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Obal, D., Wadhwa, A. the Obesity Paradox

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Obal, D., Wadhwa, A. the Obesity Paradox The obesity paradox: does it exist in the perioperative period? Detlef Obal, MD, PhD, DESAa,b,c, Anupama Wadhwa, MBBS, MSc, FASAc,d At least 30% of the surgical population consists of patients who hypertension, and hyperlipidemia, and an increased risk of fulfill the definition of obesity, mirroring the obesity epidemic in thrombosis and inflammation, leading to higher mortality rates.7 – the general population in the United States.1 3 Nearly 74% of the However, neither BMI nor waist circumference reflects the participants in the American College of Surgeons National metabolic and inflammatory profiles of the patient. Therefore, a Surgical Quality Improvement Program (NSQIP) had an abnor- new definition of obesity was introduced emphasizing the term mally high body mass index (BMI), including 17% of patients adiposopathy and acknowledging individual body fat composi- younger than 18 years of age.4,5 This development is of particular tion and functionality.8 According to the definition of adiposo- concern as obesity is associated with an increased risk of meta- pathy, 4 different types of phenotypes are distinguished as bolic syndrome, hypertension, coronary artery disease (CAD), follows: and diabetes mellitus. However, physicians, nutritionists, and the (1) Normal weight obese (NWO). general public struggle with definitions of obesity based only on (2) Metabolically obese with normal weight (MONW). total body weight proportionate to height and, therefore, BMI. (3) Metabolically healthy obese (MHO). This leads to the question of whether BMI can adequately (4) Metabolically unhealthy obese (MUO) or “at risk” obese describe the physical condition of and potential risks in our patients suffering from complications directly related to patients. obesity. BMI: an outdated measurement? MHO patientCopy According to the World Health Organization (WHO), obesity is a MHO patients were first described in the 1980s as a subgroup of “ condition in which percentage body fat is increased to an extent obese patients without the presence of hypertension, hyperlipi- ” in which health and well-being are impaired. On the basis of demia, or T2DM characterized by insulin resistance.9,10 The BMI [ie, body weight in kilograms divided by the square of the incidence of MHO is estimated to be between 6% and 40%.11,12 2 height in meters (kg/m )], patients are considered to be obese if A preserved insulin sensitivity is the hallmark of these patients.12 the total body weight reaches 20% above the ideal body weight. Insulin resistance can be calculated by a homeostatic model fi However, the usefulness of BMI, or the Quetelet index, rst assessment of insulin resistance (HOMA-IR), the product of described by Belgian statistician Adolphe Quetelet, has been fasting glucose (mg/dL) and fasting insulin levels (uIU/mL). fi questioned in recent years as this almost 200-year-old classi ca- HOMA-IR <3.16 is categorized as MHO and ≥ 3.16 as MUO.13 tion is based solely on an arithmetic approximation. BMI ignores On the basis of healthy white adipose tissue expansion, MHO the complex interaction of genetic lifestyle, dietary habits, energy individuals are relatively immune to the pathologic consequences exposure nutritional and metabolic factors, and adipocyte associated with obesity and associated lipotoxic side effects.14,15 metabolism resulting in different body compositions (eg, body They have lower C-reactive protein and high adiponectin fl – frame and muscularity, uid retention, sarcopenia in aging or levels.16 18 Ortega et al19 extracted data from the Aerobics disease, spinal deformities) and relativeAuthor's quantities of body fat and Center Longitudinal Study including 43,265, mainly male, muscle. Percentage and type of distribution of adipose tissue and Caucasian adults with a BMI ≥ 18.5 kg/m2. MHO individuals the duration of obesity may play a major role in determining demonstrated a higher level of fitness as indicated by their max- metabolic abnormalities, leading to a higher cardiovascular risk imal exercise capacity on a treadmill. After adjustment for BMI, and higher mortality in some subsets of patients.6,7 Waist cir- body fat percentage, and fitness level, MHO individuals had a cumference has been used to predict the extent of visceral fat, 38% lower risk of all-cause mortality than their MUO counter- which is associated with increased insulin resistance [conse- parts. Interestingly, there was no difference between MHO and quently, type 2 diabetes mellitus (T2DM)], hepatic steatosis, metabolically healthy normal-weight participants in terms of the all-cause mortality. Furthermore, fat distribution in the trunk, a Department of Anesthesiology, Pain, and Perioperative Medicine, Stanford chest, abdomen, and subcutaneous regions in the upper body University, Stanford, California, bStanford Cardiovascular Institute, Stanford, California, cOutcomes Research Consortium, Cleveland, Ohio and dDepartment of (android phenotype) had stronger associations with diabetes, Anesthesiology, University of California San Diego, San Diego, California CAD, gout, and uric acid renal stones, whereas reduced peri- ADDRESS CORRESPONDENCE TO: Anupama Wadhwa, MBBS, MSc, FASA, Department of hepatic and visceral fat accumulation occurred more frequently in 20 Anesthesiology, University of California, San Diego, 200 West Arbor Drive, 430 MPF MHO patients. Other characteristics of MHO patients are the bldg., San Diego, CA 92122. E-mail: [email protected] absence of hypertension, a reduced intima to media thickness Volume 58, Number 3, 14-20, DOI: 10.1097/AIA.0000000000000278 ratio of the carotid artery, and a favorable lipid, inflammation, 19,21 Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. hormonal, and liver enzyme profile. After adjusting for 14 Copyright r 2020 Wolters Kluwer Health, Inc. All rights reserved. This paper can be cited using the date of access and the unique DOI number which can be found in the footnotes. Obal and Wadhwa. International Anesthesiology Clinics (2020) 58:3 www.anesthesiaclinics.com fitness and several confounding variables, Guo and Garvey22 seem to have a survival advantage if they belong to the “slightly” found that MHO participants had a lower risk (30% to 50%, obese cohort. For example, Lee and colleagues found that com- estimated by hazard ratios) of all-cause mortality, nonfatal and pared with normal-weight nursing home residents, overweight fatal cardiovascular disease, and cancer mortality than their Chinese nursing home residents (BMI > 25 kg/m2, using the Asia MUO peers. However, this finding has been challenged by the Pacific cut-off) had the lowest mortality, whereas underweight European Prospective Investigation into Cancer and Nutrition residents had a significantly higher mortality (hazard ratio = study (EPIC-CVD), which revealed that overweight and obese 1.53, 95% confidence interval = 1.33-1.76).36,37 Similar findings individuals had higher CAD risk than lean people irrespective of are observed in elderly patients, either admitted for exacerbation metabolic health.23 Ten percent of the adult US population has a of COPD or suffering from dementia, patients with pulmonary normal BMI, but increased body fat content, and the incidence of artery hypertension, patients with exacerbation of CAD or MHO is estimated to be between 6% and 19% in children and CHF, or patients requiring intensive care in the perioperative adolescents.13,24,25 setting.36,38,39 In contrast, patients with noncatabolic medical conditions do not benefit from obesity or an additional energy support. For Obesity paradox example, Galesanu et al40 studied the impact of obesity on sur- Nonbariatric surgery presents with specific challenges in the vival in patients attending a rehabilitation program for COPD. patient with morbid obesity, both technically and in terms of After controlling for their lung function, a previously observed fi short-term and long-term outcomes. There is an increase in bene t from obesity disappeared. Similar results were found by fi obesity-related disorders that require non-bariatric surgery.26,27 Zafrir and colleagues when investigating the signi cance of BMI fi If an increased BMI is associated with an increased cardiac risk, in patients with CHF on their rst visit to the heart failure clinic, fi then it would be expected to carry a higher rate of perioperative that is, at an early stage of the disease. The authors did not nd an advantage in survival in obese patients after they adjusted for complications. Data from NSQIP suggest that patients with 41 higher BMI stay longer in the hospital, suffer more frequently age. Even in patients suffering from myocardial infarction or stroke, obesity did not improve patients’ outcomes or from postoperative surgical site infections, and undergo more 42–46 frequent reoperations.4 Despite this, a “paradoxical” survival prognosis. Thus, the obesity paradox remains a con- benefit has been observed in the surgical obese population, both troversial concept in different types of medical specialties and – for cardiac and noncardiac surgery.28 31 Decreased 30-day medical conditions. fi mortality has been observed in obese compared with underweight Nevertheless, surgical procedures pose a signi cant stress to fi patients, mostly due to a decrease in noncardiac causes, whereas patients and their metabolic pro les during elective and urgent/ emergentCopy surgical procedures. Therefore, it remains attractive to the mortality in severely obese patients is mostly from cardiac causes.4,32 The increased morbidity and mortality in
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