Efficacy of BMI on all-cause mortality in frail elderly: a dose-response meta-analysis_Chinese Journal of Evidence-Based Medicine

Authors：

ZHAO Li ¹ , XU Chang ² , CHEN Fei ¹ , NIU Fang ³ , GAO Qianqian ¹ , MEI Fan ¹ , HU Kaiyan ¹ , ZHAO Bing ⁴ , ZHANG Weiyi ⁵ , JIANG Yanbiao ⁴ ,  MA Bin ^1,4,6

1. Evidence-Based Nursing Center, School of Nursing, Lanzhou University, Lanzhou 730000, P.R.China;
2. Chinese Evidence-Based Medicine Center and Chinese Cochrane Center, West China Hospital, Sichuan University, Chengdu 610041, P.R.China;
3. Lanzhou University Second Hospital, Lanzhou 730000, P.R.China;
4. Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou 730000, P.R.China;
5. School of Public Health, Lanzhou University, Lanzhou 730000, P.R.China;
6. Key Laboratory of Evidence-Based Medicine and Clinical Transformation in Gansu Province, Lanzhou 730000, P.R.China;

Corresponding?author：

MA Bin, Email: kittymb2017@163.com

Keywords：

Body mass index; Frailty; All-cause mortality; Meta-analysis; Dose-response relationship

DOI：

10.7507/1672-2531.202011027

Video：

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Abstract Full text Figures/Tables Video References Cited by

Objective To systematically review the dose-response relationship between body mass index (BMI) and all-cause mortality in the elderly with frailty.Methods PubMed, EMbase, Web of Science, CNKI, VIP, WanFang Data, and CBM databases were electronically searched to collect cohort studies on the association of BMI and mortality in frail adults from inception to November 2019. Two reviewers independently screened literature, extracted data and assessed risk bias of included studies; Stata 15.0 software was then used to analyze the dose-response analysis of BMI and mortality by restricted cubic spline function and generalized least squares method.Results A total of 4 cohort studies involving 12 861 frail adults were included. Meta-analysis results showed that compared with normal BMI, the frail elderly who were overweight (HR=0.80, 95%CI 0.74 to 0.88, P<0.001) and obese (HR=0.89, 95%CI 0.79 to 1.00, P=0.047) had lower all-cause mortality. The results of dose-response meta-analysis showed that there was a non-linear relationship between BMI and all-cause mortality in the elderly with frailty (P value for nonlinearity was 0.035), for which the elderly with frailty had a BMI nadir of 27.5-31.9 kg/m². For linear trends, and when BMI was less than 27.5 kg/m², the risk of all-cause death was reduced by 4% for every 1 kg/m² increase in BMI (RR=0.96, 95%CI 0.90 to 1.03, P=0.320), when BMI was greater than 27.5 kg/m², the risk of all-cause death increased by 4% for every 1 kg/m² increase in BMI (RR=1.04, 95%CI 1.03 to 1.05, P<0.001).Conclusions There is a paradox of obesity and a significant nonlinear relationship between BMI and all-cause mortality in the frailty elderly, with the lowest all-cause mortality in the frailty elderly at BMI 27.5-31.9 kg/m². Due to limited quality and quantity of the included studies, more high quality studies are needed to verify the above conclusions.

Citation： ZHAO Li, XU Chang, CHEN Fei, NIU Fang, GAO Qianqian, MEI Fan, HU Kaiyan, ZHAO Bing, ZHANG Weiyi, JIANG Yanbiao, MA Bin. Efficacy of BMI on all-cause mortality in frail elderly: a dose-response meta-analysis. Chinese Journal of Evidence-Based Medicine, 2021, 21(6): 654-661. doi: 10.7507/1672-2531.202011027 Copy

1.	Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci, 2001, 56(3): M146-156.
2.	Espinoza SE, Hazuda HP. Frailty prevalence and neighborhood residence in older Mexican Americans: the San Antonio longitudinal study of aging. J Am Geriatr Soc, 2015, 63(1): 106-111.
3.	Thompson MQ, Theou O, Karnon J, et al. Frailty prevalence in Australia: findings from four pooled Australian cohort studies. Australas J Ageing, 2018, 37(2): 155-158.
4.	Herr M, Robine JM, Pinot J, et al. Polypharmacy and frailty: prevalence, relationship, and impact on mortality in a French sample of 2350 old people. Pharmacoepidemiol Drug Saf, 2015, 24(6): 637-646.
5.	Hyde Z, Flicker L, Smith K, et al. Prevalence and incidence of frailty in Aboriginal Australians, and associations with mortality and disability. Maturitas, 2016, 87: 89-94.
6.	Ensrud KE, Ewing SK, Taylor BC, et al. Frailty and risk of falls, fracture, and mortality in older women: the study of osteoporotic fractures. J Gerontol A Biol Sci Med Sci, 2007, 62(7): 744-751.
7.	Woods NF, LaCroix AZ, Gray SL, et al. Frailty: emergence and consequences in women aged 65 and older in the Women's Health Initiative Observational Study. J Am Geriatr Soc, 2005, 53(8): 1321-1330.
8.	廖秋菊, 陳彪, 李小霞, 等. 肥胖與老年衰弱相關研究進展. 中華老年多器官疾病雜志, 2019, 18(6): 478-480.
9.	American Cancer Society. Normal weight ranges: Body Mass Index (BMI). Available at: https://www.cancer.org/cancer/cancer-causes/diet-physical-activity/body-weight-and-cancer-risk/adult-bmi.html.
10.	Aune D, Sen A, Prasad M, et al. BMI and all cause mortality: systematic review and non-linear dose-response meta-analysis of 230 cohort studies with 3.74 million deaths among 30.3 million participants. BMJ, 2016, 353: i2156.
11.	Global BMI Mortality Collaboration None, Di Angelantonio E, Bhupathiraju ShN, et al. Body-mass index and all-cause mortality: individual-participant-data meta-analysis of 239 prospective studies in four continents. Lancet, 2016, 388(10046): 776-786.
12.	Sheehan KJ, O'Connell MD, Cunningham C, et al. The relationship between increased body mass index and frailty on falls in community dwelling older adults. BMC Geriatrics, 2013, 13: 132.
13.	Boutin E, Natella PA, Schott AM, et al. Interrelations between body mass index, frailty, and clinical adverse events in older community-dwelling women: The EPIDOS cohort study. Clin Nutr, 2018, 37(5): 1638-1644.
14.	Pérez-Tasigchana RF, León-Mu?oz LM, Lopez-Garcia E, et al. Metabolic syndrome and insulin resistance are associated with frailty in older adults: a prospective cohort study. Age Ageing, 2017, 46(5): 807-812.
15.	Easton JF, Stephens CR, Román-Sicilia H, et al. Anthropometric measurements and mortality in frail older adults. Exp Gerontol, 2018, 110: 61-66.
16.	Zaslavsky O, Rillamas-Sun E, LaCroix AZ, et al. Association between anthropometric measures and long-term survival in frail older women: observations from the Women's Health Initiative Study. J Am Geriatr Soc, 2016, 64(2): 277-284.
17.	Newcastle-Ottawa quality assessment scale cohort studies. Available at: http://www.Ohri.ca/programs/clinical_epidemiology/nosgen.pdf.
18.	Orsini N, Bellocco R, Greenland S. Generalized least squares for trend estimation of summarized dose-response data. Stata J, 2006, 6(1): 40-57.
19.	Bekkering GE, Harris RJ, Thomas S, et al. How much of the data published in observational studies of the association between diet and prostate or bladder cancer is usable for meta-analysis? Am J Epidemiol, 2008, 167(9): 1017-1026.
20.	Orsini N, Li R, Wolk A, et al. Meta-analysis for linear and nonlinear dose-response relations: examples, an evaluation of approximations, and software. Am J Epidemiol, 2012, 175(1): 66-73.
21.	Wells GA, Shea B, O’Connell D, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Available at: http://www.ohri.ca/programsclinical_/epidemiology/oxford.asp.
22.	Greenland S, Longnecker MP. Methods for trend estimation from summarized dose-response data, with applications to meta-analysis. Am J Epidemiol, 1992, 135(11): 1301-1309.
23.	Hamling J, Lee P, Weitkunat R, et al. Facilitating meta-analyses by deriving relative effect and precision estimates for alternative comparisons from a set of estimates presented by exposure level or disease category. Stat Med, 2008, 27(7): 954-970.
24.	Xu C, Thabane L, Liu T, et al. Flexible piecewise linear model for investigating dose-response relationship in meta-analysis: Methodology, examples, and comparison. J Evid Based Med, 2019, 12(1): 63-68.
25.	Liu TZ, Xu C, Rota M, et al. Sleep duration and risk of all-cause mortality: A flexible, non-linear, meta-regression of 40 prospective cohort studies. Sleep Med Rev, 2017, 32: 28-36.
26.	Higgins JP, Thompson SG, Deeks JJ, et al. Measuring inconsistency in meta-analyses. BMJ, 2003, 327(7414): 557-560.
27.	康德英, 許能鋒. 循證醫學(第3版). 北京: 人民衛生出版社, 2015: 80.
28.	Payette H, Coulombe C, Boutier V, et al. Weight loss and mortality among free-living frail elders: a prospective study. J Gerontol A Biol Sci Med Sci, 1999, 54(9): M440-445.
29.	Kitamura K, Nakamura K, Nishiwaki T, et al. Low body mass index and low serum albumin are predictive factors for short-term mortality in elderly Japanese requiring home care. Tohoku J Exp Med, 2010, 221(1): 29-34.
30.	徐暢, 張永剛, 韓芳芳, 等. 劑量-反應關系Meta分析的方法學簡介. 中國循證醫學雜志, 2015, 15(10): 1236-1239.
31.	馬贊甫, 劉妍珺. 回歸分析中最小樣本容量的確定. 統計與決策, 2017, (5): 20-22.
32.	Cao S, Gan Y, Dong X, et al. Association of quantity and duration of smoking with erectile dysfunction: a dose-response meta-analysis. J Sex Med, 2014, 11(10): 2376-2384.
33.	Liu Q, Shi J, Duan P, et al. Is shift work associated with a higher risk of overweight or obesity? A systematic review of observational studies with meta-analysis. Int J Epidemiol, 2018, 47(6): 1956-1971.
34.	Zaccardi F, Dhalwani NN, Papamargaritis D, et al. Nonlinear association of BMI with all-cause and cardiovascular mortality in type 2 diabetes mellitus: a systematic review and meta-analysis of 414, 587 participants in prospective studies. Diabetologia, 2017, 60(2): 240-248.
35.	Lavie CJ, De Schutter A, Parto P, et al. Obesity and prevalence of cardiovascular diseases and prognosis-the obesity paradox updated. Prog Cardiovasc Dis, 2016, 58(5): 537-547.
36.	朱潔云, 王霄玲, 鐘枝梅, 等. 體質量指數與慢性心力衰竭死亡率相關性的Meta分析. 中國循證醫學雜志, 2020, 20(2): 144-151.
37.	Ahmadi SF, Zahmatkesh G, Ahmadi E, et al. Association of body mass index with clinical outcomes in non-dialysis-dependent chronic kidney disease: a systematic review and meta-analysis. Cardiorenal Med, 2015, 6(1): 37-49.
38.	Ahmadi SF, Zahmatkesh G, Streja E, et al. Association of body mass index with mortality in peritoneal dialysis patients: a systematic review and meta-analysis. Perit Dial Int, 2016, 36(3): 315-325.
39.	Chittal P, Babu AS, Lavie CJ. Obesity paradox: does fat alter outcomes in chronic obstructive pulmonary disease? COPD, 2015, 12(1): 14-18.
40.	朱潔云, 羅毅灃, 王霄玲, 等. BMI與慢性阻塞性肺病患者死亡率相關性的Meta分析. 中國循證醫學雜志, 2019, 19(7): 811-817.
41.	Stenholm S, Strandberg TE, Pitk?l? K, et al. Midlife obesity and risk of frailty in old age during a 22-year follow-up in men and women: the Mini-Finland Follow-up Survey. J Gerontol A Biol Sci Med Sci, 2014, 69(1): 73-78.
42.	García-Esquinas E, José García-García F, León-Mu?oz LM, et al. Obesity, fat distribution, and risk of frailty in two population-based cohorts of older adults in Spain. Obesity (Silver Spring), 2015, 23(4): 847-855.
43.	Amundson DE, Djurkovic S, Matwiyoff GN. The obesity paradox. Crit Care Clin, 2010, 26(4): 583-596.
44.	Donini LM, Pinto A, Giusti AM, et al. Obesity or BMI paradox? Beneath the tip of the Iceberg. Front Nutr, 2020, 7: 53.
45.	Bowen ME. The relationship between body weight, frailty, and the disablement process. J Gerontol B Psychol Sci Soc Sci, 2012, 67(5): 618-626.
46.	Oreopoulos A, Kalantar-Zadeh K, Sharma AM, et al. The obesity paradox in the elderly: potential mechanisms and clinical implications. Clin Geriatr Med, 2009, 25(4): 643-659.
47.	Johansson H, Kanis JA, Odén A, et al. A meta-analysis of the association of fracture risk and body mass index in women. J Bone Miner Res, 2014, 29(1): 223-233.
48.	Stini WA. Body composition and longevity: is there a longevous morphotype? Med Anthropol, 1991, 13(3): 215-229.
49.	Whitlock G, Lewington S, Sherliker P, et al. Prospective studies collaboration. Body-mass index and cause-specific mortality in 900 000 adults: collaborative analyses of 57 prospective studies. Lancet, 2009, 373(9669): 1083-1096.
50.	Abdullah A, Peeters A, de Courten M, et al. The magnitude of association between overweight and obesity and the risk of diabetes: a meta-analysis of prospective cohort studies. Diabetes Res Clin Pract, 2010, 89(3): 309-319.
51.	Renehan AG, Tyson M, Egger M, et al. Body-mass index and incidence of cancer: a systematic review and meta-analysis of prospective observational studies. Lancet, 2008, 371(9612): 569-578.
52.	Jung HW, Kim SW, Lim JY, et al. Frailty status can predict further lean body mass decline in older adults. J Am Geriatr Soc, 2014, 62(11): 2110-2117.
53.	Yanase T, Yanagita I, Muta K, et al. Frailty in elderly diabetes patients. Endocr J, 2018, 65(1): 1-11.
54.	董娟, 趙籥陶, 李晶, 等. 衰弱與營養不良關系的研究進展. 中華老年醫學雜志, 2016, 35(8): 907-909.
55.	王灣灣, 李園園, 石小天, 等. 營養對衰弱影響的研究進展. 中國全科醫學, 2021, 24(6): 673-677.
56.	Gray-Donald K, Payette H, Boutier V. Randomized clinical trial of nutritional supplementation shows little effect on functional status among free-living frail elderly. J Nutr, 1995, 125(12): 2965-2971.
57.	Howie EK, Sui X, Lee DC, et al. Alcohol consumption and risk of all-cause and cardiovascular disease mortality in men. J Aging Res, 2011: 805062.
58.	Gatineau M, Mathrani S. Obesity and alcohol: an overview. London: National Obesity Observatory, 2012.
59.	Canoy D, Wareham N, Luben R, et al. Cigarette smoking and fat distribution in 21, 828 British men and women: a population-based study. Obes Res, 2005, 13(8): 1466-1475.

1. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci, 2001, 56(3): M146-156.
2. Espinoza SE, Hazuda HP. Frailty prevalence and neighborhood residence in older Mexican Americans: the San Antonio longitudinal study of aging. J Am Geriatr Soc, 2015, 63(1): 106-111.
3. Thompson MQ, Theou O, Karnon J, et al. Frailty prevalence in Australia: findings from four pooled Australian cohort studies. Australas J Ageing, 2018, 37(2): 155-158.
4. Herr M, Robine JM, Pinot J, et al. Polypharmacy and frailty: prevalence, relationship, and impact on mortality in a French sample of 2350 old people. Pharmacoepidemiol Drug Saf, 2015, 24(6): 637-646.
5. Hyde Z, Flicker L, Smith K, et al. Prevalence and incidence of frailty in Aboriginal Australians, and associations with mortality and disability. Maturitas, 2016, 87: 89-94.
6. Ensrud KE, Ewing SK, Taylor BC, et al. Frailty and risk of falls, fracture, and mortality in older women: the study of osteoporotic fractures. J Gerontol A Biol Sci Med Sci, 2007, 62(7): 744-751.
7. Woods NF, LaCroix AZ, Gray SL, et al. Frailty: emergence and consequences in women aged 65 and older in the Women's Health Initiative Observational Study. J Am Geriatr Soc, 2005, 53(8): 1321-1330.
8. 廖秋菊, 陳彪, 李小霞, 等. 肥胖與老年衰弱相關研究進展. 中華老年多器官疾病雜志, 2019, 18(6): 478-480.
9. American Cancer Society. Normal weight ranges: Body Mass Index (BMI). Available at: https://www.cancer.org/cancer/cancer-causes/diet-physical-activity/body-weight-and-cancer-risk/adult-bmi.html.
10. Aune D, Sen A, Prasad M, et al. BMI and all cause mortality: systematic review and non-linear dose-response meta-analysis of 230 cohort studies with 3.74 million deaths among 30.3 million participants. BMJ, 2016, 353: i2156.
11. Global BMI Mortality Collaboration None, Di Angelantonio E, Bhupathiraju ShN, et al. Body-mass index and all-cause mortality: individual-participant-data meta-analysis of 239 prospective studies in four continents. Lancet, 2016, 388(10046): 776-786.
12. Sheehan KJ, O'Connell MD, Cunningham C, et al. The relationship between increased body mass index and frailty on falls in community dwelling older adults. BMC Geriatrics, 2013, 13: 132.
13. Boutin E, Natella PA, Schott AM, et al. Interrelations between body mass index, frailty, and clinical adverse events in older community-dwelling women: The EPIDOS cohort study. Clin Nutr, 2018, 37(5): 1638-1644.
14. Pérez-Tasigchana RF, León-Mu?oz LM, Lopez-Garcia E, et al. Metabolic syndrome and insulin resistance are associated with frailty in older adults: a prospective cohort study. Age Ageing, 2017, 46(5): 807-812.
15. Easton JF, Stephens CR, Román-Sicilia H, et al. Anthropometric measurements and mortality in frail older adults. Exp Gerontol, 2018, 110: 61-66.
16. Zaslavsky O, Rillamas-Sun E, LaCroix AZ, et al. Association between anthropometric measures and long-term survival in frail older women: observations from the Women's Health Initiative Study. J Am Geriatr Soc, 2016, 64(2): 277-284.
17. Newcastle-Ottawa quality assessment scale cohort studies. Available at: http://www.Ohri.ca/programs/clinical_epidemiology/nosgen.pdf.
18. Orsini N, Bellocco R, Greenland S. Generalized least squares for trend estimation of summarized dose-response data. Stata J, 2006, 6(1): 40-57.
19. Bekkering GE, Harris RJ, Thomas S, et al. How much of the data published in observational studies of the association between diet and prostate or bladder cancer is usable for meta-analysis? Am J Epidemiol, 2008, 167(9): 1017-1026.
20. Orsini N, Li R, Wolk A, et al. Meta-analysis for linear and nonlinear dose-response relations: examples, an evaluation of approximations, and software. Am J Epidemiol, 2012, 175(1): 66-73.
21. Wells GA, Shea B, O’Connell D, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Available at: http://www.ohri.ca/programsclinical_/epidemiology/oxford.asp.
22. Greenland S, Longnecker MP. Methods for trend estimation from summarized dose-response data, with applications to meta-analysis. Am J Epidemiol, 1992, 135(11): 1301-1309.
23. Hamling J, Lee P, Weitkunat R, et al. Facilitating meta-analyses by deriving relative effect and precision estimates for alternative comparisons from a set of estimates presented by exposure level or disease category. Stat Med, 2008, 27(7): 954-970.
24. Xu C, Thabane L, Liu T, et al. Flexible piecewise linear model for investigating dose-response relationship in meta-analysis: Methodology, examples, and comparison. J Evid Based Med, 2019, 12(1): 63-68.
25. Liu TZ, Xu C, Rota M, et al. Sleep duration and risk of all-cause mortality: A flexible, non-linear, meta-regression of 40 prospective cohort studies. Sleep Med Rev, 2017, 32: 28-36.
26. Higgins JP, Thompson SG, Deeks JJ, et al. Measuring inconsistency in meta-analyses. BMJ, 2003, 327(7414): 557-560.
27. 康德英, 許能鋒. 循證醫學(第3版). 北京: 人民衛生出版社, 2015: 80.
28. Payette H, Coulombe C, Boutier V, et al. Weight loss and mortality among free-living frail elders: a prospective study. J Gerontol A Biol Sci Med Sci, 1999, 54(9): M440-445.
29. Kitamura K, Nakamura K, Nishiwaki T, et al. Low body mass index and low serum albumin are predictive factors for short-term mortality in elderly Japanese requiring home care. Tohoku J Exp Med, 2010, 221(1): 29-34.
30. 徐暢, 張永剛, 韓芳芳, 等. 劑量-反應關系Meta分析的方法學簡介. 中國循證醫學雜志, 2015, 15(10): 1236-1239.
31. 馬贊甫, 劉妍珺. 回歸分析中最小樣本容量的確定. 統計與決策, 2017, (5): 20-22.
32. Cao S, Gan Y, Dong X, et al. Association of quantity and duration of smoking with erectile dysfunction: a dose-response meta-analysis. J Sex Med, 2014, 11(10): 2376-2384.
33. Liu Q, Shi J, Duan P, et al. Is shift work associated with a higher risk of overweight or obesity? A systematic review of observational studies with meta-analysis. Int J Epidemiol, 2018, 47(6): 1956-1971.
34. Zaccardi F, Dhalwani NN, Papamargaritis D, et al. Nonlinear association of BMI with all-cause and cardiovascular mortality in type 2 diabetes mellitus: a systematic review and meta-analysis of 414, 587 participants in prospective studies. Diabetologia, 2017, 60(2): 240-248.
35. Lavie CJ, De Schutter A, Parto P, et al. Obesity and prevalence of cardiovascular diseases and prognosis-the obesity paradox updated. Prog Cardiovasc Dis, 2016, 58(5): 537-547.
36. 朱潔云, 王霄玲, 鐘枝梅, 等. 體質量指數與慢性心力衰竭死亡率相關性的Meta分析. 中國循證醫學雜志, 2020, 20(2): 144-151.
37. Ahmadi SF, Zahmatkesh G, Ahmadi E, et al. Association of body mass index with clinical outcomes in non-dialysis-dependent chronic kidney disease: a systematic review and meta-analysis. Cardiorenal Med, 2015, 6(1): 37-49.
38. Ahmadi SF, Zahmatkesh G, Streja E, et al. Association of body mass index with mortality in peritoneal dialysis patients: a systematic review and meta-analysis. Perit Dial Int, 2016, 36(3): 315-325.
39. Chittal P, Babu AS, Lavie CJ. Obesity paradox: does fat alter outcomes in chronic obstructive pulmonary disease? COPD, 2015, 12(1): 14-18.
40. 朱潔云, 羅毅灃, 王霄玲, 等. BMI與慢性阻塞性肺病患者死亡率相關性的Meta分析. 中國循證醫學雜志, 2019, 19(7): 811-817.
41. Stenholm S, Strandberg TE, Pitk?l? K, et al. Midlife obesity and risk of frailty in old age during a 22-year follow-up in men and women: the Mini-Finland Follow-up Survey. J Gerontol A Biol Sci Med Sci, 2014, 69(1): 73-78.
42. García-Esquinas E, José García-García F, León-Mu?oz LM, et al. Obesity, fat distribution, and risk of frailty in two population-based cohorts of older adults in Spain. Obesity (Silver Spring), 2015, 23(4): 847-855.
43. Amundson DE, Djurkovic S, Matwiyoff GN. The obesity paradox. Crit Care Clin, 2010, 26(4): 583-596.
44. Donini LM, Pinto A, Giusti AM, et al. Obesity or BMI paradox? Beneath the tip of the Iceberg. Front Nutr, 2020, 7: 53.
45. Bowen ME. The relationship between body weight, frailty, and the disablement process. J Gerontol B Psychol Sci Soc Sci, 2012, 67(5): 618-626.
46. Oreopoulos A, Kalantar-Zadeh K, Sharma AM, et al. The obesity paradox in the elderly: potential mechanisms and clinical implications. Clin Geriatr Med, 2009, 25(4): 643-659.
47. Johansson H, Kanis JA, Odén A, et al. A meta-analysis of the association of fracture risk and body mass index in women. J Bone Miner Res, 2014, 29(1): 223-233.
48. Stini WA. Body composition and longevity: is there a longevous morphotype? Med Anthropol, 1991, 13(3): 215-229.
49. Whitlock G, Lewington S, Sherliker P, et al. Prospective studies collaboration. Body-mass index and cause-specific mortality in 900 000 adults: collaborative analyses of 57 prospective studies. Lancet, 2009, 373(9669): 1083-1096.
50. Abdullah A, Peeters A, de Courten M, et al. The magnitude of association between overweight and obesity and the risk of diabetes: a meta-analysis of prospective cohort studies. Diabetes Res Clin Pract, 2010, 89(3): 309-319.
51. Renehan AG, Tyson M, Egger M, et al. Body-mass index and incidence of cancer: a systematic review and meta-analysis of prospective observational studies. Lancet, 2008, 371(9612): 569-578.
52. Jung HW, Kim SW, Lim JY, et al. Frailty status can predict further lean body mass decline in older adults. J Am Geriatr Soc, 2014, 62(11): 2110-2117.
53. Yanase T, Yanagita I, Muta K, et al. Frailty in elderly diabetes patients. Endocr J, 2018, 65(1): 1-11.
54. 董娟, 趙籥陶, 李晶, 等. 衰弱與營養不良關系的研究進展. 中華老年醫學雜志, 2016, 35(8): 907-909.
55. 王灣灣, 李園園, 石小天, 等. 營養對衰弱影響的研究進展. 中國全科醫學, 2021, 24(6): 673-677.
56. Gray-Donald K, Payette H, Boutier V. Randomized clinical trial of nutritional supplementation shows little effect on functional status among free-living frail elderly. J Nutr, 1995, 125(12): 2965-2971.
57. Howie EK, Sui X, Lee DC, et al. Alcohol consumption and risk of all-cause and cardiovascular disease mortality in men. J Aging Res, 2011: 805062.
58. Gatineau M, Mathrani S. Obesity and alcohol: an overview. London: National Obesity Observatory, 2012.
59. Canoy D, Wareham N, Luben R, et al. Cigarette smoking and fat distribution in 21, 828 British men and women: a population-based study. Obes Res, 2005, 13(8): 1466-1475.

Chinese Journal of Evidence-Based Medicine

Efficacy of BMI on all-cause mortality in frail elderly: a dose-response meta-analysis

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