Online Letters to the Editor
Association of Body Mass Index With Hospital
Mortality in ICU Patients
To the Editor:
I
n an observational cohort study including 154,308 ICU
patients, Pickkers et al (1) showed that obese and seriously
obese patients had the lowest risk of hospital death in a
recent article in Critical Care Medicine. Strengths of this study
include the large sample of patients and adjust for most of
known risk factors that can affect mortality of ICU patients.
Also, Pickkers et al (1) openly discuss the limitations of their
work. However, the study employed observational designs,
which are subject to uncontrolled confounding. In our view,
several issues in the study design may confound interpretation
of the results.
First, illness severity is one of mostly important determi-
nants for hospital death of ICU patients (2). Pickkers et al (1)
have attempted to control illness severity differences among
patients with different body mass index (BMI) by adjusting
the Simplified Acute Physiology Score II (SAPS II), but a sig-
nificant shortcoming of the SAPS II is inability to distinguish
chronic disease from acute disease. This presents a poten-
tial problem in controlling for illness severity. It is generally
believed that chronic diseases are more common in the obese
patients. In our opinion, no matter how refined the adjustment
is for differences in illness burden, it is never possible to ensure
a complete adjustment for illness severity differences among
ICU patients with various BMI and admission reasons. For
example, an obese patient with chronic cardiac insufficiency
and chronic obstructive pulmonary disease may qualify for a
SAPS II score of 16 at baseline, but this patient would have
a better short-term outcome than an underweight or normal
patient with acute cardiac failure and acute respiratory insuf-
ficiency despite an equivalent SAPS II score. That is, a chroni-
cally higher SAPS II score in obese patients may manifest as
a survival benefit. Thus, we argue that not taking impacts of
acute versus chronic disease scoring on the study outcomes
into account is injustice to conclude association between obe-
sity and hospital mortality in the ICU patients.
Second, transfusion and ethnicity were not included in
adjusted potential confounders. It has been shown that trans-
fusions independently contribute to increased risk for hospi-
tal death of ICU patients (3). Furthermore, available evidence
shows the existence of important ethnic differences in thera-
pies of ICU patients (4) and that black patients are almost
three times more likely than white patients to die in-hospital
following admission to the ICU (5). Additionally, lack of health
insurance is associated with increased risk of hospital mortal-
ity in ICU patients. Thus, we cannot exclude possibility that
these factors would have contributed to their results.
Third, their study design did not include the detail about
therapies of ICU patients. Consequently, it is difficult to esti-
mate the degree to which interventions by ICU physicians
might have influenced outcomes. From a clinical stand-
point, obese patients have more physical care requirements.
e80 www.ccmjournal.org January 2014 Volume 42 Number 1
Furthermore, they may have an improved rate of chemical
thromboprophylaxis, which is independently associated with
survival (2). These bring to light the possibility that obese
patients may be triaged to higher care standards. Thus, differ-
ences in care standards between obese and nonobese patients
could account for subsequent differences in hospital death.
The authors have disclosed that they do not have any poten-
tial conflicts of interest.
Fu-Shan Xue, MD, Shi Yu Wang, MD, Rui Ping Li, MD
Department of Anesthesiology, Plastic Surgery Hospital,
Chinese Academy of Medical Sciences and Peking Union
Medical College, Beijing, Peoples Republic of China
REFERENCES
1. Pickkers P, de Keizer N, Dusseljee J, et al: Body Mass Index Is
Associated With Hospital Mortality in Critically Ill Patients: An
Observational Cohort Study. Crit Care Med 2013; 41:18781883
2. Kiraly L, Hurt RT, Van Way CW 3rd: The outcomes of obese patients
in critical care. J Parenter Enteral Nutr 2011; 35(5 Suppl):29S35S
3. Zilberberg MD, Stern LS, Wiederkehr DP, et al: Anemia, transfusions
and hospital outcomes among critically ill patients on prolonged acute
mechanical ventilation: A retrospective cohort study. Crit Care 2008;
12:R60
4. Williams JF, Zimmerman JE, Wagner DP, et al: African-American and
white patients admitted to the intensive care unit: Is there a difference
in therapy and outcome? Crit Care Med 1995; 23:626636
5. Horner RD, Lawler FH, Hainer BL: Relationship between patient race
and survival following admission to intensive care among patients of
primary care physicians. Health Serv Res 1991; 26:531542
DOI: 10.1097/01.ccm.0000435673.83682.58
The Obesity-Mortality Paradox Phenomenon
in Critically Ill Patients: One Size Does Not
FitAll
To the Editor:
I
n a recent issue of Critical Care Medicine, I read with great
interest the article by Pickkers et al (1), which reported
that a large observational database derived from the Dutch
National Intensive Care Evaluation registry shows an inverse
association between obesity and hospital mortality in critically
ill patients that could not be explained by a variety of known
confounders.
Similarly, a short-term obesity-related survival benefit was
also concluded in some previous meta-analyses for patients
with or without surgical intervention in intensive care. Nota-
bly, these meta-analyses were statistically very heterogeneous,
which indicates the need for caution in interpreting pooled
estimates (1). As is known, types of specific diseases, sever-
ity of sickness, and management in critically ill patients may
have diverse impacts of body mass index (BMI) on the hospital
mortality. For instance, some meta-analyses conversely dem-
onstrated that obesity is associated with higher risks of ICU
death among severely traumatic patients and those with 2009
H1N1 infection (2, 3).
In addition, we have identified the severity of Glasgow Coma
Scale or Acute Physiology and Chronic Health Examination