{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,30]],"date-time":"2026-10-30T21:14:53Z","timestamp":1793394893096,"version":"4.5.0"},"reference-count":29,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2024,12,6]],"date-time":"2024-12-06T00:00:00Z","timestamp":1733443200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100018540","name":"Science Fund for Distinguished Young Scholars of Guangdong Province","doi-asserted-by":"publisher","award":["2022B1515020024"],"award-info":[{"award-number":["2022B1515020024"]}],"id":[{"id":"10.13039\/501100018540","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100001809","name":"National Natural Science Foundation of China","doi-asserted-by":"publisher","id":[{"id":"10.13039\/501100001809","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100003453","name":"Natural Science Foundation of Guangdong Province","doi-asserted-by":"publisher","id":[{"id":"10.13039\/501100003453","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Endocrinol."],"abstract":"<jats:sec><jats:title>Purpose<\/jats:title><jats:p>Emerging research indicates that individuals with non-alcoholic fatty liver disease (NAFLD) who carry excess weight have similar or even higher survival rates than their normal-weight counterparts. This puzzling \u201cobesity paradox\u201d may be attributed to underlying biases. To explore this phenomenon, we examined data extracted from the third National Health and Nutrition Examination Survey (NHANES) III, which spanned from 1988-1994.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>We specifically targeted participants diagnosed with NAFLD through ultrasound due to fatty liver presence and employed multivariate Cox regression to assess mortality risk associated with body mass index (BMI) and the waist-to-height ratio (WHtR).<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>Over a median follow-up period of 20.3 [19.9-20.7] years, 1832 participants passed away. The study revealed an intriguing \u201cobesity\u2212survival paradox\u201d, in which individuals classified as overweight (HR 0.926, 95% CI 0.925\u20130.927) or obese (HR 0.982, 95% CI 0.981\u20130.984) presented reduced mortality risks compared with those categorized as normal weight. However, this paradox vanished upon adjustments for smoking and exclusion of the initial 5-year follow-up period (HR 1.046, 95% CI 1.044\u20131.047 for overweight; HR 1.122, 95% CI 1.120\u20131.124 for obesity class I). Notably, the paradox was less pronounced with the WHtR, which was significantly different only in quartile 2 (HR 0.907, 95% CI 0.906\u20130.909) than in quartile 1, and was resolved after appropriate adjustments. In particular, when BMI and WHtR were considered together, higher levels of adiposity indicated a greater risk of mortality with WHtR, whereas BMI did not demonstrate the same trend (<jats:italic>p &amp;lt;<\/jats:italic>0.05).<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusion<\/jats:title><jats:p>The \u201cobesity paradox\u201d in NAFLD patients can be explained by smoking and reverse causation. WHtR was a better predictor of mortality than BMI.<\/jats:p><\/jats:sec>","DOI":"10.3389\/fendo.2024.1419715","type":"journal-article","created":{"date-parts":[[2024,12,6]],"date-time":"2024-12-06T04:30:51Z","timestamp":1733459451000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":8,"title":["Body mass index and waist-to-height ratio effect on mortality in non-alcoholic fatty liver: revisiting the obesity paradox"],"prefix":"10.3389","volume":"15","author":[{"given":"Hao","family":"Jiang","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mingkai","family":"Li","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hongsheng","family":"Yu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yinan","family":"Huang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bilan","family":"Yang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bin","family":"Wu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yidong","family":"Yang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2024,12,6]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","DOI":"10.1038\/s41574-019-0176-8","article-title":"Obesity: global epidemiology and pathogenesis","volume":"15","author":"Bl\u00fcher","year":"2019","journal-title":"Nat Rev Endocrinol"},{"key":"B2","doi-asserted-by":"publisher","first-page":"S32","DOI":"10.3350\/cmh.2022.0365","article-title":"Global incidence and prevalence of nonalcoholic fatty liver disease","volume":"29","author":"Teng","year":"2023","journal-title":"Clin Mol Hepatol"},{"key":"B3","doi-asserted-by":"publisher","first-page":"6","DOI":"10.1016\/j.metabol.2018.09.005","article-title":"The epidemiology of obesity","volume":"92","author":"Chooi","year":"2019","journal-title":"Metabolism: Clin experimental"},{"key":"B4","doi-asserted-by":"publisher","first-page":"11","DOI":"10.1159\/000528083","article-title":"European association for the study of obesity position statement on medical nutrition therapy for the management of overweight and obesity in adults developed in collaboration with the European federation of the associations of dietitians","volume":"16","author":"Hassapidou","year":"2023","journal-title":"Obes facts"},{"key":"B5","doi-asserted-by":"publisher","DOI":"10.1016\/S2213-8587(18)30288-2","article-title":"Association of BMI with overall and cause-specific mortality: a population-based cohort study of 3\u00b76 million adults in the UK","volume":"6","author":"Bhaskaran","year":"2018","journal-title":"Lancet Diabetes endocrinol"},{"key":"B6","doi-asserted-by":"publisher","DOI":"10.1161\/CIRCULATIONAHA.121.056076","article-title":"Myocardial rev-erb-mediated diurnal metabolic rhythm and obesity paradox","volume":"145","author":"Song","year":"2022","journal-title":"Circulation"},{"key":"B7","doi-asserted-by":"publisher","DOI":"10.1136\/heartjnl-2023-322797","article-title":"Obesity paradox is still alive in heart failure","volume":"109","author":"Lavie","year":"2023","journal-title":"Heart (British Cardiac Society)"},{"key":"B8","doi-asserted-by":"publisher","DOI":"10.1016\/s0735-1097(01)01802-2","article-title":"The impact of obesity on the short-term and long-term outcomes after percutaneous coronary intervention: the obesity paradox","volume":"39","author":"Gruberg","year":"2002","journal-title":"J Am Coll Cardiol"},{"key":"B9","doi-asserted-by":"publisher","DOI":"10.1016\/j.jhep.2015.11.004","article-title":"EASL-EASD-EASO Clinical Practice Guidelines for the management of nonalcoholic fatty liver disease","volume":"64","year":"2016","journal-title":"J Hepatol"},{"key":"B10","doi-asserted-by":"publisher","first-page":"764","DOI":"10.1053\/j.gastro.2022.06.023","article-title":"AGA clinical practice update: diagnosis and management of nonalcoholic fatty liver disease in lean individuals: expert review","volume":"163","author":"Long","year":"2022","journal-title":"Gastroenterology"},{"key":"B11","doi-asserted-by":"publisher","first-page":"6","DOI":"10.1097\/HEP.0000000000000360","article-title":"Lean NAFLD is associated with adverse liver events and mortality: Moving beyond BMI","volume":"78","author":"Do","year":"2023","journal-title":"Hepatol (Baltimore Md)"},{"key":"B12","doi-asserted-by":"publisher","DOI":"10.1002\/oby.21239","article-title":"Smoking and reverse causation create an obesity paradox in cardiovascular disease","volume":"23","author":"Stokes","year":"2015","journal-title":"Obes (Silver Spring Md)"},{"key":"B13","doi-asserted-by":"publisher","first-page":"4199","DOI":"10.1093\/eurheartj\/ehad504","article-title":"The fiction of the obesity paradox","volume":"44","author":"Guglin","year":"2023","journal-title":"Eur Heart J"},{"key":"B14","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(16)30175-1","article-title":"Body-mass index and all-cause mortality: individual-participant-data meta-analysis of 239 prospective studies in four continents","volume":"388","author":"Di Angelantonio","year":"2016","journal-title":"Lancet (London England)"},{"key":"B15","doi-asserted-by":"publisher","first-page":"97","DOI":"10.1136\/postgradmedj-2020-137542","article-title":"Effects of waist to height ratio, waist circumference, body mass index on the risk of chronic diseases, all-cause, cardiovascular and cancer mortality","volume":"2021","author":"Lo","year":"1147","journal-title":"Postgraduate Med J"},{"key":"B16","doi-asserted-by":"publisher","DOI":"10.1093\/eurheartj\/ehad083","article-title":"Anthropometric measures and adverse outcomes in heart failure with reduced ejection fraction: revisiting the obesity paradox","volume":"44","author":"Butt","year":"2023","journal-title":"Eur Heart J"},{"key":"B17","doi-asserted-by":"publisher","DOI":"10.1007\/s00508-022-02122-y","article-title":"Definition, classification and diagnosis of diabetes mellitus","volume":"122","author":"Kerner","year":"2014","journal-title":"Exp Clin Endocrinol diabetes: Off journal German Soc Endocrinol [and] German Diabetes Assoc"},{"key":"B18","doi-asserted-by":"publisher","DOI":"10.1016\/j.aohep.2024.101516","article-title":"The steatosis-associated fibrosis estimator (SAFE) outperformed the FIB-4 score in screening the population for liver disease","volume":"29","author":"Li","year":"2024","journal-title":"Ann hepatol"},{"key":"B19","doi-asserted-by":"publisher","DOI":"10.1136\/gutjnl-2020-322564","article-title":"Caucasian lean subjects with non-alcoholic fatty liver disease share long-term prognosis of non-lean: time for reappraisal of BMI-driven approach","volume":"71","author":"Younes","year":"2022","journal-title":"Gut"},{"key":"B20","doi-asserted-by":"publisher","DOI":"10.1097\/HEP.0000000000000329","article-title":"Lean individuals with NAFLD have more severe liver disease and poorer clinical outcomes (NASH-CO Study)","volume":"78","author":"Nabi","year":"2023","journal-title":"Hepatol (Baltimore Md)"},{"key":"B21","doi-asserted-by":"publisher","DOI":"10.1016\/j.mayocp.2014.06.015","article-title":"To legitimize the contentious obesity paradox","volume":"89","author":"Kalantar-Zadeh","year":"2014","journal-title":"Mayo Clinic Proc"},{"key":"B22","doi-asserted-by":"publisher","DOI":"10.1093\/ije\/dyv138","article-title":"Sex-age-specific association of body mass index with all-cause mortality among 12.8 million Korean adults: a prospective cohort study","volume":"44","author":"Yi","year":"2015","journal-title":"Int J Epidemiol"},{"key":"B23","doi-asserted-by":"publisher","DOI":"10.1001\/jama.2018.0158","article-title":"The state of US health, 1990-2016: burden of diseases, injuries, and risk factors among US states","volume":"319","author":"Mokdad","year":"2018","journal-title":"Jama"},{"key":"B24","doi-asserted-by":"publisher","DOI":"10.1093\/aje\/kwm165","article-title":"The impact of residual and unmeasured confounding in epidemiologic studies: a simulation study","volume":"166","author":"Fewell","year":"2007","journal-title":"Am J Epidemiol"},{"key":"B25","doi-asserted-by":"publisher","DOI":"10.1016\/j.ijcard.2020.10.013","article-title":"Obesity paradox in Korean male and female patients with heart failure: A report from the Korean Heart Failure Registry","volume":"325","author":"Lee","year":"2021","journal-title":"Int J Cardiol"},{"key":"B26","doi-asserted-by":"publisher","DOI":"10.1038\/s43587-022-00201-3","article-title":"The obesity paradox is mostly driven by decreased noncardiovascular disease mortality in the oldest old in China: a 20-year prospective cohort study","volume":"2","author":"Lv","year":"2022","journal-title":"Nat aging"},{"key":"B27","doi-asserted-by":"publisher","first-page":"e984","DOI":"10.1161\/CIR.0000000000000973","article-title":"Obesity and cardiovascular disease: A scientific statement from the American heart association","volume":"143","author":"Powell-Wiley","year":"2021","journal-title":"Circulation"},{"key":"B28","doi-asserted-by":"publisher","DOI":"10.1161\/RES.0000000000000421","article-title":"Obesity phenotypes, diabetes, and cardiovascular diseases","volume":"126","author":"Pich\u00e9","year":"2020","journal-title":"Circ Res"},{"key":"B29","doi-asserted-by":"publisher","DOI":"10.1017\/S1368980012002741","article-title":"Measurement error of waist circumference: gaps in knowledge","volume":"16","author":"Verweij","year":"2013","journal-title":"Public Health Nutr"}],"container-title":["Frontiers in Endocrinology"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fendo.2024.1419715\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2024,12,6]],"date-time":"2024-12-06T04:30:54Z","timestamp":1733459454000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fendo.2024.1419715\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,12,6]]},"references-count":29,"alternative-id":["10.3389\/fendo.2024.1419715"],"URL":"https:\/\/doi.org\/10.3389\/fendo.2024.1419715","relation":{},"ISSN":["1664-2392"],"issn-type":[{"value":"1664-2392","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,12,6]]},"article-number":"1419715"}}