*Article* **Association of Body Mass Index with Ischemic and Hemorrhagic Stroke**

**Masahiro Shiozawa 1, Hidehiro Kaneko 1,2,\*, Hidetaka Itoh 1, Kojiro Morita 3, Akira Okada 4, Satoshi Matsuoka 1,5, Hiroyuki Kiriyama 1, Tatsuya Kamon 1, Katsuhito Fujiu 1,2, Nobuaki Michihata 6, Taisuke Jo 6, Norifumi Takeda 1, Hiroyuki Morita 1, Sunao Nakamura 5, Koichi Node 7, Hideo Yasunaga <sup>8</sup> and Issei Komuro <sup>1</sup>**


**Abstract:** Data on the association between body mass index (BMI) and stroke are scarce. We aimed to examine the association between BMI and incident stroke (ischemic or hemorrhagic) and to clarify the relationship between underweight, overweight, and obesity and stroke risk stratified by sex. We analyzed the JMDC Claims Database between January 2005 and April 2020 including 2,740,778 healthy individuals (Median (interquartile) age, 45 (38–53) years; 56.2% men; median (interquartile) BMI, 22.3 (20.2–24.8) kg/m2). None of the participants had a history of cardiovascular disease. Each participant was categorized as underweight (BMI <18.5 kg/m2), normal weight (BMI 18.5–24.9 kg/m2), overweight (BMI 25.0–29.9 kg/m2), or obese (BMI <sup>≥</sup> 30 kg/m2). We investigated the association of BMI with incidence stroke in men and women using the Cox regression model. We used restricted cubic spline (RCS) functions to identify the association of BMI as a continuous parameter with incident stroke. The incidence (95% confidence interval) of total stroke, ischemic stroke, and hemorrhagic stroke was 32.5 (32.0–32.9), 28.1 (27.6–28.5), and 5.5 (5.3–5.7) per 10,000 person-years in men, whereas 25.7 (25.1–26.2), 22.5 (22.0–23.0), and 4.0 (3.8–4.2) per 10,000 personyears in women, respectively. Multivariable Cox regression analysis showed that overweight and obesity were associated with a higher incidence of total and ischemic stroke in both men and women. Underweight, overweight, and obesity were associated with a higher hemorrhagic stroke incidence in men, but not in women. Restricted cubic spline showed that the risk of ischemic stroke increased in a BMI dose-dependent manner in both men and women, whereas there was a U-shaped relationship between BMI and the hemorrhagic stroke risk in men. In conclusion, overweight and obesity were associated with a greater incidence of stroke and ischemic stroke in both men and women. Furthermore, underweight, overweight, and obesity were associated with a higher hemorrhagic stroke risk in men. Our results would help in the risk stratification of future stroke based on BMI.

**Keywords:** body mass index; obesity; underweight; ischemic stroke; hemorrhagic stroke

**Citation:** Shiozawa, M.; Kaneko, H.; Itoh, H.; Morita, K.; Okada, A.; Matsuoka, S.; Kiriyama, H.; Kamon, T.; Fujiu, K.; Michihata, N.; et al. Association of Body Mass Index with Ischemic and Hemorrhagic Stroke. *Nutrients* **2021**, *13*, 2343. https:// doi.org/10.3390/nu13072343

Academic Editor: Hayato Tada

Received: 13 June 2021 Accepted: 29 June 2021 Published: 9 July 2021

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