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Nevertheless, although obesity is an established risk factor for cholelithiasis, previous studies of the association of body mass index (BMI) and BTC did not take the effect of cholelithiasis fully into account. To better understand the effect of BMI on BTC, we conducted a pooled analysis using population\u2010based cohort studies in Asians. In total, 905\u2009530 subjects from 21 cohort studies participating in the Asia Cohort Consortium were included. BMI was categorized into four groups: underweight (&lt;18.5\u2009kg\/m<jats:sup>2<\/jats:sup>); normal (18.5\u201022.9\u2009kg\/m<jats:sup>2<\/jats:sup>); overweight (23\u201024.9\u2009kg\/m<jats:sup>2<\/jats:sup>); and obese (25+ kg\/m<jats:sup>2<\/jats:sup>). The association between BMI and BTC incidence and mortality was assessed using hazard ratios (HR) and 95% confidence intervals (CIs) by Cox regression models with shared frailty. Mediation analysis was used to decompose the association into a direct and an indirect (mediated) effect. Compared to normal BMI, high BMI was associated with BTC mortality (HR 1.19 [CI 1.02\u20101.38] for males, HR 1.30 [1.14\u20101.49] for females). Cholelithiasis had significant interaction with BMI on BTC risk. BMI was associated with BTC risk directly and through cholelithiasis in females, whereas the association was unclear in males. When cholelithiasis was present, BMI was not associated with BTC death in either males or females. BMI was associated with BTC death among females without cholelithiasis. This study suggests BMI is associated with BTC mortality in Asians. Cholelithiasis appears to contribute to the association; and moreover, obesity appears to increase BTC risk without cholelithiasis.<\/jats:p>","DOI":"10.1002\/ijc.34794","type":"journal-article","created":{"date-parts":[[2023,11,15]],"date-time":"2023-11-15T21:22:55Z","timestamp":1700083375000},"page":"1174-1190","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":15,"title":["Obesity is associated with biliary tract cancer mortality and incidence: A pooled analysis of 21 cohort studies in the Asia Cohort Consortium"],"prefix":"10.1002","volume":"154","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-0762-1147","authenticated-orcid":false,"given":"Isao","family":"Oze","sequence":"first","affiliation":[{"name":"Division of Cancer Epidemiology and Prevention Aichi Cancer Center Research Institute  Nagoya Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8023-4581","authenticated-orcid":false,"given":"Hidemi","family":"Ito","sequence":"additional","affiliation":[{"name":"Division of Cancer Information and Control, Department of Preventive Medicine Aichi Cancer Center Research Institute  Nagoya Japan"},{"name":"Division of Descriptive Cancer Epidemiology Nagoya University Graduate School of Medicine  Nagoya Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5675-3429","authenticated-orcid":false,"given":"Yuriko N.","family":"Koyanagi","sequence":"additional","affiliation":[{"name":"Division of Cancer Information and Control, Department of Preventive Medicine Aichi Cancer Center Research Institute  Nagoya Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3991-2739","authenticated-orcid":false,"given":"Sarah Krull","family":"Abe","sequence":"additional","affiliation":[{"name":"Division of Prevention National Cancer Center Institute for Cancer Control  Tokyo Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Md. 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