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December9,2002,Vol162,No.22>
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OriginalInvestigation | December9/23,2002

BodyMassIndexandtheRiskofStrokeinMen FREE
TobiasKurth,MD,MScJ.MichaelGaziano,MD,MPHKlausBerger,MD,MPHCarlosS.Kase,MDKathrynM.
Rexrode,MD,MPHNancyR.Cook,ScDJulieE.Buring,ScDJoAnnE.Manson,MD,DrPH
[+]AuthorAffiliations
ArchInternMed.2002162(22):25572562.doi:10.1001/archinte.162.22.2557.

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ABSTRACT
ABSTRACT|METHODS|RESULTS|COMMENT|ARTICLEINFORMATION|
REFERENCES

BackgroundAlthoughobesityisanestablishedriskfactorforcoronaryheartdisease,itsroleasarisk

3,687

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factorforstrokeremainscontroversial.

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MethodsProspectivecohortstudyamong21414USmalephysiciansparticipatinginthePhysicians'

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repositioningtheboxesbelow.

HealthStudy.Incidenceoftotal,ischemic,andhemorrhagicstrokewasmeasuredbyselfreportand
confirmedbymedicalrecordreview.WeusedCoxproportionalhazardsmodelstoevaluatetheassociationof
bodymassindex(BMI),calculatedasselfreportedweightinkilogramsdividedbythesquareoftheheight
inmeters,withriskoftotal,ischemic,andhemorrhagicstroke.

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ResultsDuring12.5yearsoffollowup,747strokes(631ischemic,104hemorrhagic,and12undefined)
occurred.ComparedwithparticipantswithBMIslessthan23,thosewithBMIsof30orgreaterhadan
adjustedrelativeriskof2.00(95%confidenceinterval[CI],1.482.71)fortotalstroke,1.95(95%CI,1.39
2.72)forischemicstroke,and2.25(95%CI,1.015.01)forhemorrhagicstroke.WhenBMIwasevaluatedas
acontinuousvariable,eachunitincreaseofBMIwasassociatedwithasignificant6%increaseinthe
adjustedrelativerisksoftotal(95%CI,4%8%),ischemic(95%CI,3%8%),andhemorrhagicstroke(95%
CI,1%12%).Additionaladjustmentforhypertension,diabetesmellitus,andhypercholesterolemiaslightly
attenuatedtherisksfortotalandischemic(relativerisk,4%95%CI,2%7%),butnothemorrhagic,stroke.

ConclusionsTheseprospectivedataindicateasignificantincreaseintherelativeriskoftotalstrokeand
its2majorsubtypeswitheachunitincreaseofBMIthatisindependentoftheeffectsofhypertension,
diabetes,andcholesterol.BecauseBMIisamodifiableriskfactor,thepreventionofstrokemaybeanother
benefitassociatedwithpreventingobesityinadults.
EXCESSWEIGHTisawelldocumentedriskfactorforcoronaryheartdisease. 14Inaddition,itis
associatedwithincreasedriskofseveralfactorsthatmayleadtostroke,includinghypertension5and
diabetesmellitus. 6However,dataontheoverallassociationofobesityandstrokeaswellasstrokesubtypes
arelimitedandinconclusive. 7 Severalstudieshavesuggestedthatahighbodymassindex(BMI)may
increasetheriskoftotalstroke, 4,8,9particularlyischemicstroke. 1013Othershavefoundanassociation
withwaisthipratio14andabdominalobesity1517 (butnotwithBMI)17 ornoassociation. 18 Moreover,itis
notclearifexcessweightitselfisindependentlyassociatedwithincreasedriskofstrokeoverandaboveits
relationshipwithstrokeriskfactors.Finally,therelationshipofBMIwithstrokeseverityhas,toour
knowledge,neverbeenprospectivelyevaluated.
Asaresult,excessweightisnotincludedintheFraminghamstrokeriskpredictionscore, 19,20norisitlisted
asaprimaryriskfactorforstrokebytheNationalInstitutesofHealth 21ortheAmericanStroke
Association. 22Obesity,however,islistedasapotentialmodifiableriskfactorforstrokeintherecent
23

LifetimeHealthandEconomic
ConsequencesofObesity
ArchInternMed.1999159(18):21772183.
doi:10.1001/archinte.159.18.2177.
HealthyLifestyleandtheRiskofStrokein
Women
ArchInternMed.2006166(13):14031409.
doi:10.1001/archinte.166.13.1403.
[+]ViewMore

RelatedCollections
CerebrovascularDisease
Neurology
Obesity
Stroke

CMERelatedbyTopic
LifestyleFactorsontheRisksofIschemic
andHemorrhagicStroke

PubMedArticles

guidelinesoftheAmericanHeartAssociation, 23butitseffectisstatedtobemainlymediatedthrough
hypertension,diabetes,andincreasedbloodlipidlevels.
Becausestroke,theleadingcauseoflongtermdisabilityandmorbidityandthethirdleadingcauseofdeath
intheUnitedStates, 24hasfeweffectivetherapies,identifyingandmanagingpotentialriskfactorssuchas
elevatedBMIremainofgreatimportance.ThePhysicians'HealthStudy(PHS)providedtheopportunityto
assessprospectivelytheassociationbetweenBMIandtheincidenceoftotal,ischemic,andhemorrhagic
stroke,aswellasstrokeseverity,amongmorethan22000USmalephysicians.

METHODS
ABSTRACT|METHODS|RESULTS|COMMENT|ARTICLEINFORMATION|
REFERENCES
ParticipantswerepartofthePHS,acompletedrandomizedtrialoflowdoseaspirinandbetacaroteneinthe
primarypreventionofcardiovasculardiseaseandcancer.Theparticipants,methods,andresultshavebeen
describedindetailpreviously. 2527 Thestudypopulationconsistedof22071USmalephysiciansaged40to
84yearsin1982,withnohistoryofmyocardialinfarction,stroke,transientcerebralischemia,orcancer
(exceptnonmelanomaskincancer),whowerefollowedfor12.5years.Morbidityandmortalitydatawere
availableformorethan99%.
Baselineinformationwasselfreportedandcollectedbyamailedquestionnairethataskedaboutmany
demographic,medicalhistory,andlifestylevariables.Every6monthsforthefirstyearandannually
thereafter,participantsreceivedfollowupquestionnairesaskingaboutcompliancewithrandomized
treatmentassignmentsandnewlydiagnosedconditions,includingstroke.Atbaseline,22065participants
(99.9%)reportedweightandheight.Ofthese,651wereexcludedbecauseofmissinginformationon
potentialconfounders,resultinginastudypopulationof21414men.Bodymassindexwascalculatedas
selfreportedweightinkilogramsdividedbythesquareoftheheightinmeters.

EVALUATIONOFSTROKE
Participantswhoselfreportedstrokeonafollowupquestionnairewereaskedforpermissiontoobtaintheir
medicalrecords.Anendpointscommitteeconfirmedadiagnosisofstrokeafterreviewofmedicalrecords
andreportsofbrainimaging.Strokewasdefinedasafocalneurologicaldeficitofvascularmechanism
lastingmorethan24hoursandwasclassifiedaccordingtocriteriaestablishedbytheNationalSurveyof
Stroke28 intoischemic,hemorrhagic(includingintraparenchymalandsubarachnoidhemorrhage),and
unknownsubtypes.Fatalstrokewasdocumentedbyevidenceofacerebrovascularmechanismobtainedfrom
allavailablesources,includingdeathcertificatesandhospitalrecords.Strokeseveritywasmeasuredusing
theModifiedRankinScale(MRS)29basedoninformationfromthehospitaldischargesummary.TheMRS
classifiesstrokecasesfrom1(noresidualsymptoms)to6(fatalstroke).Wecategorizedstrokeseverityas
mild(MRSscoreof13),severe(MRSscoreof45),orfatal(MRSscoreof6). 30
Anindependentreviewby2neurologistsofthediagnosticcodingofstrokefromthestartofrandomization
ofthePHSuntil1988yieldedexcellentinterobserveragreement. 31Asimilaranalysisofdatafrom1988until
thetrial'sendalsoyieldedstronginterraterreliability,withagreementforischemicstrokeof96.4%(=
0.84)andforhemorrhagicstrokeof97.1%(=0.87).Theoverallagreementforstrokeseverity,calculated
withquadraticweightedstatistics, 32wasexcellent,withconcordanceof94.3%(=0.71)fortheperiod
until198831and97.2%(=0.86)fortheremainderofthestudy.

STATISTICALANALYSES
WeusedCoxproportionalhazardsmodels33toanalyzetheassociationbetweenBMIandstroke.Person
timewascalculatedfromreturnofthebaselinequestionnaireuntilthedateofstroke,death,orthestudy's
end,whicheveroccurredfirst.Bodymassindexwasevaluatedinthefollowing3ways:(1)in5categories
(<23,2324.9,2526.9,2729.9,and30),(2)asthe3WorldHealthOrganization(WHO)weight
categories(normalweight,<25overweight,2529.9andobese,30),and(3)ascontinuousterm.We
testedboththeproportionalhazardsandlinearityassumptionsoftheassociationbetweenBMIandtotal,
ischemic,andhemorrhagicstrokeandfoundnoviolations.
Wecalculatedageadjustedandmultipleadjustedhazardratiosasameasureoftherelativeriskfortotal
(includingischemic,hemorrhagic,andundefinedstrokecases),ischemic,andhemorrhagic(including
intraparenchymalandsubarachnoidhemorrhage)stroke.Weusedanordinalvariabletotestfortrendin
riskacrossBMIcategories.Themultipleregressionmodelscontrolledforage(continuous)smoking(never,
past,orcurrent)alcoholconsumption(1drinksperday,26drinksperweek,1drinkperweek)exercise
(1weekor<1week)historyofangina(yesorno)parentalhistoryofmyocardialinfarctionpriorto60
years(yesorno)andrandomizedtreatmentassignment.Theuseoffinercategoriesofbothalcohol
consumptionandexercisedidnotappreciablychangetheestimatesoftheassociationbetweenBMIand
stroke.Weconsideredhypertension,diabetes,andhighcholesterollevelsaspossiblebiologicalmediatorsof
theeffectofBMIonstrokeandthereforedidnotcontrolforthesefactorsintheprimaryanalysis.However,
hypertension(definedassystolicbloodpressure140mmHgordiastolicbloodpressure90mmHgor
takingantihypertensivemedicationregardlessofbloodpressure),historyofselfreporteddiabetes,and
historyofselfreportedhighcholesterollevelswereaddedsequentiallytomultipleregressionmodelsina
secondaryanalysis.Theuseofdifferentcategorizationofbloodpressuredidnotappreciablychangethe
estimatesoftheassociationbetweenBMIandstroke.WeevaluatedeffectmodificationofBMIbysmoking,

ExploringtheDistributionofPrescriptionfor
SulfonylureasinPatientswithType2
DiabetesAccordingtoCardiovascularRisk
FactorsWithinaCanadianPrimaryCare
Setting.JPopulTherClinPharmacol
201522(3):e22836.
[Prevalenceofcardiovascularriskfactorsin
anurbanambulatoryadultpopulation:
AsuRiesgostudy,Paraguay].RevPanam
SaludPublica201538(2):136143.
ViewMore
Resultsprovidedby:

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hypertension,alcoholconsumption,andage.
Wecalculatedtheproportionoftotalstrokeandstroketypesdirectlystandardizedforagetoevaluatethe
associationofBMIandstrokeseverity.WeusedtheMantelHaenzselextensiontesttotestfortrendinrisk
acrossBMIcategories.TocompareBMImeasurementsoverthestudyperiod,wecalculatedaSpearman
correlationcoefficientcomparingbaselineBMItoBMIsfromthe8yearfollowupandstudyend
questionnairesafterexcludingsubjectswithsevereillnesses.

RESULTS
ABSTRACT|METHODS|RESULTS|COMMENT|ARTICLEINFORMATION|
REFERENCES
During12.5years(268269personyears)offollowup,747incidentstrokesoccurred,including631
ischemic,104hemorrhagic(83intraparenchymaland21subarachnoidhemorrhages),and12undefined
strokes.ThemeanBMIwas24.9,rangingfrom14.4to56.0.BasedonWHOcriteria,12125(56.6%)ofthe
21414menwereinthenormalweightcategory,8105(37.9%)wereoverweight,and1184(5.5%)were
obese.
Table1givestheageadjustedbaselinecharacteristicsoftheparticipantsaccordingtoBMIcategories.Mean
systolicanddiastolicbloodpressuresaswellasprevalenceofhypertensionincreasedwithincreasingBMI.
ThepercentageofmenwhohadneversmokeddecreasedwithincreasingBMI,whereasthepercentageof
menwhoreportedcurrentsmokingwashighestintheobesecategory.Theproportionofmenwhoreported
exercisingregularlydecreasedwithincreasingBMI.Theleanestmenweremorelikelytohavereported
alcoholconsumptionof1drinkormoreperdayandlesslikelytohavereportedconsumptionoflessthan2
drinksperweekcomparedwithobesemen.

Table1.AgeAdjustedBaselineCharacteristicsoftheStudyParticipantsAccordingtoTheirBMI
Status*

ViewLarge|SaveTable|DownloadSlide(.ppt)

Theageandmultipleadjustedrelativerisksoftotal,ischemic,andhemorrhagicstrokeaccordingtoBMI
categoriesaresummarizedinTable2.Theageadjustedrelativerisksoftotalstrokeaswellasstroketypes
increasedsteadilyacrossBMIcategoriescomparedwiththereferent(BMI<23).Multipleadjustmentsfor
variousriskfactorsattenuatedtherelativerisksonlyslightly.

Table2.AgeAdjustedandMultipleAdjustedRelativeRisksand95%ConfidenceIntervalsofTotal,
Ischemic,andHemorrhagicStrokebyBMICategory*

ViewLarge|SaveTable|DownloadSlide(.ppt)

UsingtheWHOcategories,overweightmenhadmultipleadjustedrelativerisksfortotalstrokeof1.32(95%
confidenceinterval[CI],1.141.54),forischemicstrokeof1.35(95%CI,1.151.59),andforhemorrhagic
strokeof1.25(95%CI,0.841.88)comparedwithmenwithBMIslessthan25.Obesemenhadmultiple
adjustedrelativerisksof1.91(95%CI,1.452.52)fortotalstroke,1.87(95%CI,1.382.54)forischemic
stroke,and1.92(95%CI,0.943.93)forhemorrhagicstrokecomparedwithmenwithBMIslessthan25.
WhenBMIwasexaminedasacontinuousvariable,each1unitincreaseinBMIwasassociatedwitha

multipleadjustedincreaseof6%(95%CI,4%8%)intheriskoftotalandischemicstrokeand6%(95%CI,
1%12%)forhemorrhagicstroke.
Theinfluenceofhypertension,diabetes,andhypercholesterolemiaontheassociationbetweenBMIand
strokeriskwasevaluatedinastepwisefashionusingthecontinuousmeasurementofBMI.Forbothtotal
andischemicstroke,theincreasedriskwasreducedto4%(95%CI,2%7%)perunitincreaseinBMIwhen
hypertensionwasincludedinthemodel.Additionaladjustmentfordiabetesdidnotfurtherreducethe
relativerisks.Hemorrhagicstrokewasonlymarginallymediatedbyhypertensionanddiabetes,andthe
effectestimateof6%wasunchanged.Aftercontrollingforhypertensionanddiabetes,theinclusionof
cholesterollevelsof240mg/dLorgreater(6.22mmol/L)didnotfurtherattenuatetheassociationbetween
BMIandanystroketypes.
Smoking,alcoholconsumption,andagedidnotsubstantiallymodifytheeffectfortotal,ischemic,and
hemorrhagicstroke.Theriskofbothischemicandhemorrhagicstrokewashighestamongindividualswith
hypertension,butnosubstantialeffectmodificationwasobservedbetweenhypertensionstatusandBMI
(Figure1andFigure2).

Figure1.
Ageadjustedrelativeriskforischemicstrokeaccordingtobodymassindex(BMI)categories(calculated
asselfreportedweightinkilogramsdividedbythesquareoftheheightinmeters),andhypertension
status.Reference(relativerisk=1.0):normotensivewithaBMIlessthan23(Pfortrend:hypertension,P
=.02normotension,P=.001).

ViewLarge|SaveFigure|DownloadSlide(.ppt)

Figure2.
Ageadjustedrelativeriskforhemorrhagicstrokeaccordingtobodymassindex(BMI)(forcalculationof
BMI,seelegendtoFigure1)categoriesandhypertensionstatus.Reference(relativerisk=1.0):
normotensivewithaBMIlessthan23(Pfortrend:hypertension,P=.34normotension,P=.20).

ViewLarge|SaveFigure|DownloadSlide(.ppt)

Althoughtheoverallstroke30dayfatalitywas6.3%,largedifferenceswereseenbetweenthefatalityamong
stroketypes.Amongthehemorrhagicstrokecases,27.9%werefatal(25.3%ofintraparenchymal
hemorrhagesand38.1%ofsubarachnoidhemorrhages)comparedwithonly2.4%ofischemicstrokes.
Table3summarizestheageadjustedproportionofstrokeseverityineachBMIcategory.Strokeseverityfor
totalandischemicstrokewasnotassociatedwithBMI.Forhemorrhagicstroke,mildstrokesoccurredmore
ofteninmenwithBMIsof30orgreater,whilefatalstrokesoccurredmoreofteninmenwithBMIslower
than23.Furtheranalysisofhemorrhagicstrokesubtypesshowedthattheageadjustedinverseassociation
betweenfatalhemorrhagicstrokeandBMIwasprimarilyowingtoanincreasedincidenceofsubarachnoid
hemorrhage.Ofthe29fatalhemorrhagicstrokecases,8hadsubarachnoidhemorrhages,ofwhich3(age
adjustedpercentage,45.2%)occurredinmenwithBMIslowerthan23and4(ageadjustedpercentage,
39.3%)withBMIsbetween23and24.9,whileonly1(ageadjustedpercentage,14.3%)occurredinthose
withBMIsbetween25and26.9,withnocasesintheheaviercategories.However,theageadjusted
percentageoffatalintraparenchymalhemorrhagesamongobesemen(8.4%)wasalsolowerthanthat
amongmeninBMIcategoriesoflessthan23or23to24.9(30.1%each).Thesefindingswerenotchanged
withadditionaladjustedforhypertension.

Table3.AgeAdjustedSeverityofTotal,Ischemic,andHemorrhagicStrokeAccordingtoBMI
Categories*

ViewLarge|SaveTable|DownloadSlide(.ppt)

ThecorrelationbetweenbaselineBMI,BMIat8yearsoffollowup(r=0.86),andBMIatthestudy'send(r
=0.80)washigh.Bodymassindexwasrelativelystablethroughoutthestudy,with42%ofparticipantswith
baselineBMIslessthan25remaininginthatcategoryand27%remaininginthe25to29.9BMIcategory.
Oftheparticipants,20%increasedfromnormalweighttooverweightorfromoverweighttoobeseandless
than1%shiftedfromnormalweighttoobese.

COMMENT
ABSTRACT|METHODS|RESULTS|COMMENT|ARTICLEINFORMATION|
REFERENCES
Inthisprospectivecohort,increasingBMIwasassociatedwithasteadyincreaseintherisksoftotal,
ischemic,andhemorrhagicstroke.Althoughconcomitanthypertensionanddiabetesaccountedformuchof
theincreaseintotalandischemicstroke,asignificantincreaseremainedafteradjustmentforthese
potentialbiologicalmediators.Althoughtheriskofischemicstrokewashighestamongsmokersand
individualswithhypertension,thesefactorsdidnotsubstantiallymodifytherelationshipbetweenBMIand
stroke.Bodymassindexwasnotassociatedwiththeseverityoftotalandischemicstroke,butthedata
suggestthatitmightbeinverselyassociatedwithseverityoffatalhemorrhagicstroke,particularly
subarachnoidhemorrhage.
Theassociationbetweenexcessweightandstrokeriskhasbeencontroversial.Amongmen,fewprospective
studieshaveinvestigatedthisrelationship.Someofthesehadsmallsamplesizes9,10andothersdidnot
classifystrokesubtypes. 11,12,16,17 Toourknowledge,theassociationbetweenBMIandstrokeseverityhas
notbeenexaminedprospectivelybefore.
IntheHonoluluHeartProgram,nonsmokingmeninthehighesttertileofBMIatage25yearshada2fold
increasedriskofischemicstrokeover22yearsoffollowup. 10IntheWhitehallStudy,a2foldincreasein
riskofstrokemortalitywasobservedamongmenwithBMIsof24orgreatercomparedwiththosewithBMIs
lessthan24. 12Obesitywasalsoariskfactorfornonfatalstrokeinalongtermfollowupstudyofmale
collegealumni. 34Themodesttosmallassociationsobservedinsomestudies,suchasamong2773elderly
menandwomeninChicago,Ill, 9maybearesultofcontrollingforhypertensionanddiabetes,whichmay
directlymediatetheassociationbetweenexcessweightandstroke.Otherstudies,however,failedtofinda
strongassociationbetweenobesityandstrokeinmen. 16,17,3537 Amongwomen,thedataarealso
inconsistent,withsomestudiesshowingapositiveassociation4,13,15,38 andothersshowingno
association. 8,9,14
IntheNurses'HealthStudy,anonsignificantinverseassociationwasobservedbetweenBMIand
hemorrhagicstroke. 13Incontrast,wefounda6%increaseinriskofhemorrhagicstrokeperunitincreaseof
BMI.Onexaminationbysubtype,adirectassociationwasobservedbetweenBMIandintraparenchymal
hemorrhage,whileaninverseassociationwasobservedforsubarachnoidhemorrhage.Asimilarinverse
associationwasobservedinacommunitybasedFinnishcohortof187subjectswithsubarachnoid
hemorrhage.LowBMI(23.5)wasassociatedwithamarkedlyincreasedriskofsubarachnoidhemorrhage
amongcurrentsmokersandthosewithhypertension. 39IfthesamedivergentassociationsbetweenBMIand
subarachnoidandintraparenchymalhemorrhageobservedinourcohortofmenarealsopresentinwomen,
thiscouldexplainthenonsignificantinverseassociationbetweenBMIandtotalhemorrhagicstroke
observedamongwomen, 13sincesubarachnoidhemorrhageismorefrequentinwomenthanmen. 40
TheseverityofischemicandtotalstrokedidnotappeartobeinfluencedbyBMIinourstudy,whilefatal
hemorrhagicstrokeoccurredmoreofteninleanmenthaninoverweightorobesemen.Thesefindingswere
mainlyowingtosubarachnoidhemorrhage,whichhasahigher28daycasefatalityratethan
intraparenchymalhemorrhage. 41,42However,becausefewfatalhemorrhagicstrokesoccurredinourstudy,
wewereunabletoestimatemorepreciselytheassociationbetweenhemorrhagicsubtypesandcategoriesof
BMI.
ThemechanismbywhichBMIaffectsstrokeriskindependentofestablishedriskfactorssuchas
hypertensionanddiabetesisnotfullyunderstood.Someinvestigatorshaveproposedthatanincreasein
prothrombicfactorsobservedamongoverweightandobeseindividualsmaycontributetotheirincreasedrisk
forischemicevents. 4345Higherlevelsofprothrombicfactors,suchasplasminogenactivatorinhibitor1
(PAI1)antigenandactivity,fibrinogen,vonWillebrandfactor,andfactorVII,havebeenfoundinobese
womencomparedwithnormalweightwomen. 43Adiposetissueseemstoplayaroleindeterminingelevated
plasmalevelsofPAI1, 44whicharealsolinkedtothedevelopmentofatherothrombosis. 45Increasedlevels
ofCreactiveproteininoverweightandobeseindividuals46,47 mayalsoplayaroleintheirincreasedriskof
ischemiccardiovascularevents48 sinceanassociationbetweenincreasedlevelsofinflammatorymarkers
andriskofcardiovasculardisease, 4951includingischemicstroke, 52,53hasbeendocumented.
Ourstudyhasseveralstrengths,includingitslargesize,prospectivedesign,andtherelativelyhomogeneous
natureofthecohort,whichreducesconfoundingbyseveralvariables,includingaccesstomedicalcare,
educationalattainment,andsocioeconomicstatus.Misclassificationofstrokewasreducedbydetailed
reviewofmedicalrecords,andinterobserveragreementinclassifyingstroke,strokesubtypes,andstroke

severitywashigh.Thestudyalsohasseveralpotentiallimitations.Bodymassindexwascalculatedusing
selfreporteddata,whichcanleadtomisclassification.Inseveralvalidationstudiesofothercohortsof
healthprofessionals,however,selfreportsofheight,weight,andothercardiovascularriskfactorswere
reliable. 5457 IntheHealthProfessionalsFollowupStudy,thecorrelationcoefficientforselfreportedand
measuredweightinmenwasr=0.97. 56Bodymassindexisnotaperfectmeasurementofadiposity, 58 and
abnormalregionaladipositymayfurtherincreaseriskforstroke. 15,37 Totheextentthatoursinglemeasure
ofBMIimperfectlyreflectsadiposity,ourresultswouldtendtounderestimatethedeleteriouseffectsof
obesity.Moreover,becauseourstudypopulationcontainssolelyphysicianswhoweremostlywhiteand
somewhatleanerthantheaverageUSpopulation, 59,60theresultsmaynotbegeneralizabletoaless
selectivepopulation.However,sincethepathomechanismthatleadstostrokeislikelytobesimilaracross
populations,ourresultsmayunderrepresentthecontributionofobesitytostrokerisk.
Inconclusion,thisstudydemonstratesthatoverweightandobesemenareatincreasedriskoftotal,
ischemic,andhemorrhagicstroke.Theserisksappearedtobeindependentofthepotentialbiological
mediatorsofhypertension,diabetes,andcholesterollevel.Theseresultssuggestthatindividualsandtheir
physiciansshouldconsiderincreasedriskofstrokeanotherhazardofobesity.Preventionofobesityshould
helppreventriskofstrokeinmen.

ARTICLEINFORMATION
ABSTRACT|METHODS|RESULTS|COMMENT|ARTICLEINFORMATION|
REFERENCES
AcceptedforpublicationApril24,2002.
ThisstudywassupportedbygrantsCA34944andCA40360fromtheNationalCancerInstitute,Bethesda,
MD,andgrantsHL26490andHL34595fromtheNationalHeart,Lung,andBloodInstitute,Bethesda.Dr
KurthwassupportedinpartbyagrantfromtheHeinzNixdorfStiftung,Essen,Germany.
Theabstractofthisstudywaspresentedatthe53rdannualmeetingoftheAmericanAcademyofNeurology
inPhiladelphia,Pa,April9,2001.
WeareindebtedtotheparticipantsinthePhysicians'HealthStudyfortheiroutstandingcommitmentand
cooperationtotheentirePhysicians'HealthStudystafffortheirexpertandunfailingassistanceandto
PatrickJ.Skerrett,MA,forassistanceineditingthemanuscript.
Correspondingauthor:TobiasKurth,MD,MSc,BrighamandWomen'sHospital,DivisionofPreventive
Medicine,900CommonwealthAveEast,Boston,MA022151204(email:tkurth@rics.bwh.harvard.edu).

REFERENCES
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