{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,12]],"date-time":"2026-10-12T22:58:23Z","timestamp":1791845903300,"version":"4.3.4"},"reference-count":33,"publisher":"BMJ","issue":"1","license":[{"start":{"date-parts":[[2026,8,11]],"date-time":"2026-08-11T00:00:00Z","timestamp":1786406400000},"content-version":"unspecified","delay-in-days":10,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"name":"Research Program funded Korea National Institute of Health","award":["2016ER670100"],"award-info":[{"award-number":["2016ER670100"]}]},{"name":"Research Program funded Korea National Institute of Health","award":["2016ER670101"],"award-info":[{"award-number":["2016ER670101"]}]},{"name":"Research Program funded Korea National Institute of Health","award":["2016ER670102"],"award-info":[{"award-number":["2016ER670102"]}]},{"name":"Research Program funded Korea National Institute of Health","award":["2018ER67100"],"award-info":[{"award-number":["2018ER67100"]}]},{"name":"Research Program funded Korea National Institute of Health","award":["2018ER67101"],"award-info":[{"award-number":["2018ER67101"]}]},{"name":"Research Program funded Korea National Institute of Health","award":["2018ER67102"],"award-info":[{"award-number":["2018ER67102"]}]},{"name":"Research Program funded Korea National Institute of Health","award":["2021ER120500"],"award-info":[{"award-number":["2021ER120500"]}]},{"name":"Research Program funded Korea National Institute of Health","award":["2021ER120501"],"award-info":[{"award-number":["2021ER120501"]}]},{"name":"Research Program funded Korea National Institute of Health","award":["2021ER120502"],"award-info":[{"award-number":["2021ER120502"]}]},{"name":"Research Program funded Korea National Institute of Health","award":["2024ER120100"],"award-info":[{"award-number":["2024ER120100"]}]},{"name":"Research Program funded Korea National Institute of Health","award":["2024ER120101"],"award-info":[{"award-number":["2024ER120101"]}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open Resp Res"],"accepted":{"date-parts":[[2026,7,30]]},"published-print":{"date-parts":[[2026,8]]},"abstract":"<jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>The mechanisms through which body mass index (BMI) influences the prognosis of chronic obstructive pulmonary disease (COPD) remain poorly understood. This study investigates whether BMI influences all-cause mortality in patients with COPD through mediating effects of exacerbations and cardiovascular events.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>\n                      Data were obtained from a multicentre prospective COPD cohort (\n                      <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"clintrialgov\" xlink:href=\"NCT02800499\">NCT02800499<\/jats:ext-link>\n                      ). BMI was assessed both continuously and categorically as &lt;23 (low), 23\u201327 (normal) and &gt;27 kg\/m\u00b2 (high). The primary outcome was all-cause mortality and secondary outcomes were moderate-to-severe exacerbations and cardiovascular events. Mediation analyses were applied to quantify the contribution of these events to the association between BMI and all-cause mortality.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Among 3314 patients with COPD, those with low BMI had a higher risk of mortality (adjusted OR, 1.46; 95% CI 1.04 to 2.07), whereas no significant difference was observed among those with high BMI. Mediation analyses indicated that exacerbations partially mediated the relationship between BMI and all-cause mortality, explaining 11.9% of the increased mortality among patients with low BMI and 21.9% of the reduced mortality among those with high BMI. Meanwhile, cardiovascular events showed mediating effects in the opposite direction, contributing to 5.2% lower mortality among patients with low BMI and 11.5% higher mortality among those with high BMI.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>BMI was non-linearly associated with all-cause mortality in COPD. Exacerbations mediated the excess mortality risk among patients with low BMI, whereas the decreasing risk of cardiovascular events in this group contributed to a countervailing effect that tempered the overall association between low BMI and mortality.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjresp-2026-004358","type":"journal-article","created":{"date-parts":[[2026,8,11]],"date-time":"2026-08-11T12:06:17Z","timestamp":1786449977000},"page":"e004358","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":2,"title":["Association of body mass index with mortality in COPD through exacerbations and cardiovascular events"],"prefix":"10.1136","volume":"13","clinical-trial-number":[{"clinical-trial-number":"nct02800499","registry":"10.18810\/clinical-trials-gov"},{"clinical-trial-number":"nct02800499","registry":"10.18810\/clinical-trials-gov"}],"author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-4379-0260","authenticated-orcid":false,"given":"Hyun Woo","family":"Lee","sequence":"first","affiliation":[{"name":"Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul Metropolitan Government\u2013Seoul National University Boramae Medical Center, Seoul, South Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sang Hyuk","family":"Kim","sequence":"additional","affiliation":[{"name":"Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, South 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