The Stroke–obesity Paradox Becomes Evident in yet Another Study

Pavankumar Kamat


October 07, 2021


  • Overweight or obesity may be linked to a more favourable prognosis for subsequent major adverse cardiovascular events (MACE), peripheral vascular disease (PVD) and mortality in stroke survivors, regardless of confounding variables at the time of stroke.

  • The authors warn that the stroke–obesity paradox is strictly an association and should not be considered causal.

Why this matters

  • There is contrasting evidence of the protective effects of higher body mass index (BMI) in stroke survivors.

Study design

  • The population-based cohort study included 30,702 patients with incident stroke (age, ≥18 years) with baseline BMI record and without prior history of MACE, identified from the UK Clinical Practice Research Datalink (CPRD GOLD) and Hospital Episode Statistics databases (1998-2017).

  • BMI was categorised as:

    • underweight (<18.5 kg/m2);

    • normal weight (18.5-24.9 kg/m2);

    • overweight (25.0-29.9 kg/m2);

    • obesity class I (30.0-34.9 kg/m2);

    • obesity class II (35.0-39.9 kg/m2); and

    • obesity class III (≥40 kg/m2).

  • The cohort was followed for a median of 12.9 years.

  • Primary outcome: first subsequent MACE after incident stroke.

  • Secondary outcome: all-cause mortality.

  • Funding: None.

Key results

  • Overall, 1217 (4.0%) were underweight, 10,783 (35.1%) had a normal BMI, 10,979 (35.8%) were overweight, 5206 (17.0%) had obesity class I, 1749 (5.7%) had obesity class II and 768 (2.5%) had obesity class III.

  • Patients with higher BMI vs those with normal BMI were at a lower risk of subsequent (adjusted HR [aHR]; 95% CI):

    • MACE (overweight: 0.96; 0.93-0.99);

    • PVD:

      • overweight (0.65; 0.49-0.85); and

      • obesity class III (0.19; 0.50-0.77).

    • cardiovascular-related death:

      • overweight (0.80; 0.74-0.86);

      • obesity class I (0.79; 0.71-0.88); and

      • obesity class II (0.80; 0.67-0.96).

    • all-cause mortality:

      • overweight (0.75; 0.71-0.79);

      • obesity class I (0.75; 0.70-0.81); and

      • obesity class II (0.77; 0.68-0.86).

  • Results were similar irrespective of sex, diabetes mellitus, smoking and cancer status at the time of incident stroke.


  • The study only used BMI as a marker of obesity.


Akyea RK, Doehner W, Iyen B, Weng SF, Qureshi N, Ntaios G. Obesity and long-term outcomes after incident stroke: a prospective population-based cohort study. J Cachexia Sarcopenia Muscle. 2021 Sep 27 [Epub ahead of print]. doi: 10.1002/jcsm.12818. PMID: 34581015  View abstract 

This clinical summary originally appeared on Univadis, part of the Medscape Professional Network.


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