Determining the joint effect of obesity and diabetes on functional disability at 3-months and on all-cause mortality at 1-year following an ischemic stroke

[Risk factors for disability in patients with stroke in northeastern Mexico: A retrospective cross-sectional study]

OBJECTIVE

To determine the risk factors associated with disability in patients who had a stroke in northeastern Mexico.

DESIGN

This was an observational, retrospective, cross-sectional study. SITE: Conducted at the Family Medicine Unit No. 33 of the Mexican Institute of Social Security in Reynosa, Tamaulipas, Mexico.

PARTICIPANTS

One hundred and ninety-eight males and 146 females, above 18 years old, beneficiaries of the Mexican Institute of Social Security with a diagnosis of stroke between 2018 and 2021.

INTERVENTIONS

The Barthel index that assesses the degree of dependence to perform basic activities of daily living was applied to the participants and sociodemographic, biological and anthropometric variables were collected from the digital medical record.

MAIN MEASURES

A univariate, correlational and ordinal logistic regression statistical analysis was performed between independent and dependent variables to obtain measures of frequency, percentages, and associated risks.

RESULTS

The risk factors associated with disability were age (OR 1.03, CI 1.01-1.05), overweight (OR 1.81, CI 1.03-3.1), obesity grade I (OR 2.74, CI 1.46-5.1), obesity grade II (OR 4.38, CI 1.44-13), obesity grade III (OR 9.99, CI 2.12-47); type of stroke: ischemic (OR 4.60, CI 2.6-8) or thrombotic (OR 4.95, CI 1.57-15). The number of comorbidities was associated with disability when having one comorbidity (OR 2.80, CI 1.22-6.4), two comorbidities (OR 3.43, CI 1.37-8.5), three comorbidities (OR 2.71, CI 1.01-7.3), and with five comorbidities (OR 3.17, CI 1.01-9.9).

CONCLUSIONS

The risk factors found for disability were age, overweight, obesity, and type of ischemic and thrombotic stroke. Being cared for by a relative and/or spouse reduces the probability of disability.

Possible Implications of Obesity-Primed Microglia that Could Contribute to Stroke-Associated Damage

Microglia, the resident macrophages of the central nervous system, are essential players during physiological and pathological processes. Although they participate in synaptic pruning and maintenance of neuronal circuits, microglia are mainly studied by their activity modulating inflammatory environment and adapting their phenotype and mechanisms to insults detected in the brain parenchyma. Changes in microglial phenotypes are reflected in their morphology, membrane markers, and secreted substances, stimulating neighbor glia and leading their responses to control stimuli. Understanding how microglia react in various microenvironments, such as chronic inflammation, made it possible to establish therapeutic windows and identify synergic interactions with acute damage events like stroke. Obesity is a low-grade chronic inflammatory state that gradually affects the central nervous system, promoting neuroinflammation development. Obese patients have the worst prognosis when they suffer a cerebral infarction due to basal neuroinflammation, then obesity-induced neuroinflammation could promote the priming of microglial cells and favor its neurotoxic response, potentially worsening patients' prognosis. This review discusses the main microglia findings in the obesity context during the course and resolution of cerebral infarction, involving the temporality of the phenotype changes and balance of pro- and anti-inflammatory responses, which is lost in the swollen brain of an obese subject. Obesity enhances proinflammatory responses during a stroke. Obesity-induced systemic inflammation promotes microglial M₁ polarization and priming, which enhances stroke-associated damage, increasing M₁ and decreasing M₂ responses.

Causes and Trends of Disabilities in Community-Dwelling Stroke Survivors: A Population-Based Study

Many stroke survivors live with disabilities in the community. This study aimed to investigate the causes and trends of disabilities among community-dwelling stroke survivors. A total of 1547 community-dwelling stroke survivors ≥ 19 years were identified using the Korea National Health and Nutrition Examination Survey (KNHANES) database from 2007 to 2018. We analyzed the causes and trends of disabilities in strokes survivors using complex-samples procedures. During 2007-2018, 38.0% of stroke survivors were found to have disabilities. Stroke itself was the most common cause of disabilities (21.3%). Musculoskeletal (back or neck problems, 7.0%; arthritis, 5.7%; and leg pain excluding arthritis, 2.3%), sensory (visual problems, 3.6%; and auditory problems, 1.4%), and medical problems (diabetes 2.6%; hypertension, 2.3%; heart disease, 1.5%) accounted for the rest of the other causes of disabilities. Upon analyzing the trends, we found that both the proportion of stroke survivors with disabilities and that of stroke survivors with stroke-related disabilities decreased from KNHANES IV (2007-2009) to V (2010-2012). After 2010-2012, the proportion of both groups stayed constant. The burden of disabilities in non-hospitalized stroke survivors has decreased but still remains high. Attention is warranted because many other problems than a stroke can cause disabilities in community-dwelling stroke survivors.

The obesity paradox may not lead to functional gains in stroke patients undergoing acute inpatient rehabilitation

INTRODUCTION

Obesity is a risk factor for many adverse health outcomes. However for some cardiac conditions and cancers, evidence of an "obesity paradox" seems to exist where an elevated body mass index (BMI) is linked to protective effects in mortality and functional outcomes. Within the stroke rehabilitation literature, there are conflicting findings on this phenomenon possibly due to unaccounted for variables, such as comorbid medical conditions.

OBJECTIVE

To investigate the association between BMI and functional gains made in acute inpatient stroke rehabilitation, and the effects of multiple confounding variables.

DESIGN

Retrospective cohort study.

SETTING

Tertiary academic hospital.

PATIENTS

Three hundred ninety-two adults following a recent ischemic (82%) or hemorrhagic (18%) stroke with a mean age 62.9 years.

INTERVENTIONS

Acute inpatient rehabilitation.

MAIN OUTCOME MEASURES

Functional Independence Measure (FIM) score and BMI.

RESULTS

A significant association was found between motor FIM score gains and elevated BMI when BMI was treated as a continuous variable (p < .05). However, this association disappeared when patient factors and comorbid conditions were taken into account and when BMI was conceptualized categorically (underweight [BMI <18.5], normal [BMI 18.5-24.9], overweight [BMI 25.0-29.9], obese [BMI 30.0-39.9], and severely obese [BMI ≥40.0]). Advanced age, higher motor function on admission, and a diagnosis of diabetes were all significantly associated with decreased motor FIM gains.

CONCLUSIONS

The results from this study provide insufficient evidence to support the "obesity paradox" once patient factors and comorbid conditions are taken into account. Diabetes was the single comorbidity tracked that showed a significant association with change in motor function (p = .01). Further studies might explore how the unique interventions of rehabilitation physicians and ancillary health professionals might mitigate the functional debility associated with diabetes and obesity in stroke patients.

Association between abnormal body weight and stroke outcome: A meta-analysis and systematic review

BACKGROUND AND PURPOSE

To test the hypothesis that "obesity paradox" exists in stroke patients, we conducted a meta-analysis and systematic review on the association between abnormal body weight (obesity, overweight, or underweight) and the outcome of different types of stroke.

METHODS

This meta-analysis and systematic review was performed in conformity to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines in Appendix S2. Studies investigating the association between abnormal body weight and the outcome of different types of stroke were searched for in the PubMed and Embase databases from their inception to 20 March 2021.

RESULTS

Thirty-three articles including 84,660 patients were included in this study. Obesity and overweight were associated with longer survival in mixed-stroke patients (acute ischemic stroke [AIS] combined with one or more other stroke subtypes) than was normal weight, whereas underweight was related to shorter survival; the pooled hazard ratios (HRs) of mortality were 0.77 (95% confidence interval [CI] = 0.71-0.83) for obesity, 0.76 (95% CI = 0.72-0.80) for overweight, and 1.71 (95% CI = 1.56-1.87) for underweight. However, only obesity was associated with longer survival in AIS patients compared with normal weight, and underweight was related to shorter survival; the pooled HR of mortality was 0.75 (95% CI = 0.64-0.88) for obesity and 1.53 (95% CI = 1.27-1.85) for underweight. After merging mixed-stroke and AIS patients, we obtained similar results as in mixed-stroke patients.

CONCLUSIONS

Our results suggested that in patients with mixed stroke or AIS, obesity was associated with a longer survival time than normal weight, whereas underweight was associated with a shorter survival time.

Obesity and diabetes are jointly associated with functional disability in stroke survivors

BACKGROUND

Stroke is the most common cause of complex disability. Obesity and diabetes increase risk for functional disability in the general population, but their contribution to functional disability in stroke survivors is unknown.

OBJECTIVE

To investigate the joint association of obesity and diabetes with functional disability in stroke survivors.

METHODS

Cross-sectional data from 34,376 stroke survivors from the 2015 and 2017 Behavioral Risk Factor Surveillance System (BRFSS) surveys were examined. Weighted and age-adjusted prevalence estimates and adjusted odds ratios (AOR, adjusted for sociodemographic characteristics) with 95% confidence intervals (CIs) were calculated to compare prevalence and odds for self-reported functional disability, stratified by obesity-diabetes status (i.e., neither condition, obesity only, diabetes only, both conditions).

RESULTS

Prevalence of functional disability increased across obesity-diabetes categories in the total sample: neither condition (45.4%, 95% CI: 43.4%-47.4%), obesity only (55.3%, 95% CI: 52.7%-58.0%), diabetes only (60.8%, 95% CI: 57.5%-64.1%), and both conditions (70.3%, 95% CI: 67.7%-72.9%). Compared to respondents with neither condition, those with both obesity and diabetes had 2.62 (95% CI: 2.23-3.08) higher odds for functional disability; odds were also increased for respondents with obesity only (1.52, 95% CI: 1.32-1.76) and diabetes only (1.71, CI: 1.45-2.01).

CONCLUSIONS

Our findings indicated a joint effect of obesity and diabetes on functional disability that exceeded either condition alone, placing stroke survivors with both health conditions at greatest risk for diminished functional capacity. Recognizing obesity and diabetes as modifiable risk factors may be useful for identifying stroke sub-populations that could benefit from lifestyle intervention.

Determining the Joint Effect of Obesity and Diabetes on All-Cause Mortality and Cardiovascular-Related Mortality following an Ischemic Stroke

Although obesity and diabetes mellitus, or diabetes, are independently associated with mortality-related events (e.g., all-cause mortality and cardiovascular-related mortality) following an ischemic stroke, little is known about the joint effect of obesity and diabetes on mortality-related events following an ischemic stroke. The aim of this study is to evaluate the joint effect of obesity and diabetes on mortality-related events in subjects with a recent ischemic stroke. Data from the multicenter Prevention Regimen for Effectively Avoiding Second Strokes (PRoFESS) trial was analyzed for this study. The joint effect of obesity and diabetes on mortality-related events was estimated via Cox proportional hazards regression models. No difference in the hazard of all-cause mortality following an ischemic stroke was observed between obese subjects with diabetes and underweight/normal-weight subjects without diabetes. In contrast, obese subjects with diabetes had an increased hazard of cardiovascular-related mortality following an ischemic stroke compared with underweight/normal-weight subjects without diabetes. Additionally, there was evidence of an attributable proportion due to interaction as well as evidence of a highly statistically significant interaction on the multiplicative scale for cardiovascular-related mortality. In this clinical trial cohort of ischemic stroke survivors, obesity and diabetes synergistically interacted to increase the hazard of cardiovascular-related mortality.