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Sepsis and the Obesity Paradox: Size Matters in More Than One Way.
Crit Care Med. 2020 09; 48(9):e776-e782.CC

Abstract

OBJECTIVES

Multiple studies have demonstrated an obesity paradox such that obese ICU patients have lower mortality and better outcomes. We conducted this study to determine if the mortality benefit conferred by obesity is affected by baseline serum lactate and mean arterial pressure.

DESIGN

Retrospective analysis of prospectively collected clinical data.

SETTING

Five community-based and one academic medical center in the Omaha, NE.

PATIENTS

7,967 adults hospitalized with sepsis.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients were categorized by body mass index as underweight, normal weight, overweight, or obese. Multivariable logistic regression models were used to estimate the odds of in-hospital death by body mass index category; two-way interactions between body mass index and each covariate were also evaluated. Subgroup and sensitivity analyses were conducted using an ICU cohort and Acute Physiology and Chronic Health Evaluation III scores, respectively. The overall unadjusted mortality rate was 12.1% and was consistently lower in higher body mass index categories (all comparisons, p < 0.007). The adjusted mortality benefit observed in patients with higher body mass index was smaller in patients with higher lactate levels with no mortality benefit in higher body mass index categories observed at lactate greater than 5 mmol/L. By contrast, the association between lower MAP and higher mortality was constant across body mass index categories. Similar results were observed in the ICU cohort. Finally, the obesity paradox was not observed after including Acute Physiology and Chronic Health Evaluation III scores as a covariate.

CONCLUSIONS

Our retrospective analysis suggests that although patient size (i.e., body mass index) is a predictor of in-hospital death among all-comers with sepsis-providing further evidence to the obesity paradox-it adds that illness severity is critically important whether quantified as higher lactate or by Acute Physiology and Chronic Health Evaluation III score. Our results highlight that the obesity paradox is more than a simple association between body mass index and mortality and reinforces the importance of illness severity.

Authors+Show Affiliations

Division of Pulmonary and Critical Care, Creighton University School of Medicine, Omaha, NE.Division of Pulmonary and Critical Care, Creighton University School of Medicine, Omaha, NE.Division of Clinical Research and Evaluative Sciences, Creighton University School of Medicine, Omaha, NE.Division of Pulmonary and Critical Care, Creighton University School of Medicine, Omaha, NE.Department of Internal Medicine, Creighton University School of Medicine, Omaha, NE.Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO.Division of Pulmonary and Critical Care, Creighton University School of Medicine, Omaha, NE.

Pub Type(s)

Journal Article
Multicenter Study

Language

eng

PubMed ID

32590388

Citation

Jagan, Nikhil, et al. "Sepsis and the Obesity Paradox: Size Matters in More Than One Way." Critical Care Medicine, vol. 48, no. 9, 2020, pp. e776-e782.
Jagan N, Morrow LE, Walters RW, et al. Sepsis and the Obesity Paradox: Size Matters in More Than One Way. Crit Care Med. 2020;48(9):e776-e782.
Jagan, N., Morrow, L. E., Walters, R. W., Plambeck, R. W., Wallen, T. J., Patel, T. M., & Malesker, M. A. (2020). Sepsis and the Obesity Paradox: Size Matters in More Than One Way. Critical Care Medicine, 48(9), e776-e782. https://doi.org/10.1097/CCM.0000000000004459
Jagan N, et al. Sepsis and the Obesity Paradox: Size Matters in More Than One Way. Crit Care Med. 2020;48(9):e776-e782. PubMed PMID: 32590388.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Sepsis and the Obesity Paradox: Size Matters in More Than One Way. AU - Jagan,Nikhil, AU - Morrow,Lee E, AU - Walters,Ryan W, AU - Plambeck,Robert W, AU - Wallen,Tanner J, AU - Patel,Tej M, AU - Malesker,Mark A, PY - 2020/6/27/pubmed PY - 2021/5/26/medline PY - 2020/6/27/entrez SP - e776 EP - e782 JF - Critical care medicine JO - Crit Care Med VL - 48 IS - 9 N2 - OBJECTIVES: Multiple studies have demonstrated an obesity paradox such that obese ICU patients have lower mortality and better outcomes. We conducted this study to determine if the mortality benefit conferred by obesity is affected by baseline serum lactate and mean arterial pressure. DESIGN: Retrospective analysis of prospectively collected clinical data. SETTING: Five community-based and one academic medical center in the Omaha, NE. PATIENTS: 7,967 adults hospitalized with sepsis. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients were categorized by body mass index as underweight, normal weight, overweight, or obese. Multivariable logistic regression models were used to estimate the odds of in-hospital death by body mass index category; two-way interactions between body mass index and each covariate were also evaluated. Subgroup and sensitivity analyses were conducted using an ICU cohort and Acute Physiology and Chronic Health Evaluation III scores, respectively. The overall unadjusted mortality rate was 12.1% and was consistently lower in higher body mass index categories (all comparisons, p < 0.007). The adjusted mortality benefit observed in patients with higher body mass index was smaller in patients with higher lactate levels with no mortality benefit in higher body mass index categories observed at lactate greater than 5 mmol/L. By contrast, the association between lower MAP and higher mortality was constant across body mass index categories. Similar results were observed in the ICU cohort. Finally, the obesity paradox was not observed after including Acute Physiology and Chronic Health Evaluation III scores as a covariate. CONCLUSIONS: Our retrospective analysis suggests that although patient size (i.e., body mass index) is a predictor of in-hospital death among all-comers with sepsis-providing further evidence to the obesity paradox-it adds that illness severity is critically important whether quantified as higher lactate or by Acute Physiology and Chronic Health Evaluation III score. Our results highlight that the obesity paradox is more than a simple association between body mass index and mortality and reinforces the importance of illness severity. SN - 1530-0293 UR - https://www.unboundmedicine.com/medline/citation/32590388/Sepsis_and_the_Obesity_Paradox:_Size_Matters_in_More_Than_One_Way_ L2 - https://dx.doi.org/10.1097/CCM.0000000000004459 DB - PRIME DP - Unbound Medicine ER -