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Jennifer T. Cone, Elizabeth R. Benjamin, Daniel B. Alfson and Demetrios Demetriades


Obesity has been widely reported to confer significant morbidity and mortality in both medical and surgical patients. However, contemporary data indicate that obesity may confer protection after both critical illness and certain types of major surgery. The authors hypothesized that this “obesity paradox” may apply to patients with isolated severe blunt traumatic brain injuries (TBIs).


The Trauma Quality Improvement Program (TQIP) database was queried for patients with isolated severe blunt TBI (head Abbreviated Injury Scale [AIS] score 3–5, all other body areas AIS < 3). Patient data were divided based on WHO classification levels for BMI: underweight (< 18.5 kg/m2), normal weight (18.5–24.9 kg/m2), overweight (25.0–29.9 kg/m2), obesity class 1 (30.0–34.9 kg/m2), obesity class 2 (35.0–39.9 kg/m2), and obesity class 3 (≥ 40.0 kg/m2). The role of BMI in patient outcomes was assessed using regression models.


In total, 103,280 patients were identified with isolated severe blunt TBI. Data were excluded for patients aged < 20 or > 89 years or with BMI < 10 or > 55 kg/m2 and for patients who were transferred from another treatment center or who showed no signs of life upon presentation, leaving data from 38,446 patients for analysis. Obesity was not found to confer a survival advantage on univariate analysis. On multivariate analysis, underweight patients as well as obesity class 1 and 3 patients had a higher rate of mortality (OR 1.86, 95% CI 1.48–2.34; OR 1.18, 95% CI 1.01–1.37; and OR 1.41, 95% CI 1.03–1.93, respectively). Increased obesity class was associated with an increased risk of respiratory complications (obesity class 1: OR 1.19, 95% CI 1.03–1.37; obesity class 2: OR 1.30, 95% CI 1.05–1.62; obesity class 3: OR 1.55, 95% CI 1.18–2.05) and thromboembolic complications (overweight: OR 1.43, 95% CI 1.16–1.76; obesity class 1: OR 1.45, 95% CI 1.11–1.88; obesity class 2: OR 1.55, 95% CI 1.05–2.29) despite a decreased risk of overall complications (obesity class 2: OR 0.82, 95% CI 0.73–0.92; obesity class 3: OR 0.83, 95% CI 0.72–0.97). Underweight patients had a significantly increased risk of overall complications (OR 1.39, 95% CI 1.24–1.57).


Although there was an obesity-associated decrease in overall complications, the study data did not demonstrate a paradoxical protective effect of obesity on mortality after isolated severe blunt TBI. Obese patients with isolated severe blunt TBI are at increased risk of respiratory and venous thromboembolic complications. However, underweight patients appear to be at highest risk after severe blunt TBI, with significantly increased risks of morbidity and mortality.