Obesity-related mortality in France, Italy, and the United States: A comparison using multiple cause-of-death analysis

Abstract Objectives We investigate the reporting of obesity on death certificates in three countries (France, Italy, and the United States) with different levels of prevalence, and we examine which causes are frequently associated with obesity. Methods We use cause-of-death data for all deaths at ages 50-89 in 2010-2011. Since obesity may not be the underlying cause (UC) of death, we compute age- and sex-standardized death rates considering all mentions of obesity (multiple causes or MC). We use cluster analyses to identify patterns of cause-of-death combinations. Results Obesity is selected as UC in no more than 20% of the deaths with a mention of obesity. Mortality levels, whether measured from the UC or the MC, are weakly related to levels of prevalence. Patterns of cause-of-death combinations are similar across the countries. Apart from the strong link with cardiovascular diseases and diabetes, we identify several less familiar associations. Conclusions Considering all mentions on the deaths certificates reduces the underestimation of obesityrelated mortality based on the UC only. It also enables us to describe the various mortality patterns involving obesity.