity
Exercise paradox
Genetics of obesity
Metabolic syndrome
Epidemiology of metabolic syndrome
Metabolically healthy obesity
Obesity paradox
Set point theory
Body adiposity index
Body mass index
Body fat percentage
Body Shape Index
Corpulence index
Lean body mass

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