Obesity has traditionally been considered a risk factor for ischemic stroke. However, some clinical observations have reported a complex relationship between patients who are overweight or obese with paradoxically better stroke outcomes. Stroke subtypes have differing distributions of risk factors, so this study aimed to explain the relationship between body mass index (BMI) and functional prognosis according to stroke subtype.
A prospective institutional database on stroke was accessed between March 2014 and December 2021, and consecutive patients with ischemic stroke were retrospectively selected. BMI was categorized into five groups (underweight, normal weight, overweight, obese, and morbid obesity). The outcome of interest in this study was the modified Rankin Scale (mRS) at 90 d, which was divided into favorable (mRS = 0–2) and unfavorable (mRS ≥ 3) groups. The relationship between functional outcome and BMI was analyzed according to stroke subtype.
Among 2779 patients with stroke, 913 (32.9%) had unfavorable outcomes. After a propensity score-matched analysis, obesity was inversely associated with unfavorable outcomes (adjusted odds ratio [aOR] = 0.61, 95% confidence interval [95% CI]: 0.46–0.80) in all patients with stroke. Among the stroke subtypes, overweight (aOR = 0.38, 95% CI: 0.20–0.74) and obese (aOR = 0.40, 95% CI: 0.21–0.76) groups were inversely associated with unfavorable outcomes in the cardioembolism subtype. Obesity (aOR = 0.55, 95% CI: 0.32–0.95) was inversely associated with unfavorable outcomes in the small vessel disease subtype. There was no significant relationship between stroke outcome and BMI classification in the large artery disease subtype.
These findings suggest that the obesity paradox in ischemic stroke outcomes might differ according to the stroke subtype.
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Chandramouli C, Tay WT, Bamadhaj NS, Tromp J, Teng TK, Yap JJL, et al. Association of obesity with heart failure outcomes in 11 Asian regions: a cohort study. PLOS Med. 2019;16:e1002916.
Flegal KM, Graubard BI, Williamson DF, Gail MH. Excess deaths associated with underweight, overweight, and obesity. JAMA. 2005;293:1861–7.
Gregg EW, Cheng YJ, Cadwell BL, Imperatore G, Williams DE, Flegal KM, et al. Secular trends in cardiovascular disease risk factors according to body mass index in US adults (vol 293, pg 1868, 2005). JAMA. 2005;294:182–182.
Bazzano LA, Gu DF, Whelton MR, Wu XQ, Chen CS, Duan XF, et al. Body mass index and risk of stroke among Chinese men and women. Ann Neurol. 2010;67:11–20.
Arnlov J, Ingelsson E, Sundstrom J, Lind L. Impact of body mass index and the metabolic syndrome on the risk of cardiovascular disease and death in middle-aged men. Circulation. 2010;121:230–6.
Hu G, Tuomilehto J, Silventoinen K, Sarti C, Männistö S, Jousilahti P. Body mass index, waist circumference, and waist-hip ratio on the risk of total and type-specific stroke. Arch Intern Med. 2007;167:1420–7.
Towfighi A, Ovbiagele B. The impact of body mass index on mortality after stroke. Stroke. 2009;40:2704–8.
Funada S, Shimazu T, Kakizaki M, Kuriyama S, Sato Y, Matsuda-Ohmori K, et al. Body mass index and cardiovascular disease mortality in Japan: the Ohsaki Study. Prev Med. 2008;47:66–70.
Crisp AH, Mcguiness B. Jolly fat – Relation between obesity and psychoneurosis in general population. Br Med J. 1976;1:7–9.
Curtis JP, Selter JG, Wang Y, Rathore SS, Jovin IS, Jadbabaie F, et al. The obesity paradox: Body mass index and outcomes in patients with heart failure. Arch Intern Med. 2005;165:55–61.
Lee EY, Lee YH, Yi SW, Shin SA, Yi JJ. BMI and all-cause mortality in normoglycemia, impaired fasting glucose, newly diagnosed diabetes, and prevalent diabetes: a cohort study. Diabetes Care. 2017;40:1026–33.
Doehner W, Schenkel J, Anker SD, Springer J, Audebert HJ. Overweight and obesity are associated with improved survival, functional outcome, and stroke recurrence after acute stroke or transient ischaemic attack: observations from the TEMPiS trial. Eur Heart J. 2013;34:268–77.
Andersen KK, Olsen TS. The obesity paradox in stroke: Lower mortality and lower risk of readmission for recurrent stroke in obese stroke patients. Int J Stroke. 2015;10:99–104.
Kim BJ, Lee SH, Ryu WS, Kim CK, Lee J, Yoon BW. Paradoxical longevity in obese patients with intracerebral hemorrhage. Neurology. 2011;76:567–73.
World Health Organization. Regional Office for the Western Pacific. The Asia-Pacific perspective: redefining obesity and its treatment. Health Communications, Sydney Australia, 2000.
Adams HP Jr, Biller J. Classification of subtypes of ischemic stroke: History of the trial of org 10172 in acute stroke treatment classification. Stroke. 2015;46:e114–e117.
Lyden P, Brott T, Tilley B, Welch KM, Mascha EJ, Levine S, et al. Improved reliability of the NIH Stroke Scale using video training. NINDS TPA Stroke Study Group. Stroke. 1994;25:2220–6.
Powers WJ, Derdeyn CP, Biller J, Coffey CS, Hoh BL, Jauch EC, et al. 2015 American Heart Association/American Stroke Association focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015;46:3020–35.
Li Z, Zhou T, Li Y, Chen P, Chen L. Anemia increases the mortality risk in patients with stroke: a meta-analysis of cohort studies. Sci Rep. 2016;6:26636.
Pearson TA, Mensah GA, Alexander RW, Anderson JL, Cannon RO, Criqui M, et al. Markers of inflammation and cardiovascular disease: application to clinical and public health practice: a statement for healthcare professionals from the Centers for Disease Control and Prevention and the American Heart Association. Circulation. 2003;107:499–511.
Jung JM, Kwon DY, Han C, Jo I, Jo SA, Park MH. Increased carotid intima-media thickness and plasma homocysteine levels predict cardiovascular and all-cause death: a population-based cohort study. Eur Neurol. 2013;70:1–5.
Kelly DM, Ademi Z, Doehner W, Lip GYH, Mark P, Toyoda K. Chronic kidney disease and cerebrovascular disease: consensus and guidance From a KDIGO controversies conference. Stroke. 2021;52:e328–e346.
Blanc B: nutritional anemias. Report of a WHO Scientific Group [WHO Tech Rep. Ser.]. 405. 1968. pp 1–40.
Bone RC, Balk RA, Cerra FB, Dellinger RP, Fein AM, Knaus WA. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest. The ACCP/SCCM Consensus Conference Committee. 1992;101:1644–55.
Kim J, Park MH, Kim E, Han C, Jo SA, Jo I. Plasma homocysteine is associated with the risk of mild cognitive impairment in an elderly Korean population. J Nutr. 2007;137:2093–7.
van Buuren S. Multiple imputation of discrete and continuous data by fully conditional specification. Stat Methods Med Res. 2007;16:219–42.
Rosenbaum PR, Rubin DB. Constructing a control-group using multivariate matched sampling methods that incorporate the propensity score. Am Stat. 1985;39:33–38.
Pirson FAV, Hinsenveld WH, Staals J, de Greef BTA, van Zwam WH, Dippel DWJ, et al. The effect of body mass index on outcome after endovascular treatment in acute ischemic stroke patients: a post hoc analysis of the mr clean trial. Cerebrovasc Dis. 2019;48:200–6.
Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015;372:11–20.
Burke DT, Al-Adawi S, Bell RB, Easley K, Chen S, Burke DP. Effect of body mass index on stroke rehabilitation. Arch Phys Med Rehabil. 2014;95:1055–9.
Zhao L, Du W, Zhao X, Liu L, Wang C, Wang Y, et al. Favorable functional recovery in overweight ischemic stroke survivors: Findings from the China National Stroke Registry. J Stroke Cerebrovasc Dis. 2014;23:e201–206.
Kim Y, Kim CK, Jung S, Yoon BW, Lee SH. Obesity-stroke paradox and initial neurological severity. J Neurol Neurosurg Psychiatry. 2015;86:743–7.
Whitlock G, Lewington S, Sherliker P, Clarke R, Emberson J, Halsey J, et al. Body-mass index and cause-specific mortality in 900 000 adults: collaborative analyses of 57 prospective studies. Lancet. 2009;373:1083–96.
Twig G, Yaniv G, Levine H, Leiba A, Goldberger N, Derazne E, et al. Body-mass index in 2.3 million adolescents and cardiovascular death in adulthood. N Engl J Med. 2016;374:2430–40.
Kang SH, Choi EK, Han KD, Lee SR, Lim WH, Cha MJ, et al. Underweight is a risk factor for atrial fibrillation: A nationwide population-based study. Int J Cardiol. 2016;215:449–56.
Boriani G, Ruff CT, Kuder JF, Shi MG, Lanz HJ, Rutman H, et al. Relationship between body mass index and outcomes in patients with atrial fibrillation treated with edoxaban or warfarin in the ENGAGE AF-TIMI 48 trial. Eur Heart J. 2019;40:1541–50. +
Sandhu RK, Ezekowitz J, Andersson U, Alexander JH, Granger CB, Halvorsen S, et al. The ‘obesity paradox’ in atrial fibrillation: observations from the Aristotle (apixaban for Reduction in Stroke and Other thromboembolic Events in atrial fibrillation) trial. Eur Heart J. 2016;37:2869–78.
Scherbakov N, von Haehling S, Anker SD, Dirnagl U, Doehner W. Stroke induced sarcopenia: muscle wasting and disability after stroke. Int J Cardiol. 2013;170:89–94.
Ohyama K, Watanabe M, Nosaki Y, Hara T, Iwai K, Mokuno K, et al. Correlation between skeletal muscle mass deficit and poor functional outcome in patients with acute ischemic stroke. J Stroke Cerebrovasc Dis. 2020;29:104623.
DeLany J. Leptin hormone and other biochemical influences on systemic inflammation. J Bodyw Mov Ther. 2008;12:121–32.
Lavie CJ, Milani RV, Ventura HO. Obesity and cardiovascular disease risk factor, paradox, and impact of weight loss. J Am Coll Cardiol. 2009;53:1925–32.
Kalantar-Zadeh K, Horwich TB, Oreopoulos A, Kovesdy CP, Younessi H, Anker SD, et al. Risk factor paradox in wasting diseases. Curr Opin Clin Nutr Metab Care. 2007;10:433–42.
Bornstein SR, Licinio J, Tauchnitz R, Engelmann L, Negrão AB, Gold P, et al. Plasma leptin levels are increased in survivors of acute sepsis: associated loss of diurnal rhythm in cortisol and leptin secretion. J Clin Endocrinol Metab. 1998;83:280–3.
Rozen G, Elbaz-Greener G, Margolis G, Marai I, Heist EK, Ruskin JN, et al. The obesity paradox in real-world nation-wide cohort of patients admitted for a stroke in the U.S. J Clin Med. 2022;11:1678.
Hong S, Park JH, Han K, Lee CB, Kim DS, Yu SH. Association between obesity and cardiovascular disease in elderly patients with diabetes: a retrospective cohort study. J Clin Endocrinol Metab. 2022;107:e515–e527.
Rhéaume C, Leblanc MÈ, Poirier P. Adiposity assessment: explaining the association between obesity, hypertension and stroke. Expert Rev Cardiovasc Ther. 2011;12:1557–64.
Neeland IJ, Poirier P, Després JP. Cardiovascular and metabolic heterogeneity of obesity: clinical challenges and implications for management. Circulation. 2018;137:1391–406.
Nazare JA, Smith JD, Borel AL, Haffner SM, Balkau B, Ross R, et al. Ethnic influences on the relations between abdominal subcutaneous and visceral adiposity, liver fat, and cardiometabolic risk profile: The international study of prediction of intra-abdominal adiposity and its relationship with cardiometabolic risk/intra-abdominal adiposity. Am J Clin Nutr. 2012;96:714–26.
Lam CSP, Teng TK, Tay WT, Anand I, Zhang S, Shimizu W, et al. Regional and ethnic differences among patients with heart failure in Asia: the Asian sudden cardiac death in heart failure registry. Eur Heart J. 2016;37:3141–53.
Hori M, Connolly SJ, Zhu J, Liu LS, Lau CP, Pais P, et al. Dabigatran Versus warfarin effects on ischemic and hemorrhagic strokes and bleeding in Asians and non-Asians with atrial fibrillation. Stroke. 2013;44:1891–6.
Wong KSL, Hu DY, Oomman A, Tan RS, Patel MR, Singer DE, et al. Rivaroxaban for stroke prevention in East Asian patients From the ROCKET AF trial. Stroke. 2014;45:1739–47.
Goto S, Zhu J, Liu LS, Oh BH, Wojdyla DM, Aylward P, et al. Efficacy and safety of apixaban compared with warfarin for stroke prevention in patients with atrial fibrillation from East Asia: a subanalysis of the apixaban for reduction in stroke and other thromboembolic events in atrial fibrillation (Aristotle) trial. Am Heart J. 2014;168:303–9.
This study was supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education (R2015433).
The authors declare no competing interests.
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Lee, SH., Jung, JM. & Park, MH. Obesity paradox and stroke outcomes according to stroke subtype: a propensity score-matched analysis. Int J Obes 47, 669–676 (2023). https://doi.org/10.1038/s41366-023-01318-0
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