title: Association of obesity and long-term mortality in patients with acute myocardial infarction with and without diabetes mellitus: results from the MONICA/KORA myocardial infarction registry.
abstract: BACKGROUND
  Paradoxically, beneficial effects of overweight and obesity on survival have been found in patients after cardiovascular events such as acute myocardial infarction (AMI). This obesity paradox has not been analyzed in AMI patients with diabetes even though their cardiovascular morbidity and mortality is increased compared to their counterparts without diabetes. Therefore, the objective of this long-term study was to analyze the association between body mass index (BMI) and all-cause mortality in AMI patients with and without diabetes mellitus.
  
  
  METHODS
  Included in the study were 1190 patients with and 2864 patients without diabetes, aged 28-74 years, recruited from a German population-based AMI registry. Patients were consecutively hospitalized between 1 January 2000 and 31 December 2008 with a first ever AMI and followed up until December 2011. Data collection comprised standardized interviews and chart reviews. To assess the association between BMI and long-term mortality from all causes, Cox proportional hazards models were calculated adjusted for risk factors, co-morbidities, clinical characteristics, in-hospital complications as well as medical and drug treatment.
  
  
  RESULTS
  AMI patients of normal weight (BMI 18.5-24.9 kg/m(2)) had the highest long-term mortality rate both in patients with and without diabetes with 50 deaths per 1000 person years and 26 deaths per 1000 person years, respectively. After adjusting for a selection of covariates, a significant, protective effect of overweight and obesity on all-cause mortality was found in AMI patients without diabetes (overweight: hazard ratio (HR) 0.73, 95% confidence interval (CI) 0.58-0.93; p=0.009; obesity: HR 0.64, 95% CI 0.47-0.87; p=0.004). In contrast, an obesity paradox was not found in AMI patients with diabetes. However, stratified analyses showed survival benefits in overweight AMI patients with diabetes who had been prescribed statins prior to AMI (HR 0.51, 95% CI 0.29-0.89, p=0.018) or four evidence-based medications at hospital-discharge (HR 0.52, 95% CI 0.34-0.80, p=0.003).
  
  
  CONCLUSIONS
  In contrast to AMI patients without diabetes, AMI patients with diabetes do not experience a survival benefit from an elevated BMI. To investigate the underlying reasons for these findings, further studies stratifying their samples by diabetes status are needed.
authors.affiliation: Central Hospital of Augsburg, MONICA/KORA Myocardial Infarction Registry, Stenglinstr. 2, 86156, Augsburg, Germany. Miriam.Colombo@helmholtz-muenchen.de.|Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH), Institute of Epidemiology II, Ingolstädter Landstr. 1, 85764, Neuherberg, Germany. Miriam.Colombo@helmholtz-muenchen.de.
authors.forename: Miriam Giovanna
authors.initials: MG
authors.lastname: Colombo
authors.affiliation: Central Hospital of Augsburg, MONICA/KORA Myocardial Infarction Registry, Stenglinstr. 2, 86156, Augsburg, Germany. Christa.Meisinger@helmholtz-muenchen.de.|Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH), Institute of Epidemiology II, Ingolstädter Landstr. 1, 85764, Neuherberg, Germany. Christa.Meisinger@helmholtz-muenchen.de.
authors.forename: Christa
authors.initials: C
authors.lastname: Meisinger
authors.affiliation: Central Hospital of Augsburg, MONICA/KORA Myocardial Infarction Registry, Stenglinstr. 2, 86156, Augsburg, Germany. Ute.Amann@helmholtz-muenchen.de.|Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH), Institute of Epidemiology II, Ingolstädter Landstr. 1, 85764, Neuherberg, Germany. Ute.Amann@helmholtz-muenchen.de.
authors.forename: Ute
authors.initials: U
authors.lastname: Amann
authors.affiliation: Central Hospital of Augsburg, MONICA/KORA Myocardial Infarction Registry, Stenglinstr. 2, 86156, Augsburg, Germany. Heier@helmholtz-muenchen.de.|Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH), Institute of Epidemiology II, Ingolstädter Landstr. 1, 85764, Neuherberg, Germany. Heier@helmholtz-muenchen.de.
authors.forename: Margit
authors.initials: M
authors.lastname: Heier
authors.affiliation: Central Hospital of Augsburg, Department of Internal Medicine I-Cardiology, Stenglinstr. 2, 86156, Augsburg, Germany. wolfgang.scheidt@klinikum-augsburg.de.
authors.forename: Wolfgang
authors.initials: W
authors.lastname: von Scheidt
authors.affiliation: Central Hospital of Augsburg, Department of Internal Medicine I-Cardiology, Stenglinstr. 2, 86156, Augsburg, Germany. b.kuch@donkliniken.de.|Hospital of Nördlingen, Department of Internal Medicine/Cardiology, Stoffelsberg 4, 86720, Nördlingen, Germany. b.kuch@donkliniken.de.
authors.forename: Bernhard
authors.initials: B
authors.lastname: Kuch
authors.affiliation: Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH), Institute of Epidemiology II, Ingolstädter Landstr. 1, 85764, Neuherberg, Germany. peters@helmholtz-muenchen.de.
authors.forename: Annette
authors.initials: A
authors.lastname: Peters
authors.affiliation: Central Hospital of Augsburg, MONICA/KORA Myocardial Infarction Registry, Stenglinstr. 2, 86156, Augsburg, Germany. Inge.Kirchberger@helmholtz-muenchen.de.|Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH), Institute of Epidemiology II, Ingolstädter Landstr. 1, 85764, Neuherberg, Germany. Inge.Kirchberger@helmholtz-muenchen.de.
authors.forename: Inge
authors.initials: I
authors.lastname: Kirchberger
mesh_terms: D000328:Adult; D000368:Aged; D015992:Body Mass Index; D003920:Diabetes Mellitus / Q000175:diagnosis / Q000401:mortality*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D009026:Mortality / Q000639:trends; D009203:Myocardial Infarction / Q000175:diagnosis / Q000401:mortality*; D009765:Obesity / Q000175:diagnosis / Q000401:mortality*; D012042:Registries; D013997:Time Factors