Beyond BMI: independent and opposing effects of overweight and obesity and triglycerides on 90-day functional outcomes after acute ischemic stroke

Objective: To investigate whether the "obesity paradox" in acute ischemic stroke (AIS) is a masking effect of metabolic lipid reserves. We evaluated the independent and opposing associations of body weight status and admission triglycerides (TG) with 90-day functional outcomes to distinguish the structural burden of obesity from metabolic health. Methods: ) groups. The primary endpoint was an excellent functional outcome [modified Rankin Scale (mRS) 0-1] at 90 days. Multivariable logistic regression and inverse probability weighting (IPW) were employed to isolate the independent effects of weight status and TG levels. Results: 0.019). These opposing associations remained robust in IPW sensitivity analyses. Conclusion: The "obesity paradox" in AIS appears to be a masking effect driven by TG reserves. Once disentangled from metabolic benefits, overweight and obesity emerge as independent risk factors for poorer recovery. These findings support a phase-specific metabolic management strategy: mitigating the physical and systemic burdens of obesity while ensuring sufficient TG levels within the physiological range to support neural repair during the acute window.