脳卒中とobesity paradox

脳卒中とobesity paradoxに関するレビュー論文を紹介します。

Scherbakov N, Dirnagl U, Doehner W.　Body Weight After Stroke: Lessons From the Obesity Paradox.　Stroke. 2011 Sep 29. [Epub ahead of print]

obesity paradoxは今まで慢性心不全、慢性呼吸不全、慢性腎不全で肥満患者のほうが生命予後がよいということが言われてきました。この論文では脳卒中でもobesity paradoxが当てはまるのではないかという提言です。

サルコペニアや悪液質が脳卒中後のリハの妨げになり予後を悪化させる可能性があります。現在のガイドラインでは脳卒中の二次予防に減量を推奨していますが、過栄養や軽度の肥満患者のほうが予後がよいという報告がされています。また、脳卒中後に体重が減少する患者では予後が悪いです。

脳卒中とobesity paradoxに関しては今後の研究課題ですが、単純にやせればよいというものではないかもしれません。ただ一方で、明らかな肥満患者の場合、減量することで車いすベースだったADLが歩行ベースに改善することもありますので、リハ栄養的に減量が必要な場合もあります。

Abstract

BACKGROUND AND PURPOSE: Outcome after acute stroke is determined to a large extent by poststroke complications. Nutritional status and metabolic balance may substantially contribute to outcome after stroke. Key mechanisms of stroke pathophysiology can induce systemic catabolic imbalance with impaired metabolic efficiency and degradation of body tissues.

Summary-Tissue wasting, sarcopenia, and cachexia may impair and delay poststroke rehabilitation and worsen the prognosis. Although current guidelines for secondary prevention after stroke recommend weight reduction, increasing evidence suggests that patients who are overweight and mildly obese may actually have a better outcome. An "obesity paradox" has been identified to describe the contrasting impact of being overweight in patients with chronic illness compared with healthy populations. We present an overview on the metabolic regulation in patients with stroke and evaluate current data on the impact of body weight and weight change after stroke. The emerging picture suggests that being overweight and obese may impact patients with stroke differently than it does healthy subjects.

CONCLUSIONS: We propose that current knowledge on obesity and its management in primary prevention cannot be transferred to patients with established stroke. Systematic studies on changes in body composition after stroke and on treatment options are warranted to establish the pathophysiology and evidence-driven management of nutritional status in these patients.