Electronic poster

M.K. Robinson1, K.M. Mogensen2, J.D. Casey3, C.K. McKane4, T. Moromizato5, J.D. Rawn1, K.B. Christopher5
1Brigham and Women's Hospital, Department of Surgery, Boston, United States, 2Brigham and Women's Hospital, Department of Nutrition, Boston, United States, 3Brigham and Women's Hospital, Department of Medicine, Boston, United States, 4Brigham and Women's Hospital, Department of Nursing, Boston, United States, 5Brigham and Women's Hospital, Renal Division, Boston, United States
Paris 2013
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INTRODUCTION. There is uncertainty in the literature regarding a potential association between obesity and outcomes in critical illness.
OBJECTIVES. We hypothesized that in the critically ill the association between obesity and mortality is dependent on the presence of malnutrition.
METHODS. We performed a single center observational study between 2004-2011 of patients treated in medical and surgical ICUs in Boston. We studied 6,518 critically ill patients, age = 18 years, who received a standardized evaluation by a registered dietitian from 10 days prior to critical care initiation to 2 days after. The exposure of interest was Body Mass Index (BMI) determined at the time of dietitian consultation from the estimated dry weight or admission weight. BMI was categorized a priori as < 18.5 (underweight), 18.5-24.9 (normal/referent), 25-29.9 (overweight), = 30 (obese). Malnutrition diagnoses were categorized into non-specific malnutrition, protein-calorie malnutrition or no malnutrition. The primary outcome was all cause 90-day mortality determined by the Social Security Death Master File. Associations between BMI groups and mortality were estimated by bivariable and multivariable logistic regression models.
RESULTS. In the cohort, 31% were overweight and 28% were obese. Nonspecific malnutrition was present in 56%, and specific malnutrition was present in 12%. The 90-day mortality rate was 26.6%. Patients with obesity have a decreased risk of 90-day mortality:
underweight 90-day mortality OR = 1.14 (95%CI 0.87-1.49; p=0.34);
overweight 90-day mortality OR= 0.94 (95%CI 0.82-1.08; p=0.36);
obese 90-day mortality OR= 0.77 (95%CI 0.66-0.89; p< 0.001),
all relative to patients with normal BMI, adjusted for age, gender, race, medical vs. surgical patient type, Deyo-Charlson index, vasopressor use and sepsis. There is confounding of the obesity-mortality association on the basis of malnutrition.
Additional adjustment of the obesity-mortality association for the presence of malnutrition attenuates the obesity-mortality association:
underweight 90-day mortality OR = 0.78 (95%CI 0.58-1.04;p=0.09);
overweight 90-day mortality OR= 1.04 (95%CI 0.90-1.20;p=0.58);
obese 90-day mortality OR= 0.90 (95%CI 0.77-1.05, p=0.17);
all relative to patients with normal BMI.
Further, in a subset of obese patients (n=1,822), those with malnutrition have increased mortality: OR 90-day mortality 1.86 (95%CI 1.44-2.39; p < .0001); relative to those without malnutrition, fully adjusted.
CONCLUSIONS. In a large population of critically ill adults, an association between improved mortality and obesity is confounded by malnutrition status. Obesity does not appear to be associated with improved outcome once adjustment is made for malnutrition status. Finally, obese patients with malnutrition have worse outcomes than obese patients without malnutrition.
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