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1.  Perspective: Overweight, mortality and survival 
Obesity (Silver Spring, Md.)  2013;21(9):1744-1745.
doi:10.1002/oby.20588
PMCID: PMC3803151  PMID: 23929522
BMI; overweight; mortality; epidemiologic methods; survival; obesity paradox
3.  Childhood Obesity: Are We All Speaking the Same Language?123 
Advances in Nutrition  2011;2(2):159S-166S.
Terminology and measures used in studies of weight and adiposity in children can be complex and confusing. Differences arise in metrics, terminology, reference values, and reference levels. Most studies depend on body mass index (BMI) calculated from weight and height, rather than on more direct measures of body fatness. Definitions of overweight and obesity are generally statistical rather than risk-based and use a variety of different reference data sets for BMI. As a result, different definitions often do not give the same results. A basic problem is the lack of strong evidence for any one particular definition. Rather than formulate the question as being one of how to define obesity, it might be useful to consider what BMI cut-points best predict future health risks and how efficiently to screen for such risks. The answers may be different for different populations. In addition, rather than depending solely on BMI to make screening decisions, it is likely to be useful to also consider other factors, including not only race-ethnicity, sex and age, but also factors such as family history. Despite their limitations, BMI-based definitions of overweight and obesity provide working practical definitions that are valuable for general public health surveillance and screening.
doi:10.3945/an.111.000307
PMCID: PMC3065752  PMID: 22332047
6.  Body mass index cut offs to define thinness in children and adolescents: international survey 
BMJ : British Medical Journal  2007;335(7612):194.
Objective To determine cut offs to define thinness in children and adolescents, based on body mass index at age 18 years.
Design International survey of six large nationally representative cross sectional studies on growth.
Setting Brazil, Great Britain, Hong Kong, the Netherlands, Singapore, and the United States.
Subjects 97 876 males and 94 851 females from birth to 25 years.
Main outcome measure Body mass index (BMI, weight/height2).
Results The World Health Organization defines grade 2 thinness in adults as BMI <17. This same cut off, applied to the six datasets at age 18 years, gave mean BMI close to a z score of −2 and 80% of the median. Thus it matches existing criteria for wasting in children based on weight for height. For each dataset, centile curves were drawn to pass through the cut off of BMI 17 at 18 years. The resulting curves were averaged to provide age and sex specific cut-off points from 2-18 years. Similar cut offs were derived based on BMI 16 and 18.5 at 18 years, together providing definitions of thinness grades 1, 2, and 3 in children and adolescents consistent with the WHO adult definitions.
Conclusions The proposed cut-off points should help to provide internationally comparable prevalence rates of thinness in children and adolescents.
doi:10.1136/bmj.39238.399444.55
PMCID: PMC1934447  PMID: 17591624
7.  Blood Lead Levels and Death from All Causes, Cardiovascular Disease, and Cancer: Results from the NHANES III Mortality Study 
Environmental Health Perspectives  2006;114(10):1538-1541.
Background
Analyses of mortality data for participants examined in 1976–1980 in the second National Health and Nutrition Examination Survey (NHANES II) suggested an increased risk of mortality at blood lead levels > 20 μg/dL. Blood lead levels have decreased markedly since the late 1970s. In NHANES III, conducted during 1988–1994, few adults had levels > 20 μg/dL.
Objective
Our objective in this study was to determine the risk of mortality in relation to lower blood lead levels observed for adult participants of NHANES III.
Methods
We analyzed mortality information for 9,757 participants who had a blood lead measurement and who were ≥ 40 years of age at the baseline examination. Using blood lead levels categorized as < 5, 5 to < 10, and ≥ 10 μg/dL, we determined the relative risk of mortality from all causes, cancer, and cardiovascular disease through Cox proportional hazard regression analysis.
Results
Using blood lead levels < 5 μg/dL as the referent, we determined that the relative risk of mortality from all causes was 1.24 [95% confidence interval (CI), 1.05–1.48] for those with blood levels of 5–9 μg/dL and 1.59 (95% CI, 1.28–1.98) for those with blood levels ≥ 10 μg/dL (p for trend < 0.001). The magnitude of risk was similar for deaths due to cardiovascular disease and cancer, and tests for trend were statistically significant (p < 0.01) for both causes of death.
Conclusion
In a nationally representative sample of the U.S. population, blood lead levels as low as 5–9 μg/dL were associated with an increased risk of death from all causes, cardiovascular disease, and cancer.
doi:10.1289/ehp.9123
PMCID: PMC1626441  PMID: 17035139
cancer; cardiovascular disease; lead; mortality; National Health and Nutrition Examination Survey (NHANES); United States
8.  The association of blood lead level and cancer mortality among whites in the United States. 
Environmental Health Perspectives  2002;110(4):325-329.
Lead is classified as a possible carcinogen in humans. We studied the relationship of blood lead level and all cancer mortality in the general population of the United States using data from the National Health and Nutrition Examination Survey II (NHANES II) Mortality Study, 1992, consisting of a total of 203 cancer deaths (117 men and 86 women) among 3,592 whites (1,702 men and 1,890 women) with average of 13.3 years of follow-up. We used Cox proportional hazard regression models to estimate the dose-response relationship between blood lead and all cancer mortality. Log-transformed blood lead was either categorized into quartiles or treated as a continuous variable in a cubic regression spline. Relative risks (RRs) were estimated for site-specific cancers by categorizing lead above and below the median. Among men and women combined, dose-response relationship between quartile of blood lead and all cancer mortality was not significant (ptrend = 0.16), with RRs of 1.24 [95% percent confidence interval (CI), 0.66-2.33], 1.33 (95% CI, 0.57-3.09), and 1.50 (95% CI, 0.75-3.01) for the second, third, and fourth quartiles, respectively, compared with the first quartile. Spline analyses found no dose response (p = 0.29), and none of the site-specific cancer RRs were significant. Among men, no significant dose-response relationships were found for quartile or spline analyses (p trend = 0.57 and p = 0.38, respectively). Among women, no dose-response relationship was found for quartile analysis (ptrend = 0.22). However, the spline dose-response results were significant (p = 0.001), showing a threshold effect at the 94th percentile of blood lead or a lead concentration of 24 microg/dL, with an RR of 2.4 (95% CI, 1.1-5.2) compared with the risk at 12.5 percentile. Because the dose-response relationship found in women was not found in men, occurred at only the highest levels of lead, and has no clear biologic explanation, further replication of this relationship is needed before it can be considered believable. In conclusion, individuals with blood lead levels in the range of NHANES II do not appear to have increased risk of cancer mortality.
PMCID: PMC1240793  PMID: 11940448
9.  Establishing a standard definition for child overweight and obesity worldwide: international survey 
BMJ : British Medical Journal  2000;320(7244):1240.
Objective
To develop an internationally acceptable definition of child overweight and obesity, specifying the measurement, the reference population, and the age and sex specific cut off points.
Design
International survey of six large nationally representative cross sectional growth studies.
Setting
Brazil, Great Britain, Hong Kong, the Netherlands, Singapore, and the United States.
Subjects
97 876 males and 94 851 females from birth to 25 years of age.
Main outcome measure
Body mass index (weight/height2).
Results
For each of the surveys, centile curves were drawn that at age 18 years passed through the widely used cut off points of 25 and 30 kg/m2 for adult overweight and obesity. The resulting curves were averaged to provide age and sex specific cut off points from 2-18 years.
Conclusions
The proposed cut off points, which are less arbitrary and more internationally based than current alternatives, should help to provide internationally comparable prevalence rates of overweight and obesity in children.
PMCID: PMC27365  PMID: 10797032

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