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Obesity paradox in sepsis: a systematic review and meta-analysis of short- and long-term mortality risks
Sa Yang1, Shuying Yang1, Hongjie Li1
1Department of Intensive Care Unit, Key Laboratory for Critical Care Medicine of the Ministry of Health, Emergency Medicine Research Institute, Tianjin First Central Hospital, Tianjin 300192, China.
Objective:
To clarify the association of elevated BMI with short- and long-term mortality in sepsis, and to evaluate this association specifically in patients with a BMI ≥ 40 kg/m2.
Design:
Systematic review and meta-analysis.
Setting:
PubMed, Embase, and the Cochrane Library were searched for studies published up to December 2025. Twelve studies met the inclusion criteria.
Participants:
Twelve retrospective studies with 130755 adult sepsis patients. Elevated BMI was defined as ≥30 kg/m2; normal weight as 18.5-25.0 kg/m2.
Interventions:
Not applicable.
Main Variables Of Interest:
Exposure: BMI ≥ 30 kg/m2.
Outcomes:
short-term (28-day, 30-day, ICU, in-hospital) and long-term (1-year) mortality. A separate analysis targeted BMI ≥ 40 kg/m2.
Results:
An elevated BMI was associated with reduced short-term mortality (8 studies: OR 0.75, 95% CI 0.69-0.81; I2 = 11.8%), 28-/30-day mortality (5 studies: OR 0.74, 95% CI 0.68-0.81; I2 = 7.7%), and long-term mortality (2 studies: OR 0.68, 95% CI 0.60-0.77; I2 = 0.0%). This inverse association persisted in patients with BMI ≥ 40 kg/m2 (4 studies: OR 0.70, 95% CI 0.62-0.79; I2 = 26.3%). Sensitivity analyses confirmed robustness.
Conclusions:
Elevated BMI is associated with lower short- and long-term mortality in sepsis, consistent with the obesity paradox. The inverse association also persisted in patients with a BMI ≥ 40 kg/m2.
