Obesity and Heart Failure: Focus on the Obesity Paradox

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Obesity and Heart Failure: Focus on the Obesity Paradox Salvatore Carbone, MS, Carl J. Lavie, MD, Ross Arena, PhD, PT Mayo Clinic Proceedings Volume 92, Issue 2, Pages 266-279 (February 2017) DOI: 10.1016/j.mayocp.2016.11.001 Copyright © 2016 Mayo Foundation for Medical Education and Research Terms and Conditions

Figure 1 Risk of heart failure according to categories of body mass index (BMI). Considering a BMI of 18.5 to 24.9 kg/m2 as the reference category, overweight and obese individuals had an increased risk of heart failure with reduced and preserved ejection fraction, described as hazard ratio (HR). # = P<.01 vs BMI of 18.5 to 24.9 kg/m2. Data from N Engl J Med.4 Mayo Clinic Proceedings 2017 92, 266-279DOI: (10.1016/j.mayocp.2016.11.001) Copyright © 2016 Mayo Foundation for Medical Education and Research Terms and Conditions

Figure 2 Proposed mechanisms driving obesity to heart failure (HF) and to the obesity paradox once HF is diagnosed. The dark blue arrows indicate the potential detrimental effects of body composition components (fat mass and lean mass) on cardiac function and eventually HF development. The light blue arrows indicate the potential mechanisms by which body composition improves cardiorespiratory fitness (CRF). IL = interleukin; LV = left ventricular; LVH = LV hypertrophy; SVR = systemic vascular resistance; TNF-α = tumor necrosis factor α. Mayo Clinic Proceedings 2017 92, 266-279DOI: (10.1016/j.mayocp.2016.11.001) Copyright © 2016 Mayo Foundation for Medical Education and Research Terms and Conditions

Figure 3 Total mortality stratified by body mass index (BMI) and heart failure (HF). Patients with HF and higher BMI had a lower mortality rate than those with a lower BMI. Heart failure is categorized as HF with reduced ejection fraction (HFrEF) or HF with preserved ejection fraction (HFpEF). Adapted from Int J Obes (Lond),81 with permission from Nature Publishing Group. Mayo Clinic Proceedings 2017 92, 266-279DOI: (10.1016/j.mayocp.2016.11.001) Copyright © 2016 Mayo Foundation for Medical Education and Research Terms and Conditions

Figure 4 Hypothetical relationship between obesity phenotypes, cardiac function, and cardiorespiratory fitness in patients with heart failure. The figure highlights the proposed major role of body composition, obesity phenotypes, and lean mass in the development and progression of cardiac dysfunction and cardiorespiratory fitness abnormalities. BMI = body mass index. Adapted from EC Cardiol.114 Mayo Clinic Proceedings 2017 92, 266-279DOI: (10.1016/j.mayocp.2016.11.001) Copyright © 2016 Mayo Foundation for Medical Education and Research Terms and Conditions

Figure 5 Obesity paradox and cardiorespiratory fitness (CRF). Kaplan-Meier analysis according to body mass index (BMI) in the low CRF group (peak oxygen consumption <14 mL∙kg−1∙min−1) (left) and in the high CRF group (peak oxygen consumption >14 mL∙kg−1∙min−1) (right). This figure describes the absence of the obesity paradox in patients with relatively high CRF (right) compared with those who have low CRF, in which the obesity paradox is apparent. From Mayo Clin Proc.122 Mayo Clinic Proceedings 2017 92, 266-279DOI: (10.1016/j.mayocp.2016.11.001) Copyright © 2016 Mayo Foundation for Medical Education and Research Terms and Conditions

Figure 6 Proposed nonpharmacological therapy for patients with heart failure. In addition to standard of care, we hypothesize that a diet with low proinflammatory effects (low sugars and low saturated fat) and increased resistance training, potentially increasing the amount of lean mass, will improve cardiorespiratory fitness and perhaps prognosis in patients with heart failure. ACE = angiotensin-converting enzyme; ARB = angiotensin receptor blocker. Mayo Clinic Proceedings 2017 92, 266-279DOI: (10.1016/j.mayocp.2016.11.001) Copyright © 2016 Mayo Foundation for Medical Education and Research Terms and Conditions