The obesity paradox: perception vs knowledge

Physical Activity, Cardiorespiratory Fitness, and the Obesity Paradox with Consideration for Racial and/or Ethnic Differences: A Broad Review and Call to Action

Despite decades of extensive research and clinical insights on the increased risk of all-cause and disease-specific morbidity and mortality due to obesity, the obesity paradox still presents a unique perspective, i.e., having a higher body mass index (BMI) offers a protective effect on adverse health outcomes, particularly in people with known cardiovascular disease (CVD). This protective effect may be due to modifiable factors that influence body weight status and health, including physical activity (PA) and cardiorespiratory fitness (CRF), as well as non-modifiable factors, such as race and/or ethnicity. This article briefly reviews the current knowledge surrounding the obesity paradox, its relationship with PA and CRF, and compelling considerations for race and/or ethnicity concerning the obesity paradox. As such, this review provides recommendations and a call to action for future precision medicine to consider modifiable and non-modifiable factors when preventing and/or treating obesity.

30-Day Risk Score for Mortality and Stroke in Patients with Carotid Artery Stenosis Using Artificial Intelligence Based Carotid Plaque Morphology

OBJECTIVES

The gold standard for determining carotid artery stenosis intervention is based on a combination of percent stenosis and symptomatic status. Few studies have assessed plaque morphology as an additive tool for stroke prediction. Our goal was to create a predictive model and risk score for 30-day stroke and death inclusive of plaque morphology.

METHODS

Patients with a CT angiography head/neck between 2010-2021 at a single institution and a diagnosis of carotid artery stenosis were included in our analysis. Each CT was used to create a 3D image of carotid plaque based off image recognition software. A stepwise backward regression was used to select variables for inclusion in our prediction models. Model discrimination was assessed with receiver operating characteristic curves (AUC). Additionally, calibration was performed and the model with the least Akaike Information Criterion (AIC) was selected. The risk score was modeled from the Framingham Study. Primary outcome was mortality/stroke.

RESULTS

We created three models to predict mortality/stroke from 366 patients: model A using only clinical variables, model B using only plaque morphology and model C using both clinical and plaque morphology variables. Model A used age, sex, PAD, hyperlipidemia, BMI, COPD, and history of TIA/stroke and had an AUC of 0.737 and AIC of 285.4. Model B used perivascular adipose tissue volume, lumen area, calcified volume, and target lesion length and had an AUC of 0.644 and AIC of 304.8. Finally, model C combined both clinical and software variables of age, sex, matrix volume, history of TIA/stroke, BMI, perivascular adipose tissue, lipid rich necrotic core, COPD and hyperlipidemia and had an AUC of 0.759 and an AIC of 277.6. Model C was the most predictive because it had the highest AUC and lowest AIC.

CONCLUSION

Our study demonstrates that combining both clinical factors and plaque morphology creates the best predication of a patient's risk for all-cause mortality or stroke from carotid artery stenosis. Additionally, we found that for patients with even 3 points in our risk score model have a 20% chance of stroke/death. Further prospective studies are needed to validate our findings.

Obese patients with atrial fibrillation are more efficiently protected from thrombosis under warfarin or xabans compared to non-obese patients; a systematic review and Meta-analysis of six randomized controlled trials

INTRODUCTION

Recommendations about proper anticoagulation in obese patients, body mass index (BMI) > 30 kg/m2, are not yet clearly defined. Obese patients were included in randomized controlled trials comparing new anticoagulants (NOACs) with warfarin in patients with atrial fibrillation or thromboembolism.

METHODS

We performed a medline search entering proper criteria and finally 6 post-hoc analysis of RCTs, reporting outcome according to BMI, were included in this meta-analysis. Two major outcomes were considered end points in our meta-analysis; thrombosis, including ischemic cerebral events (transient or not) and venous thrombosis (DVD) /pulmonary embolism (PE) and bleeding, including major bleeding and clinically relevant non-major bleeding.

RESULTS

In the NOACs treated group, thrombosis occurred less frequently in obese vs non-obese patients; RR and 95 % CI 0,75 (0,58-0,97), p = 0,03, while low heterogeneity was observed (I2= 40 %). In the warfarin treated subgroup there was statistically significant difference with less thrombotic events occurring in the obese vs non-obese patients; RR and (95 % CI) 0,80 (0,66-0,98), p = 0,03, and heterogeneity was low (I2 = 24 %). This protective effect called the obesity paradox is limited to obese patients anticoagulated for non-valvular atrial fibrillation (NVAF); RR (95 % CI) was 0,70 (0,58-0,85) p = 0,03 and I2 = 24 %. Bleeding events were similar under both NOACs and warfarin in obese vs non-obese analysis.

CONCLUSIONS

Obese patients anticoagulated for NVAF with either standard dose of xabans or INR guided warfarin are more efficiently protected against thrombosis compared to non-obese patients.

Obesity, body fat distribution and eye diseases

BACKGROUND

The prevalence of obesity, a chronic disease, is increasing, and obesity is now considered a global epidemic. Eye diseases are also increasing worldwide and have serious repercussions on quality of life as well as increasingly high costs for the community. The relationships between obesity and ocular pathologies are not yet well clarified and are not pathologically homogeneous: they seem to be somehow linked to excess body fat, especially to the distribution of adipose tissue and its ectopic deposits.

PURPOSE

Our objective was to examine the associations between obesity and anthropometric indices, including body mass index (BMI), waist circumference (WC), and the waist/hip ratio (WHR), and the risk of most widespread eye diseases, with particular attention given to the most significant metabolic mechanisms.

METHODS

This article provides a narrative overview of the effect of obesity and anthropometric measurements of body fat on prevalent eye diseases. We used the MEDLINE/PubMed, CINAHL, EMBASE, and Cochrane Library databases from 1984 to 2024. In addition, we hand-searched references from the retrieved articles and explored a number of related websites. A total of 153 publications were considered.

RESULTS

There is significant evidence that obesity is associated with several eye diseases. Waist circumference (WC) and the waist/hip ratio (WHR) have been observed to have stronger positive associations with eye diseases than BMI.

CONCLUSIONS

Obesity must be considered a significant risk factor for eye diseases; hence, a multidisciplinary and multidimensional approach to treating obesity, which also affects ocular health, is important. In the prevention and treatment of eye diseases related to obesity, lifestyle factors, especially diet and physical activity, as well as weight changes, both weight loss and weight gain, should not be overlooked.

LEVEL OF EVIDENCE

Level V narrative review.

Association between lipid accumulation products and osteoarthritis among adults in the United States: A cross-sectional study, NHANES 2017-2020

OBJECTIVE

Using cross-sectional data from the 2017-2020 National Health and Nutrition Examination Survey (NHANES) for American, the aim of this research is to investigate the potential association between Lipid Accumulation Products (LAP) and the risk of osteoarthritis (OA).

METHODS

Data from the NHANES (2017-2020) were downloaded and further analyzed. The participants between 20 and 80 years reported having OA, and other relevant variables and information on LAP were included. The linear and non-linear associations between LAP and OA were evaluated using multivariable logistic regression analysis and smoothed curve fitting methods. A two-part linear regression model was also used to estimate threshold effects.

RESULTS

The increased risk of OA was shown to have a nonlinear relationship with higher LAP, showing a solid threshold impact with a saturation value of 120.00 cm × mmol/L, according to our data. The two variables showed a positive relationship to the left of the saturation point but no significant association to the right, pointing to a complicated nonlinear relationship between OA prevalence and LAP.

CONCLUSIONS

Our findings revealed that LAP was an independent risk factor for OA when it was <120.00 cm × mmol/L. The LAP index may serve as a valuable method for predicting and diagnosed OA. To validate our results, further large-scale prospective research are required.

Multiplicative effect of frailty and obesity on postoperative mortality following spine surgery: a deep dive into the frailty, obesity, and Clavien-Dindo dynamic

BACKGROUND/OBJECTIVES

Obesity is a global health challenge that affects a large proportion of adults worldwide. Obesity and frailty pose considerable health risks due to their potential to interact and amplify one another's negative effects. Therefore, we sought to compare the discriminatory thresholds of the risk analysis index (RAI), 5-factor modified frailty index (m-FI-5) and patient age for the primary endpoint of postoperative mortality.

SUBJECTS/METHODS

We included spine surgery patients ≥18 years old, from the American College of Surgeons National Quality Improvement program database from 2012-2020, that were classified as obese. We performed receiver operating characteristic curve analysis to compare the discrimination threshold of RAI, mFI-5, and patient age for postoperative mortality. Proportional hazards risk-adjusted regressions were performed, and Hazard ratios and corresponding 95% Confidence intervals (CI) are reported.

RESULTS

Overall, there were 149 163 patients evaluated, and in the ROC analysis for postoperative mortality, RAI showed superior discrimination C-statistic 0.793 (95%CI: 0.773-0.813), compared to mFI-5 C-statistic 0.671 (95%CI 0.650-0.691), and patient age C-statistic 0.686 (95%CI 0.666-0.707). Risk-adjusted analyses were performed, and the RAI had a stepwise increasing effect size across frailty strata: typical patients HR 2.55 (95%CI 2.03-3.19), frail patients HR 3.48 (95%CI 2.49-4.86), and very frail patients HR 4.90 (95%CI 2.87-8.37). We found increasing postoperative mortality effect sizes within Clavein-Dindo complication strata, consistent across obesity categories, exponentially increasing with frailty, and multiplicatively enhanced within CD, frailty and obesity strata.

CONCLUSION

In this study of 149 163 patients classified as obese and undergoing spine procedures in an international prospective surgical database, the RAI demonstrated superior discrimination compared to the mFI-5 and patient age in predicting postoperative mortality risk. The deleterious effects of frailty and obesity were synergistic as their combined effect predicted worse outcomes.

Impact of Aging and a High-Fat Diet on Adipose-Tissue-Derived Extracellular Vesicle miRNA Profiles in Mice

BACKGROUND

Middle-aged adults have the highest obesity rates, leading to significant health complications in later years. Obesity triggers the release of altered molecules, including extracellular vesicles (EVs) from excess adipose tissue (AT), contributing to various health complications. In this study, we assessed the effects of age and a high-fat diet on AT-derived EV miRNA profiles to understand their potential roles in aging and obesity.

METHOD

C57BL/6 male mice were subjected to a normal chow diet (NCD) or a high-fat diet (HFD) for either 10-12 weeks (young mice, n = 10) or 50-61 weeks (middle-aged mice, n = 12). After evaluating metabolic characteristics, peri-gonadal white AT was isolated and cultured to obtain EVs. AT-derived EV miRNAs were profiled using a NanoString miRNA panel (n = 599).

RESULTS

Middle-aged mice exhibited obesity regardless of diet. Young mice fed an HFD showed similar metabolic traits to middle-aged mice. In the NCD group, 131 differentially expressed miRNAs (DE-miRNAs) emerged in middle-aged mice compared to young mice, including miR-21, miR-148a, and miR-29a, associated with cancer, neuro/psychological disorders, and reproductive diseases. In the HFD group, 55 DE-miRNAs were revealed in middle-aged mice compared to young mice. These miRNAs were associated with significantly suppressed IGF1R activity.

CONCLUSION

This study demonstrates the potential significant impact of miRNAs of AT EVs on aging- and obesity-related diseases.

Impact of Bariatric Surgery on the Prevalence and Outcomes of Atrial Fibrillation in Obese Patients

Obesity has been identified as a significant factor contributing to the development of numerous cardiovascular conditions and as a result, the cardiovascular community has prioritized efforts to address obesity and reduce its associated risks. However, despite these efforts, the prevalence of obesity continues to rise steadily, and is projected to double in the upcoming years. Atrial fibrillation is among the most prevalent and extensively researched cardiovascular comorbidities associated with obesity. Several mechanisms have been postulated, including scar tissue formation and fat deposition, which ultimately leads to atrial remodeling and subsequent arrhythmogenesis. Numerous strategies have been implemented to prevent and manage obesity, encompassing lifestyle adjustments, dietary modifications, pharmacological treatments, and surgical interventions. Bariatric surgery has garnered significant recognition over the years due to its promising outcomes, including a decrease in the overall prevalence of atrial fibrillation and other cardiovascular comorbidities in general in obese patients. This study focuses on the current trends regarding the impact of bariatric surgery on obese patients with atrial fibrillation.

Obesity indices and the risk of total and cardiovascular mortality among people with diabetes: a long-term follow-up study in Taiwan

BACKGROUND

The association between obesity indicators and mortality in individuals with diabetes remains unclear, and data on cardiovascular mortality are scarce. Therefore, we investigated the associations between the five adiposity indices and both all-cause and cardiovascular mortality in patients with diabetes.

METHODS

This cohort study included 34,686 adults with diabetes who underwent a standard health-screening program between 1996 and 2017 in Taiwan. The dates and causes of death till January 2022 were retrieved from the National Death Registry. Cox proportional hazards models were used to calculate the hazard ratios (HR) and 95% confidence intervals (CI) for all-cause and cardiovascular mortality in relation to body mass index (BMI), waist circumference, waist-hip ratio (WHR), body fat percentage (BF%), and A Body Shape Index (ABSI), using the third quintile as the reference group.

RESULTS

During a median follow-up of 15 years, there were 8,324 deaths, of which 1,748 were attributed to cardiovascular disease. After adjusting for demographics, lifestyle factors and comorbidities, ABSI was associated with all-cause mortality in an exposure-response manner; the HR (95% CI) for first and fifth vs. third quintile was 0.78 (0.69-0.89) and 1.24 (1.14-1.35), respectively. A similar but weaker exposure-response relationship was found between WHR and mortality. People with a lower BMI and BF% had an increased risk of mortality (HR [95% CI] for the first vs. third quintiles, 1.33 [1.22, 1.44] and 1.42 [1.30, 1.56], respectively). No association was observed between waist circumference categories and risk of mortality. Similar results were observed for the association of BF%, waist circumference, and ABSI with cardiovascular mortality. However, no significant association was observed between BMI and cardiovascular mortality. The association between WHR and cardiovascular mortality was stronger than that between WHR and all-cause mortality.

CONCLUSIONS

ABSI demonstrated a consistent exposure-response relationship with both all-cause and cardiovascular mortality in this Asian cohort with diabetes. Our findings highlight the importance of monitoring ABSI, a surrogate index of central adiposity, in patients with diabetes.

Association between obesity and urinary incontinence in older adults from multiple nationwide longitudinal cohorts

BACKGROUND

Obesity and urinary incontinence (UI) among older adults, particularly older men, are yet to be fully explored. Utilizing multiple nationwide prospective longitudinal cohorts representative of the US, UK, and European samples, we examined the association of body mass index (BMI) and waist circumference (WC) with UI among both older women and men.

METHODS

We derived the data from multiple longitudinal cohorts that surveyed UI. Participants were asked if they had experienced urine leakage within the past 12 months or within the past six months. The measure of obesity was based on BMI and WC. We employed a random-effect logistic model to associate BMI and WC with UI, adjusting for covariates including age, race, education, residence area, marital status, number of children, smoking, drinking, hypertension, diabetes, cancer, stroke, functional ability, and cognitive impairment. We visualized the associations by using restricted cubic spline curves.

RESULTS

A total of 200,717 participants with 718,822 observations are included in the baseline analysis. Compared to those without UI, both female and male participants with UI demonstrate a higher BMI and WC. Among females, the fully adjusted models show linear associations between BMI, WC, and UI (Ps < 0.001). However, we observe U-shaped associations of BMI, WC with UI among males. The lowest likelihood of having UI is found among male participants with a BMI between 24 and 35 kg/m2.

CONCLUSIONS

Interventions aimed at preventing UI among older adults must take sex into account. Weight loss intervention could be an effective treatment among older females who are overweight and with obesity as well as older males with obesity rather than all older males.

Examining Obesity and Its Association With Burn Injury: A Secondary Analysis of the Transfusion Requirement in Burn Care Evaluation Study

INTRODUCTION

Literature examining the connection between obesity and burn injuries is limited. This study is a secondary analysis of a multicenter trial data set to investigate the association between burn outcomes and obesity following severe burn injury.

MATERIALS AND METHODS

Body mass index (BMI) was used to stratify patients as normal weight (NW; BMI 18.5-25), all obese (AO; any BMI>30), obese I (OI; BMI 30-34.9), obese II (OII; BMI 35-39.9), or obese III (OIII; BMI>40). The primary outcome examined was mortality. Secondary outcomes included hospital length of stay (LOS), number of transfusions, injury scores, infection occurrences, number of operations, ventilator days, intensive care unit LOS, and days to wound healing.

RESULTS

Of 335 patients included for study, 130 were obese. Median total body surface area (TBSA) was 31%, 77 patients (23%) had inhalation injury and 41 patients died. Inhalation injury was higher in OIII than NW (42.1% versus 20%, P = 0.03). Blood stream infections (BSI) were higher in OI versus NW (0.72 versus 0.33, P = 0.03). Total operations, ventilator days, days to wound healing, multiorgan dysfunction score, Acute Physiology and Chronic Health Evaluationscore, hospital LOS, and intensive care unit LOS were not significantly affected by BMI classification. Mortality was not significantly different between obesity groups. Kaplan-Meier survival curves did not significantly differ between the groups (χ2 = 0.025, P = 0.87). Multiple logistic regression identified age, TBSA, and full thickness burn as significant independent predictors (P < 0.05) of mortality; however, BMI classification itself was not predictive of mortality.

CONCLUSIONS

No significant association between obesity and mortality was seen after burn injury. Age, TBSA, and percent full- thickness burn were independent predictors of mortality after burn injury, while BMI classification was not.

BMI category-specific waist circumference thresholds based on cardiovascular disease outcomes and all-cause mortality: Tehran lipid and glucose study (TLGS)

BACKGROUND

Waist circumference (WC), a representative of abdominal visceral fat, is strongly associated with cardiovascular disease (CVD) and its outcomes. We aimed to define body mass index (BMI)-specific WC thresholds as predictors of CVD and all-cause mortality.

METHODS

In this prospective cohort study in the context of the Tehran Lipid and Glucose Study (TLGS), a total of 3344 men and 4068 women were followed up for 18 years. Based on BMI, the participants were categorized into three groups: BMI < 25, 25 < BMI < 30, and BMI > 30. In each BMI category, sex-specific WC thresholds were estimated by the maximum value of Youden's index to predict based on incident CVD events and all-cause mortality prediction.

RESULTS

Overall 667 and 463 CVD events (the incidence rate of 3.1 to 4.5 in men and 1.1 to 2.6 in women per 1,000 person-years within BMI categories) and 438 and 302 mortalities (the incidence rate of 2.1 to 2.7 in men and 1.2 to 1.4 in women per 1,000 person-years within BMI categories) were recorded in men and women, respectively. WC thresholds in the BMI categories of < 25, 25-30, and BMI > 30 kg/m² with regard to CVD events were 82, 95, and 103 cm in men and 82, 89, and 100 cm in women, and regarding all-cause mortality, the respective values were 88, 95, and 103 cm in men and 83, 90, and 99 cm among women.

CONCLUSION

BMI-specific WC thresholds observed here can help to better identify individuals at high risk of developing CVDs.

Metabolic Syndrome Increases Risk of Readmission and Complications in Operative Fixation of Pilon Fractures

Background Studies demonstrate that metabolic syndrome (MetS) negatively impacts surgical outcomes. This study sought to identify how metabolic syndrome affects outcomes after open reduction and internal fixation (ORIF) of traumatic pilon fractures. Methods Patients who underwent ORIF for pilon fractures from 2012 to 2019 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Patients with MetS were compared to non-MetS patients for rates of adverse events, prolonged stay, readmission, discharge location, and operative time in the 30-day postoperative period. All statistical analyses were conducted using SPSS version 26.0 (IBM Corp., Armonk, NY, USA). Paired student t-tests were used to assess continuous variables. Pearson's Chi-square and odds ratios were used for categorical variables. Results A total of 1,915 patients met this study's inclusion criteria, and 127 MetS patients were identified in the cohort. The MetS cohort was older (62.7 vs 49.5 years old, p-value <0.01), with a greater proportion of female patients (59.1% vs 50.2%, p=0.054). MetS patients experienced significantly higher rates of infectious complications (7.9% vs 3.9% OR 2.75 (CI 1.36-5.53), p=0.008), major adverse events (11% vs 4.3%, OR 2.79 (CI 1.53-5.09) p=0.002), and readmissions. MetS patients also had longer lengths of stay (7 days vs 3.8 days, p-value<0.001), and were more likely to be discharged to a non-home location (51.2% vs 19.5%, p-value<0.01, OR 4.32 (CI=3.0-6.24) p<0.001). Conclusion Patients with MetS have an increased risk of 30-day major complications, infection, readmissions, discharge to a non-home location, and prolonged operative time, and therefore warrant additional consideration for perioperative monitoring.

Age Moderates the Effect of Obesity on Mortality Risk in Critically Ill Patients With COVID-19: A Nationwide Observational Cohort Study

OBJECTIVES

A high body mass index (BMI) is associated with an unfavorable disease course in COVID-19, but not among those who require admission to the ICU. This has not been examined across different age groups. We examined whether age modifies the association between BMI and mortality among critically ill COVID-19 patients.

DESIGN

An observational cohort study.

SETTING

A nationwide registry analysis of critically ill patients with COVID-19 registered in the National Intensive Care Evaluation registry.

PATIENTS

We included 15,701 critically ill patients with COVID-19 (10,768 males [68.6%] with median [interquartile range] age 64 yr [55-71 yr]), of whom 1,402 (8.9%) patients were less than 45 years.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

In the total sample and after adjustment for age, gender, Acute Physiology and Chronic Health Evaluation IV, mechanical ventilation, and use of vasoactive drugs, we found that a BMI greater than or equal to 30 kg/m 2 does not affect hospital mortality (adjusted odds ratio [OR adj ] = 0.98; 95% CI, 0.90-1.06; p = 0.62). For patients less than 45 years old, but not for those greater than or equal to 45 years old, a BMI greater than or equal to 30 kg/m 2 was associated with a lower hospital mortality (OR adj = 0.59; 95% CI, 0.36-0.96; p = 0.03).

CONCLUSIONS

A higher BMI may be favorably associated with a lower mortality among those less than 45 years old. This is in line with the so-called "obesity paradox" that was established for other groups of critically ill patients in broad age ranges. Further research is needed to understand this favorable association in young critically ill patients with COVID-19.

Postoperative Delirium After Intracranial Surgery: A Retrospective Cohort Study

BACKGROUND

The clinical relevance of postoperative delirium (POD) in neurosurgery remains unclear and should be investigated because these patients are vulnerable. Hence, we investigated the impact of POD, by means of incidence and health outcomes, and identified independent risk factors.

METHODS

Adult patients undergoing an intracranial surgical procedure in the Erasmus Medical Center Rotterdam between June 2017 and September 2020 were retrospectively included. POD incidence, defined by a Delirium Observation Screening Scale (DOSS) ≥3 or antipsychotic treatment for delirium within 5 days after surgery, was calculated. Logistic regression analysis on the full data set was conducted for the multivariable risk factor and health outcome analyses.

RESULTS

After including 2901 intracranial surgical procedures, POD was present in 19.4% with a mean onset in days of 2.62 (standard deviation, 1.22) and associated with more intensive care unit admissions and more discharge toward residential care. Onset of POD was not associated with increased length of hospitalization or mortality. We identified several independent nonmodifiable risk factors such as age, preexisting memory problems, emergency operations, craniotomy compared with burr-hole surgery, and severe blood loss. Moreover, we identified modifiable risk factors such as low preoperative potassium and opioid and dexamethasone administration.

CONCLUSIONS

Our POD incidence rates and correlation with more intensive care unit admission and discharge toward residential care suggest a significant impact of POD on neurosurgical patients. We identified several modifiable and nonmodifiable risk factors, which shed light on the pathophysiologic mechanisms of POD in this cohort and could be targeted for future intervention studies.

The association between obesity and postoperative outcomes in a broad surgical population: A 7-year American College of Surgeons National Surgical Quality Improvement analysis

BACKGROUND

The number of obese surgical patients continues to grow, and yet obesity's association with surgical outcomes is not totally clear. This study examined the association between obesity and surgical outcomes across a broad surgical population using a very large sample size.

METHODS

This was an analysis of the 2012 to 2018 American College of Surgeons National Surgical Quality Improvement database, including all patients from 9 surgical specialties (general, gynecology, neurosurgery, orthopedics, otolaryngology, plastics, thoracic, urology, and vascular). Preoperative characteristics and postoperative outcomes were compared by body mass index class (normal weight 18.5-24.9 kg/m², overweight 25.0-29.9, obese class I 30.0-34.9, obese II 35.0-39.9, obese III ≥40). Adjusted odds ratios were computed for adverse outcomes by body mass index class.

RESULTS

A total of 5,572,019 patients were included; 44.6% were obese. Median operative times were marginally higher for obese patients (89 vs 83 minutes, P < .001). Compared to normal weight patients, overweight and obese patients in classes I, II, and III all had higher adjusted odds of developing infection, venous thromboembolism, and renal complications, but they did not exhibit elevated odds of other postoperative complications (mortality, overall morbidity, pulmonary, urinary tract infection, cardiac, bleeding, stroke, unplanned readmission, or discharge not home (except for class III patients).

CONCLUSION

Obesity was associated with increased odds of postoperative infection, venous thromboembolism, and renal but not the other American College of Surgeons National Surgical Quality Improvement complications. Obese patients need to be carefully managed for these complications.

Clinical effectiveness of zoster vaccine live in kidney transplant recipients immunized prior to transplantation: a retrospective single-centre cohort study

OBJECTIVES

Kidney transplant (KT) recipients have an increased risk of herpes zoster (HZ) and its complications. Although recombinant zoster vaccine is favoured over zoster vaccine live (ZVL), ZVL is also recommended to prevent HZ for KT candidates. We aimed to evaluate the clinical effectiveness of ZVL in KT recipients immunized before transplantation.

METHODS

Adult patients who received kidney transplantation from January 2014 to December 2018 were enrolled. Patients were observed until HZ occurrence, death, loss of allograft, loss to follow-up, or 5 years after transplantation. The inverse probability of the treatment-weighted Cox proportional hazard model was used to compare the incidence of HZ after transplantation between vaccinated and unvaccinated patients.

RESULTS

A total of 84 vaccinated and 340 unvaccinated patients were included. The median age was higher in the vaccinated group (57 vs. 54 years, p 0.003). Grafts from deceased donors were more frequently transplanted in the unvaccinated group (16.7% vs. 51.8%, p < 0.001). Five-year cumulative HZ incidence was 11.9%, which translated to 26.27 (95% CI, 19.33-34.95) per 1000 person-years. The incidence in the vaccinated and unvaccinated groups was 3.9% and 13.7%, respectively. After adjustment, vaccination showed significant protective effectiveness against HZ (adjusted hazard ratio, 0.18, 95% CI, 0.05-0.60). In addition, all four cases of disseminated zoster occurred in the unvaccinated group.

DISCUSSION

Our study, the first on the clinical effectiveness of zoster vaccines for KT recipients, suggests that ZVL before transplantation effectively prevents HZ.

The Effects of the Obesity Paradox and In-Hospital and One-Year Outcomes in Patients With ST Elevation Myocardial Infarction (STEMI): Results From a STEMI Registry

BACKGROUND

Obesity is strongly associated with increased cardiovascular diseases (CVD) and cardiovascular risk factors, such as diabetes mellitus, hypertension, and dyslipidemia. However, numerous studies have suggested the existence of an "obesity paradox" in which overweight and mildly obese patients often exhibit a better outcome than their leaner counterparts. Therefore, this study aimed to characterize the association between BMI and in-hospital and one-year outcomes.

METHOD

This hospital-based research was conducted as a part of the Kermanshah STEMI Registry. Following the application of inclusion criteria, a total of 2,397 STEMI patients were evaluated. The data were collected using a standardized case report developed by the European Observational Registry Program (EORP). Body mass index (BMI) (kg/m2) was classified into underweight (<18.5), normal weight (18.5-24.9), overweight (25-29.9), class I/mild obese (30-34.9), and class II/extreme obese (≥35) categories. The independent predictors of the in-hospital and one-year outcomes were assessed using multivariable logistic regression models.

RESULTS

Out of the 2397 patients, 43 (1.79%) were underweight, 934 (38.97%) were normal, 1038 (43.30%) were overweight, 322 (13.43%) were class I obese, and 60 (2.50%) were class II obese. The results of the crude analysis showed that class I obesity was protective against CV death (OR 0.50; 95% CI 0.30-0.84), MACE3 (MI, stroke, and death) (OR 0.47; 95% CI 0.29-0.76), and MACE5 (MACE3 plus unstable angina and heart failure) (OR 0.59; 95% CI 0.44-0.79).

CONCLUSIONS

Multivariate adjustment eliminated the protective effect of class I obesity against death and MACE events. Therefore, it is possible that this protective effect does not exist and instead reflects the impact of confounding variables such as age.

Sarcopenic obesity versus sarcopenia alone with the use of probable sarcopenia definition for sarcopenia: Associations with frailty and physical performance

BACKGROUND & AIMS

Ageing brings alterations in body composition, as skeletal muscle gradually declines and accumulation of adipose tissue accompanies it. Although sarcopenia (S) and obesity (O) were separately reported to be associated with frailty and poor physical performance, whether they bring more detrimental or favorable effect when they coexist (i.e. sarcopenic obesity; SO) is an issue needs clarification. We aimed to study the associations of SO and S alone with frailty and poor physical performance, by using probable S definition.

METHODS

This was a retrospective, cross-sectional study including community dwelling older adults who were ≥60 years old and admitted to the outpatient clinic of a tertiary hospital between 2012 and 2020. We measured handgrip strength via hand dynamometer and defined decreased muscle strength as probable S. We performed bioimpedance analysis to evaluate body composition and used fat percentile method to define obesity. We assessed nutritional status via Mini-Nutritional Assessment-Short Form, frailty via FRAIL scale, and physical performance via Timed Up and Go (TUG) test. We examined the associations of four body phenotypes, i.e. non-S non-O, SO, S alone and O alone with frailty and impaired TUG in univariate and multivariate analyses (Model 1). We further performed a head to head analysis of SO vs S to see if one of them was associated more with frailty and impaired TUG (Model 2).

RESULTS

There were 1366 older adults included in the study (mean age: 74.6 ± 6.9; 68.3% female). The prevalences of non-S non-O, S alone, SO and O alone were 53.5, 7.5, 2.8 and 36.2%, respectively. Multivariate analysis adjusted for age, gender and nutritional status revealed that both SO and S alone were independently associated with frailty and impaired TUG, with SO demonstrating lower odds than S alone (OR = 5.9 and 6.05 for frailty, and 3.9 and 4.4 for TUG, respectively). Head-to-head comparison between SO and S alone in Model 2 showed that two groups did not demonstrate significant difference in terms of the frailty and impaired TUG risk.

CONCLUSION

Although SO and S groups demonstrated similar risks, obesity accompanying sarcopenia might show a favorable trend in terms of frailty and poor physical performance, compared to sarcopenia alone. Longitudinal studies are needed to reveal whether an obesity paradox exists for frailty and physical performance in older adults.

The impact of obesity on total knee arthroplasty outcomes: A retrospective matched cohort study

Background

Total Knee Arthroplasty (TKA) is a common orthopaedic surgery to treat advanced knee arthritis. Post-operative complications can be affected by obesity, defined as a body mass index of 30 kg/m2 or higher. We examine the rates of specific complications, revision rates, and costs of care following TKA and compare them between multifactor matched obese and non-obese patients. We hypothesize these outcomes will be worse in obese patients than in non-obese patients.

Methods

This retrospective study of the PearlDiver database queries for patients who underwent TKA under Current Procedural Terminology (CPT) and International Statistical Classification of Diseases (ICD-9) codes between January 2011 and January 2020. Patients were matched based on age, gender, and comorbidity indices, and various complications, revision rates, and costs were compared between the matched obese and non-obese patient groups.

Results

Obesity was associated with higher rates of surgical complications, such as wound complications, surgical site infections, need for revision, and higher total cost of care one year after TKA, and medical complications such as, acute kidney injury, deep vein thrombosis, urinary tract infection, and narcotics use, but significantly lower rates of anemia, arrhythmia, cardiac arrest, pneumonia, and transfusion. Obese patients also experienced significantly lower drug costs of care.

Conclusion

Outcomes were not definitively worse in obese patients when compared to matched non-obese patients. Nevertheless, understanding the complications that can arise following TKA will assist in educating patients about potential risks from surgery and guide surgeons in caring for their patients as obesity is predicted to continue increasing in prevalence. As such, future studies should examine underlying mechanisms that cause these complications to develop potential therapies.

Mid-regional proadrenomedullin, C-terminal proendothelin-1 values, and disease course are not different in critically ill SARS-CoV-2 pneumonia patients with obesity

Background/objectives

Patients affected by obesity and Coronavirus disease 2019, the disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), appear to have a higher risk for intensive care (ICU) admission. A state of low-grade chronic inflammation in obesity has been suggested as one of the underlying mechanisms. We investigated whether obesity is associated with differences in new inflammatory biomarkers mid-regional proadrenomedullin (MR-proADM), C-terminal proendothelin-1 (CT-proET-1), and clinical outcomes in critically ill patients with SARS-CoV-2 pneumonia.

Subjects/methods

A total of 105 critically ill patients with SARS-CoV-2 pneumonia were divided in patients with obesity (body mass index (BMI) ≥ 30 kg/m², n = 42) and patients without obesity (BMI < 30 kg/m², n = 63) and studied in a retrospective observational cohort study. MR-proADM, CT-proET-1 concentrations, and conventional markers of white blood count (WBC), C-reactive protein (CRP), and procalcitonin (PCT) were collected during the first 7 days.

Results

BMI was 33.5 (32–36.1) and 26.2 (24.7–27.8) kg/m² in the group with and without obesity. There were no significant differences in concentrations MR-proADM, CT-proET-1, WBC, CRP, and PCT at baseline and the next 6 days between patients with and without obesity. Only MR-proADM changed significantly over time (p = 0.039). Also, BMI did not correlate with inflammatory biomarkers (MR-proADM rho = 0.150, p = 0.125, CT-proET-1 rho = 0.179, p = 0.067, WBC rho = −0.044, p = 0.654, CRP rho = 0.057, p = 0.564, PCT rho = 0.022, p = 0.842). Finally, no significant differences in time on a ventilator, ICU length of stay, and 28-day mortality between patients with or without obesity were observed.

Conclusions

In critically ill patients with confirmed SARS-CoV-2 pneumonia, obesity was not associated with differences in MR-proADM, and CT-proET-1, or impaired outcome.

Trial registration

Netherlands Trial Register, NL8460.

Greasing the inflammatory pathogenesis of viral pneumonias in diabetes

Type 2 diabetes (T2D) and obesity are independent risk factors for increased morbidity and mortality associated with influenza and SARS-CoV-2 infection. Skewed cellular metabolism shapes immune cell inflammatory responsiveness and function in obesity, T2D, and infection. However, altered immune cell responsiveness and levels of systemic proinflammatory mediators, partly independent of peripheral immune cell contribution, are linked with SARS-CoV-2-associated disease severity. Despite such knowledge, the role of tissue parenchymal cell-driven inflammatory responses, and specifically those dominantly modified in obesity (e.g., adipocytes), in influenza and SARS-CoV-2 infection pathogenesis remain poorly defined. Whether obesity-dependent skewing of adipocyte cellular metabolism uncovers inflammatory clades and promotes the existence of a 'pathogenic-inflammatory' adipocyte phenotype that amplifies SARS-CoV-2 infection diseases severity in individuals with obesity and individuals with obesity and T2D has not been examined. Here, using the knowledge gained from studies of immune cell responses in obesity, T2D, and infection, we highlight the key knowledge gaps underlying adipocyte cellular functions that may sculpt and grease pathogenic processes associated with influenza and SARS-CoV-2 disease severity in diabetes.

Predictors of SARS-CoV-2 IgG Spike Antibody Responses on Admission and Clinical Outcomes of COVID-19 Disease in Fully Vaccinated Inpatients: The CoVax Study

BACKGROUND

SARS-CoV-2 vaccines have shown high efficacy in protecting against COVID-19, although the determinants of vaccine effectiveness and breakthrough rates are yet to be determined. We aimed at investigating several factors affecting the SARS-CoV-2 IgG Spike (S) antibody responses on admission and clinical outcomes of COVID-19 disease in fully vaccinated, hospitalized patients.

METHODS

102 subjects were enrolled in the study. Blood serum samples were collected from each patient upon admission for the semiquantitative determination of the SARS-CoV-2 IgG S levels with lateral flow assays. Factors influencing vaccine responses were documented.

RESULTS

27 subjects had a negative antibody test upon hospital admission. Out of the 102 patients admitted to the hospital, 88 were discharged and 14 died. Both the absence of anti-S SARS-CoV-2 antibodies and poor clinical outcomes of COVID-19 disease were associated with older age, lower Ct values, and a shorter period between symptom onset and hospital admission. Ct values and time between symptom onset and hospitalization were independently associated with SARS-CoV-2 IgG S responses upon admission. The PaO2/FiO2 ratio was identified as an independent predictor of in-hospital mortality.

CONCLUSIONS

Host- and disease-associated factors can predict SARS-CoV-2 IgG S responses and mortality in hospitalized patients with breakthrough SARS-CoV-2 Infection.

Effect of Low Body Mass Index on the Clinical Outcomes of Japanese Patients With Acute Myocardial Infarction - Results From the Prospective Japan Acute Myocardial Infarction Registry (JAMIR)

BACKGROUND

Acute myocardial infarction (AMI) patients with low body mass index (BMI) exhibit worse clinical outcomes than obese patients; however, to our knowledge, no prospective, nationwide study has assessed the effect of BMI on the clinical outcomes of AMI patients.

METHODS AND RESULTS

In this multi-center, prospective, nationwide Japanese trial, 2,373 AMI patients who underwent emergent percutaneous coronary intervention within 12 h of onset from the Japanese AMI Registry (JAMIR) were identified. Patients were divided into the following 4 groups based on their BMI at admission: Q1 group (BMI <18.5 kg/m2, n=133), Q2 group (18.5≤BMI<25.0 kg/m2, n=1,424), Q3 group (25.0≤BMI<30.0 kg/m2, n=672), and Q4 group (30.0 kg/m2≤BMI, n=144). The primary endpoint was all-cause death, and the secondary endpoint was a composite of cardiovascular death, non-fatal myocardial infarction (MI), and non-fatal stroke. The median follow-up period was 358 days. Q1 patients were older and had lower prevalence of coronary risk factors. Q1 patients also had higher all-cause mortality and higher incidence of secondary endpoints than normal-weight or obese AMI patients. Multivariate analysis showed that low BMI (Q1 group) was an independent predictor for primary endpoint.

CONCLUSIONS

AMI patients with low BMI had fewer coronary risk factors but worse clinical outcomes than normal-weight or obese patients.

Pharmacotherapy of obesity in complex diseases

More than 40% of adults in the United States suffer from obesity. Obesity is inextricably linked to many chronic illnesses like type-2 diabetes mellitus, hypertension, hyperlipidemia, heart disease, sleep apnea, stroke, and cancers. When used in combination with lifestyle modifications, pharmacotherapy has a vital role in treating obesity and improves short-term and long-term outcomes. A growing number of physicians are now interested in obesity medicine, and many of them are seeking guidance on how to treat complex patients with co-morbidities. This review provides a practical guide to the use of anti-obesity medications across various obesity-related comorbidities. It provides a general review of the currently approved anti-obesity medications and effective combinations. It discusses the highlights of the major trials and recent studies assessing the benefits of anti-obesity medications in comorbid conditions such as type-2 diabetes mellitus, psychiatric disorders, cardiovascular diseases, hypertension, renal diseases, and liver diseases. This review briefly examines the aspects of recognizing and addressing iatrogenic weight gain; discusses the precautions and prescribing considerations of anti-obesity medications, including side effects and possible dose adjustments in various comorbid conditions; and provides an expert opinion on an individualized choice of the best anti-obesity medication.

Reduction of Major Adverse Cardiovascular Events (MACE) after Bariatric Surgery in Patients with Obesity and Cardiovascular Diseases: A Systematic Review and Meta-Analysis

Cardiovascular diseases (CVDs) are the leading cause of death worldwide and obesity is a major risk factor that increases the morbidity and mortality of CVDs. Lifestyle modifications (e.g., diet control, physical exercise and behavioral changes) have been the first-line managements of obesity for decades. Nonetheless, when such interventions fail, pharmacotherapies and bariatric surgery are considered. Interestingly, a sudden weight loss (e.g., due to bariatric surgery) could also increase mortality. Thus, it remains unclear whether the bariatric surgery-associated weight reduction in patients with obesity and CVDs is beneficial for the reduction of Major Adverse Cardiovascular Events (MACE). Here, we performed a systematic literature search and meta-analysis of published studies comparing MACE in patients with obesity and CVDs who underwent bariatric surgery with control patients (no surgery). Eleven studies, with a total of 1,772,305 patients, which consisted of 74,042 patients who underwent any form of bariatric surgery and 1,698,263 patients with no surgery, were included in the systematic review. Next, the studies' data, including odds ratio (OR) and adjusted hazard ratio (aHR), were pooled and analyzed in a meta-analysis using a random effect model. The meta-analysis of ten studies showed that the bariatric surgery group had significantly lower odds of MACE as compared to no surgery (OR = 0.49; 95% CI 0.40-0.60; p < 0.00001; I² = 93%) and the adjustment to confounding variables in nine studies revealed consistent results (aHR = 0.57; 95% CI 0.49-0.66; p < 0.00001; I² = 73%), suggesting the benefit of bariatric surgery in reducing the occurrence of MACE in patients with obesity and CVDs (PROSPERO ID: CRD42021274343).

International external validation of the SORG machine learning algorithms for predicting 90-day and one-year survival of patients with spine metastases using a Taiwanese cohort

BACKGROUND CONTEXT

Accurately predicting the survival of patients with spinal metastases is important for guiding surgical intervention. The SORG machine-learning (ML) algorithm for the 90-day and one-year mortality of patients with metastatic cancer to the spine has been multiply validated, with a high degree of accuracy in both internal and external validation studies. However, prior external validations were conducted using patient groups located on the east coast of the United States, representing a generally homogeneous population. The aim of this study was to externally validate the SORG algorithms with a Taiwanese population.

STUDY DESIGN/SETTING

Retrospective study at a single tertiary care center in Taiwan PATIENT SAMPLE: Four hundred and twenty-seven patients who underwent surgery for metastatic spine disease from November 1, 2010 to December 31, 2018 OUTCOME MEASURES: 90-day and one-year mortality METHODS: The baseline characteristics of our validation cohort were compared with those of the previously published developmental and external validation cohorts. Discrimination (c-statistic and receiver operating curve), calibration (calibration plot, intercept, and slope), overall performance (Brier score), and decision curve analysis were used to assess the performance of the SORG ML algorithms in this cohort.

RESULTS

Ninety-day and one-year mortality rates were 110 of 427 (26%) and 256 of 427 (60%), respectively. The external validation cohort and the developmental cohort differed in body mass index (BMI), preoperative performance status, American Spinal Injury Association impairment scale, primary tumor histology and in several laboratory measurements. The SORG ML algorithm for 90-day and 1-year mortality demonstrated a high level of discriminative ability (c-statistics of 0.73 [95% confidence interval [CI], 0.67-0.78] and 0.74 [95% CI, 0.69-0.79]), overall performance, and had a positive net benefit throughout the range of threshold probabilities in decision curve analysis. The algorithm for 1-year mortality had a calibration intercept of 0.08, representing a good calibration. However, the 90-day mortality algorithm underestimated mortality for the lowest predicted probabilities, with an overall intercept of 0.81.

CONCLUSIONS

The SORG algorithms for predicting 90-day and 1-year mortality in patients with spinal metastatic disease generally performed well on international external validation in a predominately Taiwanese population. However, 90-day mortality was underestimated in this group. Whether this inconsistency was due to different primary tumor characteristics, body mass index, selection bias or other factors remains unclear, and may be better understood with further validative works that utilize international and/or diverse populations.

A retrospective case-control cohort analysis of comorbidity and health expenditure in hospitalized adults diagnosed with obesity utilizing ICD-10 diagnostic coding

The cost and comorbidity of obesity in hospitalized inpatients, is less known. A retrospective study of patients presenting to a large district hospital in Western Sydney (April 2016-February 2017) using clinical, pathological as well as diagnostic coding data for obesity as per ICD-10. Of 43 212 consecutive hospital presentations, 390 had an obesity-coded diagnosis (Ob, 0.90%), of which 244 were gender and age-matched to a non-obesity coded cohort (NOb). Weight and BMI were higher in the Ob vs NOb group (126 ± 37 vs 82 ± 25 kg; BMI 46 ± 12 vs 29 ± 8 kg/m² , P < .001) with a medical record documentation rate of 62% for obesity among Ob. The Ob cohort had 2-5× higher rates of cardiopulmonary and metabolic complications (P < .001), greater pharmacologic burden, length of stay (LOS, 225 vs 89 hours, P < .001) and stay in intensive care but no differences in the prevalence of mental disorders. Compared with BMI <35 kg/m² , inpatients with BMI >35 kg/m² were 5× more likely to require intensive care (OR 5.08 [1.43-27.3, 95% CI], P = .0047). The initiation of obesity-specific interventions by clinical teams was very low. People with obesity who are admitted to hospital carry significant cost and complications, yet obesity is seldom recognized as a clinical entity or contributor.

Obesity and risk of age-related eye diseases: a systematic review of prospective population-based studies

BACKGROUND

Obesity is a public health challenge worldwide. The relationship between obesity and age-related eye diseases including cataract, glaucoma, age-related macular degeneration (AMD) and diabetic retinopathy (DR) have remained elusive.

DESIGN AND METHODS

We conducted a systematic review of three electronic databases for longitudinal population-based studies that described associations between measures of obesity including body mass index (BMI), waist-circumference (WC), and waist-to-hip ratio (WHR), and age-related eye diseases.

RESULTS

Our search yielded 1731 articles, of which 14, 10, 16 and 8 articles met our eligibility criteria for cataract, glaucoma, AMD and DR, respectively. BMI-defined obesity was positively associated with incident cataract, incident AMD and incident DR in Western populations, but in Asian populations associations for incident AMD were not significant and associations for incident DR were inverse. WC-defined obesity was associated with incident glaucoma in non-Western populations. WHR-defined obesity but not BMI-defined obesity was associated with the incidence or progression of AMD in two Western studies.

CONCLUSIONS

Overall, we found strong evidence supporting associations between obesity and age-related eye diseases. Further research on the association of abdominal obesity and effect of weight loss and physical activity on age-related eye diseases is warranted to support clinical and public health recommendations.

The Treatment of Obesity in Cardiac Rehabilitation: A REVIEW AND PRACTICAL RECOMMENDATIONS

BACKGROUND

Cardiac rehabilitation (CR) programs have evolved from exercise-only programs designed to improve cardiorespiratory fitness to secondary prevention programs with a broader mandate to alter lifestyle-related behaviors that control cardiac risk factors and, thereby, reduce overall cardiovascular risk. As the obesity epidemic has evolved in the late 20th and early 21st centuries, the prevalence of type 2 diabetes mellitus and the metabolic syndrome have soared and blunted the otherwise expected downturn in deaths from coronary heart disease related to better control of risk factors. In that the causes of obesity are behavioral in origin, the most effective treatment strategy requires a comprehensive, behavioral-based approach.

PURPOSE

In this review, we outline optimal lifestyle approaches that can be delivered in the CR setting to assist cardiac patients with their long-term goals of reducing weight and improving cardiac risk factors while concurrently improving cardiorespiratory fitness. We also performed a survey of CR program throughout the United States and found that only 8% currently deliver a behavioral weight programs.

CONCLUSIONS

Cardiac rehabilitation programs need to take on an important challenge of secondary prevention, which is to develop behavioral weight loss programs to assist cardiac patients to lose weight and, thereby, improve multiple risk factors and long-term prognosis.

Bodyweight change and cognitive performance in the older population

Preservation of cognitive function is one of the major concerns in contemporary ageing societies. At the same time, overweight and obesity, which have been identified as risk factors for poor health development, have been increasing in many countries all over the world. This study examines the relationship between bodyweight change and cognitive decline in old age and it aims to determine whether and how changes in body mass index (BMI) affect the development of cognitive functioning in old age. Using longitudinal data from the Survey of Health, Ageing and Retirement in Europe (SHARE), covering four waves between 2006 and 2016 with 58,389 participants from 15 countries aged 50+, we estimated asymmetric fixed effects models by gender, adding possible confounding variables such as age, grip strength, health conditions, and physical activity. Additionally, we investigated possible heterogeneity in the BMI-cognition relation. We found a positive association between BMI change and change in cognitive performance, which was dominantly driven by BMI decrease. Weight loss was typically negatively related to cognition, particularly at low levels of BMI and mainly due to health conditions affecting both bodyweight and cognitive performance. Weight gain was, on average, not significantly related to cognitive performance; only respondents with preceding weight loss profited from small increases in BMI. Our analyses provide no support for an “obesity paradox” in cognition, according to which higher weight preserves cognition in old age. The association between weight change and cognitive performance in older age is based on weight changes being related to illness and recovery.

Impact of BMI on Survival Outcomes of Immunotherapy in Solid Tumors: A Systematic Review

Growing research has focused on obesity as a prognostic factor during therapy with immune-checkpoint inhibitors (ICIs). The role of body-mass index (BMI) in predicting response and toxicity to ICIs is not clear, as studies have shown inconsistent results and significant interpretation biases. We performed a systematic review to evaluate the relationship between BMI and survival outcomes during ICIs, with a side focus on the incidence of immune-related adverse events (irAEs). A total of 17 studies were included in this systematic review. Altogether, the current evidence does not support a clearly positive association of BMI with survival outcomes. Regarding toxicities, available studies confirm a superimposable rate of irAEs among obese and normal weight patients. Intrinsic limitations of the analyzed studies include the retrospective nature, the heterogeneity of patients’ cohorts, and differences in BMI categorization for obese patients across different studies. These factors might explain the heterogeneity of available results, and the subsequent absence of a well-established role of baseline BMI on the efficacy of ICIs among cancer patients. Further prospective studies are needed, in order to clarify the role of obesity in cancer patients treated with immunotherapy.

Digital Predictors of Morbidity, Hospitalization, and Mortality Among Older Adults: A Systematic Review and Meta-Analysis

The widespread adoption of digital health technologies such as smartphone-based mobile applications, wearable activity trackers and Internet of Things systems has rapidly enabled new opportunities for predictive health monitoring. Leveraging digital health tools to track parameters relevant to human health is particularly important for the older segments of the population as old age is associated with multimorbidity and higher care needs. In order to assess the potential of these digital health technologies to improve health outcomes, it is paramount to investigate which digitally measurable parameters can effectively improve health outcomes among the elderly population. Currently, there is a lack of systematic evidence on this topic due to the inherent heterogeneity of the digital health domain and the lack of clinical validation of both novel prototypes and marketed devices. For this reason, the aim of the current study is to synthesize and systematically analyse which digitally measurable data may be effectively collected through digital health devices to improve health outcomes for older people. Using a modified PICO process and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) framework, we provide the results of a systematic review and subsequent meta-analysis of digitally measurable predictors of morbidity, hospitalization, and mortality among older adults aged 65 or older. These findings can inform both technology developers and clinicians involved in the design, development and clinical implementation of digital health technologies for elderly citizens.

Obesity and mortality in critically ill COVID-19 patients with respiratory failure

BACKGROUND

Patients with obesity are at increased risk of severe COVID-19, requiring mechanical ventilation due to acute respiratory failure. However, conflicting data are obtained for intensive care unit (ICU) mortality.

OBJECTIVE

To analyze the relationship between obesity and in-hospital mortality of ICU patients with COVID-19.

SUBJECTS/METHODS

Patients admitted to the ICU for COVID-19 acute respiratory distress syndrome (ARDS) were included retrospectively. The following data were collected: comorbidities, body mass index (BMI), the severity of ARDS assessed with PaO₂/FiO₂ (P/F) ratios, disease severity measured by the Simplified Acute Physiology Score II (SAPS II), management and outcomes.

RESULTS

For a total of 222 patients, there were 34 patients (15.3%) with normal BMI, 92 patients (41.4%) who were overweight, 80 patients (36%) with moderate obesity (BMI:30-39.9 kg/m²), and 16 patients (7.2%) with severe obesity (BMI ≥ 40 kg/m²). Overall in-hospital mortality was 20.3%. Patients with moderate obesity had a lower mortality rate (13.8%) than patients with normal weight, overweight or severe obesity (17.6%, 21.7%, and 50%, respectively; P = 0.011. Logistic regression showed that patients with a BMI ≤ 29 kg/m² (odds ratio [OR] 3.64, 95% CI 1.38-9.60) and those with a BMI > 39 kg/m² (OR 10.04, 95% CI 2.45-41.09) had a higher risk of mortality than those with a BMI from 29 to 39 kg/m². The number of comorbidities (≥2), SAPS II score, and P/F < 100 mmHg were also independent predictors for in-hospital mortality.

CONCLUSIONS

COVID-19 patients admitted to the ICU with moderate obesity had a lower risk of death than the other patients, suggesting a possible obesity paradox.

Clinical outcomes and inflammatory marker levels in patients with Covid-19 and obesity at an inner-city safety net hospital

OBJECTIVES

Patients with Covid-19 and obesity have worse clinical outcomes which may be driven by increased inflammation. This study aimed to characterize the association between clinical outcomes in patients with obesity and inflammatory markers.

METHODS

We analyzed data for patients aged ≥18 years admitted with a positive SARS-CoV-2 PCR test. We used multivariate logistic regression to determine the association between BMI and intensive care unit (ICU) transfer and all-cause mortality. Inflammatory markers (C-reactive protein [CRP], lactate dehydrogenase [LDH], ferritin, and D-dimer) were compared between patients with and without obesity (body mass index [BMI] ≥30 kg/m2).

RESULTS

Of 791 patients with Covid-19, 361 (45.6%) had obesity. In multivariate analyses, BMI ≥35 was associated with a higher odds of ICU transfer (adjusted odds ratio [aOR] 2.388 (95% confidence interval [CI]: 1.074-5.310) and hospital mortality (aOR = 4.3, 95% CI: 1.69-10.82). Compared to those with BMI<30, patients with obesity had lower ferritin (444 vs 637 ng/mL; p<0.001) and lower D-dimer (293 vs 350 mcg/mL; p = 0.009), non-significant differences in CRP (72.8 vs 84.1 mg/L, p = 0.099), and higher LDH (375 vs 340, p = 0.009) on the first hospital day.

CONCLUSIONS

Patients with obesity were more likely to have poor outcomes even without increased inflammation.

Impact of Cardiorespiratory Fitness on the Obesity Paradox in Heart Failure with Reduced Ejection Fraction

Fundamento:

Índice de massa corporal (IMC) elevado tem sido associado a desfechos melhores em pacientes com insuficiência cardíaca com fração de ejeção reduzida. Este achado tem levado ao conceito do paradoxo da obesidade.

Objetivo:

Investigar o impacto de tolerância ao exercício e capacidade cardiorrespiratória no paradoxo da obesidade.

Método:

Pacientes ambulatoriais com insuficiência cardíaca sintomática e fração de ejeção ventricular esquerda (FEVE) ≤ 40%, acompanhados no nosso centro, foram prospectivamente submetidos à avaliação abrangente de linha de base incluindo parâmetros clínicos, laboratoriais, eletrocardiográficos, ecocardiográficos e de exercício cardiopulmonar. A população do estudo foi dividida de acordo com o IMC (< 25, 25 – 29,9 e ≥ 30 kg/m²). Todos os pacientes foram acompanhados durante 60 meses. O desfecho composto foi definido como morte cardíaca, transplante cardíaco urgente ou necessidade de suporte circulatório mecânico. Valores de p < 0,05 foram considerados significativos.

Resultados:

Dos 282 pacientes incluídos (75% masculino, 54 ± 12 anos, IMC 27 ± 4 kg/m², FEVE 27% ± 7%), o desfecho composto ocorreu em 24,4% durante o acompanhamento. Os pacientes com IMC elevado eram mais velhos e apresentavam FEVE e níveis séricos de sódio mais elevados, bem como menor inclinação de eficiência ventilatória (VE/VCO₂). VE/VCO₂ e consumo de oxigênio de pico (VO₂p) eram fortes preditores prognósticos (p < 0,001). Na análise univariada de regressão de Cox, o IMC elevado foi associado a desfechos melhores (razão de risco 0,940, intervalo de confiança 0,886 – 0,998, p 0,042). Porém, após ajustar para ou inclinação VE/VCO₂ ou VO₂p, o papel protetor do IMC sumiu. O benefício de sobrevida do IMC não foi evidente quando os pacientes foram agrupados de acordo com a classe de aptidão cardiorrespiratória (VE/VCO₂, valor de corte de 35, e VO₂p, valor de corte de 14 mL/kg/min).

Conclusão:

Estes resultados sugerem que a aptidão cardiorrespiratória supera a relação entre o IMC e a sobrevida em pacientes com insuficiência cardíaca.

Temporal trends in prevalence of cardiovascular disease (CVD) and CVD risk factors among U.S. older workers: NHIS 2004-2018

PURPOSE

This study examined trends in the prevalence of cardiovascular disease (CVD) and CVD risk factors among U.S. older adults and workers. We also investigated correlations between the temporal prevalence of CVD and selected risk factors (hypertension, obesity, physical inactivity, smoking, and treated diabetes) among participants.

METHODS

Data were obtained from the National Health Interview Survey (2004-2018) for U.S. adults aged greater than or equal to 50 years (n = 207,539), of which 84,180 were employed. Temporal trends in prevalence were assessed by fitting weighted regression models to the age-standardized prevalence to the 2010 U.S.

POPULATION

The relationship between temporal prevalence of CVD with each risk factor was assessed using Spearman's correlation coefficient.

RESULTS

Among all older adults, the prevalence of CVD significantly declined (β = -0.16, P < .001) during 2004-2018; similar decline was observed among employed adults (β = -0.16, P = .001). Temporal prevalence in CVD was positively correlated to physical inactivity (r = 0.73, P = .002) and smoking (r = 0.81, P < .001), but not to any of the other risk factors.

CONCLUSIONS

Among employed adults aged greater than or equal to 50 years, the prevalence of CVD, physical inactivity, and smoking dramatically declined over the past 15 years. The temporal decline in prevalence of CVD was significantly associated with decline prevalence of physical inactivity and smoking.

Obesity and cardiovascular disease in women

As the prevalence of obesity continues to grow worldwide, the health and financial burden of obesity-related comorbidities grows too. Cardiovascular disease (CVD) is clearly associated with increased adiposity. Importantly, women are at higher risk of CVD when obese and insulin resistant, in particular at higher risk of developing heart failure with preserved ejection fraction and ischemic heart disease. Increased aldosterone and mineralocorticoid receptor activation, aberrant estrogenic signaling and elevated levels of androgens are among some of the proposed mechanisms explaining the heightened CVD risk. In addition to traditional cardiovascular risk factors, understanding nontraditional risk factors specific to women, like excess weight gain during pregnancy, preeclampsia, gestational diabetes, and menopause are central to designing personalized interventions aimed to curb the epidemic of CVD. In the present review, we examine the available evidence supporting a differential cardiovascular impact of increased adiposity in women compared with men and the proposed pathophysiological mechanisms behind these differences. We also discuss women-specific cardiovascular risk factors associated with obesity and insulin resistance.

Skeletal Muscle Composition and Glucose Levels in Children Who Are Overweight and Obese

BACKGROUND

Skeletal muscle is overlooked in the realm of insulin resistance in children who are overweight and obese despite the fact that it accounts for the most glucose disposal.

OBJECTIVES

Therefore, this study examined fasted glucose levels and muscle cross-sectional area and echo intensity (EI) via ultrasound images of the first dorsal interosseous, vastus lateralis, and rectus femoris in children who are normal weight and overweight and obese aged 8-10 years.

METHODS

In total, 13 males (age = 9.0 [0.7] y) and 7 females (age = 9.0 [0.8] y) volunteered for this study. Independent samples t tests and effect sizes (ESs) were used to examine potential differences in skeletal muscle composition and glucose concentrations.

RESULTS

There were no significant differences between groups for glucose concentration (P = .07, ES = 0.86); however, the children who were overweight and obese had significantly greater EI (P < .01, ES = 0.98-1.63) for the first dorsal interosseous, vastus lateralis, and rectus femoris and lower cross-sectional area when normalized to EI when collapsed across muscles (P < .04, ES = 0.92). Glucose concentrations correlated with EI and cross-sectional area/EI for the vastus lateralis (r = .514 to -.593) and rectus femoris (r = .551 to -.513), but not the first dorsal interosseous.

DISCUSSION

There is evidence that adiposity-related pathways leading to insulin resistance and skeletal muscle degradation are active in young children who are overweight and obese.

Prognostic impact of body mass index and culprit lesion calcification in patients with acute myocardial infarction

Patients with acute myocardial infarction (AMI) with low body mass index (BMI) have worse outcomes than obese patients, and this phenomenon is recognized as "obesity paradox." Coronary calcification is associated with cardiac events. However, the association between BMI and calcification and their involvement in the mortality of AMI patients remain unknown. This study consecutively enrolled 517 patients with AMI who underwent emergent coronary intervention within 24 h after onset. Patients were divided into four groups according to the baseline BMI interquartile ranges: Q1 (BMI < 21.9 kg/m²), Q2 (21.9 ≤ BMI < 24.0 kg/m²), Q3 (24.0 ≤ BMI < 26.0 kg/m²), and Q4 (BMI ≥ 26.0 kg/m²). Calcification in the culprit lesion was also evaluated. The Q1 group was older and had a lower frequency of coronary risk factors. Moderate/severe calcification was most frequently observed in Q1, followed by Q2, Q3, and Q4. The Q1 group had the highest all-cause mortality, and patients with moderate/severe calcification had a higher all-cause mortality than that in patients without calcification. The highest all-cause mortality was observed in Q1with calcification, and the lowest was in Q4 without calcification. Q1 and the presence of moderate/severe calcification were independently associated with all-cause mortality. Although low-BMI patients with AMI had a lower frequency of coronary risk factors, they had a worse all-cause mortality than that in high-BMI patients. Our findings suggest that lesion calcification and its possible association with low BMI are involved in the higher mortality rate in these patients.

Hyperlipidemias and Obesity

The organs require oxygen and other types of nutrients (amino acids, sugars, and lipids) to function, the heart consuming large amounts of fatty acids for oxidation and adenosine triphosphate (ATP) generation.

The Relationship between Generalized and Abdominal Obesity with Diabetic Kidney Disease in Type 2 Diabetes: A Multiethnic Asian Study and Meta-Analysis

This study examined the associations of body mass index (BMI), waist circumference (WC), waist-hip ratio (WHR) and waist-height ratio (WHtR) with diabetic kidney disease (DKD) in a clinical sample of Asian patients with type 2 diabetes (T2DM); substantiated with a meta-analysis of the above associations. We recruited 405 patients with T2DM (mean (standard deviation (SD)) age: 58 (7.5) years; 277 (68.4%) male; 203 (50.1%) with DKD) from a tertiary care centre in Singapore. DKD was defined as urinary albumin-creatinine ratio >3.3 mg/mmoL and/or estimated glomerular filtration rate <60 mL/min/1.73 m². All exposures were analysed continuously and categorically (World Health Organization cut-points for BMI and WC; median for WHR and WHtR) with DKD using stepwise logistic regression models adjusted for traditional risk factors. Additionally, we synthesized the pooled odds ratio of 18 studies (N = 19,755) in a meta-analysis of the above relationships in T2DM. We found that overweight and obese persons (categorized using BMI) were more likely to have DKD compared to under/normal weight individuals, while no associations were found for abdominal obesity exposures. In meta-analyses however, all obesity parameters were associated with increased odds of DKD. The discordance in our abdominal obesity findings compared to the pooled analyses warrants further validation via longitudinal cohorts.

Obesity in patients with end-stage heart failure

Obesity poses an increasing problem in patients with end-stage heart failure (HF). The most commonly used indicator of obesity is body mass index. The value of this parameter is widely taken into consideration when selecting the best way of treatment for patients with advanced HF. The aim of this paper is to outline the recent knowledge about obesity in the abovementioned group of patients.

Obesity in coronary heart disease: An unaddressed behavioral risk factor

Obesity is an independent risk factor for the development and progression of coronary heart disease (CHD). Over 80% of patients with CHD are overweight or obese. While obesity is often considered a relatively "minor" CHD risk factor, weight loss is a broadly effective risk-factor intervention. Weight loss can profoundly influence a number of "major" risk factors including: hypertension, dyslipidemia and insulin resistance/type 2 diabetes mellitus. Despite its prominence as a risk factor most cardiac rehabilitation (CR) programs do not have a specific, targeted intervention to assist patients with weight loss. Consequently, the weight loss that occurs during CR is quite small and unlikely to appreciably alter risk factors. Relying on CR associated exercise as a sole intervention is an ineffective strategy to promote weight loss. There is evidence, however, that behavioral weight loss (BWL) interventions can be effectively employed in the CR setting. In contrast to programs that do not offer a targeted intervention, studies show that participants in CR-related BWL programs lose significantly more weight. The additional weight loss from the BWL intervention is associated with greater improvements in insulin sensitivity and other components of the metabolic syndrome such as hypertension and lipid abnormalities. As a means of maximizing CHD risk factor reduction CR programs need to incorporate BWL programs as a standard programming for overweight/obese patients.

Shortcuts to a functional adipose tissue: The role of small non-coding RNAs

Metabolic diseases such as type 2 diabetes are a major public health issue worldwide. These diseases are often linked to a dysfunctional adipose tissue. Fat is a large, heterogenic, pleiotropic and rather complex tissue. It is found in virtually all cavities of the human body, shows unique plasticity among tissues, and harbors many cell types in addition to its main functional unit - the adipocyte. Adipose tissue function varies depending on the localization of the fat depot, the cell composition of the tissue and the energy status of the organism. While the white adipose tissue (WAT) serves as the main site for triglyceride storage and acts as an important endocrine organ, the brown adipose tissue (BAT) is responsible for thermogenesis. Beige adipocytes can also appear in WAT depots to sustain heat production upon certain conditions, and it is becoming clear that adipose tissue depots can switch phenotypes depending on cell autonomous and non-autonomous stimuli. To maintain such degree of plasticity and respond adequately to changes in the energy balance, three basic processes need to be properly functioning in the adipose tissue: i) adipogenesis and adipocyte turnover, ii) metabolism, and iii) signaling. Here we review the fundamental role of small non-coding RNAs (sncRNAs) in these processes, with focus on microRNAs, and demonstrate their importance in adipose tissue function and whole body metabolic control in mammals.