Abstract P302: Lack of Obesity Paradox in 30 Day and Annual Cumulative Acute Decompensated Heart Failure Readmissions

<p dir="ltr">As global populations age and the prevalence of obesity and metabolic disorders rises, understanding the complex relationships between body mass index (BMI), metabolic health, and aging becomes increasingly critical. This thesis sought to unravel these connections, focusing on how BMI and metabolic health are associated with biological aging and all-cause mortality while considering the nonlinear effects of BMI and age differences. By employing measures of biological aging - encompassing functional (functional aging Index, FAI), physiological (frailty index - FI), and cellular (epigenetic age acceleration - EAA) levels - we aimed to provide a comprehensive examination of the BMI, metabolic health, and biological aging connections.</p><p dir="ltr"><b>Study I </b>examined the independent and joint associations of midlife and late-life BMI and metabolic health status (MHS) assessments with risk of all-cause mortality. Data from 6,252 Swedish twins in midlife (65 years and below) and 6,215 in late life (over 65 years) were analyzed using Cox proportional hazards models. In the joint models, being metabolically unhealthy (MU) was consistently associated with increased mortality risk robust to BMI adjustments, while the mortality risk associated with BMI categories attenuated. In the interaction models, MU with obesity in midlife and across all BMI categories in late life was associated with higher mortality risk than metabolically healthy normal weight (MHN). Conversely, metabolically healthy with overweight (MHOw) or obesity in midlife and late life was not associated with higher mortality risks. In fact, late-life MHOw was associated with a lower mortality risk compared to MHN. These findings suggest that MHS plays a more significant role than BMI in predicting mortality risk.</p><p dir="ltr"><b>Study II</b> investigated how BMI and MHS jointly associate with biological aging, measured by FAI and FI, and whether these associations varied by chronological age. A cross-sectional analysis of 1,825 Swedish twins using mixed-effects linear models revealed a U-shaped association between BMI and FAI, where low and high BMI were associated with higher biological aging. MU was also associated with higher FAI. Significant three-way interactions between BMI, MHS, and chronological age on FI prompted the stratification of the analysis by age: below 65, 65 to 85, and over 85 years. In these groups, low BMI, high BMI and MU were consistently associated with greater FI, with significant modifications by MU and chronological age in the 65 to 85 and over 85 groups, respectively. This study highlights a complex interplay between BMI, MHS, and chronological age. Low BMI, high BMI, and MU were associated with higher biological aging, indicating their potential contribution to age acceleration.</p><p dir="ltr"><b>Study III</b> explored if biological aging, measured by EAA, mediates the BMI- mortality relationship. Using data from 3,840 participants in the U.S. Health and Retirement Study, a nonlinear association was found: both low and high BMI were associated with increased EAA and shorter life expectancy. Mediation analysis showed that high BMI's association with shorter life expectancy was strongly mediated by EAA, supporting the hypothesis that obesity accelerates biological aging. In contrast, the association of low BMI with shorter life expectancy was mainly driven by direct effects rather than mediation through biological aging.</p><p dir="ltr"><b>Study IV </b>analyzed the bidirectional relationship between change in BMI and biological aging, measured by FAI and FI, in 1,902-1,976 Swedish twins aged 60 to 91.9, using dual change score models. The age trajectory of BMI followed an almost linear, declining pattern, whereas FAI and FI exhibited exponentially increasing trends. The study found a unidirectional relationship where higher FAI predicted a steeper BMI decline. In contrast, the BMI-FI relationship was bidirectional - higher BMI predicted increased FI and higher FI contributed to a steeper BMI decline.</p><p dir="ltr">These findings underscore the complex nature of the relationships between BMI, metabolic health, and aging, revealing the distinct influences of high BMI, low BMI, and metabolic health on biological aging and life expectancy. Together, these results emphasized the importance of integrating BMI, metabolic health, and biological aging into the assessment of late-life health, offering new insights into how these factors may converge to potentially shape the aging process and survival.</p><p dir="ltr"><b>Keywords</b>: aging, all-cause mortality, biological aging, body mass index, frailty, epigenetic age, metabolic health, obesity, mediation analysis, dual change score models</p><h3>List of scientific papers</h3><p dir="ltr">I. <b>Ler P,</b> Li X, Hassing LB, Reynolds CA, Finkel D, Karlsson IK, Dahl Aslan AK. Independent and joint effects of body mass index and metabolic health in mid- and late-life on all-cause mortality: a cohort study from the Swedish Twin Registry with a mean follow-up of 13 years. BMC Public Health. 2022;22(1):718. <a href="https://doi.org/10.1186/s12889-022-13082-3" rel="noreferrer" target="_blank">https://doi.org/10.1186/s12889-022-13082-3</a></p><p dir="ltr">II. <b>Ler P,</b> Ploner A, Finkel D, Reynolds CA, Zhan Y, Jylhävä J, Dahl Aslan AK, Karlsson IK. Interplay of body mass index and metabolic syndrome: association with physiological age from midlife to late- life. Geroscience. 2024;46(2):2605 - 2617. <a href="https://doi.org/10.1007/s11357-023-01032-9" rel="noreferrer" target="_blank">https://doi.org/10.1007/s11357-023-01032-9</a></p><p dir="ltr">III. <b>Ler P,</b> Jylhava J, Finkel D, Aslan Dahl AK, Ploner A, Karlsson IK. Does biological aging mediate the association between body mass index and survival among older adults? [Manuscript]</p><p dir="ltr">IV. <b>Ler P,</b> Mak JKL, Reynolds CA, Ploner A, Pedersen NL, Jylhävä J, Aslan Dahl AK, Finkel D, Karlsson IK. Longitudinal study of body mass index and biological aging: investigating the temporal dynamics. [Submitted]</p><p dir="ltr">Paper I @ Ler et al., 2022. Published by Springer Nature. This is an open-access article under the terms of CC BY-NC-CD or CC BY 4.0.</p><p dir="ltr">Paper II @ Ler et al., 2022. Published by Springer Nature. This is an open-access article under the terms of CC BY 4.0.</p>

BackgroundWeight gain among people living with HIV (PLWH) on antiretroviral therapy (ART) may lead to obesity. This study evaluated association between body mass index (BMI) and health-related quality of life (HRQoL) from the patient’s perspective. MethodsA cross-sectional study using self-reported data from the 2018 and 2019 US National Health and Wellness Survey (NHWS), a nationally representative online survey of ~75,000 adults was conducted. Respondents self-reporting a physician diagnosis of and prescription use for treatment of HIV were included. HRQoL was assessed using Short-Form 36-Item Health Survey Version 2 [Mental and Physical Component Summary scores (MCS and PCS)] and EQ-5D-5L [dimension responses: “no” vs “any problems”/“yes”); EQ-Visual Analogue Scale (VAS) score]. Bivariate analyses (chi-square tests for categorical and ANOVA for continuous variables) compared patient characteristics and HRQoL outcomes across BMI (kg/m2) categories: normal weight (NW; 18.5-< 25), overweight (OW; 25-< 30) and obese (OB; ≥30). Multivariable models analyzed each outcome as a function of BMI, controlling for age, sex, race, and Charlson Comorbidity Index (CCI; excluding HIV/AIDS). ResultsA total of 566 respondents were analyzed. Majority were aged ≥50 years (58%) and male (87%). The OB (vs NW) group had higher proportion of respondents who were female (22% vs 10%), Black (37% vs 24%), residing in the South (46% vs 33%), and higher mean CCI score (1.28 vs. 0.97) (Table 1). A higher proportion of OB (vs NW) respondents reported having pain/discomfort and problems with mobility and usual activities but not self-care. Anxiety/depression was reported less in OB vs NW groups (Table 1) However, self-reported use of prescription medications for anxiety (19% vs 20%) and depression (34% vs 25%) was similar in OB and NW groups. PCS and EQ-VAS scores were lower in OB vs OW and NW, but no difference in MCS score was observed (Table 1). Lower PCS and EQ-VAS scores were associated with higher BMI (both p=0.01) but not MCS (p=0.68) in multivariate models.ConclusionPLWH with higher BMI have poorer physical and general HRQoL. Impact of potential adverse weight gain and transition to higher BMI on humanistic and clinical outcomes should be considered when selecting ART regimens. Table 1. Comorbidity Burden and Quality of Life in People Living with HIV by BMI Categories.DisclosuresJennifer Ken-Opurum, PhD, Kantar Health (Employee) Girish Prajapati, M.B.B.S., MPH , Merck & Co., Inc. (Employee, Shareholder) Joana E. Matos, PhD, Kantar Health (Employee) Princy N. Kumar, MD, AMGEN (Other Financial or Material Support, Honoraria)Eli Lilly (Grant/Research Support)Gilead (Grant/Research Support, Shareholder, Other Financial or Material Support, Honoraria)GSK (Grant/Research Support, Shareholder, Other Financial or Material Support, Honoraria)Merck & Co., Inc. (Grant/Research Support, Shareholder, Other Financial or Material Support, Honoraria)

Retrospective cohort study. To determine if an association exists between body mass index (BMI) and the rate of revision surgery after single-level minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). MIS TLIF is an effective treatment for lumbar degenerative disease. Previous studies in the orthopedic literature have associated increased BMI with increased postoperative complications and need for revision. Few studies have evaluated the association between BMI and the risk for revision after minimally invasive spinal procedures. A surgical registry of patients who underwent a single-level MIS TLIF for degenerative pathology between 2005 and 2014 was reviewed. Patients were stratified based on BMI category: normal weight (BMI<25), overweight (BMI, 25-29.9), obese I (BMI, 30-34.9), and obese II-III (BMI≥35). BMI category was tested for association with demographic and procedural characteristics using 1-way analysis of variance (ANOVA) for continuous variables, and χ analysis or the Fisher exact test for categorical variables. BMI category was tested for association with undergoing a revision fusion procedure within 2 years after MIS TLIF using multivariate Cox proportional hazards survival analysis modeling. In total, 274 patients were analyzed; of these, 52 (18.98%) were normal weight, 101 (36.86%) were overweight, 62 (22.63%) were obese I, and 59 (21.53%) were obese II-III. On multivariate Cox proportional hazards survival analysis modeling, BMI category was not associated with undergoing a revision procedure within 2 years after MIS TLIF (P=0.599). On multivariate analysis, younger age (P=0.004) was associated with increased risk of undergoing a revision after MIS TLIF. The results of this study suggest that increasing BMI is not a risk factor for undergoing a revision procedure after MIS TLIF. As such, patients with high BMI should be counseled regarding having similar rates of needing a revision procedure after MIS TLIF as those with lower BMI. Level IV.

Background/Objectives: Obesity is a common comorbidity but there remains limited understanding on how higher obesity rates in rural areas may impact physical function decline and other health domains among cancer patients. This study addresses this gap by examining the association between body mass index (BMI) and physical function among a cohort of rural advanced cancer patients. Methods: This cross-sectional analysis uses baseline data from the Nurse AMIE trial (NCT04673019). Individuals were categorized as 'normal weight' (BMI ≤ 25 kg/m2), 'overweight' (BMI > 25 to 30 kg/m2), and 'obese' (BMI > 30 kg/m2). Objective physical function was measured by the Short Physical Performance Battery (SPPB) and subjective physical function and health domains were measured using surveys (PROMIS; SF-36). Results: Of 348 patients included, 88 (25.3%) were classified as 'normal weight', 107 (30.7%) as 'overweight', and 153 (44.0%) as 'obese'. Average age was 64.8 years (SD = 12.2), 46% (n = 160) were female, 95% were white (n = 331), and 52% (n = 182) were Stage 4. Total SPPB scores revealed poorer functioning with higher BMI (M ± SD: BMI ≤ 25 kg/m2: 9.1 ± 2.3; BMI > 25-30 kg/m2: 8.3 ± 3.1; BMI > 30 kg/m2: 8.1 ± 2.8; p = 0.04). Similarly, scores from the SF-36 revealed subjective physical function was lower with higher BMI (BMI ≤ 25 kg/m2: 57.9 ± 29.1; BMI > 25-30 kg/m2: 53.7 ± 28.0; BMI > 30 kg/m2: 47.6 ± 27.6; p = 0.004). Participants reported lower levels of energy and greater fatigue with higher BMI (BMI ≤ 25 kg/m2: 49.8 ± 26.1; BMI > 25-30 kg/m2: 45.1 ± 24.6; BMI > 30 kg/m2: 40.7 ± 22.6; p = 0.01). Conclusions: Higher BMI is associated with poorer physical function and increased fatigue among rural advanced cancer patients, highlighting the need for supportive care related to physical function in this at-risk group.

Background Cardiac amyloidosis (CA) is a severe condition characterized by infiltrative cardiomyopathy and heart failure, primarily with preserved ejection fraction (HFpEF), resulting from the deposition of amyloid fibrils in the myocardial extracellular space. While obesity generally linked with increased health risks, studies in chronic cardiac conditions have shown a relationship between body mass index (BMI) and patient’s outcomes. Aim We therefore sought to investigate the association of BMI and clinical outcomes in patients with diagnosed CA, focusing on whether lower BMI serves as a marker for increased risk in this patient population. Methods In this study, we conducted a retrospectively analysis of CA patients enrolled in a clinical registry. Patients were categorized by baseline BMI into underweight (BMI &amp;lt; 18.5), normal weight (BMI 18.5–24.9), overweight (BMI 25.0–29.9), and obese (BMI ≥ 30.0) groups. We used Kaplan-Meier survival analysis to examine the relationship between BMI categories and patient outcomes over a 10 year follow-up period. Results A total of 418 patients were included, with a median age of 75.5 years, interquartile range (IQR): 33.6 – 94.0. Of these, 77.5 % were male, and 39.7% were classified as NYHA functional class. Kaplan-Meier curves demonstrated that patients with a lower BMI had a significantly higher risk of both all-cause mortality and/or heart-failure related hospitalizations compared to those in the overweight and obese categories (p &amp;lt; 0.05). Conclusions These findings underscore that lower BMI is associated with poorer outcomes in patients with CA. This observed "obesity paradox", where higher BMI appears protective, highlights the need for individualized management strategies in CA patients, especially those with lower BMI who may be at elevated risk for adverse outcomes.

To investigate the association between body mass index (BMI) and ectopic pregnancy (EP) following embryo transfer (ET). Retrospective cohort study. University-affiliated hospital. A total of 16378 pregnancies derived from either fresh ET or frozen-thawed ET between January 2008 and December 2017. We used the generalised estimating equation (GEE) to analyse the association between BMI categories and EP, as one woman may contribute to more than one pregnancy. Generalised additive models were also used to demonstrate the non-linear association. Models were adjusted for age, parity, gravidity, previous history of ectopic pregnancy, duration of infertility, polycystic ovary syndrome, endometriosis, diagnosis of tubal problems, ovarian reserve markers, ovarian stimulation parameters, insemination protocol, endometrial thickness and embryo transfer policies. Ectopic pregnancy. According to the WHO criteria, the number of cycles with low (<18.5kg/m2 ), normal (18.5-24.9kg/m2 ) and high (≥25kg/m2 ) BMI were 2155, 13447 and 776, respectively. In comparison with the normal BMI group, the rate of EP was significantly increased in the low BMI group (2.92% versus 2.02%, relative risk 1.45, 95% CI 1.11-1.90), but not in the high BMI group (2.84%, relative risk 1.41, 95% CI 0.92-2.20). Adjusted for confounding factors, the odds ratio for EP comparing low BMI versus normal BMI was 1.61 (95% CI 1.19-2.16) and that comparing high BMI versus normal BMI was 1.12 (95% CI 0.72-1.76). Low BMI is associated with an increased risk of EP. The ectopic pregnancy rate after embryo transfer for lean women is higher than that for women of normal weight.

N-terminal pro-B-type natriuretic peptide (NT-proBNP) concentrations are lower in patients with obesity. The interaction between body mass index (BMI) and NT-proBNP with respect to heart failure risk remains incompletely defined. Data were pooled across three randomized clinical trials enrolling predominantly patients who were overweight or obese with established cardiometabolic disease: SAVOR-TIMI 53, DECLARE-TIMI 58 and CAMELLIA-TIMI 61. Hospitalization for heart failure (HHF) was examined across strata of baseline BMI and NT-proBNP. The effect of dapagliflozin versus placebo was assessed for a treatment interaction across BMI categories in patients with or without an elevated baseline NT-proBNP (≥125 pg/ml). Among 24 455 patients, the median NT-proBNP was 96 (interquartile range [IQR]: 43-225) pg/ml and the median BMI was 33 (IQR 29-37) kg/m2, with 68% of patients having a BMI ≥30 kg/m2. There was a significant inverse association between NT-proBNP and BMI which persisted after adjustment for all clinical variables (p < 0.001). Within any range of NT-proBNP, those at higher BMI had higher risk of HHF at 2 years (comparing BMI <30 vs. ≥40 kg/m2 for NT-proBNP ranges of <125, 125-<450 and ≥450 pg/ml: 0.0% vs. 0.6%, 1.3% vs. 4.0%, and 8.1% vs. 13.8%, respectively), which persisted after multivariable adjustment (adjusted hazard ratio [HRadj] 7.47, 95% confidence interval [CI] 3.16-17.66, HRadj 3.22 [95% CI 2.13-4.86], and HRadj 1.87 [95% CI 1.35-2.60], respectively). In DECLARE-TIMI 58, dapagliflozin versus placebo consistently reduced HHF across BMI categories in those with an elevated NT-proBNP (p-trend for HR across BMI = 0.60), with a pattern of greater absolute risk reduction (ARR) at higher BMI (ARR for BMI <30 to ≥40 kg/m2: 2.2% to 4.7%; p-trend = 0.059). The risk of HHF varies across BMI categories for any given range of circulating NT-proBNP. These findings showcase the importance of considering BMI when applying NT-proBNP for heart failure risk stratification, particularly for patients with low-level elevations in NT-proBNP (125-<450 pg/ml) where there appears to be a clinically meaningful absolute and relative risk gradient.

Objective: The positive relation between body mass index (BMI) and risk of incident hypertension (HT) has been reported mainly in the Western subjects with high BMI. However, there are a few reports in the Asian with relatively lower BMI. This study investigated the relation of BMI with risk of incident HT in the population-based prospective cohort study of Japan, the Suita study. Methods: Participants who had no HT at baseline (1,591 men and 1,973 women) aged 30-84 years were included in this study. BMI categories were defined as following: underweight (BMI&lt;18.5), normal (18.5≤BMI&lt;25.0), and overweight (BMI ≥ 25.0). The Cox proportional hazards model was used to estimate hazard ratios (HRs) of BMI categories for incident HT by sex. HRs were adjusted for age, cigarette smoking and alcohol drinking. The HRs according to quartiles of BMI were also estimated, using the lowest quartile of BMI as a reference. Results: During median follow-up of 7.2 years, 1,325 participants (640 men and 685 women) developed HT. The HR (95% CI) of 1kg/m2 increment of BMI for HT in men and women was 1.08 (1.05-1.11) and 1.10 (1.07-1.12), respectively. When we set a normal BMI as a reference, HR of overweight BMI in men and women was 1.37 (1.13-1.67) and 1.45 (1.18-1.77), whereas HR of underweight BMI in men and women was 0.63 (0.45-0.90) and 0.60 (0.45-0.80), respectively. In addition, compared to the lowest quartile, HR of the highest quartile of BMI in men and women was 1.67 (1.33-2.10, trend p&lt;0.001) and 2.10 (1.67-2.64, trend p&lt;0.001), respectively. Conclusion: In this study, we showed that higher BMI was associated with increased risk of hypertension in both Japanese men and women.

To examine the association between body mass index (BMI) and aggressive biochemical recurrence (BCR) using the Shared Equal Access Regional Cancer Hospital (SEARCH) database. We identified 4123 men with complete data treated by radical prostatectomy between 1988 and 2015. We tested the association between BMI and BCR using Cox models, and among men with BCR, prostate-specific antigen doubling time (PSADT) was compared across BMI categories using linear regression. Models were adjusted for age, race, prostate-specific antigen, biopsy Gleason score, clinical stage, year and surgical centre. Overall, 922 men (22%) were of normal weight (BMI <25kg/m2 ), 1863 (45%) were overweight (BMI 25-29.9 kg/m2 ), 968 (24%) were obese (BMI 30-34.9 kg/m2 ), and 370 (9%) were moderately or severely obese (BMI ≥35 kg/m2 ). After adjustment for multiple clinical characteristics, higher BMI was significantly associated with higher risk of BCR (P = 0.008). Among men with BCR, men in the four BMI categories had similar multivariable-adjusted PSADT values (increasing BMI categories: 20.9 vs 21.3 vs 21.0 vs 14.9months; P = 0.48). While we confirmed that higher BMI was associated with BCR, we found no link between BMI and PSADT at the time of recurrence. Our data suggest obese men do not have more aggressive recurrences. Future studies are needed to test whether obesity predicts response to salvage therapies.

Background: Studies conducted mainly in Western countries have reported a relationship between body mass index (BMI) and prognosis among women with breast cancer. Only a few studies have been conducted in Japan so far because the percentage of high BMI is low. In the present retrospective study, we investigated the associations between BMI and the clinical characteristics and prognosis among breast cancer patients. Methods: We analyzed 1,744 breast cancer patients who started treatment between 2004 and 2012 at a single hospital in Japan. All patients with ductal carcinoma in situ, male breast cancer as well as metachronous and synchronous bilateral breast cancer were excluded. Median age was 57 years (range 23–91). The number of patients less than 50 years old was 496. World Health Organization BMI classifications were used: Underweight, less than18.5 kg/m2, n=157; Normal, 18.5–24.9 kg/m2, n=1181; Overweight, 25–29.9 kg/m2, n=316; and Obese, more than or equal to 30kg/m2, n=90. The Cox proportional hazards model was used to estimate hazard ratios for recurrence free survival (RFS) in relation to BMI classifications. Results: Median follow up interval was 4.2 years. During the follow-up period, 126 breast cancer recurrences were observed. BMI classification correlated with clinical tumor size (cT) significantly and BMI classification tended to correlate with lymph node metastases and estrogen receptor (ER) status. Among patients less than 50 years old, the RFS of those with BMI ≥25.0 kg/m2 was compared to that of patients with BMI &amp;lt;25.0 kg/m2. In multivariate analyses, BMI classification was one of the significant factors (p=0.02) along with lymph node metastases (p=0.0001) and ER status (p=0.04). However in patients aged 50 years or over BMI category was not a significant factor (p=0.12). Conclusions: It has been reported that higher BMI is a risk factor for breast cancer recurrence among postmenopausal patients. Our results suggest that higher BMI is also associated with an increased risk of breast cancer recurrence among premenopausal patients. It raises the possibility that maintaining an appropriate body weight improves the prognosis in premenopausal patients after they have been diagnosed. Citation Format: Toshinari Yamashita, Tomoyuki Aruga, Hiromi Miyamoto, Kazumi Horiguchi, Yayoi Honda, Nami Idera, Risa Goto, Katsumasa Kuroi. Body mass index and prognosis after breast cancer diagnosis in Japanese women [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P6-09-09.

Synergistic Assessment of Mortality Risk According to Body Mass Index and Exercise Ability and Capacity in Patients Referred for Radionuclide Stress Testing

Unintentional dural puncture is a known risk after epidural or combined spinal-epidural procedures, occurring in approximately 1% of labor epidural catheters placed in parturients with normal body habitus but may be as high as 4% in morbidly obese parturients. Anecdotal experience and limited publications suggest that an inverse relationship between body mass index (BMI) and postdural puncture headache (PDPH) may exist. We hypothesized that parturients with increased BMI have a lower incidence of PDPH than those with a lower BMI after unintentional dural puncture. After IRB approval, we performed a retrospective cohort study by medical record review. Case logs from our institution were searched for patients with documented unintentional dural puncture during attempted neuraxial analgesia between January 1, 2004, and December 13, 2013. The primary outcome was the incidence of PDPH. The association between BMI and PDPH was assessed using binary logistic regression, and the Wilcoxon-Mann-Whitney odds and confidence intervals (CIs) for a random pair of BMI values from a PDPH subject compared with a non-PDPH subject were calculated from the area under the receiver operator characteristics curve. Classification tree analysis was used to determine the BMI cutoff value for the risk of developing a PDPH. The presence or absence of second-stage labor pushing and placement of an intrathecal catheter after unintentional dural puncture were compared in parturients with and without PDPH using the Fisher exact test. BMI groups were dichotomized at the cutoff value (low and high BMI groups). We compared the incidence of a PDPH between high and low BMI groups using the Fisher exact test after controlling for pushing during labor and placement of an intrathecal catheter at the time of unintentional dural puncture. Secondary analysis evaluated the highest reported numeric rating of pain scores for headache and the need for an epidural blood patch between BMI groups. Unintentional dural puncture was identified in 518 (0.53%) patients (95% CI, 0.48%-0.58%). The overall incidence of PDPH after unintentional dural puncture was 51% (95% CI, 46%-55%). The Wilcoxon-Mann-Whitney odds for a random pair of BMI values from a PDPH subject compared with a non-PDPH subject was 0.74 (95% CI, 0.60-0.90, P = 0.001). The odds ratio for developing a PDPH in women who pushed during delivery was 2.4 (95% CI, 1.2-3.9, P = 0.001) compared with women who did not push. Classification tree analysis identified a BMI cutoff value of 31.5 kg/m for prediction of a PDPH. The incidence of PDPH in parturients with a BMI ≥31.5 kg/m (39%) was lower than in parturients with a BMI <31.5 kg/m (56%; difference -17%; 95% CI, -7% to -26%, P = 0.0004). The odds ratio for a PDPH in the high BMI compared with the low BMI group was 0.36 (95% CI, 0.14-0.92, P = 0.04) in parturients who pushed during labor and 0.62 (95% CI, 0.41-0.97, P = 0. 04) in parturients who did not push. After the unintentional dural puncture, 112 (22%) parturients had an intrathecal catheter placed. The incidence of PDPH in parturients with an intrathecal catheter was 59% (95% CI, 49%-68%) compared with 48% (95% CI, 43%-54%) in women with an epidural catheter (P = 0.06). Median (interquartile range) headache severity (0-10 verbal rating scale) was 8 (6-9) and did not differ between parturients in the high versus low BMI groups (P = 0.61). The rate of epidural blood patch administration for PDPH treatment was similar in BMI groups (difference -12%; 95% CI, 4 to -27, P = 0.13). The findings are consistent with previous reports of decreased PDPH incidence after unintentional dural puncture in parturients with an increased BMI, even after controlling for pushing during labor. Severity of headache and need for epidural blood patch treatment were similar in low and high BMI groups.

To evaluate the association between body mass index (BMI) and incident hypertension in a cohort of rural women in the Chinese population. A population-based sample of 11,468 rural Chinese women aged >or=35 years and free from hypertension at baseline were followed-up from 2004-2006 to 2008. We calculated BMI from measured weight and height. Incident hypertension was defined as systolic blood pressure (BP) >or=140 mm Hg, diastolic BP>or=90 mm Hg or current use of antihypertensive medications. During a median follow-up of 28 months, 2,666 participants developed hypertension. Higher baseline BMI, even within the 'normal' range, was consistently associated with an increased risk of hypertension. Compared with participants in the lowest BMI quintile (18.5-21.1 kg/m(2)), the multivariable-adjusted relative risks (95% confidence interval) of developing hypertension for women with a BMI of 21.2 to 22.4, 22.5 to 23.7, 23.8 to 25.4 and >or=25.4 kg/m(2) were 1.200 (1.058-1.361), 1.250 (1.100-1.419), 1.466 (1.291-1.666) and 1.785 (1.584-2.012), respectively (P for trend, <0.001). Further adjustment for baseline BP did not substantially alter these results. We found similar associations using other BMI categories and after excluding women with smoking history at baseline. The pattern of association also existed among old women (age >or=55 years). In this large cohort, we found a strong gradient association between higher BMI and increased risk of hypertension, even among older women within the normal BMI range. Clinicians should emphasize the importance of weight management for the primary prevention of hypertension in rural women in the Chinese population.

The relationship between Body Mass Index (BMI) and acute heart failure (HF) remains ill-defined. This study aimed to compare the influence of BMI on in-hospital mortality between patients with acute HF with preserved ejection fraction (HFpEF) and those with acute HF with reduced ejection fraction (HFrEF) and to examine the specific phenotypes of HFpEF/HFrEF according to BMI. This multicenter retrospective study included 5313 and 6332 consecutive patients with acute HFpEF and HFrEF, respectively. Low, normal, and high BMIs were defined as BMI <18.5, 18.5 ≤BMI <25.0, and BMI ≥25.0, respectively. Overweight/obesity was defined as BMI ≥25.0. Kaplan-Meier survival curves and log-rank tests were used for between-group comparisons of in-hospital mortality. Univariable and multivariable Cox regression analyses were performed to identify significant prognostic factors. A paradoxical association between overweight/obesity and survival benefits, the so-called obesity paradox exists in HFpEF (log-rank P<0.05 in low BMI vs. normal BMI, low BMI vs. high BMI, and normal BMI vs. high BMI). In HFrEF, a trend towards lower in-hospital mortality was observed in patients with higher BMI. However, the obesity paradox in patients with HFrEF was not as evident as that in patients with HFpEF. Significant differences in the clinical characteristics and prognostic factors for in-hospital mortality were observed among the groups according to BMI. The obesity paradox was more evident in patients with HFpEF than in those with HFrEF. Specific phenotypes of HFpEF and HFrEF according to BMI were revealed.

To the Editor: Many epidemiological studies have found higher prevalence of hypertension in obese patients and a positive association between body mass index (BMI) and blood pressure (BP).1 This linear relationship between BMI and BP has been observed in young and middle-aged individuals. Subsequently, obesity and weight gain in young individuals are associated with greater cardiovascular mortality. Few data are available on the effect of obesity on cardiovascular morbidity in older patients. The association between coronary heart disease and obesity was not documented in Honolulu or in the Framingham Study, although in the Systolic Hypertension in the Elderly Program, low BMI was associated with greater cardiovascular morbidity and mortality.2,3 The aim of the current study was to determine the relationship between body weight and prevalence of hypertension in an older adult population. Six hundred fifteen subjects (70.2% men, 47.7% women) were included in the analysis. Mean age±standard deviation was 73.5±6.1. Mean BMI was 26.4±3.8 kg/m2; 69.2% of men and 63.7% of women had a BMI of 25.0 or higher. There were more overweight participants in all of the age categories. Mean BMI was significantly lower in the normotensive population aged 75 to 79. Most overweight subjects were aged 70 to 74. The overall prevalence of hypertension was 425 of 615 (69.1%, 95% confidence interval (CI)=66.5–71.6), 70.7% of men and 67.0% of women. Hypertension prevalence rates rose with age (from 63.5% in those aged 65-69 to 76.8% in those aged ≥80). In participants aged 65 to 69 and 70 to 74, the prevalence of hypertension was higher in patients with a BMI of 25.0 or higher (aged 65–69: 72.0% vs 48.3% in those with a BMI<25, P<.001; aged 70–74: 73.3%, vs 56.9% in those with a BMI<25, P=.03) but with no significant difference after the age of 74 (70.9%, vs 71.4% in those with a BMI<25) (Table 1). Although prevalence was higher in overweight participants, the trend was toward a greater rise in prevalence of hypertension with age in lean participants (and a decrease of hypertension prevalence in the overweight group especially after the age of 74) than in the overweight group (BMI<25 in 48.3% of those aged 65–69, 56.9% of those aged 70–74, 71.4% of those aged 75–79, and 72.3% of those aged ≥80; P<.001). The odds ratio (OR) of development of hypertension adjusted for age was 2.16 (95% CI=1.46–3.18) for persons with a BMI of 25.0 or higher. The OR for participants older than 75 was 1.19 (95% CI=0.63–2.25). In this study, prevalence of hypertension was higher in individuals with a BMI of 25.0 or higher and continued to increase with age. In many population-based surveys, BMI has been reported to correlate scientifically with systolic BP, diastolic BP, and hypertension prevalence,4 although the correlation between BP and BMI decreases significantly after the age of 60. An important finding of the current study was the greater risk for hypertension in individuals with a BMI of less than 25.0. Although hypertension prevalence was higher in overweight people than in those who were lean, the trend was toward a higher rise in prevalence with age in the lean group with statistical significance. This may be partly due to selective mortality of individuals with hypertension and partly due to reduction in BMI with age, whereas systolic BP rises for other reasons. Evidence from several genetic models suggests that obesity is not consistently associated with higher blood pressure.5,6 Although the relationship between hypertension, BMI, and age is complex, published analyses of data from the Third National Health and Nutrition Examination Survey (NHANES III) have presented interesting results supporting these findings.7 One study showed that the prevalence of hypertension at older ages, associated with higher BMI, is lower than at younger ages.8 The prevalence of hypertension in elderly men is high (50%) even in the normal range of BMI (BMI<25). Age of 60 and older was found to be the strongest risk factor for hypertension in both sexes after adjusting for BMI category. Thus, age could be a confounding factor in analyses of hypertension. A higher prevalence of hypertension in the lean than in the overweight group (OR=1.29, P=.03) was reported in an analysis of 3,600 participants in NHANES III.9 The exclusion of persons undergoing antihypertensive therapy raises a concern about possible bias in the assessment of the relationship between obesity and hypertension. From the same authors but in a different sample analysis, pulse pressure was lower with higher BMI. Several methodological problems of this study have to be considered. Sodium and potassium were not measured, physical activity was not assessed, and birth weight, as a risk factor for hypertension, was not recorded. These factors may influence BMI and hypertension and act as potential confounders. BMI, which was used as an indicator of adiposity, may be less sensitive in elderly people in whom abdominal adiposity is correlated with greater cardiovascular mortality even within the range of normal BMI values. Abdominal obesity in the current study was not evaluated through the waste to hip ratio, which is a stronger predictor of cardiovascular prognosis.10 Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the author and has determined that none of the authors have any financial or any other kind of personal conflicts with this letter. Author Contributions: E. A. Skliros, P. Merkouris, and A. Sotiropoulos: concept and design, interpretation of data, and preparation of letter. M. Papasotiriou, C. Xipnitos, and Helen Liva: acquisition of subjects and data, and analysis and interpretation of data. Sponsor's Role: None.