Body Mass Index and Death by Stroke

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.