Letter by Doehner et al Regarding Article, “Association Between Obesity and Mortality After Acute First-Ever Stroke: The Obesity–Stroke Paradox”
To the Editor:
In their recent article, Vemmos et al reported the impact of body weight on short-term and long-term outcome after stroke.1 They observed that overweight and obesity were associated with lower, not higher, mortality as compared with normal body mass index (BMI). Although these results run counter to common knowledge on obesity as an adverse factor in primary disease prevention, they are fully in line with an increasing body of evidence of an inverse (or paradox) association in subjects with established chronic or acute diseases.
The authors themselves, however, seem hesitant to rely on their results for clinical application. They conclude, that “the results cannot support recommendations to patients not to loose weight.” Disentangling this double negation leaves us with an encoded statement that current recommendations on weight management should be pursued regardless of the contrasting evidence of this and other studies.
Viewing these data from an interdisciplinary perspective, Vemmos and coworkers in fact contribute to close the gap to several other cardiovascular conditions, which consistently reported similar findings. Data in chronic heart failure from a large range of studies (ELITE II, SOLVD, DIG, Copernicus, V-HeFT II, CIBIS II, COMET, CHARM, Val-HeFT, and others) with >30 000 patients have shown that (1) overweight carries a survival benefit in these patients; and (2) recording weight loss in the course of the disease is associated with disease progression and death.2 Besides other chronic illnesses such as of the lungs, bowels, joints, and kidneys and also in acute events including acute decompensation of heart failure, of chronic obstructive pulmonary disease, myocardial infarction, emergency percutaneous balloon intervention, or bypass surgery, it has been reported that overweight and obesity carry not an increased, but rather a lower risk of death.
The data in patients with stroke in the study by Vemmos et al do not stand alone. Indeed, in contrast to the authors' proposition, previous reports in stroke exist that are fully consistent with the findings of the present study. In a cohort of 21 884 patients from the Danish National Indicator Project registry, mortality after stroke during 5-year follow-up was 27% lower in overweight (BMI 25.0 to 29.9 kg/m2) and 16% lower in obese (BMI 30.0 to 34.9 kg/m2) patients than in patients with normal weight (BMI 18.5 to 24.9 kg/m2) and underweight (BMI <18.5 kg/m2).3 The Feed Or Ordinary Food (FOOD) trial examined the nutritional status in a cohort of 2955 patients with stroke.4 The study has shown that overweight patients (BMI >30 kg/m2) had lowest mortality and poststroke dependency compared with those with normal weight (BMI 20 to 30 kg/m2) or underweight patients (BMI <20 kg/m2).
By contrast, data to support the widely adopted recommendation to reduce body weight after stroke are lacking.5 In view of this emerging evidence, it seems well justified to challenge recent weight reduction recommendations because an “obesity paradox” seems apparent in stroke similar to previous reports in other illnesses. The question why we are calling this finding a paradox reveals more about our expectation than about the available evidence. These expectations are in fact based on our experience from primary disease prevention in which obesity is doubtless associated with increased risk of developing a disease. Our perspective on body weight should, however, carefully differentiate between healthy populations and patients in whom primary prevention is no longer a concern. Clearly, prospective data are required to decide which recommendations on body weight management in patients after stroke should be pursued.
Wolfram Doehner, MD, PhD
Nadja Scherbakov, MD
Heinrich J. Audebert, MD
Center for Stroke Research Berlin
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- © 2011 American Heart Association, Inc.
- Vemmos K,
- Ntaios G,
- Spengos K,
- Savvari P,
- Vemmou A,
- Pappa T,
- et al
- Mann DL
- Doehner W,
- von Haehling S,
- Anker SD
FOOD Trial Collaboration, Poor nutritional status on admission predicts poor outcomes after stroke: observational data from the FOOD trial. Stroke. 2003; 34: 1450–1456.