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AUTHOR: CAROLINE WELLBERY, M.D.

TITLE: Is Obesity a Protective Factor in Heart Failure?

SOURCE: American Family Physician 75 no5 732 Mr 1 2007

COPYRIGHT: Copyright (C) American Academy of Family Physicians (AAFP). All rights reserved. Any reuse,
distribution or alteration without the express written permission of the AAFP is prohibited.

Background: Although analyses of data from the Framingham database suggest that increased
body mass index (BMI) is a risk factor for the development of heart failure, recent studies have noted
that obesity maybe associated with better outcomes in heart failure. This has become known as the
"obesity paradox." Because these findings may lead; physicians to discourage patients with heart
failure from losing weight, a better understanding of the relationship between obesity and heart
failure is warranted.
Results: Habbu and colleagues evaluated eight studies looking at the relationship between heart
failure and BMI. All studies showed a correlation between higher BMI and survival. However, most
studies had limitations such as sample size, insufficient delineation of variables used in adjustment,
and the use of clinical instead of objective criteria in diagnosing heart failure; lead-time bias also was
a possibility in one study. More importantly, the studies' findings suggest a negative impact from
cachexia rather than positive effects from obesity. One study excluded patients with cachexia
(defined as unintentional weight loss) but included patients with BMIs around 22 kg per m[sup2], who
had the same comparatively poor outcomes as the excluded patients. In another study the reverse
occurred--patients with unintentional weight loss but a normal BMI remained in the study, whereas
patients with very low BMIs were excluded.
Conclusion: Overall, the study results show an inverse relationship between BMI and survival, but
one possible cause may be that patients were thinner because they were less healthy. In addition, the
studies do not exclude the possibility that patients with very high BMIs (i.e., greater than 35 kg per
m[sup2]) have worse mortality outcomes. If this is so, the U-shaped curve describing the relationship
between BMI and mortality in the general population also would apply to patients with heart failure.
ADDED MATERIAL
Source: Habbu A, et al. The obesity paradox: fact or fiction? Am J Cardiol 2006;98:944-8.
EDITOR'S NOTE: This study raises questions similar to those posed by larger studies relating
overweight and obesity to mortality. One study demonstrated a U-shaped curve with optimal BMIs at
25 kg per m[sup2] and steady increases in mortality in the overweight range.(FN1) Another study
showed excess mortality in underweight and obese persons but no correlation between obesity and
mortality in the overweight range (BMI = 25 to 29.9 kg per m[sup2]).(FN2) Mortality may not be the
best outcome measure because of the long lead times between morbidity and mortality and because
of unhealthy conditions accounting for lower weights.--c.w.

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