Survival bias may explain the appearance of the obesity paradox in hip fracture patients

Amin, Raj M.; Raad, Micheal; Rao, Sandesh S.; Musharbash, Farah N.; Amanatullah, Derek F.

doi:10.1007/s00198-021-06046-7

Cited by 11 publications

(12 citation statements)

References 50 publications

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“…Table 1 summarizes the characteristics of the studies included in the review. All studies were observational cohorts; 41 were prospective [ 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 ] and 17 were retrospective [ 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , …”

Section: Resultsmentioning

confidence: 99%

“…One involved patients with chronic diseases [ 59 ], and two involved patients with type 2 diabetes mellitus [ 27 , 63 ]. Of the 58 studies, 34 used the threshold of BMI ≥ 25.0 kg/m 2 [ 11 , 12 , 14 , 16 , 19 , 20 , 21 , 22 , 24 , 26 , 30 , 31 , 32 , 34 , 38 , 40 , 41 , 44 , 45 , 51 , 52 , 54 , 55 , 57 , 58 , 60 , 66 , 67 , 68 ]. A further 10 studies used a threshold different from 25 kg/m 2 and found evidence of the obesity paradox [ 13 , 18 , 23 , 25 , 33 , 35 , 37 , 48 , 61 , 64 ].…”

Section: Resultsmentioning

confidence: 99%

“…A further 10 studies used a threshold different from 25 kg/m 2 and found evidence of the obesity paradox [ 13 , 18 , 23 , 25 , 33 , 35 , 37 , 48 , 61 , 64 ]. Regarding the time points, 9 studies looked at short-term mortality (less than 12-month mortality, ICU mortality, hospital mortality) [ 11 , 12 , 19 , 30 , 40 , 52 , 55 , 64 , 68 ]. All of these, except Yamamoto et al [ 40 ] and Kananen et al [ 68 ], found evidence of the obesity paradox.…”

Section: Resultsmentioning

confidence: 99%

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The Obesity Paradox and Mortality in Older Adults: A Systematic Review

Dramé

Godaert

2023

Nutrients

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“Obesity paradox” describes the counterintuitive finding that aged overweight and obese people with a particular disease may have better outcomes than their normal weight or underweight counterparts. This systematic review was performed to summarize the publications related to the obesity paradox in older adults, to gain an in-depth understanding of this phenomenon. PubMed©, Embase©, and Scopus© were used to perform literature search for all publications up to 20 March 2022. Studies were included if they reported data from older adults on the relation between BMI and mortality. The following article types were excluded from the study: reviews, editorials, correspondence, and case reports and case series. Publication year, study setting, medical condition, study design, sample size, age, and outcome(s) were extracted. This review has been registered with PROSPERO (no. CRD42021289015). Overall, 2226 studies were identified, of which 58 were included in this systematic review. In all, 20 of the 58 studies included in this review did not find any evidence of an obesity paradox. Of these 20 studies, 16 involved patients with no specific medical condition, 1 involved patients with chronic diseases, and 2 involved patients with type 2 diabetes mellitus. Seven out of the nine studies that looked at short-term mortality found evidence of the obesity paradox. Of the 28 studies that examined longer-term mortality, 15 found evidence of the obesity paradox. In the studies that were conducted in people with a particular medical condition (n = 24), the obesity paradox appeared in 18 cases. Our work supports the existence of an obesity paradox, especially when comorbidities or acute medical problems are present. These findings should help guide strategies for nutritional counselling in older populations.

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

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The Obesity Paradox and Mortality in Older Adults: A Systematic Review

Dramé

Godaert

2023

Nutrients

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“…Moreover, more attention to accepting that bone metabolism, bone turnover, and mineral content are altered in severe obesity 52 is indicated. 53 It also appears that while the skeleton can adapt to some degree relative to excess body weight, this does not preclude limits of this adaption to offset all mechanical loads imposed on the bone, especially in cases of extreme obesity. 54 To forge a better understanding of these possible clinically relevant body responses that may arise in the face of excess body weight, and prove detrimental rather than protective, but are currently nonconclusive, poorly understood, and somewhat disparate, carefully construed clinical studies that are prospective in nature, and that examine the bone impacts of varying categories of body weight in the realm of different age and health status groups as far as their possible implications for bone architecture, bone biology and biochemistry, as well as bone vascular and fat cell impacts are concerned are especially indicated.…”

Section: Discussionmentioning

confidence: 99%

Obesity and bone health: key 2020–2022 highlights and implications

Marks¹

2022

AOWMC

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Sound bone health is crucial for life affirming activities, but is bone physiology impacted in the face of excess body weight? Since fractures and osteoporosis are on the rise, is obesity a risk factor for, as well as a possible negative albeit remediable correlate of bone health in the older adult? To examine this premise the PUBMED and GOOGLE SCHOLAR data bases were sourced for relevant data published between January 1 2020 and November 1 2022 in an effort to capture post COVID-19 possible research observations on the topic. These data bases show while a pervasive idea has been that obesity may be beneficial in some respects to bone mineral density attributes and impart fracture protection, several current publications tend to portray a negative impact of obesity on bone health via multiple proposed mechanisms. However, the research points to a strong need for continued research as well as clinical vigilance of vulnerable individuals both young and old in a period where obesity rates in all age groups appear to be on the rise, along with cases of bone fragility and osteoarthritis that can both foster high morbidity and mortality rates and possibly more challenging weight issues in the face of painful fractures or joint derangement.

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“…Literature regarding the association of BMI and mortality or morbidity risk following hip fracture is divided. Despite an apparent "obesity paradox," with obese patients having a lower risk of mortality, several studies have found contrasting results where obese, super-obese, and very underweight patients have higher rates of poor outcomes and mortality [6][7][8][9]. Similar to BMI, current research has demonstrated smoking to be associated with worse perioperative outcomes and higher rates of mortality following surgery [10][11][12][13].…”

Section: Introductionmentioning

confidence: 99%

The Role of Smoking and Body Mass Index in Mortality Risk Assessment for Geriatric Hip Fracture Patients

Meltzer-Bruhn¹,

Esper²,

Herbosa³

et al. 2022

Cureus

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BackgroundSmoking, obesity, and being below a healthy body weight are known to increase all-cause mortality rates and are considered modifiable risk factors. The purpose of this study is to assess whether adding these risk factors to a validated geriatric inpatient mortality risk tool will improve the predictive capacity for hip fracture patients. We hypothesize that the predictive capacity of the Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) tool will improve. MethodologyBetween October 2014 and August 2021, 2,421 patients >55-years-old treated for hip fractures caused by low-energy mechanisms were analyzed for demographics, injury details, hospital quality measures, and mortality. Smoking status was recorded as a current every-day smoker, former smoker, or never smoker. Smokers (current and former) were compared to non-smokers (never smokers). Body mass index (BMI) was defined as underweight (<18.5 kg/m 2 ), healthy weight (18.5-24.9 kg/m 2 ), overweight (25.0-24.9 kg/m 2 ), or obese (>30 kg/m 2 ). The baseline STTGMA tool for hip fractures (STTGMAHIP_FX_SCORE) was modified to include patients' BMI and smoking status (STTGMA_MODIFIABLE), and new mortality risk scores were calculated. Each model's predictive ability was compared using DeLong's test by analyzing the area under the receiver operating curves (AUROCs). Comparative analyses were conducted on each risk quartile. ResultsA comparison of smokers versus non-smokers demonstrated that smokers experienced higher rates of inpatient (p = 0.025) and 30-day (p = 0.048) mortality, myocardial infarction (p < 0.01), acute respiratory failure (p < 0.01), and a longer length of stay (p = 0.014). Comparison among BMI cohorts demonstrated that underweight patients experienced higher rates of pneumonia (p = 0.033), decubitus ulcers (p = 0.046), and the need for an intensive care unit (ICU) (p < 0.01). AUROC comparison demonstrated that STTGMA_MODIFIABLE significantly improved the predictive capacity for inpatient mortality compared to STTGMAHIP_FX_SCORE (0.792 vs. 0.672, p = 0.0445). Quartile stratification demonstrated the highest risk cohort had a longer length of stay (p < 0.01), higher rates of inpatient (p < 0.01) and 30-day mortality (p < 0.01), and need for an ICU (p < 0.01) compared to the minimal risk cohort. Patients in the lowest risk quartile were most likely to be discharged home (p < 0.01). ConclusionsSmoking, obesity, and being below a healthy body weight increase the risk of perioperative complications and poor outcomes. Including smoking and BMI improves the STTGMAHIP_FX_SCORE tool to predict mortality and risk stratify patient outcomes. Because smoking, obesity, and being below a healthy body weight are modifiable patient factors, providers can counsel patients and implement lifestyle changes to potentially decrease their risk of longer-term poor outcomes, especially in the setting of another fracture. For patients who are former smokers, providers can use this information to encourage continued restraint and healthy choices.

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Survival bias may explain the appearance of the obesity paradox in hip fracture patients

Cited by 11 publications

References 50 publications

The Obesity Paradox and Mortality in Older Adults: A Systematic Review

The Obesity Paradox and Mortality in Older Adults: A Systematic Review

Obesity and bone health: key 2020–2022 highlights and implications

The Role of Smoking and Body Mass Index in Mortality Risk Assessment for Geriatric Hip Fracture Patients

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