European Heart Journal (2023) 44, 4199
https://doi.org/10.1093/eurheartj/ehad504
The fiction of the obesity paradox
1
Maya Guglin *
1
Division of Cardiovascular Disease, Krannert Institute of Cardiology, Indiana University School of Medicine, 1801 Senate Avenue Suite 2000, Indianapolis, IN 46202, USA
Online publish-ahead-of-print 2 August 2023
This commentary refers to ‘Anthropometric measures and
adverse outcomes in heart failure with reduced ejection
fraction: revisiting the obesity paradox’, by J. H. Butt
et al., https://doi.org/10.1093/eurheartj/ehad083.
We read, with great interest, the paper by Butt et al.,1 who found no
obesity paradox in heart failure (HF), using antropometric characteris­
tics other than body mass index (BMI).
Obesity paradox is the most counter-intuitive phenomenon in HF.
In essence, the concept is that increased BMI is protective and is asso­
ciated with reduced mortality.
Indeed, this is paradoxical: before the onset of the disease, obesity
is a risk factor for its development, but once the disease is present,
obesity becomes protective. In the past, we analysed the literature
on obesity paradox in HF and discovered some striking similarities
in the baseline characteristics of participants across the studies.
Patients with higher BMI differed from normal weight patients not
only by obesity but also by multiple other parameters, and differences
had to be overcome by statistical methods. First and foremost, obese
patients were significantly younger than their normal weight counter­
parts. This held true in 17 of the 19 examined studies, and in the re­
maining two studies, the difference was not significant.2 Second,
systolic blood pressure was higher in obese subjects, favouring sur­
vival in this group. All studies, which provided actual numbers for sys­
tolic blood pressure of the participants, reported higher values,
sometimes by 8–9 mmHg, in the high BMI groups. Third, the distribu­
tion of the left ventricular ejection fraction (LVEF) values among dif­
ferent BMI classes was also beneficial for obese group. Percentage
of individuals with LVEF <30% was 32.5% in subjects with normal
weight and only 18.1% in obese.3 Whenever the absolute numbers
of LVEF were significantly different, they favoured obese individuals.2
Besides, obese individuals with HF had higher LVEF,2 better renal func­
tion, less prevalent and less severe valvular regurgitation, better nutri­
tional status, and more favourable values of other indicators of
wellness, including pre-albumin and cholesterol. A smaller proportion
of obese patients had advanced functional class (New York Heart
Association III and IV).2
* Corresponding author. Tel: (317) 218-1994, Fax: (317) 323-6475, Email: mguglin@ggmail.com
© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
DISCUSSION FORUM
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Being younger and having superior cardiac function, better blood
pressure, and nutritional status, obese patients, not surprisingly, had
better survival.
We also previously showed that not accounting for some unknown fac­
tors can result in false presumption that obesity is indeed associated with
favourable outcomes, when in reality it may represent a statistical artefact.4
This unknown factor is likely the combination of favourable phenotypical
features, a synergistic effect of younger age, higher LVEF, better renal func­
tion, higher systolic blood pressure, and better nutrition. To confirm our
conclusion, several studies showed that the course of HF improves after
weight loss,5 which is perfectly aligned with obesity being a cardiovascular
risk factor, and is not compatible with obesity being favourable for survival.
Supplementary data
Supplementary data are not available at European Heart Journal online.
Declarations
Disclosure of Interest
All authors declare no conflict of interest for this contribution.
References
1. Butt JH, Petrie MC, Jhund PS, Sattar N, Desai AS, Køber L, et al. Anthropometric measures
and adverse outcomes in heart failure with reduced ejection fraction: revisiting the obesity
paradox. Eur Heart J 2023;44:1136–53. https://doi.org/10.1093/eurheartj/ehad083
2. Guglin M, Baxi K, Schabath M. Anatomy of the obesity paradox in heart failure. Heart Fail
Rev 2014;19:621–35. https://doi.org/10.1007/s10741-013-9406-7
3. Schwartzenberg S, Benderly M, Malnick S, George J, Goland S. The “obesity paradox”:
does it persist among Israeli patients with decompensated heart failure? A subanalysis
of the Heart Failure Survey in Israel (HFSIS). J Card Fail 2012;18:62–7. https://doi.org/
10.1016/j.cardfail.2011.09.013
4. Charnigo R, Guglin M. Obesity paradox in heart failure: statistical artifact, or impetus to
rethink clinical practice? Heart Fail Rev 2017;22:13–23. https://doi.org/10.1007/s10741-
016-9577-0
5. Lim CP, Fisher OM, Falkenback D, Boyd D, Hayward CS, Keogh A, et al. Bariatric surgery
provides a “bridge to transplant” for morbidly obese patients with advanced heart failure
and may obviate the need for transplantation. Obes Surg 2016;26:486–93. https://doi.org/
10.1007/s11695-015-1789-1