Body mass index and death by stroke: no obesity paradox.

IMPORTANCE: Reports of an obesity paradox have led to uncertainty about secondary prevention in obese patients with stroke. The paradox is disputed and has been claimed to be an artifact due to selection bias. OBJECTIVE: To determine whether the obesity paradox in stroke is real or an artificial finding due to selection bias. DESIGN, SETTING, AND PARTICIPANTS: We studied survival after stroke in relation to body mass index (BMI, calculated as weight in kilograms divided by height in meters squared). To overcome selection bias, we studied only deaths caused by the index stroke on the assumption that death by stroke reported on a death certificate was due to the index stroke if death occurred within the first month poststroke. We used the Danish Stroke Register, containing information on all hospital admissions for stroke in Denmark from 2003 to 2012, and the Danish Registry of Causes of Death. The study included all registered Danes (n = 71 617) for whom information was available on BMI (n = 53 812), age, sex, civil status, stroke severity, stroke subtype, a predefined cardiovascular profile, and socioeconomic status. MAIN OUTCOMES AND MEASURES: The independent relation between BMI and death by the index stroke within the first week or month by calculating hazard ratios in multivariate Cox regression analysis and multiple imputation for cases for whom information on BMI was missing. RESULTS: Of the 71 617 patients, 7878 (11%) had died within the first month; of these, stroke was the cause of death of 5512 (70%). Of the patients for whom information on BMI was available, 9.7% were underweight, 39.0% were of normal weight, 34.5% were overweight, and 16.8% were obese. Body mass index was inversely related to mean age at stroke onset (P < .001). There was no difference in the risk for death by stroke in the first month among patients who were normal weight (reference), overweight (hazard ratio, 0.96; 95% CI, 0.88-1.04), and obese (hazard ratio, 1.0; 95% CI, 0.88-1.13). Analysis of deaths within 1 week gave similar results. CONCLUSIONS AND RELEVANCE: We found no evidence of an obesity paradox in patients with stroke. Stroke occurred at a significantly younger age in patients with higher BMI. Hence, obese patients with stroke should continue to aim for normal weight.

Higher Blood Glucose within the Normal Range Is Associated with More Severe Strokes.

Background. Higher fasting blood glucose (FBG) concentrations in the hyperglycemic range are associated with more severe strokes. Whether this association also extends into patients with FBG in the normoglycemic range is unclear. We studied the association of stroke severity and FBG in normoglycemic patients with ischemic stroke in a median of 7 days after stroke when the initial glycemic stress response has resolved. Method and Material. Included were 361 nondiabetic ischemic stroke patients with admission fasting blood glucose within 70-130 mg/dL admitted into an acute stroke rehabilitation unit in a median of 7 days after stroke. Data including neuroimaging, vital signs, cardiovascular risk factors, and admission functional independence measure (AFIM) were recorded prospectively. Results. FBG correlated with stroke severity in the normoglycemic 70-130 mg/dL range (FBG-AFIM correlation coefficient -0.17; P = 0.003). Odds ratio for more severe injury (below average AFIM score) was 2.02 for patients with FBG 110-130 mg/dL compared to FBG 70-90 mg/dL (95% confidence interval 1.10-3.73, P = 0.022). Each mg/dL increase in FBG was associated with an average decrease of 0.25 FIM points. In a multiple linear regression model, FBG was associated with more severe stroke (P = 0.002). Conclusion. One week after ischemic stroke, FBG within the normoglycemic range was associated with stroke severity.

Stroke and long-term exposure to outdoor air pollution from nitrogen dioxide: a cohort study.

BACKGROUND AND PURPOSE: Years of exposure to tobacco smoke substantially increase the risk for stroke. Whether long-term exposure to outdoor air pollution can lead to stroke is not yet established. We examined the association between long-term exposure to traffic-related air pollution and incident and fatal stroke in a prospective cohort study. METHODS: We followed 57,053 participants of the Danish Diet, Cancer and Health cohort in the Hospital Discharge Register for the first-ever hospital admission for stroke (incident stroke) between baseline (1993-1997) and 2006 and defined fatal strokes as death within 30 days of admission. We associated the estimated mean levels of nitrogen dioxide at residential addresses since 1971 to incident and fatal stroke by Cox regression analyses and examined the effects by stroke subtypes: ischemic, hemorrhagic, and nonspecified stroke. RESULTS: Over a mean follow-up of 9.8 years of 52,215 eligible subjects, there were 1984 (3.8%) first-ever (incident) hospital admissions for stroke of whom 142 (7.2%) died within 30 days. We detected borderline significant associations between mean nitrogen dioxide levels at residence since 1971 and incident stroke (hazard ratio, 1.05; 95% CI, 0.99-1.11, per interquartile range increase) and stroke hospitalization followed by death within 30 days (1.22; 1.00-1.50). The associations were strongest for nonspecified and ischemic strokes, whereas no association was detected with hemorrhagic stroke. CONCLUSIONS: Long-term exposure to traffic-related air pollution may contribute to the development of ischemic but not hemorrhagic stroke, especially severe ischemic strokes leading to death within 30 days.

Early home-supported discharge of stroke patients: a health technology assessment.

OBJECTIVES: A comprehensive and systematic assessment (HTA) of early home-supported discharge by a multidisciplinary team that plans, coordinates, and delivers care at home (EHSD) was undertaken and the results were compared with that of conventional rehabilitation at stroke units. METHODS: A systematic literature search for randomized trials (RCTs) on "early supported discharge" was closed in April 2005. RCTs on EHSD without information on (i) death or institution at follow-up, (ii) change in Barthél Index, (iii) length of hospital stay, (iv) intensity of home rehabilitation, or (v) baseline data are excluded. Seven RCTs on EHSD with 1,108 patients followed 3-12 months after discharge are selected for statistical meta-analysis of outcomes. The costs are calculated as a function of the average number of home training sessions. Economic evaluation is organized as a test of dominance (both better outcomes and lower costs). RESULTS: The odds ratio (OR) for "Death or institution" is reduced significantly by EHSD: OR = .75 (confidence interval [CI], .46-.95), and number needed to treat (NNT) = 14. Referrals to institution have OR = .45 (CI, .31-.96) and NNT = 20. The reduction of the rate of death is not significant. Length of stay is significantly reduced by 10 days (CI, 2.6-18 days). All outcomes have a nonsignificant positive covariance. The median number of home sessions is eleven, and the average cost per EHSD is 1,340 USD. The "action mechanism" and financial barriers to EHSD are discussed. CONCLUSIONS: EHSD is evidenced as a dominant health intervention. However, financial barriers between municipalities and health authorities have to be overcome. For qualitative reasons, a learning path of implementation is recommended where one stroke unit in a region initiates EHSD for dissemination of new experience to the other stroke units.