Body mass index predicts insulin sensitivity during cardiac surgery: a prospective observational study

  • Yosuke Nakadate
  • Hiroaki Sato
  • Tamaki Sato
  • Takumi Codere-Maruyama
  • Takashi Matsukawa
  • Thomas Schricker
Reports of Original Investigations



Taking into account the previously described link between body weight and diabetes mellitus (DM) in non-surgical patients, and the understanding that the degree of intraoperative insulin resistance is a predictor of adverse clinical outcomes, we investigated the relationship between body mass index (BMI) and insulin sensitivity during cardiac surgery.


We prospectively enrolled 400 patients scheduled for elective cardiac surgery and divided them into groups based on the presence or absence of type-2 DM. They were further categorized into four subgroups based on their BMI: group 1- normal weight, BMI 18.5-24.9 kg·m−2; group 2 - overweight, BMI 25-29.9 kg·m−2; group 3 - obese, BMI 30-34.9 kg·m−2; group 4 - morbidly obese, BMI ≥ 35 kg·m−2. Insulin sensitivity was assessed using the hyperinsulinemic-normoglycemic clamp technique during surgery. We also analyzed the association of BMI, quality of postoperative glycemic control, and postoperative outcomes.


A linear negative relationship between BMI and insulin sensitivity (r = 0.42, P < 0.001) was observed, independent of the patients’ diabetic state. There was also a positive correlation between BMI and postoperative glycemia (r = 0.30, P < 0.001) though the relationship between BMI and major and infectious complication was not significant (P = 0.56, P = 0.10, respectively).


Patient BMI may be used as a simple predictor of insulin sensitivity during cardiac surgery and as a predictor of the quality of postoperative glycemic control. A larger cohort will be necessary to evaluate the association of BMI, perioperative insulin resistance, and clinical outcomes.

L’indice de masse corporelle prédit la sensibilité à l’insuline au cours de la chirurgie cardiaque : étude observationnelle prospective



En tenant compte du lien déjà décrit entre poids corporel et diabète chez des patients non chirurgicaux et la notion que le niveau de résistance peropératoire à l’insuline est un élément prédictif de résultats cliniques défavorables, nous avons étudié le lien entre l’indice de masse corporelle (IMC) et la sensibilité à l’insuline au cours de la chirurgie cardiaque.


Nous avons recruté de façon prospective 400 patients devant subir une chirurgie cardiaque élective et les avons séparés en groupes en fonction de l’existence ou de l’absence d’un diabète de type 2 (DT2). En outre, ils ont été également classés en quatre sous-groupes en fonction de leur IMC : groupe 1 — poids normal, IMC : 18,5 à 24,9 kg m−2; groupe 2 — surcharge pondérale, IMC : 25 à 29,9 kg m−2; groupe 3 — obésité, IMC : 30 à 34,9 kg m−2; groupe 4 — obésité morbide, IMC > 35 kg m−2. La sensibilité à l’insuline a été évaluée au moyen de la technique du clamp hyperinsulinémique-normoglycémique au cours de l’intervention. Nous avons également analysé l’association de l’IMC, de la qualité du contrôle glycémique postopératoire et de l’évolution postopératoire.


Une relation linéaire négative entre l’IMC et la sensibilité à l’insuline (r = 0,42, P < 0,001) a été observée, indépendamment du statut de diabète du patient. Il y a eu aussi une corrélation positive entre l’IMC et la glycémie postopératoire (r = 0,30, P < 0,001) bien que les relations entre l’IMC et les complications majeures ou infectieuses n’aient pas été significatives (respectivement, P = 0,56, P = 0,10).


L’IMC des patients peut être utilisé comme simple facteur prédictif de la sensibilité à l’insuline au cours de la chirurgie cardiaque et comme élément prédictif de la qualité du contrôle glycémique postopératoire. Une plus grande cohorte sera nécessaire pour évaluer l’association entre IMC, résistance à l’insuline périopératoire et l’évolution clinique.


Conflicts of interest

All authors declare that they have no financial or non-financial interests that may be relevant to the submitted work.

Editorial responsibility

This submission was handled by Dr. Hilary P. Grocott, Editor-in-Chief, Canadian Journal of Anesthesia.

Author contributions

Hiroaki Sato and Thomas Schricker designed the study. Hiroaki Sato, Tamaki Sato, Takumi Codere-Maruyama, and Thomas Schricker acquired data. Yosuke Nakadate, Hiroaki Sato, Tamaki Sato, and Thomas Schricker analyzed and interpreted the data. Yosuke Nakadate, Hiroaki Sato, and Thomas Schricker did statistical analysis. Yosuke Nakadate and Hiroaki Sato drafted the manuscript. All authors critically revised the manuscript and approved the final version.


This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.


  1. 1.
    Mukherjee B, Hossain CM, Mondal L, Paul P, Ghosh MK. Obesity and insulin resistance: an abridged molecular correlation. Lipid Insights 2013; 6: 1-11.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Ortiz VE, Kwo J. Obesity: physiologic changes and implications for preoperative management. BMC Anesthesiol 2015; 15: 97.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Huschak G, Busch T, Kaisers UX. Obesity in anesthesia and intensive care. Best Pract Res Clin Endocrinol Metab 2013; 27: 247-60.CrossRefPubMedGoogle Scholar
  4. 4.
    Kuan P, Bernstein SB, Ellestad MH. Coronary artery bypass surgery morbidity. J Am Coll Cardiol 1984; 3: 1391-7.CrossRefPubMedGoogle Scholar
  5. 5.
    Prasad US, Walker WS, Sang CT, Campanella C, Cameron EW. Influence of obesity on the early and long term results of surgery for coronary artery disease. Eur J Cardiothorac Surg 1991; 5: 67-72 discussion 72-3.CrossRefPubMedGoogle Scholar
  6. 6.
    Brandt M, Harder K, Walluscheck KP, et al. Severe obesity does not adversely affect perioperative mortality and morbidity in coronary artery bypass surgery. Eur J Cardiothorac Surg 2001; 19: 662-6.CrossRefPubMedGoogle Scholar
  7. 7.
    Clough RA, Leavitt BJ, Morton JR, et al. The effect of comorbid illness on mortality outcomes in cardiac surgery. Arch Surg 2002; 137: 428-32 discussion 432-3.CrossRefPubMedGoogle Scholar
  8. 8.
    Ludvik B, Nolan JJ, Baloga J, Sacks D, Olefsky J. Effect of obesity on insulin resistance in normal subjects and patients with NIDDM. Diabetes 1995; 44: 1121-5.CrossRefPubMedGoogle Scholar
  9. 9.
    Unni US, Ramakrishnan G, Raj T, et al. Muscle mass and functional correlates of insulin sensitivity in lean young Indian men. Eur J Clin Nutr 2009; 63: 1206-12.CrossRefPubMedGoogle Scholar
  10. 10.
    Hsu WC, Okeke E, Cheung S, et al. A cross-sectional characterization of insulin resistance by phenotype and insulin clamp in East Asian Americans with type 1 and type 2 diabetes. PLoS ONE 2011; 6: e28311.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Tewari N, Awad S, Macdonald IA, Lobo DN. Obesity-related insulin resistance: implications for the surgical patient. Int J Obes (Lond) 2015; 39: 1575-88.CrossRefGoogle Scholar
  12. 12.
    Sato H, Carvalho G, Sato T, Lattermann R, Matsukawa T, Schricker T. The association of preoperative glycemic control, intraoperative insulin sensitivity, and outcomes after cardiac surgery. J Clin Endocrinol Metab 2010; 95: 4338-44.CrossRefPubMedGoogle Scholar
  13. 13.
    Thiessen S, Vanhorebeek I, Van den Berghe G. Glycemic control and outcome related to cardiopulmonary bypass. Best Pract Res Clin Anaesthesiol 2015; 29: 177-87.CrossRefPubMedGoogle Scholar
  14. 14.
    Leary AC, Stote RM, Breedt HJ, O’Brien J, Buckley B. Pharmacokinetics and pharmacodynamics of intranasal insulin administered to healthy subjects in escalating doses. Diabetes Technol Ther 2005; 7: 124-30.CrossRefPubMedGoogle Scholar
  15. 15.
    Parsonnet V, Dean D, Bernstein AD. A method of uniform stratification of risk for evaluating the results of surgery in acquired adult heart disease. Circulation 1989; 79: I3-12.PubMedGoogle Scholar
  16. 16.
    Roques F, Nashef SA, Michel P, et al. Risk factors and outcome in European cardiac surgery: analysis of the EuroSCORE multinational database of 19030 patients. Eur J Cardiothorac Surg 1999; 15: 816-22 discussion 822-3.CrossRefPubMedGoogle Scholar
  17. 17.
    Dobson G, Chong M, Chow L, et al. Guidelines to the practice of anesthesia – revised edition 2017. Can J Anesth 2017; 64: 65-91.Google Scholar
  18. 18.
    Monzillo LU, Hamdy O. Evaluation of insulin sensitivity in clinical practice and in research settings. Nutr Rev 2003; 61: 397-412.CrossRefPubMedGoogle Scholar
  19. 19.
    Holzinger U, Kitzberger R, Fuhrmann V, Funk GC, Madl C, Ratheiser K. Correlation of calculated indices of insulin resistance (QUICKI and HOMA) with the euglycaemic hyperinsulinaemic clamp technique for evaluating insulin resistance in critically ill patients. Eur J Anaesthesiol 2007; 24: 966-70.CrossRefPubMedGoogle Scholar
  20. 20.
    Caro JF. Clinical review 26: Insulin resistance in obese and nonobese man. J Clin Endocrinol Metab 1991; 73: 691-5.CrossRefPubMedGoogle Scholar
  21. 21.
    Singer M, Deutschman CS, Seymour CW, et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA 2016; 315: 801-10.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Sjogren J, Malmsjo M, Gustafsson R, Ingemansson R. Poststernotomy mediastinitis: a review of conventional surgical treatments, vacuum-assisted closure therapy and presentation of the Lund University Hospital mediastinitis algorithm. Eur J Cardiothorac Surg 2006; 30: 898-905.CrossRefPubMedGoogle Scholar
  23. 23.
    Rockx MA, Fox SA, Stitt LW, et al. Is obesity a predictor of mortality, morbidity and readmission after cardiac surgery? Can J Surg 2004; 47: 34-8.PubMedPubMedCentralGoogle Scholar
  24. 24.
    Pan W, Hindler K, Lee VV, Vaughn WK, Collard CD. Obesity in diabetic patients undergoing coronary artery bypass graft surgery is associated with increased postoperative morbidity. Anesthesiology 2006; 104: 441-7.CrossRefPubMedGoogle Scholar
  25. 25.
    Stamou SC, Nussbaum M, Stiegel RM, et al. Effect of body mass index on outcomes after cardiac surgery: is there an obesity paradox? Ann Thorac Surg 2011; 91: 42-7.CrossRefPubMedGoogle Scholar
  26. 26.
    Phan K, Khuong JN, Xu J, Kanagaratnam A, Yan TD. Obesity and postoperative atrial fibrillation in patients undergoing cardiac surgery: systematic review and meta-analysis. Int J Cardiol 2016; 217: 49-57.CrossRefPubMedGoogle Scholar
  27. 27.
    Najjar M, Yerebakan H, Sorabella RA, et al. Acute kidney injury following surgical aortic valve replacement. J Cardiac Surg 2015; 30: 631-9.CrossRefGoogle Scholar
  28. 28.
    Schimmer C, Gross J, Ramm E, et al. Prevention of surgical site sternal infections in cardiac surgery: a two-centre prospective randomized controlled study. Eur J Cardiothorac Surg 2017; 51: 67-72.CrossRefPubMedGoogle Scholar
  29. 29.
    Hysi I, Pinçon C, Guesnier L, et al. Results of elective cardiac surgery in patients with severe obesity (body mass index ≥ 35 kg/m2). Arch Cardiovasc Dis 2014; 107: 540-5.CrossRefPubMedGoogle Scholar
  30. 30.
    Johnson AP, Parlow JL, Whitehead M, Xu J, Rohland S, Milne B. Body mass index, outcomes, and mortality following cardiac surgery in Ontario, Canada. J Am Heart Assoc 2015; 4: e002140.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Davenport DL, Xenos ES, Hosokawa P, Radford J, Henderson WG, Endean ED. The influence of body mass index obesity status on vascular surgery 30-day morbidity and mortality. J Vasc Surg 2009; 49(140–7): e1.Google Scholar
  32. 32.
    Mullen JT, Moorman DW, Davenport DL. The obesity paradox: body mass index and outcomes in patients undergoing nonbariatric general surgery. Ann Surg 2009; 250: 166-72.CrossRefPubMedGoogle Scholar
  33. 33.
    Hainer V, Aldhoon-Hainerova I. Obesity paradox does exist. Diabetes Care 2013; 36(Suppl 2): S276-81.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Lavie CJ, Sharma A, Alpert MA, et al. Update on obesity and obesity paradox in heart failure. Prog Cardiovasc Dis 2016; 58: 393-400.CrossRefPubMedGoogle Scholar
  35. 35.
    Thorell A, Nygren J, Ljungqvist O. Insulin resistance: a marker of surgical stress. Curr Opin Clin Nutr Metab Care 1999; 2: 69-78.CrossRefPubMedGoogle Scholar
  36. 36.
    Ljungqvist O, Nygren J, Thorell A. Insulin resistance and elective surgery. Surgery 2000; 128: 757-60.CrossRefPubMedGoogle Scholar
  37. 37.
    Gelijns AC, Moskowitz AJ, Acker MA, et al. Management practices and major infections after cardiac surgery. J Am Coll Cardiol 2014; 64: 372-81.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Canadian Anesthesiologists' Society 2018

Authors and Affiliations

  1. 1.Department of AnesthesiaMcGill University Health Centre Glen Site, Royal Victoria HospitalMontrealCanada
  2. 2.Department of AnesthesiologyUniversity of YamanashiYamanashiJapan

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