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This analysis investigated the independent association of BMI versus surrogate measures of central adiposity with all-cause mortality in individuals with type 2 diabetes.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Methods<\/jats:title>\n                <jats:p>The Renal Insufficiency And Cardiovascular Events Italian Multicentre Study is a prospective cohort study that enrolled 15,773 patients in 19 Italian centres in 2006\u20132008. Exposures were BMI and the surrogate measures of central adiposity waist circumference (WC), waist-to-height ratio (WHtR), and A Body Shape Index (ABSI). Vital status was retrieved on 31 October 2015 for 15,656 patients (99.3%),<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Results<\/jats:title>\n                <jats:p>Age- and sex-adjusted hazard ratios and 95% confidence intervals were significantly higher in BMI-based underweight (1.729 [1.193\u20132.505), <jats:italic>P<\/jats:italic>\u2009=\u20090.004), moderately obese (1.214 [1.058\u20131.392), <jats:italic>P<\/jats:italic>\u2009=\u20090.006) and severely obese (1.703 [1.402\u20132.068), <jats:italic>P<\/jats:italic>\u2009&lt;\u20090.0001), lower in overweight (0.842 [0.775\u20130.915), <jats:italic>P<\/jats:italic>\u2009&lt;\u20090.0001) and similar in mildly obese (0.950 [0.864\u20131.045), <jats:italic>P<\/jats:italic>\u2009=\u20090.292), compared to normal-weight individuals. When further adjusting for smoking, physical activity (PA), and comorbidities, risk was lower also in mildly obese versus normal-weight patients. The BMI-mortality relationship did not change after sequentially excluding ever smokers, individuals with comorbidities, and those died within two years from enrollment and when analyzing separately participants below and above the median age. Conversely, a paradox relationship was observed among inactive\/moderately inactive, but not moderately\/highly active patients. Mortality risk adjusted for age, gender, smoking, PA and comorbidities was significantly higher in the highest tertile of WC (1.279 [1.089\u20131.501], <jats:italic>P<\/jats:italic>\u2009=\u20090.003), WHtR (1.372 [1.165\u20131.615], <jats:italic>P<\/jats:italic>\u2009&lt;\u20090.0001), and ABSI (1.263 [1.067\u20131.495], <jats:italic>P<\/jats:italic>\u2009=\u20090.007) versus the lowest tertile. However, risk was lower in the intermediate versus lowest tertile for WC (0.823 [0.693\u20130.979], <jats:italic>P<\/jats:italic>\u2009=\u20090.028), similar for WHtR, and higher, though not significantly, for ABSI.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Conclusions<\/jats:title>\n                <jats:p>An \u201coverweight paradox\u201d remained after controlling for age, smoking, and comorbidities, arguing against a collider bias or reverse causation. However, it could be partly explained by confounding from PA level, possibly through its impact on lean mass and cardiorespiratory fitness. No obesity paradox was observed with WHtR and especially ABSI, which predicted mortality risk associated with central adiposity better than WC.<\/jats:p>\n                <jats:p><jats:italic>Trial registration<\/jats:italic> ClinicalTrials.gov, NCT00715481, 15 July, 2008<\/jats:p>\n              <\/jats:sec>","DOI":"10.1186\/s12933-022-01706-2","type":"journal-article","created":{"date-parts":[[2022,12,2]],"date-time":"2022-12-02T11:53:59Z","timestamp":1669982039000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":31,"title":["Body mass index versus surrogate measures of central adiposity as independent predictors of mortality in type 2 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EB: consultant fees from Abbott, Bayer, Becton Dickinson, Boehringer Ingelheim, Daiichi-Sankyo, Eli Lilly, and Novo Nordisk. CF: lecture fees from Abbot, Boehringer Ingelheim, Daiichi Sankyo, Eli Lilly, Merck Sharp & Dohme, Mundipharma, and Theras Lifetech. RT: consultant fees from AstraZeneca, Boehringer Ingelheim, Eli Lilly, Merck Sharp & Dohme, Novo Nordisk, and Sanofi-Aventis, and lecture fees from AstraZeneca, Boehringer Ingelheim, Eli Lilly, and Novo Nordisk. MV: lecture fees from Lifescan and Novo Nordisk. FC: consultant fees from Boehringer Ingelheim, and lecture fees from AstraZeneca. OL: lecture fees from Eli-Lilly, and grant support from Merck Serono and Merck Sharp & Dohme. JH: lecture fees from Boehringer Ingelheim. AN: consultant fees from AstraZeneca, lecture fees from Eli Lilly, Medtronic, and Novo Nordisk, and grant support from AlfaSigma, Novo Nordisk, Pikdare, Sanofi, Shionogi, SOBI, and Theras. GP: consultant fees from Abbot, Bayer, and Novo Nordisk, and lecture fees from AstraZeneca, Boehringer Ingelheim, Eli Lilly, and Novo Nordisk. No other disclosures were reported.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"266"}}