Obesity and the risk of early and late mortality after coronary artery bypass graft surgery

Background

Obesity is often considered to be a significant risk factor for postoperative mortality when selecting candidates for coronary artery bypass grafting (CABG).

Methods

We included all patients undergoing a first isolated CABG at the Karolinska Hospital in Stockholm, Sweden, between 1980 and 1995 (n = 6728). Patients were categorized on the basis of body mass index (BMI): non-overweight (BMI <25 kg/m²), overweight (25 kg/m² ≤ BMI <30 kg/m²), and obese (BMI ≥30 kg/m²). Multivariate Cox regression was used to assess the risk of re-operation for bleeding, deep sternal wound infection, and early (≤30 days) and late (≤5 years) mortality rates.

Results

The average length of follow-up was 6.5 years. There were 252 re-operations for bleeding, 53 deep sternal wound infections, and 628 deaths. Patients who were obese had a significantly lower risk of re-operation for bleeding (risk ratio [RR], 0.32; 95% CI, 0.19-0.53), but a greater risk of deep sternal wound infection (RR, 2.66; 95% CI, 1.21-5.88) compared with patients who were not overweight. However, patients who were obese and patients who were not overweight experienced similar 30-day (RR, 0.65; 95% CI, 0.34-1.27), 1-year (RR, 0.56; 95% CI, 0.29-1.10), and 5-year mortality rates (RR, 0.91; 95% CI, 0.66-1.25). Results for patients who were overweight were consistent with those of patients who were obese.

Conclusion

Patients who are obese are not at a greater risk of early and late mortality after CABG compared with patients who are not overweight, although they appear to have a lower risk of re-operation for bleeding and a greater risk of deep sternal wound infection. Therefore, obesity per se is not a contraindication for CABG.     

Association between body mass index and anti–citrullinated protein antibody–positive and anti–citrullinated protein antibody–negative rheumatoid arthritis: Results from a population‐based case–control study

Objective

Being overweight or obese is associated with many chronic diseases, but previous studies of the association with rheumatoid arthritis (RA) have shown inconsistent results. The aim of this study was to investigate the association between body mass index (BMI) and the risk of developing the 2 main subtypes of RA.

Methods

At inclusion, cases and controls answered questions about their weight and height and donated blood samples. The presence of antibodies to citrullinated protein antigens (ACPAs) was analyzed among 2,748 cases and 3,444 controls (28% men). Odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated using conditional logistic regression.

Results

Compared to those with normal weight (BMI <25 kg/m²), the adjusted overall OR for developing ACPA‐negative RA was 1.1 (95% CI 0.9–1.3) for overweight individuals (BMI ≥25 to <30 kg/m²) and 1.4 (95% CI 1.1–1.9) for obese individuals (BMI ≥30 kg/m²). When stratified by sex, the OR for ACPA‐negative RA for obese women was 1.6 (95% CI 1.2–2.2), and there was no association between obesity and ACPA‐negative RA in men (OR 1.1, 95% CI 0.6–1.8). In obese men compared to men with normal weight, the OR for ACPA‐positive RA was 0.6 (95% CI 0.3–0.9), while there was no association between BMI and ACPA‐positive RA among women (OR 1.0, 95% CI 0.8–1.2).

Conclusion

Our findings show that obesity is associated with developing ACPA‐negative RA in women, and indicate an inverse association between BMI and ACPA‐positive RA in men.     

Association between physical exercise,body mass index,and risk of fibromyalgia: Longitudinal data from the Norwegian Nord‐Trøndelag Health Study

Objective

To examine the association between leisure time physical exercise, body mass index (BMI), and risk of fibromyalgia (FM).

Methods

A longitudinal study with baseline assessment of physical exercise (frequency, duration, and intensity) and BMI was used to explore the risk of having FM at 11‐year followup in a large, unselected female population (n = 15,990) without FM or physical impairments at baseline.

Results

At followup, 380 cases of incident FM were reported. A weak dose‐response association was found between level of physical exercise and risk of FM (for trend, P = 0.13) where women who reported the highest exercise level had a relative risk (RR) of 0.77 (95% confidence interval [95% CI] 0.55–1.07). BMI was an independent risk factor for FM (for trend, P < 0.001), and overweight or obese women (BMI ≥25.0 kg/m²) had a 60–70% higher risk compared with women with normal weight (BMI 18.5–24.9 kg/m²). Overweight or obese women who exercised ≥1 hour per week had an RR of 1.72 (95% CI 1.07–2.76) compared with normal‐weight women with a similar activity level, whereas the risk was >2‐fold higher for overweight or obese women who were either inactive (RR 2.09, 95% CI 1.36–3.21) or exercised <1 hour per week (RR 2.19, 95% CI 1.39–3.46).

Conclusion

Being overweight or obese was associated with an increased risk of FM, especially among women who also reported low levels of physical exercise. Community‐based measures aimed at reducing the incidence of FM should emphasize the importance of regular exercise and the maintenance of normal body weight.     

Body mass index,obesity, and prevalent gout in the United States in 1988–1994 and 2007–2010

Objective

To determine the association and prevalence of gout among overweight, obese, and morbidly obese segments of the US population.

Methods

Among participants (age ≥20 years) of the National Health and Nutrition Examination Surveys in 1988–1994 and 2007–2010, gout status was ascertained by self‐report of a physician diagnosis. Body mass index (BMI) was examined in categories of <18.5 kg/m², 18.5–24.9 kg/m², 25–29.9 kg/m², 30–34.9 kg/m², and ≥35 kg/m² and as a continuous variable. The cross‐sectional association of BMI category with gout status was adjusted for demographic and obesity‐related medical disorders.

Results

In the US, the crude prevalence of gout was 1–2% among participants with a normal BMI (18.5–24.9 kg/m²), 3% among overweight participants, 4–5% with class I obesity, and 5–7% with class II or class III obesity. The adjusted prevalence ratio comparing the highest to a normal BMI category was 2.46 (95% confidence interval [95% CI] 1.44–4.21) in 1988–1994 and 2.21 (95% CI 1.50–3.26) in 2007–2010. Notably, there was a progressively greater prevalence ratio of gout associated with successively higher categories of BMI. In both survey periods, for an average American adult standing 1.76 meters (5 feet 9 inches), a 1‐unit higher BMI, corresponding to 3.1 kg (～6.8 pounds) greater weight, was associated with a 5% greater prevalence of gout, even after adjusting for serum uric acid (P < 0.001).

Conclusion

Health care providers should be aware of the elevated burden of gout among both overweight and obese adults, applicable to both women and men, and observed among non‐Hispanic whites, non‐Hispanic African Americans, and Mexican Americans in the US.     

Body mass, fitness and survival in veteran patients: another obesity paradox?

Purpose

The paradox of obesity in patients with heart failure (HF) also has been observed in non-HF veteran patients. Veterans had to have met military fitness requirements at the time of their enlistment. Therefore, we assessed the relation of body mass index (BMI) to mortality in a clinical cohort of non-HF veterans, adjusting for fitness.

Methods

After excluding HF patients (n = 580), the study population comprised 6876 consecutive patients (mean age 58 [±11] years) referred for exercise testing. Patients were classified by BMI category: normal weight (BMI 18.5-24.9 kg/m²), overweight (BMI 25.0-29.9 kg/m²), or obese (BMI ≥30.0 kg/m²). The association between BMI, fitness, other clinical variables, and all-cause mortality was assessed by Cox proportional hazards analysis.

Results

During a mean (±SD) follow-up of 7.5 ± 4.5 years, a total of 1571 (23%) patients died. In a multivariate analysis including clinical, risk factor, and exercise test data, higher BMI was associated with better survival. Expressing the data by BMI category, obese patients were 22% less likely to die (relative risk [RR] = 0.78, 95% confidence interval [CI], 0.69-0.90, P <.001) than patients of normal weight. After further adjustment for cardiorespiratory fitness (CRF), this relationship strengthened such that mortality risk for the obese category was 35% lower (RR = 0.65, 95% CI, 0.57-0.76, P <.001), versus the normal weight category.

Conclusions

As has been observed in HF patients, obesity was associated with a substantially lower mortality risk in a clinical population of non-HF veterans. Higher CRF and obesity in later life may account for an obesity paradox in this population.     

Increasing trends in incidence of overweight and obesity over 5 decades

Purpose

We evaluated trends in the incidence of overweight and obesity over the past 50 years.

Methods

We evaluated trends in the incidence of overweight (25 ≤ body mass index [BMI] <30 kg/m²), obesity (BMI ≥30 kg/m²) and stage 2 obesity (BMI ≥35 kg/m²) from 1950 to 2000 in Framingham Study participants (n = 6798, 54% women). Individuals aged 40-55 years who attended 2 examinations 8 years apart in each decade were eligible.

Results

The incidences of overweight, obesity, and stage 2 obesity increased across the decades in both sexes (P for trend <.001). For men, the incidence of overweight rose from 21.8% (95% confidence interval [CI], 17.6-26.5) in the 1950s to 35.2% (95% CI, 28.6-42.5) in the 1990s; of obesity from 5.8% (95% CI, 4.4-7.6) to 14.8% (95% CI, 12.2-17.9); and of stage 2 obesity from 0.2% (95% CI, 0.1-0.9) to 5.4% (95% CI, 4.0-7.2). For women, incidence rates of overweight increased from 15.0% (95% CI, 12.3-18.1) to 33.1% (95% CI, 29.0-37.4); of obesity from 3.9% (95% CI, 2.9-5.3) to 14% (95% CI, 11.6-16.7); and of stage 2 obesity from 1.7% (95% CI, 1.1-2.6) to 4.4% (95% CI, 3.2-6.0). Overall, incidence rates of overweight increased 2-fold and that of obesity more than 3-fold over 5 decades, findings that remained robust upon additional adjustment for baseline BMI in each decade.

Conclusions

The incidence of overweight and obesity increased progressively over the last 5 decades, suggesting that the rising trend in prevalence is not a recent phenomenon.     

Body mass index and mortality in patients with severe coronary artery diseases: A cohort study from China

Background and aimsIt is still controversial whether obesity and overweight increase the risk of mortality for patients with coronary artery disease. The current study aimed to investigate the relationship between body mass index (BMI) and mortality in patients with triple-vessel disease (TVD).Methods and resultsFrom April 2004 to February 2011, 8943 patients with angiographically confirmed TVD were consecutively enrolled. Patients were divided into five groups according to BMI: underweight (<18.5 kg/m²), normal weight (18.5–23.9 kg/m²), overweight: (24–27.9 kg/m²), mild obesity (28–31.9 kg/m²), and severe obesity (≥32 kg/m²). The primary end point was all-cause death. Subgroup analysis was performed for treatment strategies: revascularization and medical treatment alone. During a median follow-up of 7.5 years, lower risks of mortality were observed in patients with overweight (adjusted HR 0.85, 95% CI 0.75–0.97) and mild obesity (adjusted HR 0.83, 95% CI 0.69–1.00) compared to those with normal weight. Polynomial Cox regression suggested a U-shape association between BMI and adjusted mortality risk. In the revascularization subgroup, there was a significantly higher mortality risk in patients with severe obesity (adjusted HR 1.57, 95% CI 1.03–2.40) than in those with normal weight. While in the medical treatment subgroup, mortality risk decreased as BMI increased, with the lowest risk being observed in patients with severe obesity.ConclusionThere is a U-shape relationship between BMI and all-cause death in patients with TVD, with increased risks among both underweight and severely obese patients. This relationship may be influenced by treatment strategies.     

The Obesity Paradox, Weight Loss, and Coronary Disease

Purpose

Because obesity is a cardiovascular risk factor but is associated with a more favorable prognosis among cohorts of cardiac patients, we assessed this “obesity paradox” in overweight and obese patients with coronary heart disease enrolled in a cardiac rehabilitation and exercise training (CRET) program, making this assessment in patients classified as overweight/obese using both traditional body mass index (BMI) and percent body fat assessments. Additionally, we assessed the efficacy and safety of purposeful weight loss in overweight and obese coronary patients.

Patients and Methods

We retrospectively studied 529 consecutive CRET patients following major coronary events before and after CRET, and compared baseline and post program data in 393 overweight and obese patients (body mass index [BMI] ≥25 kg/m²) divided by median weight change (median = −1.5%; mean +2% vs −5%, respectively). In addition, we assessed 3-year total mortality in various baseline BMI categories as well as compared mortality in those with high baseline percent fat (>25% in men and >35% in women) versus those with low baseline fat.

Results

Following CRET, the overweight and obese with greater weight loss had improvements in BMI (−5%; P <.0001), percent fat (−8%; P <.0001), peak oxygen consumption (+16%; P <.0001), low-density lipoprotein cholesterol (−5%; P <.02), high-density lipoprotein cholesterol (+10%; P <.0001), triglycerides (−17%; P <.0001), C-reactive protein (−40%; P <.0001), and fasting glucose (−4%; P = .02), as well as marked improvements in behavioral factors and quality-of-life scores. Those with lower weight loss had no significant improvements in percent fat, low-density lipoprotein cholesterol, triglycerides, C-reactive protein, and fasting glucose. During 3-year follow-up, overall mortality trended only slightly lower in those with baseline overweightness/obesity who had more weight loss (3.1% vs 5.1%; P = .30). However, total mortality was considerably lower in the baseline overweight/obese (BMI ≥25 kg/m²) than in 136 CRET patients with baseline BMI <25 kg/m² (4.1% vs 13.2%; P <.001), as well as in those with high baseline fat compared with those with low fat (3.8% vs 10.6%; P <.01).

Conclusions

Purposeful weight loss with CRET in overweight/obese coronary patients is associated with only a nonsignificant trend for lower mortality but is characterized by marked improvements in obesity indices, exercise capacity, plasma lipids, and inflammation, as well as behavioral factors and quality of life. Although an “obesity paradox” exists using either baseline BMI or baseline percent fat criteria, these results support the safety and potential long-term benefits of purposeful weight loss in overweight and obese patients with coronary heart disease.     

Influence of Obesity on Outcomes in Atrial Fibrillation: Yet Another Obesity Paradox

Background

Obese patients have favorable outcomes in congestive heart failure, hypertension, peripheral vascular disease, and coronary artery disease. Obesity also has been linked with increased incidence of atrial fibrillation, but its influence on outcomes in atrial fibrillation patients has not been investigated. The objective of this research is to investigate the effect of obesity on outcomes in atrial fibrillation.

Methods

The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study was one of the largest multicenter trials of atrial fibrillation, with 4060 patients. Subjects were randomized to rate versus rhythm-control strategy. We performed a post hoc analysis of the National Heart, Lung and Blood Institute limited access dataset of atrial fibrillation patients who had body mass index (BMI) data available in the AFFIRM study. BMI data were not available on 1542 patients. Patients with BMI ≥18.5 were split into normal (18.5-25), overweight (25-30), and obese (>30) categories as per BMI (kg/m²). Multivariate Cox proportional hazards regression was used on the eligible 2492 patients. End points were all-cause mortality and cardiovascular mortality.

Results

Over three fourths of all patients in our cohort were overweight or obese. There were 304 deaths (103 among normal weight, 108 among overweight, and 93 among obese) and 148 cardiovascular deaths (54 among normal weight, 41 among overweight, and 53 among obese) over a mean period of 3 years of patient follow-up. On multivariate analysis, overweight (hazard ratio [HR] 0.64; 95% confidence interval [CI], 0.48-0.84; P = .001) and obese (HR 0.80; 95% CI, 0.68-0.93; P = .005) categories were associated with lower all-cause mortality as compared with normal weight. Overweight (HR 0.40; 95% CI, 0.26-0.60; P <.001) and obese patients (HR 0.77; 95% CI, 0.62-0.95; P = .01) also had lower cardiovascular mortality as compared with the normal weight patients.

Conclusions

Although in prior studies, obesity has been associated with increased risk of atrial fibrillation, an obesity paradox exists for outcomes in atrial fibrillation. Obese patients with atrial fibrillation appear to have better long-term outcomes than nonobese patients.     

The association between obesity and outcomes in critically ill patients

BACKGROUND:

Obesity rates are increasing worldwide, particularly in North America. The impact of obesity on the outcome of critically ill patients is unclear.

METHODS:

A prospective observational cohort study of consecutive patients admitted to a tertiary critical care unit in Canada between January 10, 2008 and March 31, 2009 was conducted. Exclusion criteria were age <18 years, admission <24 h, planned cardiac surgery, pregnancy, significant ascites, unclosed surgical abdomen and brain death on admission. Height, weight and abdominal circumference were measured at the time of intensive care unit (ICU) admission. Coprimary end points were ICU mortality and a composite of ICU mortality, reintubation, ventilator-associated pneumonia, line sepsis and ICU readmission. Subjects were stratified as obese or nonobese, using two separate metrics: body mass index (BMI) ≥30 kg/m² and a novel measurement of 75th percentile for waist-to-height ratio (WHR).

RESULTS:

Among 449 subjects with a BMI ≥18.5 kg/m², both BMI and WHR were available for comparative analysis in 348 (77.5%). Neither measure of obesity was associated with the primary end points. BMI ≥30 kg/m² was associated with a lower odds of six-month mortality than the BMI <30 kg/m² group (adjusted OR 0.59 [95% CI 0.36 to 0.97]; P=0.04) but longer intubation times (adjusted RR 1.56 [95% CI 1.17 to 2.07]; P=0.003) and longer ICU length of stay (adjusted RR 1.67 [95% CI 1.21 to 2.31]; P=0.002). Conversely, measurement of 75th percentile for WHR was associated only with decreased ICU readmission (OR 0.23 [95% CI 0.07 to 0.79]; P=0.02).

CONCLUSIONS:

Obesity was not necessarily associated with worse outcomes in critically ill patients.     

Body mass index,cardiac surgery and clinical outcome. A single-center experience with 9125 patients

Background and AimThere is evidence for a J-shaped association between Body Mass Index (BMI) and all-cause mortality in general populations. In cardiac surgical patients, the effect of BMI on mortality and major adverse cardiac and cerebrovascular events (MACCE) is not completely clear.Methods and ResultsWe investigated the effect of BMI on MACCE (primary endpoint), as well as intensive care unit (ICU)-related outcomes and mid-term mortality in 9125 consecutive patients who were operated on at our institution between July 2009 and July 2012. Of the study cohort, 3.0% were underweight (BMI < 20 kg/m²), 28.0% had a normal BMI (20–24.99 kg/m²), 43.1% were overweight (BMI 25–29.99 kg/m²), 19.3% were obese (BMI 30–34.99 kg/m²), and 6.6% were severely obese (BMI ≥ 35 kg/m²). Compared with overweight patients (lowest incidence of MACCE), the multivariable-adjusted odds ratio of MACCE in severely obese patients was 1.39 (95% CI: 1.03–1.87). Underweight and severely obese patients had the longest risk-adjusted duration of mechanical ventilator support and ICU stay (P-values 0.004–0.001). The red blood cell concentrates requirement was highest in underweight patients (P < 0.001). Compared with normal and overweight patients, the multivariable-adjusted hazard ratio of 2-year mortality was higher in underweight patients (1.72 [95% CI: 1.26–2.36] and =2.07 [95% CI: 1.51–2.83], respectively), but did not differ significantly in severely obese patients.ConclusionData demonstrate that both severe obesity and underweight are independent risk factors for operative complications in cardiac surgical patients. With respect to mid-term survival, special attention should be paid to underweight patients scheduled for cardiac surgery.     

Inverse relationship between body mass index and mortality in older nursing home residents: a meta‐analysis of 19,538 elderly subjects

Body mass index (BMI) and mortality in old adults from the general population have been related in a U‐shaped or J‐shaped curve. However, limited information is available for elderly nursing home populations, particularly about specific cause of death. A systematic PubMed/EMBASE/CINAHL/SCOPUS search until 31 May 2014 without language restrictions was conducted. As no published study reported mortality in standard BMI groups (<18.5, 18.5–24.9, 25–29.9, ≥30 kg/m²), the most adjusted hazard ratios (HRs) according to a pre‐defined list of covariates were obtained from authors and pooled by random‐effect model across each BMI category. Out of 342 hits, 20 studies including 19,538 older nursing home residents with 5,223 deaths during a median of 2 years of follow‐up were meta‐analysed. Compared with normal weight, all‐cause mortality HRs were 1.41 (95% CI = 1.26–1.58) for underweight, 0.85 (95% CI = 0.73–0.99) for overweight and 0.74 (95% CI = 0.57–0.96) for obesity. Underweight was a risk factor for higher mortality caused by infections (HR = 1.65 [95% CI = 1.13–2.40]). RR results corroborated primary HR results, with additionally lower infection‐related mortality in overweight and obese than in normal‐weight individuals. Like in the general population, underweight is a risk factor for mortality in old nursing home residents. However, uniquely, not only overweight but also obesity is protective, which has relevant nutritional goal implications in this population/setting.     

Higher Prevalence of Obesity in Gastric Cardia Adenocarcinoma Compared to Gastric Non-Cardia Adenocarcinoma

Background and Aims

Obesity is one of the main risk factors for gastric cardia adenocarcinoma (GCA) in the West. Also, recent studies have suggested that GCA is distinct from distal stomach tumor, with differing risk factors, tumor characteristics, and biological behavior. The objective of our research was to evaluate the relationship between obesity and GCA compared to non-cardia adenocarcinoma.

Materials and Methods

A total of 298 patients who were diagnosed with gastric adenocarcinoma and underwent surgery at Seoul National University Bundang Hospital were evaluated. Ninety-one cases were GCA, and 207 cases were non-cardiac adenocarcinoma. Obesity was estimated by body mass index (BMI, kg/m²). The degree of obesity was determined by using BMI <18.5, 18.5–23.9, 24–27.9, and ≥28 (kg/m²) as the cut-off points for underweight, normal weight, overweight, and obese, respectively. Association with obesity was estimated by odds ratio (OR) and 95% confidence interval (CI).

Results

Obesity was more prevalent in patients with GCA at the time of diagnosis for gastric cancer. Among obese persons with a BMI of 28 kg/m² or higher, the OR was 3.937 (95% CI, 1.492–10.389; p = 0.006) for GCA compared to non-cardia adenocarcinoma. For overweight individuals, the OR was 2.194 (95% CI, 1.118–4.305; p = 0.022). Multivariate analysis of age, Helicobacter pylori infection, smoking, stage, and BMI with logistic regression was performed. BMI was an independent risk factor for GCA (OR, 1.123; 95% CI, 1.037–1.217; p = 0.004).

Conclusion

Obesity was more prevalent in patients with GCA compared to that in patients with gastric non-cardia adenocarcinoma. Also, BMI was an independent risk factor for GCA.     

Influence of Body Mass Index on the Management and Outcomes of Acute Myocardial Infarction-Cardiogenic Shock in the United States, 2008–2017

BackgroundThere are limited data on influence of body mass index (BMI) on outcomes of acute myocardial infarction-cardiogenic shock (AMI-CS).MethodsAdult AMI-CS admissions from 2008 to 2017 were identified from the National Inpatient Sample and stratified by BMI into underweight (<19.9 kg/m²), normal-BMI (19.9–24.9 kg/m²) and overweight/obese (>24.9 kg/m²). Outcomes of interest included in-hospital mortality, invasive cardiac procedures use, hospitalization costs, and discharge disposition.ResultsOf 339,364 AMI-CS admissions, underweight and overweight/obese constitute 2356 (0.7%) and 46,675 (13.8%), respectively. In 2017, compared to 2008, there was an increase in underweight (adjusted odds ratio [aOR] 6.40 [95% confidence interval {CI} 4.91–8.31]; p < 0.001) and overweight/obese admissions (aOR 2.93 [95% CI 2.78–3.10]; p < 0.001). Underweight admissions were on average older, female, with non-ST-segment-elevation AMI-CS, and higher comorbidity. Compared to normal and overweight/obese admissions, underweight admissions had lower rates of coronary angiography (57% vs 72% vs 78%), percutaneous coronary intervention (40% vs 54% vs 54%), and mechanical circulatory support (28% vs 46% vs 49%) (p < 0.001). In-hospital mortality was lower in underweight (32.9% vs 34.1%, aOR 0.64 [95% CI 0.57–0.71], p < 0.001) and overweight/obese (27.6% vs 38.4%, aOR 0.89 [95% CI 0.87–0.92], p < 0.001) admissions. Higher hospitalization costs were seen in overweight/obese admissions while underweight admissions were discharged more often to skilled nursing facilities.ConclusionUnderweight patients received less frequent cardiac procedures and were discharged more often to skilled nursing facilities. Underweight and overweight/obese AMI-CS admissions had lower in-hospital mortality compared to normal BMI.     

Obesity paradox in patients with hypertension and coronary artery disease

Purpose

An obesity paradox, a “paradoxical” decrease in morbidity and mortality with increasing body mass index (BMI), has been shown in patients with heart failure and those undergoing percutaneous coronary intervention. However, whether this phenomenon exists in patients with hypertension and coronary artery disease is not known.

Methods

A total of 22,576 hypertensive patients with coronary artery disease (follow-up 61,835 patient years, mean age 66 ± 9.8 years) were randomized to a verapamil-SR or atenolol strategy. Dose titration and additional drugs (trandolapril and/or hydrochlorothiazide) were added to achieve target blood pressure control according to the Sixth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure targets. Patients were classified into 5 groups according to baseline BMI: less than 20 kg/m² (thin), 20 to 25 kg/m² (normal weight), 25 to 30 kg/m² (overweight), 30 to 35 kg/m² (class I obesity), and 35 kg/m² or more (class II-III obesity). The primary outcome was first occurrence of death, nonfatal myocardial infarction, or nonfatal stroke.

Results

With patients of normal weight (BMI 20 to <25 kg/m²) as the reference group, the risk of primary outcome was lower in the overweight patients (adjusted hazard ratio [HR] 0.77, 95% confidence interval [CI], 0.70-0.86, P <.001), class I obese patients (adjusted HR 0.68, 95% CI, 0.59-0.78, P <.001), and class II to III obese patients (adjusted HR 0.76, 95% CI, 0.65-0.88, P <.001). Class I obese patients had the lowest rate of primary outcome and death despite having smaller blood pressure reduction compared with patients of normal weight at 24 months (−17.5 ± 21.9 mm Hg/−9.8 ± 12.4 mm Hg vs −20.7 ± 23.1 mm Hg /−10.6 ± 12.5 mm Hg, P <.001).

Conclusion

In a population with hypertension and coronary artery disease, overweight and obese patients had a decreased risk of primary outcome compared with patients of normal weight, which was driven primarily by a decreased risk of all-cause mortality. Our results further suggest a protective effect of obesity in patients with known cardiovascular disease in concordance with data in patients with heart failure and those undergoing percutaneous coronary intervention.     

Overweight,Obesity, and the Likelihood of Achieving Sustained Remission in Early Rheumatoid Arthritis: Results From a Multicenter Prospective Cohort Study

Objective

Obesity is implicated in rheumatoid arthritis (RA) development, severity, outcomes, and treatment response. We estimated the independent effects of overweight and obesity on ability to achieve sustained remission (sREM) in the 3 years following RA diagnosis.

Methods

Data were from the Canadian Early Arthritis Cohort, a multicenter observational trial of early RA patients treated by rheumatologists using guideline‐based care. sREM was defined as Disease Activity Score in 28 joints (DAS28) <2.6 for 2 consecutive visits. Patients were stratified by body mass index (BMI) as healthy (18.5–24.9 kg/m²), overweight (25–29.9 kg/m²), and obese (≥30 kg/m²). Cox regression was used to estimate the effect of the BMI category on the probability of achieving sREM over the first 3 years, controlling for age, sex, race, education, RA duration, smoking status, comorbidities, baseline DAS28, Health Assessment Questionnaire disability index, C‐reactive protein level, and initial treatment.

Results

Of 982 patients, 315 (32%) had a healthy BMI, 343 (35%) were overweight, and 324 (33%) were obese; 355 (36%) achieved sREM within 3 years. Initial treatment did not differ by BMI category. Compared to healthy BMI, overweight patients (hazard ratio [HR] 0.75 [95% confidence interval (95% CI) 0.58–0.98]) and obese patients (HR 0.53 [95% CI 0.39–0.71]) were significantly less likely to achieve sREM.

Conclusion

Rates of overweight and obesity were high (69%) in this early RA cohort. Overweight patients were 25% less likely, and obese patients were 47% less likely, to achieve sREM in the first 3 years, despite similar initial disease‐modifying antirheumatic drug treatment and subsequent biologic use. This is the largest study demonstrating the negative impact of excess weight on RA disease activity and supports a call to action to better identify and address this risk in RA patients.

     

The impact of underweight and obesity on outcomes in anticoagulated patients with atrial fibrillation: A systematic review and meta‐analysis on the obesity paradox

Although obesity is associated with the development and progression of atrial fibrillation (AF), an obesity paradox may be present, illustrated by seemingly protective effects of obesity on AF‐related outcomes. Body mass index (BMI) has an impact on outcomes in AF patients using oral anticoagulants. After searching Medline and Embase, meta‐analysis of results of four randomized and five observational studies demonstrated significantly lower risks of stroke or systemic embolism (RR 0.80, 95%CI [0.73–0.87]; RR 0.63, 95%CI [0.57–0.70]; and RR 0.42, 95%CI [0.31–0.57], respectively) and all‐cause mortality (RR 0.73, 95%CI [0.64–0.83]; RR 0.61, 95%CI [0.52–0.71]; and RR 0.56, 95%CI [0.47–0.66], respectively) in overweight, obese and morbidly obese anticoagulated AF patients (BMI 25 to <30, ≥30 and ≥40 kg/m², respectively) compared to normal BMI anticoagulated AF patients (BMI 18.5 to <25 kg/m²). In contrast, thromboembolic (RR 1.92, 95%CI [1.28–2.90]) and mortality (RR 3.57, 95%CI [2.50–5.11]) risks were significantly increased in underweight anticoagulated AF patients (BMI <18.5 kg/m²). In overweight and obese anticoagulated AF patients, the risks of major bleeding (RR 0.86, 95%CI [0.76–0.99]; and RR 0.88, 95%CI [0.79–0.98], respectively) and intracranial bleeding (RR 0.75, 95%CI [0.58–0.97]; and RR 0.57, 95%CI [0.40–0.80], respectively) were also significantly lower compared to normal BMI patients, while similar risks were observed in underweight and morbidly obese patients. This meta‐analysis demonstrated lower thromboembolic and mortality risks with increasing BMI. However, as this paradox was driven by results from randomized studies, while observational studies rendered more conflicting results, these seemingly protective effects should still be interpreted with caution.     

Association Between Obesity,Age, and Functional Decline in Survivors of Cardiac Surgery

Background/Objectives

Little is known about the effect of obesity on functional decline after cardiac surgery, especially in elderly adults. Our goal was to determine the association between obesity and functional decline in the 2 years after cardiac surgery and the interaction between obesity and age.

Design

Retrospective cohort study.

Setting

The Health and Retirement Study, 2004–2014.

Participants

U.S. adults aged 50 and older who indicated having cardiac surgery and had a body mass index (BMI) of 18.5 kg/m² or greater (N = 1,731).

Measurements

BMI was classified as normal or overweight (18.5–29.9 kg/m²) and obese (≥30 kg/m²). Primary outcome was decline in ability to perform an activity of daily living (ADL) after surgery.

Results

Respondents had a median age of 71, 59.3% were female, and 34.3% were obese. Obese respondents had a higher incidence of ADL decline (22.4%) than those who were not obese (17.1%) (P = .007). In the multivariable analysis of our full cohort, obesity was not associated with ADL decline (odds ratio (OR)=1.20, 95% confidence interval (CI)=0.90–1.59, P = .21) after cardiac surgery, although obese respondents aged 50 to 79 had greater odds of ADL decline (OR=1.45, 95% CI=1.06–2.00, P = .02). Obese respondents aged 80 and older had nonstatistically significantly lower odds of ADL decline (OR=0.61, 95% CI=0.30–1.24, P = .18) compared to non‐obese respondents.

Conclusion

The association between obesity and postoperative functional decline in survivors of cardiac surgery differed according to age. Additional research is needed to identify interventions to improve outcomes in groups of older adults in whom obesity may increase the risk of postoperative functional decline.     

Interaction of Physical Activity and Body Mass Index on Mortality in Coronary Heart Disease: Data from the Nord-Trøndelag Health Study

Objective

The role of physical activity in the relationship between body mass index (BMI) and survival in coronary heart disease is unclear. Our aim was to examine the isolated and combined associations among BMI, physical activity, and mortality in subjects with coronary heart disease.

The enigma of increased non-cancer mortality after weight loss in healthy men who are overweight or obese

Abstract. Nilsson PM, Nilsson J‐A, Hedblad B, Berglund G, Lindgärde F. (University Hospital, Malmö, Sweden). The enigma of increased non‐cancer mortality after weight loss in healthy men who are overweight or obese. J Intern Med 2002; 252: 70?78. Objective. To study effects on non‐cancer mortality of observational weight loss in middle‐aged men stratified for body mass index (BMI), taking a wide range of possible confounders into account. Design. Prospective, population based study. Setting. Male population of Malmö, Sweden. Participants. In all 5722 men were screened twice with a mean time interval of 6 years in Malmö, southern Sweden. They were classified according to BMI category at baseline (<21, 22?25, overweight: 26?30, and obesity: 30+ kg m^?2) and weight change category until second screening (weight stable men defined as having a baseline BMI ± 0.1 kg m^?2 year^?1 at follow‐up re‐screening). Main outcome measures. Non‐cancer mortality calculated from national registers during 16 years of follow‐up after the second screening. Data from the first year of follow‐up were excluded to avoid bias by mortality caused by subclinical disease at re‐screening. Results. The relative risk (RR; 95% CI) for non‐cancer mortality during follow‐up was higher in men with decreasing BMI in all subgroups: RR 2.64 (1.46?4.71, baseline BMI <21 kg m^?2), 1.39 (0.98?1.95, baseline BMI 22?25 kg m^?2), and 1.71 (1.18?2.47, baseline BMI 26+ kg m^?2), using BMI‐stable men as reference group. Correspondingly, the non‐cancer mortality was also higher in men with increasing BMI, but only in the obese group (baseline BMI 26+ kg m^?2) with RR 1.86 (1.31?2.65). In a subanalysis, nonsmoking obese (30+ kg m^?2) men with decreased BMI had an increased non‐cancer mortality compared with BMI‐stable obese men (Fischer's test: P=0.001). The mortality risk for nonsmoking overweight men who increased their BMI compared with BMI‐stable men was also significant (P=0.006), but not in corresponding obese men (P=0.094). Conclusions. Weight loss in self‐reported healthy but overweight middle‐aged men, without serious disease, is associated with an increased non‐cancer mortality, which seems even more pronounced in obese, nonsmoking men, as compared with corresponding but weight‐stable men. The explanation for these observational findings is still enigmatic but could hypothetically be because of premature ageing effects causing so‐called weight loss of involution.