Update on Obesity and Obesity Paradox in Heart Failure
Section snippets
Impact of obesity on cardiac morphology and performance
Alpert and colleagues7., 8. have recently reviewed this topic in detail. Considerable evidence underscores the adverse effects of excessive adipose accumulation and associated fat-free mass on central and peripheral hemodynamics, as well as on cardiac structure and systolic and diastolic LV function (Fig 1, Table 1).5., 7.
Obesity and HF
Considering the adverse effects of adiposity on hemodynamics and LV structure and ventricular function, not surprisingly, obesity leads to marked increases in the prevalence of HF.5., 6. Additionally, myocardial lipotoxicity and lipoapoptosis have also been described with severe obesity in animal models and may potentially contribute to an obesity cardiomyopathy in humans; however, other factors, including increased activation of the renin–angiotensin–aldosterone system, increased sympathetic
Obesity paradox in HF
Despite the adverse affects of obesity on LV structure and function that markedly increase the prevalence of HF in obesity, numerous studies have now reported a powerful relationship between obesity and prognosis, with overweight and, especially, obese Class I and II HF patients having the better prognosis than do their leaner counterparts with HF.5., 6. Horwich and colleagues19 first described this almost 15 years ago, and this association has now been confirmed in many studies and
Mechanisms for the obesity paradox in HF
The mechanisms for the obesity paradox in CVD and HF particularly remain somewhat unclear and difficult to reconcile, but several potential reasons are listed in Table 2.5 Certainly, advanced HF is a catabolic state, and heavier HF patients may have more metabolic reserve, whereas frail and cachectic patients (discussed later) experience greater morbidity and mortality for many diseases, including HF. Adipose tissue is also known to promote soluble tumor necrosis factor-alpha receptors that
Impact of frailty/cachexia in HF
Frailty can be defined as a biological syndrome that is characterized by declining overall function and loss of resistance to stressors, which is associated with increased morbidity, mortality, and healthcare expenditures, particularly in the elderly, who have a high prevalence of HF.28 A recent study indicates that frailty was highly prevalent among community patients with HF, and this predicted a significant increase in the risk of hospitalization and emergency department encounters,
Impact of severe or Class III obesity
Although an obesity paradox exists for most CVD as well as HF, it is most likely that this mostly applies to overweight and mildly obese patients, less so for Class II obesity (BMI 35–40 kg/m2) and probably not for more severe, or Class III obesity (BMI ≥ 40 kg/m2).32., 33. In CHD, for example, although an obesity paradox was noted short-term for all classes of BMI, more severe obesity was associated with worse survival during long-term follow-up.34., 35. The impact of morbid or Class III obesity
Impact of fitness in HF
Substantial data indicate that muscular strength and levels of CRF markedly impact prognosis in many CVD patients, including HF.27., 36. In fact, low levels of CRF may be one of the strongest risk factors for CVD and total mortality.37., 38., 39. High levels of CRF, including higher workloads on treadmill stress tests, longer 6-min walking time, and higher peak oxygen consumption (VO2), are associated with better prognosis in most CVD, including CHD and HF.36., 37., 38., 39., 40., 41. In
Intentional weight loss in HF
Intentional weight loss may be one of the most effective long-term therapies for improving the hemodynamics and cardiac structure and functional abnormalities associated with obesity, most of which adversely impact HF.5., 7. Despite this evidence, however, and considering the previously discussed obesity paradox and adverse impact of cardiac cachexia and frailty in HF,5., 7., 28. the major HF societies during the past decade have vastly different recommendations regarding intentional weight
Conclusions
Obesity adversely affects hemodynamics and cardiac structure and function, leading to systolic and, particularly diastolic LV dysfunction. Despite this effect, however, many studies suggest an obesity paradox, where overweight and mildly obese HF patients have a better prognosis than do normal weight patients with HF. In contrast, underweight HF patients, as well as those with frailty and cardiac cachexia, particularly have a poor prognosis. Although long-term studies of intentional weight loss
Statement of conflict of interest
Dr. Lavie served as a Speaker and Consultant for the Coca-Cola Company (but on physical activity, exercise, and fitness and not on their products) and is author of the book The Obesity Paradox.
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Statement of Conflict of Interest: see page 399.