Does the obesity paradox predict functional outcome in intracerebral hemorrhage?

Restricted access


Being overweight or mildly obese has been associated with a decreased risk of death or hospitalization in patients with cardiovascular disease. Similarly, overweight patients admitted to an intensive care unit (ICU) have improved survival up to 1 year after admission. These counterintuitive observations are examples of the “obesity paradox.” Does the obesity paradox exist in patients with intracerebral hemorrhage (ICH)? In this study the authors examined whether there was an association between obesity and functional outcome in patients with ICH.


The authors analyzed 202 patients admitted to the neurological ICU (NICU) who were prospectively enrolled in the Columbia University ICH Outcomes Project between September 2009 and December 2012. Patients were categorized into 2 groups: overweight (body mass index [BMI] ≥ 25 kg/m2) and not overweight (BMI < 25 kg/m2). The primary outcome was defined as survival with favorable outcome (modified Rankin Scale [mRS] score 0–3) versus death or severe disability (mRS score 4–6) at 3 months.


The mean age of the patients in the study was 61 years. The mean BMI was 28 ± 6 kg/m2. The mean Glasgow Coma Scale score was 10 ± 4 and the mean ICH score was 1.9 ± 1.3. The overall 90-day mortality rate was 41%. Among patients with a BMI < 25 kg/m2, 24% (17/70) had a good outcome, compared with 39% (52/132) among those with a BMI ≥ 25 kg/m2 (p = 0.03). After adjusting for ICH score, sex, do-not-resuscitate code status, and history of hypertension, being overweight or obese (BMI ≥ 25 kg/m2) was associated with twice the odds of having a good outcome compared with patients with BMI < 25 kg/m2 (adjusted odds ratio 2.05, 95% confidence interval 1.03–4.06, p = 0.04).


In patients with ICH admitted to the NICU, being overweight or obese (BMI ≥ 25 kg/m2) was associated with favorable outcome after adjustment for established predictors. The reason for this finding requires further study.

ABBREVIATIONS BMI = body mass index; CI = confidence interval; DNR = do not resuscitate; GCS = Glasgow Coma Scale; ICH = intracerebral hemorrhage; ICHOP = Intracerebral Hemorrhage Outcomes Project; IVH = intraventricular hemorrhage; mRS = modified Rankin Scale; NICU = neurological intensive care unit; OR = odds ratio.

Article Information

Correspondence Stephan A. Mayer, Department of Neurology, Henry Ford Health System, 2799 W Grand Ave., Detroit, MI 48202. email:

INCLUDE WHEN CITING Published online December 8, 2017; DOI: 10.3171/2017.5.JNS163266.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Distribution of 90-day mRS outcomes according to BMI. The primary outcome measure was assessed using the mRS, a functional outcome scale. The 7 outcome categories are 0 (no symptoms), 1 (no significant disability despite symptoms and able to perform all usual duties and activities), 2 (slight disability; unable to perform all previous activities but able to look after own affairs without assistance), 3 (moderate disability; requires some help, but able to walk without assistance), 4 (moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance), 5 (severe disability; bedridden, incontinent, and requires constant nursing and attention), and 6 (death). Figure is available in color online only.



Andersen KKOlsen TS: Body mass index and stroke: overweight and obesity less often associated with stroke recurrence. J Stroke Cerebrovasc Dis 22:e576e5812013


Andersen KKOlsen TS: The obesity paradox in stroke: lower mortality and lower risk of readmission for recurrent stroke in obese stroke patients. Int J Stroke 10:991042015


Bagheri MSpeakman JRShabbidar SKazemi FDjafarian K: A dose-response meta-analysis of the impact of body mass index on stroke and all-cause mortality in stroke patients: a paradox within a paradox. Obes Rev 16:4164232015


Barba RMarco JRuiz JCanora JHinojosa JPlaza S: The obesity paradox in stroke: impact on mortality and short-term readmission. J Stroke Cerebrovasc Dis 24:7667702015


Chang HWLi YHHsieh CHLiu PYLin GM: Association of body mass index with all-cause mortality in patients with diabetes: a systemic review and meta-analysis. Cardiovasc Diagn Ther 6:1091192016


Dehlendorff CAndersen KKOlsen TS: Body mass index and death by stroke: no obesity paradox. JAMA Neurol 71:9789842014


Flegal KMKit BKOrpana HGraubard BI: Association of all-cause mortality with overweight and obesity using standard body mass index categories: a systematic review and meta-analysis. JAMA 309:71822013


Hemphill JC IIIBonovich DCBesmertis LManley GTJohnston SC: The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke 32:8918972001


Hemphill JC IIIGreenberg SMAnderson CSBecker KBendok BRCushman M: Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 46:203220602015


Jönsson ACLindgren INorrving BLindgren A: Weight loss after stroke: a population-based study from the Lund Stroke Register. Stroke 39:9189232008


Kim BJLee SHRyu WSKim CKLee JYoon BW: Paradoxical longevity in obese patients with intracerebral hemorrhage. Neurology 76:5675732011


McAuley PABeavers KM: Contribution of cardiorespiratory fitness to the obesity paradox. Prog Cardiovasc Dis 56:4344402014


Nie WZhang YJee SHJung KJLi BXiu Q: Obesity survival paradox in pneumonia: a meta-analysis. BMC Med 12:612014


Oga EAEseyin OR: The obesity paradox and heart failure: a systematic review of a decade of evidence. J Obes 2016:90402482016


Rincon FMayer SA: The epidemiology of intracerebral hemorrhage in the United States from 1979 to 2008. Neurocrit Care 19:951022013


Sharma ALavie CJBorer JSVallakati AGoel SLopez-Jimenez F: Meta-analysis of the relation of body mass index to all-cause and cardiovascular mortality and hospitalization in patients with chronic heart failure. Am J Cardiol 115:142814342015


Zalesin KCFranklin BAMiller WMPeterson EDMcCullough PA: Impact of obesity on cardiovascular disease. Med Clin North Am 95:9199372011


Zhao LDu WZhao XLiu LWang CWang Y: Favorable functional recovery in overweight ischemic stroke survivors: findings from the China National Stroke Registry. J Stroke Cerebrovasc Dis 23:e201e2062014




All Time Past Year Past 30 Days
Abstract Views 190 190 64
Full Text Views 417 417 58
PDF Downloads 332 332 43
EPUB Downloads 0 0 0


Google Scholar