Skip to main content

Main menu

  • Home
  • Current issue
  • Authors/reviewers
    • Instructions for authors
    • Submit a manuscript
    • COVID-19 submission information
    • Institutional open access agreements
    • Peer reviewer login
  • Alerts
  • Subscriptions
  • ERS Publications
    • European Respiratory Journal
    • ERJ Open Research
    • European Respiratory Review
    • Breathe
    • ERS Books
    • ERS publications home

User menu

  • Log in
  • Subscribe
  • Contact Us
  • My Cart

Search

  • Advanced search
  • ERS Publications
    • European Respiratory Journal
    • ERJ Open Research
    • European Respiratory Review
    • Breathe
    • ERS Books
    • ERS publications home

Login

European Respiratory Society

Advanced Search

  • Home
  • Current issue
  • Authors/reviewers
    • Instructions for authors
    • Submit a manuscript
    • COVID-19 submission information
    • Institutional open access agreements
    • Peer reviewer login
  • Alerts
  • Subscriptions

Challenging the obesity paradox: extreme obesity and COPD mortality in the SUMMIT trial

Emily P. Brigham, Julie A. Anderson, Robert D. Brook, Peter M.A. Calverley, Bartolome R. Celli, Nicholas J. Cowans, Courtney Crim, James E. Diserens, Fernando J. Martinez, Meredith C. McCormack, David E. Newby, Julie Yates, Jorgen Vestbo, Tianshi David Wu, Robert A. Wise
ERJ Open Research 2021 7: 00902-2020; DOI: 10.1183/23120541.00902-2020
Emily P. Brigham
1Division of Pulmonary and Critical Care Medicine, Johns Hopkins Medicine, Baltimore, MD, USA
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • ORCID record for Emily P. Brigham
  • For correspondence: ebrigham@jhmi.edu
Julie A. Anderson
2Research and Development, GlaxoSmithKline, Stockley Park, UK
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • ORCID record for Julie A. Anderson
Robert D. Brook
3Division of Cardiovascular Diseases, Wayne State University, Detroit, MI, USA
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Peter M.A. Calverley
4Dept of Medicine, Clinical Sciences Centre, University of Liverpool, University Hospital Aintree, Liverpool, UK
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Bartolome R. Celli
5Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • ORCID record for Bartolome R. Celli
Nicholas J. Cowans
6Statistics and Programming, Veramed Ltd, Twickenham, UK
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Courtney Crim
7Research and Development, GlaxoSmithKline, Research Triangle Park, NC, USA
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
James E. Diserens
6Statistics and Programming, Veramed Ltd, Twickenham, UK
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Fernando J. Martinez
8Division of Pulmonary and Critical Care Medicine, Weill Cornell Medicine, New York, NY, USA
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Meredith C. McCormack
1Division of Pulmonary and Critical Care Medicine, Johns Hopkins Medicine, Baltimore, MD, USA
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
David E. Newby
9Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Julie Yates
7Research and Development, GlaxoSmithKline, Research Triangle Park, NC, USA
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Jorgen Vestbo
10Division of Infection, Immunity and Respiratory Medicine, Manchester Academic Health Sciences Centre, The University of Manchester and Manchester University NHS Foundation Trust, Manchester, UK
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • ORCID record for Jorgen Vestbo
Tianshi David Wu
11Section of Pulmonary, Critical Care, and Sleep Medicine, Baylor College of Medicine, Houston, TX, USA
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • ORCID record for Tianshi David Wu
Robert A. Wise
1Division of Pulmonary and Critical Care Medicine, Johns Hopkins Medicine, Baltimore, MD, USA
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • ORCID record for Robert A. Wise
  • Article
  • Figures & Data
  • Info & Metrics
  • PDF
Loading

Figures

  • Tables
  • Supplementary Materials
  • FIGURE 1
    • Download figure
    • Open in new tab
    • Download powerpoint
    FIGURE 1

    All-cause mortality by body mass index (BMI) category. Adjusted for age, sex, region, race, ischaemic heart disease, vascular disease, smoking status, cardiovascular history/risk, previous COPD exacerbations, % predicted forced expiratory volume in 1 s, treatment arm and BMI.

Tables

  • Figures
  • Supplementary Materials
  • TABLE 1

    Baseline characteristics of study participants by body mass index (BMI) category

    Underweight <20 kg·m−2Normal 20– <25 kg·m−2Overweight 25– <30 kg·m−2Class I obesity 30– <35 kg·m−2Class II obesity 35– <40 kg·m−2Class III obesity ≥40 kg·m−2
    Subjects n11114306566234521367587
    Demographics
     BMI (kg·m−2)18.3±1.322.9±1.427.4±1.432.1±1.437.0±1.444.0±4.0
     Age years65.4±8.465.8±8.065.5±7.965.0±7.563.4±7.862.3±7.8
     Female229 (21%)941 (22%)1373 (24%)946 (27%)455 (33%)252 (43%)
    Race
     White468 (42%)2941 (68%)4841 (85%)3236 (94%)1314 (96%)557 (95%)
     Asian625 (56%)1262 (29%)694 (12%)126 (4%)13 (<1%)3 (<1%)
     Other18 (2%)103 (2%)127 (2%)90 (3%)40 (3%)27 (5%)
    Region
     USA75 (7%)443 (10%)859 (15%)655 (19%)344 (25%)214 (36%)
     Europe340 (31%)2322 (54%)3700 (65%)2365 (69%)889 (65%)302 (51%)
     Asia625 (56%)1245 (29%)681 (12%)120 (3%)12 (<1%)3 (<1%)
     Rest of world71 (6%)296 (7%)422 (7%)312 (9%)122 (9%)68 (12%)
    Current smokers617 (56%)2281 (53%)2589 (46%)1389 (40%)570 (42%)232 (40%)
    Smoking history (pack-years)39.1±23.640.4±23.440.2±23.841.8±25.142.4±27.141.9±26.3
    Lung function
     Post-BD FEV1 (L) at screening1.5±0.41.6±0.41.7±0.41.7±0.41.7±0.41.7±0.4
     % Predicted post-BD FEV1 at  screening60.0±6.359.8±6.259.8±6.159.4±5.959.2±6.158.9±6.1
     FEV1 reversibility (% of pre-BD FEV1)  at screening7.6±12.28.1±12.28.1±11.68.0±12.09.0±12.49.0±12.2
    Pre-study COPD exacerbations in 12 months before study
     0717 (65%)2675 (62%)3390 (60%)2065 (60%)828 (61%)346 (59%)
     1233 (21%)1009 (23%)1418 (25%)888 (26%)338 (25%)134 (23%)
     ≥2161 (14%)622 (14%)854 (15%)499 (14%)201 (15%)107 (18%)
    Cardiovascular inclusion criteria#
     Manifest disease
      Coronary artery disease445 (40%)2056 (48%)2951 (52%)1868 (54%)745 (54%)314 (53%)
      Peripheral arterial disease245 (22%)841 (20%)1096 (19%)629 (18%)234 (17%)100 (17%)
      Previous stroke147 (13%)439 (10%)546 (10%)309 (9%)108 (8%)46 (8%)
      Previous myocardial infarction144 (13%)653 (15%)967 (17%)666 (19%)246 (18%)98 (17%)
      Diabetes with target organ disease58 (5%)237 (6%)458 (8%)414 (12%)230 (17%)106 (18%)
     At risk
      Hypercholesterolaemia547 (49%)2467 (57%)3579 (63%)2300 (67%)906 (66%)391 (67%)
      Hypertension833 (75%)3506 (81%)4931 (87%)3183 (92%)1274 (93%)538 (92%)
      Diabetes mellitus200 (18%)818 (19%)1395 (25%)1103 (32%)588 (43%)272 (46%)
      Peripheral arterial disease130 (12%)420 (10%)564 (10%)309 (9%)100 (7%)54 (9%)
    SUMMIT treatment assignment
     Fluticasone furoate298 (27%)1086 (25%)1420 (25%)860 (25%)336 (25%)135 (23%)
     Vilanterol280 (25%)1061 (25%)1400 (25%)881 (26%)325 (24%)171 (29%)
     Fluticasone furoate/vilanterol280 (25%)1052 (24%)1437 (25%)857 (25%)344 (25%)151 (26%)
     Placebo253 (23%)1107 (26%)1405 (25%)854 (25%)362 (26%)130 (22%)

    Data are presented as mean±sd or n (%), unless otherwise stated. FEV1: forced expiratory volume in 1 s; BD: bronchodilator. #: patients could have several cardiovascular diseases or risks at study entry.

    • TABLE 2

      Total on- and post-treatment cause-specific mortality by body mass index (BMI) category

      Underweight <20 kg·m−2Normal 20– <25 kg·m−2Overweight 25– <30 kg·m−2Class I obesity 30– <35 kg·m−2Class II obesity 35– <40 kg·m−2Class III obesity ≥40 kg·m−2
      Subjects n11114306566234521367587
      Respiratory mortality
       Deaths (%)24 (2.2%)49 (1.1%)27 (0.5%)23 (0.7%)8 (0.6%)6 (1.0%)
       Hazard ratio (95% CI)1.44 (0.86–2.41)Ref.0.51 (0.32–0.81)0.77 (0.46–1.30)0.80 (0.37–1.72)1.31 (0.54–3.16)
      Cardiovascular mortality
       Deaths (%)41 (3.7%)132 (3.1%)119 (2.1%)94 (2.7%)35 (2.6%)24 (4.1%)
       Hazard ratio (95% CI)1.30 (0.90–1.87)Ref.0.69 (0.53–0.88)0.90 (0.68–1.19)1.04 (0.71–1.53)1.87 (1.19–2.94)

      Hazard ratio (95% CI) per Cox proportional hazards. Adjusted model accounts for age, sex, region, race, ischaemic heart disease indicator, vascular disease indicator, smoking status, cardiovascular entry criteria (history and risk by age), previous COPD exacerbations, % predicted forced expiratory volume in 1 s, treatment arm and BMI.

      • TABLE 3

        On-treatment system-specific morbidity by body mass index (BMI) categories

        Underweight <20 kg·m−2 (n=1111)Normal 20– <25 kg·m−2 (n=4306)Overweight 25– <30 kg·m−2 (n=5662)Class I obesity 30– <35 kg·m−2 (n=3452)Class II obesity 35– <40 kg·m−2 (n=1367)Class III obesity ≥40 kg·m−2 (n=587)
        Moderate/severe COPD exacerbation#
         Events (%)325 (29.3%)1206 (28.0%)1551 (27.4%)1005 (29.1%)429 (31.4%)188 (32.0%)
         Hazard ratio (95% CI)1.01 (0.89–1.14)Ref.0.97 (0.90–1.05)1.02 (0.93–1.11)1.14 (1.01–1.28)1.05 (0.89–1.23)
        Severe COPD exacerbation¶
         Events (%)128 (11.5%)367 (8.5%)384 (6.8%)265 (7.7%)105 (7.7%)44 (7.5%)
         Hazard ratio (95% CI)1.18 (0.96–1.46)Ref.0.85 (0.73–0.98)1.02 (0.87–1.21)1.14 (0.90–1.43)1.07 (0.77–1.49)
        Pneumonia
         Events (%)106 (9.5%)260 (6.0%)235 (4.2%)153 (4.4%)58 (4.2%)26 (4.4%)
         Hazard ratio (95% CI)1.33(1.05–1.67)REF.0.76 (0.63–0.91)0.83(0.67–1.03)0.84(0.62–1.14)0.80(0.52–1.22)
        Composite cardiovascular events+
         Events (%)46 (4.1%)191 (4.4%)231 (4.1%)154 (4.5%)47 (3.4%)19 (3.2%)
         Hazard ratio (95% CI)1.01 (0.73–1.40)Ref.0.90 (0.74–1.10)0.98 (0.78–1.22)0.88 (0.64–1.23)0.93 (0.57–1.50)

        Hazard ratio (95% CI) per Cox proportional hazards. Adjusted model accounts for age, sex, region, race, ischaemic heart disease indicator, vascular disease indicator, smoking status, cardiovascular entry criteria (history and risk by age), previous COPD exacerbations, % predicted forced expiratory volume in 1 s, treatment arm and BMI. #: moderate COPD exacerbations were exacerbation treated with antibiotics and/or systemic corticosteroids; ¶: severe COPD exacerbations were those that required hospitalisation; +: composite cardiovascular events were predefined secondary end-points, contains myocardial infarction, stroke, transient ischaemic attack, unstable angina, and on-treatment cardiovascular death.

        Supplementary Materials

        • Figures
        • Tables
        • Supplementary Material

          Please note: supplementary material is not edited by the Editorial Office, and is uploaded as it has been supplied by the author.

          Supplementary material 00902-2020.SUPPLEMENT

        PreviousNext
        Back to top
        Vol 7 Issue 3 Table of Contents
        ERJ Open Research: 7 (3)
        • Table of Contents
        • Index by author
        Email

        Thank you for your interest in spreading the word on European Respiratory Society .

        NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

        Enter multiple addresses on separate lines or separate them with commas.
        Challenging the obesity paradox: extreme obesity and COPD mortality in the SUMMIT trial
        (Your Name) has sent you a message from European Respiratory Society
        (Your Name) thought you would like to see the European Respiratory Society web site.
        CAPTCHA
        This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
        Print
        Citation Tools
        Challenging the obesity paradox: extreme obesity and COPD mortality in the SUMMIT trial
        Emily P. Brigham, Julie A. Anderson, Robert D. Brook, Peter M.A. Calverley, Bartolome R. Celli, Nicholas J. Cowans, Courtney Crim, James E. Diserens, Fernando J. Martinez, Meredith C. McCormack, David E. Newby, Julie Yates, Jorgen Vestbo, Tianshi David Wu, Robert A. Wise
        ERJ Open Research Jul 2021, 7 (3) 00902-2020; DOI: 10.1183/23120541.00902-2020

        Citation Manager Formats

        • BibTeX
        • Bookends
        • EasyBib
        • EndNote (tagged)
        • EndNote 8 (xml)
        • Medlars
        • Mendeley
        • Papers
        • RefWorks Tagged
        • Ref Manager
        • RIS
        • Zotero
        Share
        Challenging the obesity paradox: extreme obesity and COPD mortality in the SUMMIT trial
        Emily P. Brigham, Julie A. Anderson, Robert D. Brook, Peter M.A. Calverley, Bartolome R. Celli, Nicholas J. Cowans, Courtney Crim, James E. Diserens, Fernando J. Martinez, Meredith C. McCormack, David E. Newby, Julie Yates, Jorgen Vestbo, Tianshi David Wu, Robert A. Wise
        ERJ Open Research Jul 2021, 7 (3) 00902-2020; DOI: 10.1183/23120541.00902-2020
        del.icio.us logo Digg logo Reddit logo Technorati logo Twitter logo CiteULike logo Connotea logo Facebook logo Google logo Mendeley logo
        Full Text (PDF)

        Jump To

        • Article
          • Abstract
          • Abstract
          • Introduction
          • Methods
          • Results
          • Discussion
          • Supplementary material
          • Acknowledgements
          • Footnotes
          • References
        • Figures & Data
        • Info & Metrics
        • PDF

        Subjects

        • COPD and smoking
        • Tweet Widget
        • Facebook Like
        • Google Plus One

        More in this TOC Section

        Original research articles

        • Diagnosis of PH with 129Xe MRI/MRS
        • Safety of prolonged treatment with bedaquiline
        • Longitudinal passive cough monitoring
        Show more Original research articles

        COPD

        • SNPs in SUMF1 are associated with lung function and COPD
        • Predictors of COPD in women who never smoked
        • EFL in a cohort of highly symptomatic COPD patients
        Show more COPD

        Related Articles

        Navigate

        • Home
        • Current issue

        About ERJ Open Research

        • Editorial board
        • Journal information
        • Press
        • Permissions and reprints
        • Advertising

        The European Respiratory Society

        • Society home
        • myERS
        • Privacy policy
        • Accessibility

        ERS publications

        • European Respiratory Journal
        • ERJ Open Research
        • European Respiratory Review
        • Breathe
        • ERS books online
        • ERS Bookshop

        Help

        • Feedback

        For authors

        • Instructions for authors
        • Publication ethics and malpractice
        • Submit a manuscript

        For readers

        • Alerts
        • Subjects
        • RSS

        Subscriptions

        • Accessing the ERS publications

        Contact us

        European Respiratory Society
        442 Glossop Road
        Sheffield S10 2PX
        United Kingdom
        Tel: +44 114 2672860
        Email: journals@ersnet.org

        ISSN

        Online ISSN: 2312-0541

        Copyright © 2022 by the European Respiratory Society