Muscle mass, BMI, and mortality among adults in the United States: A population-based cohort study.
Abramowitz Matthew K,Hall Charles B,Amodu Afolarin,Sharma Deep,Androga Lagu,Hawkins Meredith
PloS one
BACKGROUND:The level of body-mass index (BMI) associated with the lowest risk of death remains unclear. Although differences in muscle mass limit the utility of BMI as a measure of adiposity, no study has directly examined the effect of muscle mass on the BMI-mortality relationship. METHODS:Body composition was measured by dual-energy x-ray absorptiometry in 11,687 participants of the National Health and Nutrition Examination Survey 1999-2004. Low muscle mass was defined using sex-specific thresholds of the appendicular skeletal muscle mass index (ASMI). Proportional hazards models were created to model associations with all-cause mortality. RESULTS:At any level of BMI ≥22, participants with low muscle mass had higher body fat percentage (%TBF), an increased likelihood of diabetes, and higher adjusted mortality than other participants. Increases in %TBF manifested as 30-40% smaller changes in BMI than were observed in participants with preserved muscle mass. Excluding participants with low muscle mass or adjustment for ASMI attenuated the risk associated with low BMI, magnified the risk associated with high BMI, and shifted downward the level of BMI associated with the lowest risk of death. Higher ASMI was independently associated with lower mortality. Effects were similar in never-smokers and ever-smokers. Additional adjustment for waist circumference eliminated the risk associated with higher BMI. Results were unchanged after excluding unintentional weight loss, chronic illness, early mortality, and participants performing muscle-strengthening exercises or recommended levels of physical activity. CONCLUSIONS:Muscle mass mediates associations of BMI with adiposity and mortality and is inversely associated with the risk of death. After accounting for muscle mass, the BMI associated with the greatest survival shifts downward toward the normal range. These results provide a concrete explanation for the obesity paradox.
10.1371/journal.pone.0194697
Physical activity, weight status, and mortality among congestive heart failure patients.
Loprinzi Paul D
International journal of cardiology
BACKGROUND:Although obesity contributes to increased heart failure risk, and in alignment with the "obesity paradox", studies demonstrate that overweight/obese patients with established heart failure have better clinical outcomes when compared to their normal weight counterparts. To address this, the purpose of this study was to evaluate the fat-but-fit paradigm among those with congestive heart failure. METHODS:Participant data from the 1999-2006 National Health and Nutrition Examination Survey were utilized, with follow-up through 2011. Analyses are based on data from 573 participants who had a physician-diagnosis of congestive heart failure. Based on self-reported physical activity status and measured body mass index, participants were categorized into 6 mutually exclusive groups: Group 1: Normal Weight and Inactive, Group 2) Overweight and Inactive, Group 3) Obese and Inactive, Group 4) Normal Weight and Active, Group 5) Overweight and Active and Group 6) Obese and Active. RESULTS:When compared to Group 1, those in Groups 2, 4, 5, and 6 had a reduced risk of all-cause mortality. CONCLUSION:Physically active congestive heart failure patients, regardless of weight status, have survival benefits.
10.1016/j.ijcard.2016.03.180
Weight-adjusted waist index is positively and linearly associated with all-cause and cardiovascular mortality in metabolic dysfunction-associated steatotic liver disease: findings from NHANES 1999-2018.
Frontiers in endocrinology
Background:Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most common chronic liver disease. Body mass index (BMI) is the most used obesity index but has important limitations. The weight-adjusted waist index (WWI) is a novel obesity metric and accurately reflects body composition. We explored the association of WWI with all-cause and cardiovascular disease (CVD) mortality in MASLD. Methods:Adult participants with MASLD were included from NHANES 1999-2018. WWI was calculated by dividing the waist circumference (WC) by the square root of body weight. MASLD was diagnosed by the presence of hepatic steatosis and at least one cardiometabolic risk factor in the absence of other causes of steatosis. A fatty liver index ≥60 suggested the presence of hepatic steatosis. Mortality data was obtained by prospectively linking to the National Death Index. Multivariate Cox proportional hazards regression analyses were used to explore these associations and multiple adjustment models were constructed including crude, partial, and fully adjusted models. Results:After adjusting for all covariates including BMI, WWI remained positively and linearly associated with all-cause and CVD mortality in MASLD (hazard ratios [HR] 1.247 and 1.218, respectively). Higher WWI was associated with a significantly increased risk of mortality (both p for trend <0.05). There was an "obesity paradox" between BMI and all-cause mortality in MASLD, with significantly lower all-cause mortality in those with overweight/obesity compared to normal BMI (HR 0.625 and 0.596, respectively, p for trend = 0.024), and no association between BMI and CVD mortality. Interaction analyses indicated that these associations were influenced by several demographic variables and disease status. Time-dependent receiver operating characteristic curves indicated that the predictive value of WWI for mortality in MASLD was higher than that of BMI, WC, and waist-to-height ratio across all follow-up durations. Conclusions:WWI was positively and linearly associated with all-cause and CVD mortality in MASLD, whereas BMI did not accurately reflect mortality risk. WWI provided the optimal predictive value for mortality compared to traditional obesity indicators. These findings emphasize the potential use of WWI as a novel obesity indicator for mortality risk assessment, stratification, and prevention in MASLD.
10.3389/fendo.2024.1457869
The obesity paradox in elderly patients with heart failure: analysis of nutritional status.
Casas-Vara Antonio,Santolaria Francisco,Fernández-Bereciartúa Ainhoa,González-Reimers Emilio,García-Ochoa Alfonso,Martínez-Riera Antonio
Nutrition (Burbank, Los Angeles County, Calif.)
OBJECTIVE:The obesity paradox refers to the improved survival of obese compared with non-obese elderly or diseased patients for reasons that are not clear. To assess the relative roles of fat and other factors in this improved survival, we analyzed the prognostic value of overweight and obesity elderly patients with heart failure (HF), controlling for other nutritional data such as midarm anthropometrics, serum proteins, and muscle strength. METHODS:Two hundred forty-four patients (83.2 ± 0.5 y old) hospitalized for HF were included. A nutritional survey was performed in all patients. After discharge, the patients were followed up by telephone. RESULTS:Fourteen patients (5.7%) died during hospitalization. The median survival was 984 d. Patients with better nutritional status as assessed by the body mass index (BMI), subjective score, midarm muscle area, triceps skinfold thickness, handgrip, lymphocyte count, and serum albumin, prealbumin, and cholesterol levels showed better short- and long-term prognoses. Obese patients with a BMI above 30 kg/m(2) showed a better long-term prognosis than those with a BMI from 25 to 30 kg/m(2), those with a BMI from 20 to 25 kg/m(2), and those with a BMI lower than 20 kg/m(2). However, survival was not significantly related to a triceps skinfold thickness above the 95th percentile. Obese and overweight patients were younger and had better a nutritional status than those with a normal or decreased BMI as shown by the anthropometrics, subjective score, handgrip, lymphocyte count, hemoglobin, and serum albumin, prealbumin, and cholesterol levels. All the nutritional data correlated closely with each other. New York Heart Association class also correlated with nutrition-derived data: as the HF class increased, the nutritional status deteriorated. On multivariate analysis, to predict long-term survival, neither BMI nor triceps skinfold thickness showed an independent predictive value, whereas a larger midarm muscle area did. CONCLUSION:The obesity paradox was confirmed in this series of elderly patients with HF. Those with a high BMI and improved survival had a better nutritional status and New York Heart Association functional class than those with a lower BMI, which may explain the differences in survival.
10.1016/j.nut.2011.10.006
The association between obesity and mortality in the elderly differs by serum concentrations of persistent organic pollutants: a possible explanation for the obesity paradox.
Hong N S,Kim K S,Lee I K,Lind P M,Lind L,Jacobs D R,Lee D H
International journal of obesity (2005)
OBJECTIVE:Numerous studies have documented an obesity paradox in which the overweight and obese elderly have a better prognosis than those with ideal body weight. Good prognosis among the overweight or obese elderly may reflect the relative safety of storing the harmful lipophilic chemicals, known as persistent organic pollutants (POPs), in adipose tissue rather than in other critical organs. Therefore, we hypothesized lower mortality among the obese elderly with a higher body burden of POPs, but this pattern may not exist among the obese elderly with a lower body burden of POPs. PARTICIPANTS:Using the National Health and Nutrition Examination Survey (NHANES) 1999-2004 study with a mean 4.2-year follow-up, we tested whether the association between fat mass and total mortality in 635 (652 for organochlorine pesticides) elderly participants aged ≥70 years differed depending on serum concentrations of 23 POPs. RESULTS:There were statistically significant interactions between fat mass and POPs in predicting total mortality. In those with low POP concentrations, there was no obesity paradox; mortality increased with fat mass (hazard ratios about 2-3 in the highest vs. lowest quintile of fat mass). However, consistent with an obesity paradox, these patterns completely disappeared in those with high POP concentrations. Compared with the lowest quintile of fat mass, statistically significantly lower mortality was observed in the elderly in the third to fifth quintiles of fat mass. In the case of polychlorinated biphenyls, the mortality in the highest quintile of fat mass was only one-fifth of that in the lowest quintile. CONCLUSION:These findings are consistent with our hypothesis that adipose tissue provides relatively safe storage of toxic lipophilic chemicals, a phenomenon that could explain the obesity paradox. Although weight loss may be beneficial among the obese elderly with low POP concentrations, weight loss in the obese elderly with higher serum concentrations of POPs may carry some risk.
10.1038/ijo.2011.187
The American paradox: the role of energy-dense fat-reduced food in the increasing prevalence of obesity.
Astrup A
Current opinion in clinical nutrition and metabolic care
Although surveys have reported that the fat content of the diet has decreased over past decades, the prevalence of obesity has continued to rise in Europe and North America. This phenomenon, 'the American paradox', has been attributed partly to an inability of the reduction in dietary fat to reduce excess body fat, and partly to the over-consumption of low-fat products, which, despite their reduced fat content, have in some cases been accused of maintaining a high energy density due to low fibre and water contents, and a high content of refined carbohydrates. In Denmark, the prevalence of obesity has increased in a period in which national dietary surveys have reported a reduction of more than 10% in dietary fat content. Analysing the Danish situation, it seems unlikely that the occurrence of the American paradox in Denmark is caused by the increased consumption of energy-dense, low-fat foods. Other explanations, e.g. the under-reporting of dietary fat in surveys and the clustering of obesity-promoting lifestyles in subgroups of the population, should be sought.
10.1097/00075197-199811000-00016
Gender Disparities in the Food Insecurity-Overweight and Food Insecurity-Obesity Paradox among Low-Income Older Adults.
Hernandez Daphne C,Reesor Layton,Murillo Rosenda
Journal of the Academy of Nutrition and Dietetics
BACKGROUND:Obesity and obesity-related comorbidities are increasing among older adults. Food insecurity is a nutrition-related factor that coexists with obesity among low-income individuals. The majority of the research on the food insecurity-obesity paradox has been conducted on low-income mothers and children, with research lacking on large diverse samples of older adults. OBJECTIVE:The purpose of this study was to assess gender disparities in the association between food insecurity and overweight and obesity among low-income older adults. STUDY DESIGN:Cross-sectional 2011 and 2012 National Health Interview Survey data were used. Food insecurity status was determined by ≥3 affirmative responses on the 10-item US Department of Agriculture Food Security Scale (FSS). Body mass index (BMI) was calculated as outlined by the Centers for Disease Control and Prevention based on self-reported height and weight. PARTICIPANTS/SETTINGS:Adults included were low-income (≤1.99 federal poverty level [FPL]), older (aged ≥60 years), with a normal BMI (18.5) or greater who had complete data on FSS, BMI, and the following covariates: age, race or ethnicity, marital status, income, nativity status, physical activity, poor health status, health insurance coverage, problems paying medical bills or for medicine, and region of residency (N=5,506). STATISTICAL ANALYSES PERFORMED:Multivariate logistic regression models were stratified by gender to estimate the association between food insecurity and higher weight status. All models included covariates. RESULTS:In covariate-adjusted models, compared with low-income, food secure men, low-income, food-insecure men had 42% and 41% lower odds of being overweight and overweight or obese, respectively. Despite the high prevalence rate of obesity among low-income, food-insecure women, food insecurity was not significantly related to overweight, obesity, or overweight or obesity for older adult women in adjusted models. CONCLUSIONS:Food insecurity-overweight and -obesity paradox appears not to be present in older men. However, food insecurity and obesity coexist among low-income, older women.
10.1016/j.jand.2017.01.014
Obesity Paradox and the Effect of NT-proBNP on All-Cause and Cause-Specific Mortality.
Clinical cardiology
BACKGROUND:In heart failure patients, obesity is associated with better outcomes as compared to normal weight, a phenomenon called the obesity paradox. OBJECTIVE:To examine if obesity modifies the relationship between NT-proBNP and all-cause and cause-specific mortality in adults without coronary artery disease or heart failure history. METHODS:We used the National Health and Nutrition Examination Survey (NHANES) data from 1999 to 2004 and linked it with mortality through December 31, 2019. Participants > 18 years were categorized into normal weight (BMI ≤ 25 kg/m), overweight (BMI > 25-29.9 kg/m) and obese (BMI > 29.9 kg/m). NT-proBNP levels were categorized as low (< 126 pg/mL) or high (≥ 126 pg/mL). Using Cox proportional hazard models, we examined effect modification by obesity using interaction, without and with adjusting for potential confounders. RESULTS:Of the 12 621 participants, 2794 (22%) died during 202 859 person-years follow-up. In adjusted models, normal-weight participants with high NT-proBNP had 2 times higher all-cause mortality risk than those with low NT-proBNP (HR = 2.05; 95%CI = 1.74, 2.41; p < 0.001); however, this mortality risk was 27% lower in obese participants (HR interaction = 0.73; 95%CI = 0.59, 0.92; p = 0.008). Similarly, in normal-weight participants, the difference in other-cause mortality risk between high and low NT-proBNP participants was significant in adjusted models (HR = 2.27; 95%CI = 1.81, 2.85; p < 0.001) and obese participants had 48% lower other-cause mortality risk between those with high and low NT-proBNP (interaction HR = 0.52; 95%CI = 0.36, 0.77; p = 0.001). Conversely, obesity did not modify the relationship between NT-proBNP and cardiovascular or cancer mortality. CONCLUSIONS:In patients free of heart failure or coronary artery disease, obesity may be protective against mortality associated with high NT-proBNP.
10.1002/clc.70044
The obesity paradox in the elderly: potential mechanisms and clinical implications.
Oreopoulos Antigone,Kalantar-Zadeh Kamyar,Sharma Arya M,Fonarow Gregg C
Clinics in geriatric medicine
The prevalence of overweight and obesity in the elderly has become a growing concern. Recent evidence indicates that in the elderly, obesity is paradoxically associated with a lower, not higher, mortality risk. Although obesity in the general adult population is associated with higher mortality, this relationship is unclear for persons of advanced age and has lead to great controversy regarding the relationship between obesity and mortality in the elderly, the definition of obesity in the elderly, and the need for its treatment in this population. This article examines the evidence on these controversial issues, explores potential explanations for these findings, discusses the clinical implications, and provides recommendations for further research in this area.
10.1016/j.cger.2009.07.005
Association between body composition and the risk of mortality in the obese population in the United States.
Frontiers in endocrinology
Background:Recent studies have presented the concept of the obesity paradox, suggesting that individuals with obesity have a lower risk of death than those without obesity. This paradox may arise because body mass index (BMI) alone is insufficient to understand body composition accurately. This study investigated the relationship between fat and muscle mass and the risk of mortality in individuals with overweight/obesity. Methods:We used data from the National Health and Nutrition Examination Survey (NHANES) from 1999 to 2006 and 2011 to 2018, which were linked to mortality information obtained from the National Death Index. Multiple Cox regression analyses were performed to estimate mortality risk. Subgroup analysis was conducted using propensity score-matched (PSM) data for age, sex, and race/ethnicity. Results:This study included 16,555 participants who were overweight/obese (BMI≥25 kg/m). An increase in appendicular skeletal muscle mass index was associated with a lower mortality risk (hazard ratio [HR]: 0.856; 95% confidence interval [CI]: 0.802-0.915). This finding was consistent with the subgroup analysis of the PSM data. Contrastingly, a high fat mass index was associated with an increased risk of mortality. Sarcopenic overweight/obesity was significantly associated with high mortality compared to obesity without sarcopenia (HR: 1.612, 95%CI: 1.328-1.957). This elevated risk was significant in both age- and sex-based subgroups. This finding was consistent with the subgroup analysis using PSM data. Conclusion:In contrast to the obesity paradox, a simple increase in BMI does not protect against mortality. Instead, low body fat and high muscle mass reduce mortality risk.
10.3389/fendo.2023.1257902
Overview of epidemiology and contribution of obesity to cardiovascular disease.
Bastien Marjorie,Poirier Paul,Lemieux Isabelle,Després Jean-Pierre
Progress in cardiovascular diseases
The prevalence of obesity has increased worldwide and is a source of concern since the negative consequences of obesity start as early as in childhood. The most commonly used anthropometric tool to assess relative weight and classify obesity is the body mass index (BMI); BMI alone shows a U- or a J-shaped association with clinical outcomes and mortality. Such an inverse relationship fuels a controversy in the literature, named the 'obesity paradox', which associates better survival and fewer cardiovascular (CV) events in patients with elevated BMI afflicted with chronic diseases compared to non-obese patients. However, BMI cannot make the distinction between an elevated body weight due to high levels of lean vs. fat body mass. Generally, an excess of body fat (BF) is more frequently associated with metabolic abnormalities than a high level of lean body mass. Another explanation for the paradox is the absence of control for major individual differences in regional BF distribution. Adipose tissue is now considered as a key organ regarding the fate of excess dietary lipids, which may determine whether or not body homeostasis will be maintained (metabolically healthy obesity) or a state of inflammation/insulin resistance will be produced, with deleterious CV consequences. Obesity, particularly visceral obesity, also induces a variety of structural adaptations/alterations in CV structure/function. Adipose tissue can now be considered as an endocrine organ orchestrating crucial interactions with vital organs and tissues such as the brain, the liver, the skeletal muscle, the heart and blood vessels themselves. Thus, the evidence reviewed in this paper suggests that adipose tissue quality/function is as important, if not more so, than its amount in determining the overall health and CV risks of overweight/obesity.
10.1016/j.pcad.2013.10.016
Obesity paradox and aging: Visceral Adiposity Index and all-cause mortality in older individuals: A prospective cohort study.
Frontiers in endocrinology
Background:The relationship between body mass index (BMI) and mortality in older adults diminished. It is necessary to examine other factors that may accurately predict mortality in older adults. The visceral adiposity index (VAI) is an uncomplicated marker specific to the gender that incorporates anthropometric data and lipid profiles. VAI has been proposed as a marker of visceral adipose tissue dysfunction and of the related cardiometabolic risk. The aim of this study was to evaluate the link of VAI with all-cause mortality among the elderly. Methods:The present prospective cohort study included data from 1999 to 2014 provided by the National Health and Nutrition Examination Survey (NHANES) in the United States. NHANES participants at or above the age of 65 were included. Data collection was carried out by taking face-to-face interviews, mobile-physical examinations, and lab tests. From the start of the survey to the end of December 2015, mortality-related follow-up statistics are available. The shape of the link between VAI and all-cause mortality was investigated using a restricted cubic spline model. Univariate- and multivariate-adjusted Cox proportional hazard models were estimated for VAI, and the results were presented as regression coefficients and 95% confidence intervals (CI). Results:The 82,091 NHANES participants represented 442.2 million non-institutionalized residents of the United States. A total of 11,173 older individuals (representing 23.3 million; aged 73.4 ± 5.8 years; 56.3% women, 82.7% non-Hispanic Whites, 6.8% non-Hispanic Blacks, and 3.3% Mexican Americans) were included in the study. During the 80-month follow-up period, 4466 fatalities were reported, including 825 deaths from cancer, 867 from heart disease, and 211 from cerebrovascular disease. The restricted cubic spline model demonstrated a robust J-shaped link between VAI and all-cause mortality, revealing a significant decrease in risk within the lower range of VAI, which attained the lowest risk close to 1.7. With VAI greater than 1.7, the risk of mortality increased with the increase of VAI (P for non-linearity = 0.025). In the multivariate-adjusted model, the risk of all-cause mortality was 0.73 (0.56-0.97) and 1.05 (1.01-1.09) in participants with VAI less than 1.7 and VAI greater than or equal to 1.7, respectively. Conclusion:This investigation is a population-based cohort study with high sample sizes and a long-term in older individuals follow-up that showed a J-shaped link between VAI levels and all-cause mortality. Understanding the independent roles of VAI in the relationship between BMI and mortality is crucial to understanding the obesity paradox phenomenon.
10.3389/fendo.2022.975209
The obesity paradox in the US population.
The American journal of clinical nutrition
BACKGROUND:Recently a number of studies have found a lower risk of dying for obese individuals than for normal-weight individuals. The explanation for these paradoxical findings has not yet been identified. OBJECTIVE:The objective was to assess whether this paradoxical pattern exists in the US population and whether it can be explained by reverse causation. DESIGN:Survival analyses were used to calculate the RR of all-cause mortality for obesity by using data from 35,673 participants in NHANES I (1971-1975), NHANES II (1976-1980), and NHANES III (1988-1994), which reported 7087 deaths during 3 different 15-y follow-up periods. RESULTS:With normal weight as a referent, a lower relative mortality risk of obesity was found only in NHANES III and only among men with a wide variety of preexisting serious illnesses. For this subgroup, the relative mortality risks in NHANES I, II, and III were 2.22 (95% CI: 1.45, 3.40), 0.89 (95% CI: 0.70, 1.15), and 0.65 (95% CI: 0.47, 0.91), respectively. Whereas the mortality rate among seriously ill normal-weight men did not change significantly between NHANES I and III, it did decrease significantly among seriously ill obese men, suggesting that reverse causation was not responsible for the lower relative mortality risk among seriously ill obese men in NHANES III. CONCLUSIONS:Only obese NHANES male participants with a wide variety of serious illnesses experienced lower mortality risk than their normal-weight counterparts and only in NHANES III. Reverse causation seems unlikely to have played a role. These conclusions require confirmation.
10.3945/ajcn.112.045815
Impact of obesity and the obesity paradox on prevalence and prognosis in heart failure.
Lavie Carl J,Alpert Martin A,Arena Ross,Mehra Mandeep R,Milani Richard V,Ventura Hector O
JACC. Heart failure
Obesity has reached epidemic proportions in the United States and worldwide. Considering the adverse effects of obesity on left ventricular (LV) structure, diastolic and systolic function, and other risk factors for heart failure (HF), including hypertension and coronary heart disease, HF incidence and prevalence, not surprisingly, is markedly increased in obese patients. Nevertheless, as with most other cardiovascular diseases, numerous studies have documented an obesity paradox, in which overweight and obese patients, defined by body mass index, percent body fat, or central obesity, demonstrate a better prognosis compared with lean or underweight HF patients. This review will describe the data on obesity in the context of cardiopulmonary exercise testing in HF. Additionally, the implications of obesity on LV assist devices and heart transplantation are reviewed. Finally, despite the obesity paradox, we address the current state of weight reduction in HF.
10.1016/j.jchf.2013.01.006
The "Obesity Paradox" in Patients With HFpEF With or Without Comorbid Atrial Fibrillation.
Guo Linjuan,Liu Xiao,Yu Peng,Zhu Wengen
Frontiers in cardiovascular medicine
Overweight and mildly obese individuals have a lower risk of death than their normal-weight counterparts; this phenomenon is termed "obesity paradox." Whether this "obesity paradox" exists in patients with heart failure (HF) or can be modified by comorbidities is still controversial. Our current study aimed to determine the association of body mass index (BMI) with outcomes with patients with HF with preserved ejection fraction (HFpEF) with or without coexisting atrial fibrillation (AF). Patients with HFpEF from the Americas in the TOPCAT trial were categorized into the 3 groups: normal weight (18.5-24.9 kg/m), overweight (25.0-29.9 kg/m), and obesity (≥30 kg/m). The Cox proportional-hazards models were used to calculate the adjusted hazard ratios (HRs) and CIs. We identified 1,749 patients with HFpEF, 42.1% of which had baseline AF. In the total population of HFpEF, both overweight (HR = 0.59, 95% CI: 0.42-0.83) and obesity (HR = 0.49, 95% CI: 0.35-0.69) were associated with a reduced risk of all-cause death. Among patients with HFpEF without AF, overweight (HR = 0.51, 95% CI: 0.27-0.95) and obesity (HR = 0.64, 95% CI: 0.43-0.98) were associated with a lower risk of all-cause death. In those with AF, obesity (HR = 0.62, 95% CI: 0.40-0.95) but not overweight (HR = 0.81, 95% CI: 0.54-1.21) was associated with a decreased risk of all-cause death. The "obesity paradox" assessed by BMI exists in patients with HFpEF regardless of comorbid AF. https://clinicaltrials.gov, identifier: NCT00094302.
10.3389/fcvm.2021.743327
Obesity Paradox in Atrial Fibrillation and its Relation with the New Oral Anticoagulants.
Current cardiology reviews
Obesity, a chronic disease established as a global epidemic by the World Health Organization, is considered a risk factor for atrial fibrillation (AF), the most common sustained cardiac arrhythmia, which has high morbidity and mortality. Although both obesity and AF are diseases associated with negative outcomes, studies have shown the presence of an obesity paradox, in which patients with a high body mass index (BMI) and AF have a better prognosis than patients with a normal BMI. Despite the fact that the mechanisms that lead to this paradox are still uncertain, adequate anticoagulation in obese patients seems to play an important role in reducing adverse events in this group. In this perspective article, the authors discuss the relationship between new oral anticoagulants (NOACs), namely, apixaban, edoxaban and rivaroxaban (factor Xa inhibitors) and dabigatran (direct inhibitor of thrombin), and the obesity paradox, seeking to deepen the understanding of the mechanism that leads to this paradox.
10.2174/1573403X18666220324111343
The Obesity Paradox and Heart Failure: A Systematic Review of a Decade of Evidence.
Oga Emmanuel Aja,Eseyin Olabimpe Ruth
Journal of obesity
There is scientific consensus that obesity increases the risk of cardiovascular diseases, including heart failure. However, among persons who already have heart failure, outcomes seem to be better in obese persons as compared with lean persons: this has been termed the obesity paradox, the mechanisms of which remain unclear. This study systematically reviewed the evidence of the relationship between heart failure mortality (and survival) and weight status. Search of the PubMed/MEDLINE and EMBASE databases was done according to the PRISMA protocol. The initial search identified 9879 potentially relevant papers, out of which ten studies met the inclusion criteria. One study was a randomized clinical trial and 9 were observational cohort studies: 6 prospective and 3 retrospective studies. All studies used the BMI, WC, or TSF as measure of body fatness and NYHA Classification of Heart Failure and had single outcomes, death, as study endpoint. All studies included in review were longitudinal studies. All ten studies reported improved outcomes for obese heart failure patients as compared with their normal weight counterparts; worse prognosis was demonstrated for extreme obesity (BMI > 40 kg/m(2)). The findings of this review will be of significance in informing the practice of asking obese persons with heart failure to lose weight. However, any such recommendation on weight loss must be consequent upon more conclusive evidence on the mechanisms of the obesity paradox in heart failure and exclusion of collider bias.
10.1155/2016/9040248
The Obesity Paradox: Effect of Body Mass Index and Waist Circumference on Post-Stroke Cognitive Impairment.
Diabetes, metabolic syndrome and obesity : targets and therapy
Background:Obesity is a risk factor for dementia within the old population however not within the middle-aged population, that is referred to the "obesity paradox". This study explored the association of body mass index (BMI) and waist circumference (WC) with post-stroke cognitive impairment (PSCI) in middle-aged (40-65 years) versus old population (≥ 65 years). Methods:The current study enrolled 1735 individuals over the age of 40 who had their first ischemic stroke from the Impairment of Cognition and Sleep (ICONS) subgroup of the China National Stroke Registry-3 (CNSR-3). BMI and WC were used for the diagnosis of obesity and central obesity, respectively. PSCI was diagnosed according to the Montreal Cognitive Assessment (MoCA). The main clinical outcome was the incidence of PSCI assessed at three months after stroke. Multivariable regression analysis was performed to evaluate the association between obesity and three-month PSCI. Stratified analysis was also performed to explore the effect of age on the relationship between obesity and PSCI. Results:In the general population, multivariable logistic regression found that the adjusted odds ratio (OR) with 95% confidence interval (CI) of general obesity was 1.45 (1.06-1.98) and that of central obesity was 1.54 (1.24-1.91) for the three-month incidence of PSCI. Stratified analysis by age showed that the adjusted OR with a 95% CI of general obesity was 1.84 (1.24-2.72) in middle-aged patients and 0.89 (0.52-1.54) in elderly patients (p-value for interaction = 0.05). Central obesity was associated with PSCI in all age groups: 1.57 (1.18-2.09) in middle-aged patients and 1.52 (1.08-2.15) in elderly patients (p-value for interaction= 0.93). Conclusion:General obesity was related to an increased risk of PSCI in middle-aged but not elderly patients, whereas central obesity was associated with an increased risk of PSCI in all age groups, suggesting that the obesity paradox arises only obesity is outlined by BMI.
10.2147/DMSO.S420824
The obesity paradox is mostly driven by decreased noncardiovascular disease mortality in the oldest old in China: a 20-year prospective cohort study.
Nature aging
National and international recommendations of healthy body mass index (BMI) are primarily based on evidence in young and middle-aged populations, with an insufficient representation of the oldest old (aged ≥80 years). Here, we report associations between BMI and mortality risk in 27,026 community-dwelling oldest old (mean age, 92.7 ± 7.5 years) in China from 1998 to 2018. Nonlinear curves showed reverse J-shaped associations of BMI with cardiovascular disease (CVD), non-CVD and all-cause mortality, with a monotonic decreased risk up to BMIs in the overweight and mild obesity range and flat hazard ratios thereafter. Compared to normal weight, overweight and obesity were significantly associated with decreased non-CVD and all-cause mortality, but not with CVD mortality. Similar associations were found for waist circumference. Our results lend support to the notion that optimal BMI in the oldest old may be around the overweight or mild obesity range and challenge the application of international and national guidelines on optimal BMI in this age group.
10.1038/s43587-022-00201-3
"The obesity paradox" in disease--is the protective effect of obesity true?
Braun Nina,Gomes Filomena,Schütz Philipp
Swiss medical weekly
Although obesity and the associated metabolic syndrome negatively impact on health outcomes, a paradoxical relationship between obesity and mortality has been reported for specific patient populations - the "obesity paradox". However, underlying mechanisms remain unclear and several possible explanations are being discussed. First, a true protective effect of obesity is possible, mediated through differences in the immune response and more metabolic reserves. Although there is a growing body of evidence supporting this hypothesis, the influence of obesity on immune function is complex and not completely understood. Second, a statistical bias is possible, owing to confounding, selection bias, performance bias and measurement bias of most observational studies reporting the obesity paradox. Within this article, we summarise current concepts regarding the underlying pathophysiology and possible explanation for the obesity paradox, and discuss open questions such as whether age is an effect modifier on the relationship of obesity and mortality.
10.4414/smw.2015.14265
The Interaction of Cardiorespiratory Fitness With Obesity and the Obesity Paradox in Cardiovascular Disease.
Oktay Ahmet Afşin,Lavie Carl J,Kokkinos Peter F,Parto Parham,Pandey Ambarish,Ventura Hector O
Progress in cardiovascular diseases
Overweight and obesity are well-established risk factors for most cardiovascular diseases (CVD), including coronary heart disease (CHD), heart failure (HF), and atrial fibrillation. Despite the strong link between excess adiposity and risk of CVD, growing evidence has demonstrated an obesity paradox in patients with CVD. This phenomenon is characterized by a better prognosis in overweight and mildly obese CVD patients than their leaner counterparts. Moreover, the worst outcomes are often incurred by underweight CVD patients, followed by those of normal weight or severely obese. The obesity paradox is now a well-established phenomenon across different types of CVD, and it occurs regardless of age and ethnicity of patients, and severity of CVD. Physical inactivity and low cardiorespiratory fitness (CRF) have long been recognized as major risk factors for CVD. In contrast, high levels of physical activity (PA) and CRF largely neutralize the adverse effects of excess adiposity and other traditional CVD risk factors, including hypertension, metabolic syndrome, and type-2 diabetes. Higher CRF also results in better CVD outcomes across different BMI groups and significantly alters the obesity paradox in patients with HF and CHD. Prognostic benefits of overweight/obesity tend to be limited to unfit patients with HF and CHD, and the obesity paradox usually disappears with improved levels of CRF. Nevertheless, increased PA and exercise training, to maintain or improve CRF, are effective, safe, and proven strategies for primary and secondary prevention of CVD in all weight groups. In this review, we discuss the current concepts of individual and combined contributions of fatness and fitness to CVD risk and prognosis. We then examine the influence of fitness on the obesity paradox in individuals with CVD.
10.1016/j.pcad.2017.05.005
Obesity and CardiovascularDiseases.
Parto Parham,Lavie Carl J
Current problems in cardiology
Obesity has reached epidemic proportions both in the United States and worldwide. There are numerous adverse effects on cardiac structure, hemodynamics, and cellular abnormalities, as well as increases in cardiovascular disease (CVD) risk factors such as hypertension, coronary heart disease, dyslipidemia, atrial fibrillation, and depression. Despite these overwhelming findings, large amounts of evidence support the presence of an "obesity paradox," where obese patients with CVD have a better prognosis than do lean or normal weight in patients with CVD. This review discusses the role of obesity in CVD risk factors and the implications of the obesity paradox in this subset of patients.
10.1016/j.cpcardiol.2017.04.004
Obesity paradoxes.
McAuley Paul A,Blair Steven N
Journal of sports sciences
In this review, we examine the original obesity paradox phenomenon (i.e. in cardiovascular disease populations, obese patients survive better), as well as three other related paradoxes (pre-obesity, "fat but fit" theory, and "healthy" obesity). An obesity paradox has been reported in a range of cardiovascular and non-cardiovascular conditions. Pre-obesity (defined as a body mass index of 25.0-29.9 kg · m⁻²) presents another paradox. Whereas "overweight" implies increased risk, it is in fact associated with decreased mortality risk compared with normal weight. Another paradox concerns the observation than when fitness is taken into account, the mortality risk associated with obesity is offset. The final paradox under consideration is the presence of a sizeable subset of obese individuals who are otherwise healthy. Consequently, a large segment of the overweight and obese population is not at increased risk for premature death. It appears therefore that low cardiorespiratory fitness and inactivity are a greater health threat than obesity, suggesting that more emphasis should be placed on increasing leisure time physical activity and cardiorespiratory fitness as the main strategy for reducing mortality risk in the broad population of overweight and obese adults.
10.1080/02640414.2011.553965
Obesity Paradox in Heart Failure Revisited: Etiology as Effect Modifier.
The American journal of cardiology
The prognostic value of overweight/obesity in heart failure (HF) may vary according to HF etiologies. We aim to determine whether body mass index has differential impacts on survival among hospitalized HF patients with varying etiologies. Consecutive hospitalized HF patients between December 2006 and December 2017 were included. Multivariable analyses, including Cox proportional hazard models and restricted cubic splines, were used to investigate the impact of body mass index on mortality by HF etiology. Among the 3,836 patients included (mean age 57.1 years, 28.4% women), 1,475 (38.5%) were identified as having ischemic etiology. Of the remaining 2,361 patients with non-ischemic etiologies, dilated cardiomyopathy (DCM) accounted for 45.6% (n = 1,077). The rest of the patients were uniformly classified as having non-ischemic-non-DCM HF. The unadjusted data demonstrated an adiposity-related survival paradox in HF across all etiologies. However, the paradox holds only among non-ischemic-non-DCM HF patients after multivariate adjustment, wherein overweight patients exhibit the lowest mortality compared with their normal-weight counterparts (adjusted hazard ratio [aHR] 0.69, 95% confidence interval [CI] 0.52 to 0.91), with a nadir in mortality risk at 28.18 kg/m. Similar survival benefits of overweight were not demonstrated in ischemic or DCM HF patients (ischemic etiology: aHR 1.07, 95% CI 0.84 to 1.36; DCM etiology: aHR 0.97, 95% CI 0.74 to 1.28). In conclusion, being overweight or obese does not confer better survival in HF patients of ischemic or DCM etiology, and the prognostic benefit of being overweight is maintained only in non-ischemic-non-DCM HF patients. Pathophysiologic interpretations are warranted, and whether patients of certain etiologies would benefit from weight reduction needs to be explored.
10.1016/j.amjcard.2023.09.024
An Obesity Paradox: Increased Body Mass Index Is Associated with Decreased Aortic Atherosclerosis.
Barth Rolf F,Maximilian Buja L,Cao Lei,Brodsky Sergey V
Current hypertension reports
Brodsky et al. (Cardiovasc Pathol 25(6), 515-520, 2016) recently have reported that there was an unexpected and highly significant inverse correlation between body mass index (BMI) and atherosclerosis of the aortas of morbidly obese decedents (BMI >40 kg/m). In a series of 304 decedents, 65 of whom were morbidly obese, minimal or no atherosclerosis was seen in 46 of them (70%) versus 20 (30%) who had severe atherosclerosis (P = 0.008). This obesity paradox was unexpected and raises important questions about the etiology and pathogenesis of atherosclerosis, which will be the subject of this commentary. The concept of healthy versus unhealthy adiposity may in part provide an explanation for the "obesity paradox." Another factor that will be considered is the possible role of adipokines and their genetic determinants that may significantly reduce the risk of developing aortic atherosclerosis in morbidly obese individuals. Considering the marked variability in the pattern and extent of atherosclerosis of the aorta, hemodynamic factors and endothelial cell shear stress may be the most important determinants that might explain the obesity paradox that we have observed. Finally, the possible role of gut microbiota and inflammation as factors in the etiopathogenesis of atherosclerosis will be considered, but their importance is less clear than that of hemodynamic factors. We conclude with the remarkable finding that a 5300-year-old, well-preserved mummy of the "Iceman," Ötzi had atherosclerotic disease of a number of major arteries and the interesting questions that this raises.
10.1007/s11906-017-0753-y
The obesity paradox in chronic heart failure: what does it mean?
Chase Paul J,Davis Paul G,Bensimhon Daniel R
Current heart failure reports
Heart failure (HF) is a growing health problem, at least in part due to the concurrent obesity epidemic plaguing developed countries. However, once a patient develops HF, an elevated BMI appears to confer a survival benefit--a phenomenon termed the "obesity paradox." The exact explanation for this paradox has been difficult to ascertain. Numerous plausible mechanisms have been asserted, including the fact that obese patients tend to be younger and more symptomatic, leading them to seek medical attention earlier in the course of their HF. Obese patients may also have larger energy reserves that help to offset the catabolic changes seen with HF. Other hypotheses highlight the limitations of BMI as an obesity classifier. The purpose of this review is to examine the various theories for the obesity paradox in HF and discuss the implications for the clinical management of obese patients with HF.
10.1007/s11897-013-0184-2
The molecular mechanisms of obesity paradox.
Antonopoulos Alexios S,Tousoulis Dimitris
Cardiovascular research
Clinical observations suggest a complex relationship between human obesity and cardiovascular disease. Whilst abdominal (visceral) adiposity leads to deleterious metabolic disturbances, subcutaneous fat accumulation has a benign effect on cardiometabolic risk. Notably, an accumulating body of evidence paradoxically links increased body mass index with a better prognosis in patients with established cardiovascular disease, a finding that has been termed the 'obesity paradox'. Whilst this is now acknowledged to be an epidemiological finding, a metabolically healthy obese group associated with low cardiovascular risk has also been identified. The current concept of adipose tissue (AT) biology suggests that AT expansion is feasible without accompanying adipocyte dysfunction. A metabolically healthy obese phenotype can be promoted by exercise, but is also linked with intrinsic AT molecular characteristics such as efficient fat storage and lipid droplet formation, high adipogenesis capacity, low extracellular matrix fibrosis, angiogenesis potential, adipocyte browning and low macrophages infiltration/activation. Such features are associated with a secretomic profile of human AT which is protective for the cardiovascular system. In the present review, we summarize the existing knowledge on the molecular mechanisms underlying the 'obesity paradox' and whether fatness can be healthy too.
10.1093/cvr/cvx106
Obesity Impact on SARS-CoV-2 Infection: Pros and Cons "Obesity Paradox"-A Systematic Review.
Journal of clinical medicine
BACKGROUND:During the last years, the COVID-19 pandemic meets the pandemic generated by obesity, raising many questions regarding the outcomes of those with severe forms of infection. METHODS:The present systematic review summarises and analyses the data providing evidence for or against the "obesity-paradox" in COVID-19 patients. After applying the inclusion and exclusion criteria, 23 studies were included. We also analysed the presumably underlying basic mechanisms. RESULTS:The patients with a body mass index (BMI) of 30-40 kg/m presented severe symptoms that led to intensive care unit (ICU) admission but not increased death rate. Those with a higher degree of obesity, with a BMI higher than 40 kg/m, led to a rise in the death rate, particularly in young patients. Obesity was associated with a higher rate of ICU admission but was not determined as an independent predictor of increased mortality. In contrast, some studies suggest a strong association between obesity or morbid obesity and the risk of death. CONCLUSIONS:The existence of "obesity-paradox" cannot be stated; our study presents obesity as a critical risk factor in the evolution of COVID-19.
10.3390/jcm11133844
[Obesity Paradox and Stroke].
Baumgartner Ralf,Oesch Lisa,Sarikaya Hakan
Praxis
The obesity paradox suggests that overweight and obese patients of older age may have higher survival rates after stroke as compared to normalweight patients. However, the results need a cautious interpretation due to selection bias, treatment bias and different patients’ characteristics. Moreover, randomized studies that prove a benefit of weight reduction are still lacking. As obesity is an independet risk factor for stroke, weight reduction should still be recommended in overweight patients. Randomized-controlled studies are needed to prove the effect of weight reduction on morbidity and mortality after stroke.
10.1024/1661-8157/a002408
Obesity Paradox in Intracerebral Hemorrhage.
Persaud Steven R,Lieber Adam C,Donath Elie,Stingone Jeanette A,Dangayach Neha S,Zhang Xiangnan,Mocco J,Kellner Christopher P
Stroke
Background and Purpose- Although obesity is an established risk factor for cardiovascular disease and stroke, studies have shown evidence of an obesity paradox-a protective effect of obesity in patients who already have these disease states. Data on the obesity paradox in intracerebral hemorrhage is limited. Methods- Clinical data for adult intracerebral hemorrhage patients were extracted from the National Inpatient Sample between 2007 and 2014. Multivariable logistic regression analyzed the association of body habitus with in-hospital mortality, discharge disposition, length of stay, tracheostomy or gastrostomy placement, and ventriculoperitoneal shunt placement. Results- There were 99 212 patients who were eligible. Patients with both obesity (OR=0.69; 95% CI=0.62-0.76; P<0.001) and morbid obesity (OR=0.85; 95% CI=0.74-0.97; P=0.02) were associated with decreased odds of in-hospital mortality. Morbid obesity was significantly associated with increased odds of a tracheostomy or gastrostomy placement (OR=1.42; 1.20-1.69; P<0.001) and decreased odds of a routine discharge disposition (OR=0.84; 0.74-0.97; P=0.014). Conclusions- Obesity and morbid obesity appear to protect against mortality in intracerebral hemorrhage.
10.1161/STROKEAHA.119.024638
Obesity and the obesity paradox in heart failure.
Clark Adrienne L,Fonarow Gregg C,Horwich Tamara B
Progress in cardiovascular diseases
Obesity is a growing public health problem in the general population, and significantly increases the risk for the development of new-onset heart failure (HF). However, in the setting of chronic HF, overweight and mild to moderate obesity is associated with substantially improved survival compared to normal-weight patients. Evidence exists for an "obesity paradox" in HF, with the majority of data measuring obesity by body mass index, but also across various less-frequently used measures of body fat (BF) and body composition including waist circumference, waist-hip ratio, skinfold estimates of percent BF, and bioelectrical impedance analysis of body composition. Other emerging areas of investigation such as the relationship of the obesity paradox to cardiorespiratory fitness are also discussed. Finally, this review explores various explanations for the obesity paradox, and summarizes the current evidence for intentional weight loss treatments for HF in context.
10.1016/j.pcad.2013.10.004
Obesity and the obesity paradox in heart failure.
Gupta Pritha P,Fonarow Gregg C,Horwich Tamara B
The Canadian journal of cardiology
Obesity has reached epidemic proportions in the general population and is associated with an increased risk for the development of new-onset heart failure (HF). However, in acute and chronic HF, overweight and mild to moderate obesity is associated with substantially improved survival compared with normal weight. This phenomenon has been termed the "obesity paradox" in HF. The majority of data pertaining to the obesity paradox identifies obesity with body mass index; however, the reliability of this method has been questioned. Newer studies have explored the use of other measures of body fat and body composition, including waist circumference, waist-to-hip ratio, skinfold thickness, and bioelectrical impedance analysis of body composition. The relationship between the obesity paradox and cardiorespiratory fitness in HF is also discussed in this review, and we explore the various potential explanations for the obesity paradox and summarize the current evidence and guidelines for intentional weight loss treatments for HF in the obese population.
10.1016/j.cjca.2014.08.004
Anthropometric measures and adverse outcomes in heart failure with reduced ejection fraction: revisiting the obesity paradox.
European heart journal
AIMS:Although body mass index (BMI) is the most commonly used anthropometric measure, newer indices such as the waist-to-height ratio, better reflect the location and amount of ectopic fat, as well as the weight of the skeleton, and may be more useful. METHODS AND RESULTS:The prognostic value of several newer anthropometric indices was compared with that of BMI in patients with heart failure (HF) and reduced ejection fraction (HFrEF) enrolled in prospective comparison of ARNI with ACEI to determine impact on global mortality and morbidity in heart failure. The primary outcome was HF hospitalization or cardiovascular death. The association between anthropometric indices and outcomes were comprehensively adjusted for other prognostic variables, including natriuretic peptides. An 'obesity-survival paradox' related to lower mortality risk in those with BMI ≥25 kg/m2 (compared with normal weight) was identified but this was eliminated by adjustment for other prognostic variables. This paradox was less evident for waist-to-height ratio (as an exemplar of indices not incorporating weight) and eliminated by adjustment: the adjusted hazard ratio (aHR) for all-cause mortality, for quintile 5 vs. quintile 1, was 1.10 [95% confidence interval (CI) 0.87-1.39]. However, both BMI and waist-to-height ratio showed that greater adiposity was associated with a higher risk of the primary outcome and HF hospitalization; this was more evident for waist-to-height ratio and persisted after adjustment e.g. the aHR for HF hospitalization for quintile 5 vs. quintile 1 of waist-to-height ratio was 1.39 (95% CI 1.06-1.81). CONCLUSION:In patients with HFrEF, alternative anthropometric measurements showed no evidence for an 'obesity-survival paradox'. Newer indices that do not incorporate weight showed that greater adiposity was clearly associated with a higher risk of HF hospitalization.
10.1093/eurheartj/ehad083
Reverse epidemiology of obesity paradox: Fact or fiction?
Physiological reports
Obesity paradox refers to the clinical observation that when acute cardiovascular decompensation occurs, patients with obesity may have a survival benefit. This apparently runs counter to the epidemiology of obesity, which may increase the risk for non-communicable diseases (NCDs). The scientific community is split on obesity paradox, with some supporting it, while others call it BMI paradox. This review: (a) defines the obesity paradox, and its proposed role in overall mortality in NCDs; (b) delineates evidence for and against obesity paradox; (c) presents the importance of using different indices of body mass to assess the risk in NCDs; (d) examines the role of metabolically healthy obesity in obesity paradox, and emerging importance of cardio-respiratory fitness (CRF) as an independent predictor of CVD risk and all-cause mortality in patients with/without obesity. Evidence suggests that the development of obesity and insulin resistance are influenced by genetic (or ethnic) make up and dietary habits (culture) of the individuals. Hence, this review presents lean diabetes, which has higher total CVD and non-CVD mortality as compared to diabetics with obesity and the possibility of maternal factors programming cardiometabolic risk during fetal development, which may lead to a paradigm shift in our understanding of obesity.
10.14814/phy2.70107
Obesity paradox in stroke - Myth or reality? A systematic review.
Oesch Lisa,Tatlisumak Turgut,Arnold Marcel,Sarikaya Hakan
PloS one
BACKGROUND AND PURPOSE:Both stroke and obesity show an increasing incidence worldwide. While obesity is an established risk factor for stroke, its influence on outcome in ischemic stroke is less clear. Many studies suggest a better prognosis in obese patients after stroke ("obesity paradox"). This review aims at assessing the clinical outcomes of obese patients after stroke by performing a systematic literature search. METHODS:The reviewers searched MEDLINE from inception to December 2015. Studies were eligible if they included outcome comparisons in stroke patients with allocation to body weight. RESULTS:Twenty-five studies (299'750 patients) were included and none was randomised. Ten of 12 studies (162'921 patients) reported significantly less mortality rates in stroke patients with higher BMI values. Seven of 9 studies (92'718 patients) ascertained a favorable effect of excess body weight on non-fatal outcomes (good clinical outcome, recurrence of vascular events). Six studies (85'042 patients) indicated contradictory results after intravenous thrombolysis (IVT), however. Several methodological limitations were observed in major part of studies (observational study design, inaccuracy of BMI in reflecting obesity, lacking body weight measurement, selection bias, survival bias). CONCLUSION:Most observational data indicate a survival benefit of obese patients after stroke, but a number of methodological concerns exist. No obesity paradox was observed in patients after IVT. There is a need for well-designed randomized controlled trials assessing the effects of weight reduction on stroke risk in obese patients.
10.1371/journal.pone.0171334
Obesity and heart failure with preserved ejection fraction: a paradox or something else?
Tadic Marijana,Cuspidi Cesare
Heart failure reviews
Obesity represents one of the most common comorbidities in patients with heart failure and preserved ejection fraction (HFpEF). Studies have shown that obesity is not only a comorbidity, but it could also be an important risk factor for HFpEF development. The mechanisms that connect obesity and HFpEF vary from obesity-induced hemodynamic changes to important biohumoral systems such as adipocitokines, renin-angiotensin-aldosterone and sympathetic nervous systems, natriuretic peptide, and oxidative stress. Studies agree about the negative influence of morbid obesity on cardiac remodeling and HFpEF development. However, there is still no agreement regarding the relationship between body mass index, as the most commonly used parameter of obesity, and HFpEF incidence or outcome in patients who already have HFpEF. The relationship varies from the linear to the U-shaped and, therefore, the "obesity paradox," which refers to the reduced risk in mildly overweight subjects in comparison with normal and underweight individuals, deserves more attention not only in the research but also in the clinical approach to these patients. In the absence of a satisfactory pharmacological approach, which would improve the outcome of this large group of patients, alternative methods such as weight loss and physical activity seem to provide encouraging results. This review article provides a clinical overview of the available data about the mechanisms that connect obesity and HFpEF, the most relevant studies on this topic, clinical relevance of the obesity paradox, and the therapeutic approach including weight loss and physical activity in obese patients with HFpEF.
10.1007/s10741-018-09766-x
"Obesity paradox" in coronary artery disease.
Akin Ibrahim,Nienaber Christoph A
World journal of cardiology
Obesity used to be among the more neglected public health problems, but has unfolded as a growing medical and socioeconomic burden of epidemic proportions. Morbid obesity is linked to traditional cardiovascular risk factors like, hypertension, hyperlipidemia and diabetes, and suspected to incur increased morbidity and mortality in the Western and even third world populations. This patient cohort is also at greater risk to develop coronary artery disease. Recent population-based registries revealed that 43% and 24% of all cases of coronary revascularization were carried out in overweight and obese patients, respectively. However, despite evidence of a positive correlation between obesity and increased cardiovascular morbidity, some authors have described a better clinical outcome in overweight and obese patients, a phenomenon they coined "obesity paradoxon". Thus, there is an ongoing debate in light of conflicting data and the possibility of confounding bias causing misconception and challenging the "obesity paradox". In this review article we present the current evidence and throughly discuss the validity of the "obesity paradoxon" in a variety of clinical settings.
10.4330/wjc.v7.i10.603
Obesity, Metabolic Syndrome, and Obesity Paradox in Heart Failure: A Critical Evaluation.
Current heart failure reports
PURPOSE OF REVIEW:Since the turn of the millennium, obesity has been on the rise worldwide, and particularly so throughout the United States. Even more concerning is the rate at which persons with severe obesity continue to trend upwards. Given the detrimental effects of obesity on cardiac structure and function, it is not surprising that obesity stands as one of the leading risk factors for developing heart failure (HF). This state-of-the-art article aims to review the updated literature on the obesity paradox to help further understand its relationship to body composition, weight loss, fitness, and exercise. RECENT FINDINGS:An intriguing phenomenon appears to exist in which obesity is associated with a better prognosis in those with HF, compared to patients with lesser body mass. Recent studies suggest, however, that weight loss induced by pharmacologic strategies might be beneficial in patients with HF with preserved ejection fraction. Despite the presence of an obesity paradox, recent data suggest that obesity could be targeted in HF, however, long-term data are currently lacking. Consequently, definitive guidelines for managing obesity, and specifically the body composition of these patients, remain amiss.
10.1007/s11897-024-00690-w
Obesity paradox in heart failure: statistical artifact, or impetus to rethink clinical practice?
Charnigo Richard,Guglin Maya
Heart failure reviews
The "obesity paradox" in heart failure (HF) is a phenomenon of more favorable prognosis, especially better survival, in obese versus normal-weight HF patients. Various explanations for the paradox have been offered; while different in their details, they typically share the premise that obesity per se is not actually the cause of reduced mortality in HF. Even so, there is a lingering question of whether clinicians should refrain from, or at least soft-pedal on, encouraging weight loss among their obese HF patients. Against the backdrop of recent epidemiological analysis by Banack and Kaufman, which speculates that collider stratification bias may generate the obesity paradox, we seek to address the aforementioned question. Following a literature review, which confirms that obese HF patients are demographically and clinically different from their normal-weight counterparts, we present four hypothetical data sets to illustrate a spectrum of possibilities regarding the obesity-mortality association. Importantly, these hypothetical data sets become indistinguishable from each other when a crucial variable is unmeasured or unreported. While thorough, the discussion of these data sets is intended to be accessible to a wide audience, especially including clinicians, without a prerequisite of familiarity with advanced epidemiology. We also furnish intuitive visual diagrams which depict a version of the obesity paradox. These illustrations, along with reflection on the distinction between weight and weight loss (and, furthermore, between voluntary and involuntary weight loss), lead to our recommendation for clinicians regarding the encouragement of weight loss. Finally, our conclusion explicitly addresses the questions posed in the title of this article.
10.1007/s10741-016-9577-0
The obesity paradox in heart failure: What is the role of cardiorespiratory fitness?
Khan Asad,Van Iterson Erik H,Laffin Luke J
Cleveland Clinic journal of medicine
The obesity paradox describes a survival benefit for higher body mass index in patients with heart failure. But other factors like cardiorespiratory fitness may play a role in heart failure development, severity, and survival. Although more research is needed to better understand the relationships between body mass index and fitness in patients with heart failure, evidence indicates that recommending weight loss and an exercise program is appropriate for most patients.
10.3949/ccjm.88a.20098
Obesity paradox and stroke outcomes according to stroke subtype: a propensity score-matched analysis.
International journal of obesity (2005)
OBJECTIVE:Obesity has traditionally been considered a risk factor for ischemic stroke. However, some clinical observations have reported a complex relationship between patients who are overweight or obese with paradoxically better stroke outcomes. Stroke subtypes have differing distributions of risk factors, so this study aimed to explain the relationship between body mass index (BMI) and functional prognosis according to stroke subtype. METHODS:A prospective institutional database on stroke was accessed between March 2014 and December 2021, and consecutive patients with ischemic stroke were retrospectively selected. BMI was categorized into five groups (underweight, normal weight, overweight, obese, and morbid obesity). The outcome of interest in this study was the modified Rankin Scale (mRS) at 90 d, which was divided into favorable (mRS = 0-2) and unfavorable (mRS ≥ 3) groups. The relationship between functional outcome and BMI was analyzed according to stroke subtype. RESULTS:Among 2779 patients with stroke, 913 (32.9%) had unfavorable outcomes. After a propensity score-matched analysis, obesity was inversely associated with unfavorable outcomes (adjusted odds ratio [aOR] = 0.61, 95% confidence interval [95% CI]: 0.46-0.80) in all patients with stroke. Among the stroke subtypes, overweight (aOR = 0.38, 95% CI: 0.20-0.74) and obese (aOR = 0.40, 95% CI: 0.21-0.76) groups were inversely associated with unfavorable outcomes in the cardioembolism subtype. Obesity (aOR = 0.55, 95% CI: 0.32-0.95) was inversely associated with unfavorable outcomes in the small vessel disease subtype. There was no significant relationship between stroke outcome and BMI classification in the large artery disease subtype. CONCLUSIONS:These findings suggest that the obesity paradox in ischemic stroke outcomes might differ according to the stroke subtype.
10.1038/s41366-023-01318-0
The obesity paradox in intracerebral hemorrhage: a systematic review and meta-analysis.
Frontiers in endocrinology
Background:Intracerebral hemorrhage (ICH) has a mortality rate which can reach 30-40%. Compared with other diseases, obesity is often associated with lower mortality; this is referred to as the 'obesity paradox'. Herein, we aimed to summarize the studies of the relations between obesity and mortality after ICH. Method:For this systematic review and meta-analysis (PROSPERO registry CRD42023426835), we conducted searches for relevant articles in both PubMed and Embase. Non-English language literature, irrelevant literature, and non-human trials were excluded. All included publications were then qualitatively described and summarized. Articles for which quantitative analyses were possible were evaluated using Cochrane's Review Manager. Results:Ten studies were included. Qualitative analysis revealed that each of the 10 studies showed varying degrees of a protective effect of obesity, which was statistically significant in 8 of them. Six studies were included in the quantitative meta-analysis, which showed that obesity was significantly associated with lower short-term (0.69 [0.67, 0.73], p<0.00001) and long-term (0.62 [0.53, 0.73], p<0.00001) mortality. (Data identified as (OR [95%CI], p)). Conclusion:Obesity is likely associated with lower post-ICH mortality, reflecting the obesity paradox in this disease. These findings support the need for large-scale trials using standardized obesity classification methods. Systematic review registration:https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023426835, identifier CRD42023426835.
10.3389/fendo.2023.1255538
Obesity, Heart Failure, and Obesity Paradox.
Hamzeh Nikoo,Ghadimi Fatemeh,Farzaneh Rojin,Hosseini Seyed Kianoosh
The journal of Tehran Heart Center
The incidence and prevalence of obesity are fast increasing worldwide. Various indices have been used to measure and assess obesity. The body mass index (BMI) is the most common and practical of these indices. Overweight and obesity exert considerable adverse effects on the cardiovascular system. These effects are mediated through various neurohormonal and cytokine pathways, most of which are inflammatory mediators. Systolic and / or diastolic heart failure is more prevalent among obese and overweight individuals than among normal weight people. The concept of the "obesity paradox" has been proposed by some previously published studies, in which the prognosis of obese patients with established cardiovascular diseases, especially heart failure, is better than that of their leaner counterparts. In this review, we discuss the obesity paradox and its possible pathophysiologic mechanisms.
Obesity Paradox in Atrial Fibrillation: Implications for Outcomes and Relationship with Oral Anticoagulant Drugs.
Proietti Marco,Boriani Giuseppe
American journal of cardiovascular drugs : drugs, devices, and other interventions
In the last 40 years, concern about the obesity epidemic has increased. Data from the current literature highlight a strong relationship between obesity and atrial fibrillation (AF), particularly in relation to an increased risk for incident and recurrent AF. A phenomenon called the "obesity paradox" has emerged: the apparently counterintuitive evidence from epidemiological data indicating that overweight and obese patients may have a better prognosis than healthy-weight patients. A differential impact of oral anticoagulants (OACs) in terms of effectiveness and safety in the various body mass index categories has been postulated, particularly in the comparison between non-vitamin-K antagonist oral anticoagulants and vitamin K antagonists. This review aims to summarize the evidence on the impact of obesity in patients with AF, focusing on descriptions of the obesity paradox and its relationships with OAC treatment.
10.1007/s40256-019-00374-0
The obesity paradox: is it really a paradox? Hypertension.
Lechi Alessandro
Eating and weight disorders : EWD
This article is a narrative overview of the role of hypertension on the relationships between obesity, morbidity, and mortality. We used as sources MEDLINE/PubMed, CINAHL, EMBASE, and Cochrane Library, from inception to March 2016. Key words include overweight, obesity, visceral obesity, obesity paradox, and hypertension. In addition, we hand-searched references from the retrieved articles. This work is one of the works of the topical collection "Obesity Paradox". The positive association between overweight, obesity, and cardiovascular diseases is well established, though this relation is typically U shaped with an increased risk in low-weight subjects or even a beneficial effect of overweight and obesity, the so-called "obesity paradox". In addition, the relationship between obesity and arterial hypertension has been demonstrated in both children and adults by many epidemiological studies. Moreover, weight reduction is followed by a decrease in blood pressure in many patients and ameliorates the cardiovascular risk profile. Recent studies using more appropriate obesity indices raise some doubt about the real significance of obesity paradox and there are several studies that central obesity shows either no protective or even a worse effect. These observations raise the question: what kind of obesity is protective and what kind of obesity is harmful? The studies of obesity paradox suffer from several methodological limitations: most of these are retrospective analyses or were not specifically designed to study obesity paradox as a primary goal; a few studies have data on preceding unintentional weight loss and on some particular confounding variables. In conclusion, more prospective and accurate studies are necessary to better elucidate the clinical importance of obesity paradox. When weight loss is functional to reduce hypertension and cardiovascular risk, it should be encouraged, while an unintentional weight in a patient with chronic diseases may indicate an unfavorable course.
10.1007/s40519-016-0330-4
Obesity phenotypes and their paradoxical association with cardiovascular diseases.
Vecchié Alessandra,Dallegri Franco,Carbone Federico,Bonaventura Aldo,Liberale Luca,Portincasa Piero,Frühbeck Gema,Montecucco Fabrizio
European journal of internal medicine
The pro-inflammatory state of the visceral adipose tissue (VAT) is supposed to accelerate cardiovascular (CV) and metabolic diseases in obese subjects. Some studies have recently reported an improved CV prognosis in certain obese and overweight patients as compared with leaner ones. This phenomenon, known as the "obesity paradox" (OP), has been described in many chronic diseases. This narrative review is based on the material searched for and obtained via PubMed and Web of Science up to May 2017. The search terms we used were: "obesity, paradox, adipose tissue" in combination with "cardiovascular, coronary heart disease, heart failure, arrhythmias". Using the current Body Mass Index (BMI)-based obesity definition, individuals with different clinical and biochemical characteristics are gathered together in the same category. Emerging evidence point to the existence of many "Obesity phenotypes" with different association with CV risk, accordingly to physical and life-style features. In this narrative review, we discussed if obesity phenotypes may be associated with a different CV risk, potentially explaining the OP. As a globally accepted definition of obesity is still lacking, we emphasized the need of a new approach, which should consider the heterogeneity of obesity. Better defining "obesities" and related CV risk is critical to markedly improve the classical BMI-based definition of obesity.
10.1016/j.ejim.2017.10.020
Obesity paradox in patients undergoing coronary intervention: A review.
Patel Nirav,Elsaid Ossama,Shenoy Abhishek,Sharma Abhishek,McFarlane Samy I
World journal of cardiology
There is strong relationship exist between obesity and cardiovascular disease including coronary artery disease (CAD). However, better outcomes noted in obese patients undergoing percutaneous cardiovascular interventions for CAD, a phenomenon known as the obesity paradox. In this review, we performed extensive search for obesity paradox in obese patients undergoing percutaneous coronary intervention and discussed possible mechanism and disparities in different race and sex.
10.4330/wjc.v9.i9.731
The Obesity Paradox in Type 2 Diabetes and Mortality.
Tobias Deirdre K,Manson JoAnn E
American journal of lifestyle medicine
The obesity paradox for survival among individuals with type 2 diabetes has been observed in some but not all studies. Conflicting evidence for the role of overweight and obesity in all-cause mortality may largely be a result of differences in study populations, epidemiological methods, and statistical analysis. For example, analyses among populations with long-term prevalent diabetes and the accrual of other chronic health conditions are more likely to observe that the sickest participants have lower body weights, and therefore, relative to normal weight, overweight and even obesity appear advantageous. Other mortality risk factors, such as smoking, also confound the relationship between body weight and survival, but this behavior varies widely in intensity and duration, making it difficult to assess and effectively adjust for in statistical models. Disentangling the potential sources of bias is imperative in understanding the relevance of excess body weight to mortality in diabetes. In this review, we summarize methodological considerations underlying the observed obesity paradox. Based on the available evidence, we conclude that the obesity paradox is likely an artifact of biases, and once these are accounted for, it is evident that compared with normal body weight, excess body weight is associated with a greater mortality risk.
10.1177/1559827616650415
Obesity and the obesity paradox in abdominal aortic aneurysm.
Frontiers in endocrinology
Obesity, characterized by its complexity and heterogeneity, has emerged as a significant public health concern. Its association with increased incidence and mortality of cardiovascular diseases stems not only from its complications and comorbidities but also from the endocrine effects of adipose tissue. Abdominal aortic aneurysm (AAA), a chronic inflammatory condition, has been closely linked to obesity. Intriguingly, mild obesity appears to confer a protective effect against AAA mortality, whereas severe obesity and being underweight do not, giving rise to the concept of the "obesity paradox". This review aims to provide an overview of obesity and its paradoxical relationship with AAA, elucidate its underlying mechanisms, and discuss the importance of preoperative weight loss in severely obese patients with AAA.
10.3389/fendo.2024.1410369
The Obesity Paradox in Chronic Heart Disease and Chronic Obstructive Pulmonary Disease.
Cureus
Obesity in recent years has become an epidemic. A high body mass index (BMI) is one of today's most crucial population health indicators. BMI does not directly quantify body fat but correlates well with easier body fat measurements. Like smoking, obesity impacts multiple organ systems and is a major modifiable risk factor for countless diseases. Despite this, reports have emerged that obesity positively impacts the prognosis of patients with chronic illnesses such as chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD), a phenomenon known as the Obesity Paradox. This article attempts to explain and summarize this phenomenon. As it stands, two theories explain this paradox. The muscle mass hypothesis states that obese patients are better adapted to tide through acute exacerbations due to increased reserve because of greater muscle mass. The other theory focuses on brown adipose tissue and its anti-inflammatory effects on the body. We performed a literature review on research articles published in English from 1983 to the present in the following databases - PubMed, Elsevier, and Google Scholar. The following search strings and Medical Subject Headings (MeSH) terms were used: "Obesity," "Heart Failure," "COPD," and "Cardio-Respiratory Fitness." In this review, we looked at the obesity paradox in Heart Failure and COPD. We summarized the current literature on the Obesity Paradox and reviewed its relationship with Cardio-Respiratory Fitness.
10.7759/cureus.25674
The Obesity Paradox in Heart Failure: Is It Still Valid in Light of New Therapies?
Cardiology
BACKGROUND:Obesity increases the risk of cardiovascular disease and heart failure (HF). However, in patients with established HF, many studies observed greater survival with increasing adiposity. This counterintuitive observation has been termed the "obesity paradox." In recent years, new HF therapies have emerged that improve prognosis in patients with HF. Some of these, such as sodium-glucose cotransporter 2 inhibitors (SGLT2i), cause weight loss and may therefore interfere with the obesity paradox. SUMMARY:This article is a narrative review on the relationship between body weight and outcomes in patients with HF with special focus on new HF treatments. PubMed was searched for studies reporting the prognostic impact of obesity in HF from 2002 to February 22, 2022. More than 400 records were examined, with 150 being included in the present review. Literature provides evidence for an obesity paradox in a broad range of HF patients, including acute and chronic HF across the spectrum of left ventricular ejection fraction. It has been verified in HF patients treated with SGLT2i but not in those using sacubitril/valsartan. Cardiorespiratory fitness and the severity of HF seem to be important confounders of the obesity paradox in HF. While unintentional weight loss is associated with a poor prognosis in HF, weight loss associated with SGLT2i treatment appears safe. KEY MESSAGES:Consensus has yet to emerge as to whether the obesity paradox is a true phenomenon in HF. As cardiorespiratory fitness is strongly associated with prognosis and significantly modifies the relationship between adiposity and survival in HF, regular physical activity is recommended irrespective of the body weight. In HF patients with severe obesity, a modest weight reduction of 5-10% may be reasonable to improve HF symptoms and quality of life.
10.1159/000527332
Obesity or BMI Paradox? Beneath the Tip of the Iceberg.
Donini Lorenzo Maria,Pinto Alessandro,Giusti Anna Maria,Lenzi Andrea,Poggiogalle Eleonora
Frontiers in nutrition
The obesity paradox refers to extant evidence showing that obesity in older subjects or in patients with several chronic diseases may be protective and associated with decreased mortality. A number of mechanisms have been postulated to support the existence of obesity paradox; however, marked heterogeneity was found across studies and this has cast doubt on the actual presence of this phenomenon. The aim of the present narrative review is to summarize evidence underlying the concept of obesity paradox, focusing on limitations and bias related to this phenomenon, with emphasis on the use of body mass index (BMI). A major cause of the discrepancy between studies may be related to the use of BMI in the definition of obesity, that should consider, instead, excess body fat as the main characteristic of this disease and as the unique determinant of its complications. In addition, the adjustment for potential confounders (e.g., stage and grade of diseases, smoking habit, inability to capture the presence of signs of undernutrition in the normal-weight comparative group, consideration of body composition) may significantly scale down the protective role of obesity in terms of mortality. However, it is still necessary to acknowledge few biases (e.g., reverse causation, attrition bias, selection bias of healthy obese subjects or resilient survivors) that would still apply to obesity even when defined according with body composition. Further research should be prompted in order to promote correct phenotyping of patients in order to capture properly the trajectories of mortality in a number of diseases.
10.3389/fnut.2020.00053
Update on obesity, the obesity paradox, and obesity management in heart failure.
Progress in cardiovascular diseases
Obesity is a major public health challenge worldwide. It is costly, predisposes to many cardiovascular (CV) diseases (CVD), is increasing at an alarming rate, and disproportionately affects people of low-socioeconomic status. It has a myriad of deleterious effects on the body, particularly on the CV system. Obesity is a major risk factor for heart failure (HF) and highly prevalent in this population, particularly in those with HF with preserved ejection fraction (HFpEF), to the extent that an obesity HFpEF phenotype has been proposed in the literature. However, once HF is developed, an obesity paradox exists where those with obesity have better short- and mid-term survival than normal or underweight individuals, despite a greater risk for hospitalizations. It may be argued that excess energy reserve, younger patient population, higher tolerability of HF therapy and better nutritional status may account for at least part of the obesity paradox on survival. Furthermore, body mass index (BMI) may not be an accurate measure of body composition, especially in HF, where there is an excess volume status. BMI also fails to delineate fat-free mass and its components, which is a better predictor of functional capacity and cardiorespiratory fitness (CRF), which particularly is increasingly being recognized as a risk modifier in both healthy individuals and in persons with comorbidities, particularly in HF. Notably, when CRF is accounted for, the obesity paradox disappears, suggesting that improving CRF might represent a therapeutic target with greater importance than changes in body weight in the setting of HF. In this narrative review, we discuss the current trends in obesity, the causal link between obesity and HF, an update on the obesity paradox, and a description of the major flaws of BMI in this population. We also present an overview of the latest in HF therapy, weight loss, CRF, and the application of these therapeutic approaches in patients with HF and concomitant obesity.
10.1016/j.pcad.2024.01.003
Obesity paradox and stroke: a narrative review.
Forlivesi Stefano,Cappellari Manuel,Bonetti Bruno
Eating and weight disorders : EWD
BACKGROUND:Despite obesity is an established risk factor for stroke, several studies reported a better outcome after stroke in obese and overweight patients. This counterintuitive finding, which was described in the whole spectrum of cardiovascular diseases, is known as obesity paradox. OBJECTIVE:This is a narrative overview on the obesity paradox and stroke. METHODS:We used as sources MEDLINE/PubMed, CINAHL, EMBASE, and Cochrane Library from inception to 2019, and selected papers that discussed the association of obesity with outcome and mortality after stroke. RESULTS:The majority of studies reported lower mortality rates and better functional outcome after stroke in obese and overweight patients compared with normal weight and underweight patients, suggesting the existence of an obesity paradox in stroke. However, available studies are limited by several major methodological concerns including absence of randomized trials, retrospective nature of most studies, assessment of obesity with body mass index (BMI), non-linear relationship between BMI and outcome, short follow-up period, and differences in co-morbid conditions and stroke characteristics. CONCLUSIONS:The existence of an obesity paradox in stroke is still controversial and further higher quality evidence is needed to clarify the relationship between obesity and stroke outcome. LEVEL OF EVIDENCE:Level V, narrative review.
10.1007/s40519-020-00876-w
An Overview and Update on Obesity and the Obesity Paradox in Cardiovascular Diseases.
Elagizi Andrew,Kachur Sergey,Lavie Carl J,Carbone Salvatore,Pandey Ambarish,Ortega Francisco B,Milani Richard V
Progress in cardiovascular diseases
Obesity increases a number of cardiovascular disease (CVD) risk factors, but patients with many types of CVD may have a better prognosis if classified as overweight or obese, a phenomenon known as the "obesity paradox". This paradoxical benefit of a medically unfavorable phenotype is particularly strong in the overweight and class I obesity, and less pronounced in the more severe or morbidly obese populations (class II-III and greater). Rather than an obesity paradox, it is possible that this phenomenon may represent a "lean paradox", in which individuals classified as normal weight or underweight may have a poorer prognosis with respect to CVD, as a result of a progressive catabolic state and lean mass loss. Cardiorespiratory fitness (CRF) is a fundamental part of this discussion. A greater CRF is associated with lower CVD risk, regardless of body mass index (BMI). Also, the assessment of body composition compartments (i.e., fat mass, fat-free mass, lean mass) and the presence of metabolic derangements may be better indicators of CVD risk than BMI alone. The focus of this review is to summarize the current evidence of the obesity paradox. Moreover, we discuss the utility and limitations of BMI for cardiometabolic risk stratification, in addition to concepts such as "metabolically healthy obesity" (MHO) and the "fat but fit" phenomenon, which describe patients who are diagnosed with obesity using BMI, but without major metabolic derangements and with greater CRF, respectively. Finally, we propose that obese patients presenting with an excess body fat, yet without metabolic abnormalities, should still be viewed as an "at risk" population, and as such should receive advice to change their lifestyle to improve their CRF and to prevent the development of impaired fasting glucose, diabetes mellitus and other CVD risk factors as a form of primary prevention.
10.1016/j.pcad.2018.07.003
Obesity paradox and heart failure.
Donataccio Maria Pia,Vanzo Angiola,Bosello Ottavio
Eating and weight disorders : EWD
BACKGROUND:There is scientific consensus that obesity increases the risk of cardiovascular diseases (CVD), including heart failure (HF). However, in CVD, many studies observed greater survival in overweight or class 1 obesity individuals. This counterintuitive observation was termed "obesity paradox" (OP). OBJECTIVE AND METHODS:This article is a narrative overview of the relationship between OP and CVD, particularly HF. The sources used were MEDLINE/PubMed, CINAHL, EMBASE, and Cochrane Library, from 2001 to 31 May 2020, exception for a 1983 work of historical importance. Studies reporting association and prognostic impact of obesity in HF and the impact of body composition on cardiac structure and myocardial function in obesity were also included in this review. In addition, we examined references from the retrieved articles and explored several related websites. Ultimately, we chose 79 relevant documents. Fifty-three were specifically focused on OP and HF. RESULTS:In this review, we made a summary of the evidence coming from a series of studies investigating OP. Many of these studies do not take into consideration or underestimate some of the more important morpho-functional variables of patients suffering from HF: among these, body composition and visceral adiposity, sarcopenic obesity, muscle fitness (MF), and cardiorespiratory fitness (CRF). A high body mass index (BMI) represents a risk factor for HF, but it also seems to exert a protective effect under certain circumstances. Fat distribution, lean mass, and cardio fitness could play an essential role in determining the observed differences in the HF population. CONCLUSION:BMI does not distinguish between the metabolically healthy and metabolically unhealthy obesity. The obesity impact on morbidity and premature mortality can be underestimated and, therefore, may lead to incorrect clinical courses. LEVEL OF EVIDENCE:Level V, Narrative review.
10.1007/s40519-020-00982-9
The obesity paradox and diabetes.
Gravina Giovanni,Ferrari Federica,Nebbiai Grazia
Eating and weight disorders : EWD
BACKGROUND:Obesity has been proven to be a risk factor for type 2 diabetes mellitus (T2DM) through numerous pathogenetic mechanisms. Unexpectedly, some studies suggest that subjects with overweight/obesity and T2DM have better clinical outcome than their normal weight peers. This finding is described as "obesity paradox" and calls into question the importance of weight loss in this specific population. OBJECTIVE:This article is a narrative overview on the obesity and type 2 diabetes mellitus, particularly regarding the obesity paradox in T2DM patients. METHODS:We used as sources MEDLINE/PubMed, CINAHL, EMBASE, and Cochrane Library, from inception to March 2020; we chose 30 relevant papers regarding the association of obesity with clinical outcome and mortality of patients affected by T2DM. RESULTS:Many studies report that in patients with T2DM, overweight and obesity are associated with a better prognosis than underweight or normal weight, suggesting the presence of an obesity paradox. However, these studies have numerous limitations due to their mainly retrospective nature and to numerous confounding factors, such as associated pathologies, antidiabetic treatments, smoking habit, lack of data about distribution of body fat or weight history. CONCLUSION:Literature data regarding the phenomenon of obesity paradox in T2DM patients are controversial due to the several limitations of the studies; therefore in the management of patients with overweight/obesity and T2DM is recommended referring to the established guidelines, which indicate diet and physical activity as the cornerstone of the treatment. LEVEL OF EVIDENCE:Level V: narrative review.
10.1007/s40519-020-01015-1
The Obesity Paradox and Mortality in Older Adults: A Systematic Review.
Nutrients
"Obesity paradox" describes the counterintuitive finding that aged overweight and obese people with a particular disease may have better outcomes than their normal weight or underweight counterparts. This systematic review was performed to summarize the publications related to the obesity paradox in older adults, to gain an in-depth understanding of this phenomenon. PubMed©, Embase©, and Scopus© were used to perform literature search for all publications up to 20 March 2022. Studies were included if they reported data from older adults on the relation between BMI and mortality. The following article types were excluded from the study: reviews, editorials, correspondence, and case reports and case series. Publication year, study setting, medical condition, study design, sample size, age, and outcome(s) were extracted. This review has been registered with PROSPERO (no. CRD42021289015). Overall, 2226 studies were identified, of which 58 were included in this systematic review. In all, 20 of the 58 studies included in this review did not find any evidence of an obesity paradox. Of these 20 studies, 16 involved patients with no specific medical condition, 1 involved patients with chronic diseases, and 2 involved patients with type 2 diabetes mellitus. Seven out of the nine studies that looked at short-term mortality found evidence of the obesity paradox. Of the 28 studies that examined longer-term mortality, 15 found evidence of the obesity paradox. In the studies that were conducted in people with a particular medical condition ( = 24), the obesity paradox appeared in 18 cases. Our work supports the existence of an obesity paradox, especially when comorbidities or acute medical problems are present. These findings should help guide strategies for nutritional counselling in older populations.
10.3390/nu15071780
Obesity and cardiovascular disease: risk factor, paradox, and impact of weight loss.
Lavie Carl J,Milani Richard V,Ventura Hector O
Journal of the American College of Cardiology
Obesity has reached global epidemic proportions in both adults and children and is associated with numerous comorbidities, including hypertension (HTN), type II diabetes mellitus, dyslipidemia, obstructive sleep apnea and sleep-disordered breathing, certain cancers, and major cardiovascular (CV) diseases. Because of its maladaptive effects on various CV risk factors and its adverse effects on CV structure and function, obesity has a major impact on CV diseases, such as heart failure (HF), coronary heart disease (CHD), sudden cardiac death, and atrial fibrillation, and is associated with reduced overall survival. Despite this adverse association, numerous studies have documented an obesity paradox in which overweight and obese people with established CV disease, including HTN, HF, CHD, and peripheral arterial disease, have a better prognosis compared with nonoverweight/nonobese patients. This review summarizes the adverse effects of obesity on CV disease risk factors and its role in the pathogenesis of various CV diseases, reviews the obesity paradox and potential explanations for these puzzling data, and concludes with a discussion regarding the current state of weight reduction in the prevention and treatment of CV diseases.
10.1016/j.jacc.2008.12.068
The obesity paradox.
Amundson Dennis E,Djurkovic Svetolik,Matwiyoff Gregory N
Critical care clinics
The term "obesity paradox" refers to the observation that, although obesity is a major risk factor in the development of cardiovascular and peripheral vascular disease, when acute cardiovascular decompensation occurs, for example, in myocardial infarction or congestive heart failure, obese patients may have a survival benefit. In addition, it has been suggested that obese patients tend to fare better after certain surgical procedures, such as coronary artery bypass surgery. Moreover, it appears that obese men with chronic hypertensive heart disease live longer than men of normal weight. Mounting evidence shows that obesity alone may confer a survival benefit independent of age, medical care, or therapy. Perhaps the definition of obesity needs to be revisited, and it is also possible that all fat is not equal.
10.1016/j.ccc.2010.06.004
Obesity paradox in cardiovascular disease: where do we stand?
Carbone Salvatore,Canada Justin M,Billingsley Hayley E,Siddiqui Mohammad S,Elagizi Andrew,Lavie Carl J
Vascular health and risk management
Obesity is associated with an increased risk of developing cardiovascular disease (CVD), particularly heart failure (HF) and coronary heart disease (CHD). The mechanisms through which obesity increases CVD risk involve changes in body composition that can affect hemodynamics and alters heart structure. Pro-inflammatory cytokines produced by the adipose tissue itself which can induce cardiac dysfunction and can promote the formation of atherosclerotic plaques. When obesity and HF or CHD coexist, individuals with class I obesity present a more favorable prognosis compared to individuals who are normal or underweight. This phenomenon has been termed the "obesity paradox." Obesity is defined as an excess fat mass (FM), but individuals with obesity typically also present with an increased amount of lean mass (LM). The increase in LM may explain part of the obesity paradox as it is associated with improved cardiorespiratory fitness (CRF), a major determinant of clinical outcomes in the general population, but particularly in those with CVD, including HF. While increased LM is a stronger prognosticator in HF compared to FM, in patients with CHD excess FM can exert protective effects particularly when not associated with increased systemic inflammation. In the present review, we discuss the mechanisms through which obesity may increase the risk for CVD, and how it may exert protective effects in the setting of established CVD, with a focus on body composition. We also highlight the importance of measuring or estimating CRF, including body composition-adjusted measures of CRF (ie, lean peak oxygen consumption) for an improved risk status stratification in patients with CVD and finally, we discuss the potential non-pharmacologic therapeutics, such as exercise training and dietary interventions, aimed at improving CRF and perhaps clinical outcomes.
10.2147/VHRM.S168946
Obesity Paradox: Fact or Fiction?
Current obesity reports
PURPOSE OF REVIEW:Obesity is related to several comorbidities such as type 2 diabetes mellitus, cardiovascular disease, heart failure, and various types of cancers. While the detrimental effect of obesity in both mortality and morbidity has been well established, the concept of the obesity paradox in specific chronic diseases remains a topic of continuous interest. In the present review, we examine the controversial issues around the obesity paradox in certain conditions such as cardiovascular disease, several types of cancer and chronic obstructive pulmonary disease, and the factors that may confound the relation between obesity and mortality. RECENT FINDINGS:We refer to the obesity paradox when particular chronic diseases exhibit an interesting "paradoxical" protective association between the body mass index (BMI) and clinical outcomes. This association, however, may be driven by multiple factors among which the limitations of the BMI itself; the unintended weight loss precipitated by chronic illness; the various phenotypes of obesity, i.e., sarcopenic obesity or the athlete's obesity phenotype; and the cardiorespiratory fitness levels of the included patients. Recent evidence highlighted that previous cardioprotective medications, obesity duration, and smoking status seem to play a role in the obesity paradox. The obesity paradox has been described in a plethora of chronic diseases. It cannot be emphasized enough that the incomplete information received from a single BMI measurement may interfere with outcomes of studies arguing in favor of the obesity paradox. Thus, the development of carefully designed studies, unhampered by confounding factors, is of great importance.
10.1007/s13679-023-00497-1
Obesity and the Obesity Paradox in Heart Failure.
Horwich Tamara B,Fonarow Gregg C,Clark Adrienne L
Progress in cardiovascular diseases
Obesity continues to be a public health problem in the general population, and also significantly increases the risk for the development of new-onset heart failure (HF). However, in patients with already-established, chronic HF, overweight and mild to moderate obesity is associated with substantially improved survival compared to normal weight patients; this has been termed the "obesity paradox". The majority of studies measure obesity by body mass index, but studies utilizing less-frequently used measures of body fat and body composition, including waist circumference, waist-hip ratio, skinfold estimates, and bioelectrical impedance analysis also confirm the obesity paradox in HF. Other areas of investigation such as the relationship of the obesity paradox to cardiorespiratory fitness, gender, and race are also discussed. Finally, this review explores various explanations for the obesity paradox, and summarizes the current evidence for intentional weight loss treatments for HF in context.
10.1016/j.pcad.2018.05.005
Obesity paradox and aging.
Bosello Ottavio,Vanzo Angiola
Eating and weight disorders : EWD
BACKGROUND:In association with the rapid lengthening of life expectancy and the ever-rising prevalence of obesity, many studies explored in the elderly the phenomenon usually defined as the obesity paradox. OBJECTIVE AND METHODS:This article is a narrative overview of seventy-two papers (1999-2019) that investigated the obesity paradox during the aging process. Twenty-nine documents are examined more in detail. RESULTS:The majority of studies suggesting the existence of an obesity paradox have evaluated just BMI as an index of obesity. Some aspects are often not assessed or are underestimated, in particular body composition and visceral adiposity, sarcopenic obesity, and cardio fitness. Many studies support that central fat and relative loss of fat-free mass may become relatively more important than BMI in determining the health risk associated with obesity in older ages. CONCLUSION:Inaccurate assessments may lead to a systematic underestimation of the impact of obesity on morbidity and premature mortality and, consequently, to clinical behaviors that are not respectful of the health of elderly patients. Knowledge of the changes in body composition and fat distribution will help to better understand the relationship between obesity, morbidity, and mortality in the elderly. LEVEL OF EVIDENCE:Level V, narrative overview.
10.1007/s40519-019-00815-4
Updates on obesity and the obesity paradox in cardiovascular diseases.
Progress in cardiovascular diseases
The prevalence of obesity has reached pandemic proportions worldwide and certainly in the United States. Obesity is a well-established independent risk factor for development of many cardiovascular diseases (CVD), including heart failure, coronary heart disease, atrial fibrillation, and hypertension. Therefore, it is logical to expect obesity would have a strong correlation with CVD mortality. However, a substantial body of literature demonstrates a paradox with improved prognosis of overweight and obese patients with established CVD compared to lean patients with the identical CVD. Surprisingly, similar data has also shown that cardiovascular fitness, rather than weight loss alone, influences the relationship between obesity and mortality in those with established CVD. The impact of fitness, exercise, physical activity (PA), and weight loss and their relationship to the obesity paradox are all reviewed here.
10.1016/j.pcad.2022.11.013