The Association Between BMI and Mortality in Surgical Patients

Abstract

Background

While obesity is commonly associated with increased morbidity and mortality, in patients with chronic diseases, it has have been associated with a better prognosis, a phenomenon known as the 'obesity paradox'.

Objective

We investigated the relationship between mortality, length of hospital stay (LOHS), and body mass index (BMI) in patients hospitalized to general surgical wards.

Methods

We extracted data of patients admitted to the hospital between January 2011 and December 2017. BMI was classified according to the following categories: underweight (< 18.5), normal weight (18.5–24.9), overweight (25–29.9), obesity (30–34.9) and severe obesity (≥ 35). Main outcomes were mortality at 30-day mortality and at the end-of-follow-up mortality), as well as LOHS.

Results

A total of 27,639 patients (mean age 55 ± 20 years; 48% males; 19% had diabetes) were included in the study. Median LOHS was longer in patients with diabetes vs. those without diabetes (4.0 vs 3.0 days, respectively), with longest LOHS among underweight patients. A 30-day mortality was 2% of those without (371/22,297) and 3% of those with diabetes (173/5,342). In patients with diabetes, 30-day mortality risk showed a step-wise decrease with increased BMI: 10% for underweight, 6% for normal weight, 3% for overweight, 2% for obese and only 1% for severely obese patients. In patients without diabetes, 30-day mortality was found to be 6% for underweight, 3% for normal weight and 1% across the overweight and obese categories. Mortality rate at the end-of-follow-up was 9% of patients without diabetes and 18% of those with diabetes (adjusted OR = 1.3, 95% CI, 1.2–1.5). In patients with diabetes, mortality risk showed an inverse association with respect to BMI: 52% for underweight, 29% for normal weight, 17% for overweight, 14% for obesity and 7% for severely obese patients, with similar trend in patients without diabetes.

Conclusions

The results support the ‘obesity paradox’ in the general surgical patients as those with and without diabetes admitted to surgical wards, BMI had an inverse association with short- and long-term mortality.

This is a preview of subscription content, access via your institution.

We’re sorry, something doesn't seem to be working properly.

Please try refreshing the page. If that doesn't work, please contact support so we can address the problem.

Fig. 1

References

  1. 1.

    Obesity: preventing and managing the global epidemic (2000) Report of a WHO consultation. World Health Organ Tech Rep Ser 894:1–253.

  2. 2.

    Gurwitz AA (2014) The spreading worldwide obesity epidemic. J Community Health 39(5):827

    PubMed  Article  Google Scholar 

  3. 3.

    Imes CC, Burke LE (2014) The obesity epidemic: the united states as a cautionary tale for the rest of the world. Curr Epidemiol Rep 1(2):82–88

    PubMed  PubMed Central  Article  Google Scholar 

  4. 4.

    Misra A, Khurana L (2008) Obesity and the metabolic syndrome in developing countries. J Clin Endocrinol Metab 93(11 Suppl 1):S9-30

    CAS  PubMed  Article  Google Scholar 

  5. 5.

    Must A et al (1999) The disease burden associated with overweight and obesity. JAMA 282(16):1523–1529

    CAS  PubMed  Article  Google Scholar 

  6. 6.

    Flegal KM et al (2007) Cause-specific excess deaths associated with underweight, overweight and obesity. JAMA 298(17):2028–2037

    CAS  PubMed  Article  Google Scholar 

  7. 7.

    Berrington de Gonzalez A (2010) Body-mass index and mortality among 1.46 million white adults. N Engl J Med. 363(23):2211–2219

    CAS  PubMed  Article  Google Scholar 

  8. 8.

    Calle EE et al (1999) Body-mass index and mortality in a prospective cohort of US adults. N Engl J Med 341(15):1097–1105

    CAS  PubMed  Article  Google Scholar 

  9. 9.

    Khan SS et al (2018) Association of body mass index with lifetime risk of cardiovascular disease and compression of morbidity. JAMA Cardiol 3(4):280–287

    PubMed  PubMed Central  Article  Google Scholar 

  10. 10.

    Calle EE et al (2003) Overweight, obesity and mortality from cancer in a prospectively studied cohort of US adults. N Engl J Med 348(17):1625–1638

    PubMed  Article  Google Scholar 

  11. 11.

    Bhaskaran K et al (2018) Association of BMI with overall and cause-specific mortality: a population-based cohort study of 36 million adults in the UK. Lancet Diabetes Endocrinol 6(12):944–953

    PubMed  PubMed Central  Article  Google Scholar 

  12. 12.

    Docimo S Jr et al (2018) Increased incidence of surgical site infection with a body mass index >/= 35 kg/m(2) following abdominal wall reconstruction with open component separation. Surg Endosc 19:356

    Google Scholar 

  13. 13.

    Nelson JA et al (2014) A population-level analysis of abdominal wall reconstruction by component separation in the morbidly obese patient: can it be performed safely? J Plast Surg Hand Surg 48(5):305–311

    PubMed  Article  Google Scholar 

  14. 14.

    Ghanta RK et al (2017) Obesity increases risk-adjusted morbidity, mortality and cost following cardiac surgery. J Am Heart Assoc 6(3):365

    Article  Google Scholar 

  15. 15.

    Soderback H et al (2019) Incidence of wound dehiscence after colorectal cancer surgery: results from a national population-based register for colorectal cancer. Int J Colorectal Dis 34(10):1757–1762

    PubMed  Article  Google Scholar 

  16. 16.

    Sood RF et al (2019) Respiratory failure following abdominal wall reconstruction: an analysis of the nationwide inpatient sample. Plast Reconstr Surg 143(1):165e–171e

    CAS  PubMed  Article  Google Scholar 

  17. 17.

    Meijs AP et al (2019) The effect of body mass index on the risk of surgical site infection. Infect Control Hosp Epidemiol 40(9):991–996

    PubMed  Article  Google Scholar 

  18. 18.

    Pedersen AB et al (2017) Impact of body mass index on risk of acute kidney injury and mortality in elderly patients undergoing hip fracture surgery. Osteoporos Int 28(3):1087–1097

    CAS  PubMed  Article  Google Scholar 

  19. 19.

    Smith RK et al (2014) Impact of BMI on postoperative outcomes in patients undergoing proctectomy for rectal cancer: a national surgical quality improvement program analysis. Dis Colon Rectum 57(6):687–693

    PubMed  Article  Google Scholar 

  20. 20.

    Thornqvist C et al (2014) Body mass index and risk of perioperative cardiovascular adverse events and mortality in 34,744 Danish patients undergoing hip or knee replacement. Acta Orthop 85(5):456–462

    PubMed  PubMed Central  Article  Google Scholar 

  21. 21.

    Nasraway SA Jr et al (2006) Morbid obesity is an independent determinant of death among surgical critically ill patients. Crit Care Med 34(4):964–970

    PubMed  Article  Google Scholar 

  22. 22.

    Visscher TL et al (2000) Underweight and overweight in relation to mortality among men aged 40–59 and 50–69 years: the Seven Countries Study. Am J Epidemiol 151(7):660–666

    CAS  PubMed  Article  Google Scholar 

  23. 23.

    Flegal KM et al (2005) Excess deaths associated with underweight, overweight and obesity. JAMA 293(15):1861–1867

    CAS  PubMed  Article  Google Scholar 

  24. 24.

    Mathis MR et al (2013) Patient selection for day case-eligible surgery: identifying those at high risk for major complications. Anesthesiology 119(6):1310–1321

    PubMed  Article  PubMed Central  Google Scholar 

  25. 25.

    Mariscalco G et al (2017) Body mass index and mortality among adults undergoing cardiac surgery: a nationwide study with a systematic review and meta-analysis. Circulation 135(9):850–863

    PubMed  Article  PubMed Central  Google Scholar 

  26. 26.

    Lee Y et al (2018) Relationship of body mass index and waist circumference with clinical outcomes following percutaneous coronary intervention. PLoS ONE 13(12):e0208817

    PubMed  PubMed Central  Article  Google Scholar 

  27. 27.

    Dowsey MM et al (2018) Body mass index is associated with all-cause mortality after THA and TKA. Clin Orthop Relat Res 476(6):1139–1148

    PubMed  PubMed Central  Article  Google Scholar 

  28. 28.

    Wang C et al (2018) Association of body mass index and outcomes following lobectomy for non-small-cell lung cancer. World J Surg Oncol 16(1):90

    PubMed  PubMed Central  Article  Google Scholar 

  29. 29.

    Pedersen AB et al (2016) Body mass index, risk of allogeneic red blood cell transfusion and mortality in elderly patients undergoing hip fracture surgery. Osteoporos Int 27(9):2765–2775

    CAS  PubMed  Article  Google Scholar 

  30. 30.

    Mullen JT et al (2008) Impact of body mass index on perioperative outcomes in patients undergoing major intra-abdominal cancer surgery. Ann Surg Oncol 15(8):2164–2172

    PubMed  Article  Google Scholar 

  31. 31.

    Ishizuka M et al (2011) Underweight patients show an increased rate of postoperative death after surgery for hepatocellular carcinoma. J Surg Oncol 104(7):809–813

    PubMed  Article  Google Scholar 

  32. 32.

    Zizza C et al (2004) Length of hospital stays among obese individuals. Am J Public Health 94(9):1587–1591

    PubMed  PubMed Central  Article  Google Scholar 

  33. 33.

    Carson JL et al (2002) Diabetes mellitus increases short-term mortality and morbidity in patients undergoing coronary artery bypass graft surgery. J Am Coll Cardiol 40(3):418–423

    PubMed  Article  Google Scholar 

  34. 34.

    Yong PH et al (2018) The presence of diabetes and higher HbA1c are independently associated with adverse outcomes after surgery. Diabetes Care 41(6):1172–1179

    PubMed  Article  Google Scholar 

  35. 35.

    Hutagalung R et al (2011) The obesity paradox in surgical intensive care unit patients. Intensive Care Med 37(11):1793–1799

    PubMed  Article  Google Scholar 

  36. 36.

    Nafiu OO et al (2011) The association of body mass index to postoperative outcomes in elderly vascular surgery patients: a reverse J-curve phenomenon. Anesth Analg 112(1):23–29

    PubMed  Article  Google Scholar 

  37. 37.

    Mullen JT, Moorman DW, Davenport DL (2009) The obesity paradox: body mass index and outcomes in patients undergoing nonbariatric general surgery. Ann Surg 250(1):166–172

    PubMed  Article  Google Scholar 

  38. 38.

    Buck DL, Moller MH, Danish S (2014) Clinical Register of Emergency, Influence of body mass index on mortality after surgery for perforated peptic ulcer. Br J Surg. 101(8):993–999

    CAS  PubMed  Article  Google Scholar 

  39. 39.

    Utzolino S et al (2014) The obesity paradox in surgical intensive care patients with peritonitis. J Crit Care 29(5):887

    PubMed  Article  Google Scholar 

  40. 40.

    Tsujinaka T et al (2007) Influence of overweight on surgical complications for gastric cancer: results from a randomized control trial comparing D2 and extended para-aortic D3 lymphadenectomy (JCOG9501). Ann Surg Oncol 14(2):355–361

    PubMed  Article  Google Scholar 

  41. 41.

    Fleming JB et al (2009) Influence of obesity on cancer-related outcomes after pancreatectomy to treat pancreatic adenocarcinoma. Arch Surg 144(3):216–221

    PubMed  Article  Google Scholar 

  42. 42.

    Hussan H et al (2016) Morbid obesity is associated with increased mortality, surgical complications and incremental health care utilization in the peri-operative period of colorectal cancer surgery. World J Surg 40(4):987–994

    PubMed  Article  Google Scholar 

  43. 43.

    Jackson RS et al (2012) Obesity is an independent risk factor for death and cardiac complications after carotid endarterectomy. J Am Coll Surg 214(2):148–155

    PubMed  Article  Google Scholar 

  44. 44.

    Alizadeh RF et al (2016) Body mass index significantly impacts outcomes of colorectal surgery. Am Surg 82(10):930–935

    PubMed  Article  Google Scholar 

  45. 45.

    Hakeem AR et al (2013) Increased morbidity in overweight and obese liver transplant recipients: a single-center experience of 1325 patients from the United Kingdom. Liver Transpl 19(5):551–562

    PubMed  Article  PubMed Central  Google Scholar 

  46. 46.

    Valentijn TM et al (2013) Impact of obesity on postoperative and long-term outcomes in a general surgery population: a retrospective cohort study. World J Surg 37(11):2561–2568

    PubMed  Article  PubMed Central  Google Scholar 

  47. 47.

    Okura T et al (2018) Impact of body mass index on survival of pancreatic cancer patients in Japan. Acta Med Okayama 72(2):129–135

    CAS  PubMed  PubMed Central  Google Scholar 

  48. 48.

    Upala S et al (2016) Underweight and obesity increase the risk of mortality after lung transplantation: a systematic review and meta-analysis. Transpl Int 29(3):285–296

    PubMed  Article  PubMed Central  Google Scholar 

  49. 49.

    Malik AT et al (2019) The impact of metabolic syndrome on 30-day outcomes following elective anterior cervical discectomy and fusions. Spine Phila Pa 2019 44(5):E282–E287

    Google Scholar 

Download references

Funding

No funding was received for this study.

Author information

Affiliations

Authors

Corresponding author

Correspondence to Amit Akirov.

Ethics declarations

Conflict of interest

The authors have no conflicts of interest to disclose.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This research did not receive any specific grant.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Dotan, I., Shochat, T., Shimon, I. et al. The Association Between BMI and Mortality in Surgical Patients. World J Surg (2021). https://doi.org/10.1007/s00268-021-05961-4

Download citation