Högskolan i Skövde

Background: The role of biological ageing in the association between body mass index (BMI) and survival remains unclear. We examined whether epigenetic age acceleration (EAA), a biomarker of biological ageing, mediates the BMI-survival association. Methods: We analysed data from 3840 participants (aged 51–100) in the 2016 US Health and Retirement Study, with survival information through 2020. Mediation analyses were performed using linear regression and Gompertz proportional hazards models with restricted cubic splines, adjusting for age, sex, ethnicity/race, smoking, education, and metabolic health. Average direct effects (ADE) of BMI and average causal mediation effects of EAA (HannumAgeAcc, PhenoAgeAcc, GrimAgeAcc, and DunedinPace) on survival time were estimated with 95% confidence intervals (CI). Findings: Associations between BMI, EAA, and survival were nonlinear: high and low BMIs were associated with higher EAA and reduced survival time. ADEs of high BMI (35 kg/m2 versus 27 kg/m2) were not statistically significant (reduced survival time: 1.21–1.58 years) but significant for low BMI (19 kg/m2 versus 27 kg/m2, reduced survival time: 5.60–6.38 years). For high BMI, mediation was significant through all EAAs, with reduced survival time ranging from 0.28 to 0.71 years, accounting for 15–37% of total effects. For low BMI, mediation was statistically significant through HannumAgeAcc (reduced survival time: 0.44, CI: 0.08–0.86) and GrimAgeAcc (reduced survival time: 0.73, CI: 0.15–1.38), accounting for 7–11% of total effects. Interpretation: EAA partially mediated the high BMI-survival association, supporting the mediating role of accelerated ageing in the obesity-survival relationship. Mediation through EAA in the low BMI-survival association was weaker, indicating that alternative mechanisms, other than accelerated ageing, may dominate. Funding: Forte, Vetenskaprådet, SFOepi, Karolinska Institutet's Research Foundation, Loo and Hans Osterman Foundation, the Foundation for Geriatric Diseases at Karolinska Institutet.