Obesity and Prevalence of Cardiovascular Diseases and Prognosis—The Obesity Paradox Updated

doi:10.1016/j.pcad.2016.01.008

Progress in Cardiovascular Diseases

Volume 58, Issue 5, March–April 2016, Pages 537-547

https://doi.org/10.1016/j.pcad.2016.01.008 Get rights and content

Abstract

The prevalence and severity of obesity have increased in the United States and most of the Westernized World over recent decades, reaching worldwide epidemics. Since obesity worsens most of the cardiovascular disease (CVD) risk factors, not surprisingly, most CVDs, including hypertension, coronary heart disease, heart failure, and atrial fibrillation, are all increased in the setting of obesity. However, many studies and meta-analyses have demonstrated an obesity paradox with regards to prognosis in CVD patients, with often the overweight and mildly obese having a better prognosis than do their leaner counterparts with the same CVD. The implication for fitness to markedly alter the relationship between adiposity and prognosis and the potential impact of weight loss, in light of the obesity paradox, are all reviewed.

Section snippets

Causes of weight gain, obesity, and energy balance

During recent years, the etiology of the obesity epidemic has been hotly debated.3., 10., 11. Regardless, it is widely accepted that changes in body weight and overall adiposity, at the most fundamental level, are the result of chronic positive energy balance, meaning energy expenditure is less than energy intake (or calories burned < calories consumed).³ There certainly have been several studies suggesting that energy or food intake is largely, if not completely, responsible for the obesity

Impact of obesity on hemodynamics and CV structure and function

Overweight and obesity have many adverse effects on risk factors, hemodynamics, and CV structure and function (Fig 1, Table 1)⁷ which has been reviewed in detail elsewhere.3., 4., 5., 6., 7. Obesity particularly increases blood volume, stroke volume, and cardiac output, which leads to an increase in cardiac work. These changes also lead to left ventricular (LV) dilatation and LV hypertrophy (LVH), both of the eccentric but also the concentric type, the latter particularly occurring when

Obesity and impact on CVD and prognosis—the obesity paradox

Due to the adverse effects that obesity has on CV risk factors and CV structure and function, not surprisingly, the prevalence of almost all CVD is increased in the setting of obesity, however, many studies have demonstrated surprisingly good prognosis among overweight and at least mildly obese patients with CVD, the so-called obesity paradox.3., 7., 8.

Mechanisms of the obesity paradox

The mechanisms of this obesity paradox in various CVD are difficult to reconcile, although several potential mechanisms are listed in Table 2.³ Certainly, it has been argued that some of the obesity paradox may be due to the inaccuracies of BMI to assess true body fatness,36., 37., 38., 54. but we and others have also demonstrated this paradox with % BF25., 26., 27., 28., 55. and even WC.,29., 56. Certainly, many have suggested that this paradox may be due to unmeasured confounders, including

Impact of severity of obesity

The prevalence of class III or “morbid” obesity (BMI ≥ 40 kg/m²) has been dramatically increasing and is now present in over 3% of the US population.1., 2. Although an obesity paradox exists, sometimes even in short-term follow-up even with extreme obesity, generally more severe obesity in long-term follow-up is associated with an ominous prognosis.3., 8., 31., 59., 60. Therefore, the obesity paradox is probably more of an “overweight paradox” or at least more confined to those in the mildly obese

Impact of cardiorespiratory fitness

Body fatness and CRF are strong predictors of CVD risk factors, as well as CV morbidity and mortality.3., 61., 62., 63., 64. In most CVD, patients with high levels of CRF have lower mortality than do patients without this disorder but with low levels of CRF.² In a major meta-analysis of 33 studies of over 100,000 participants where CRF was assessed by treadmill stress testing, Kodama and colleagues⁶⁵ demonstrated that for every 1 metabolic equivalent (MET) increase in CRF, all-cause and CHD/CVD

Impact of CRF on the obesity paradox

Several studies have indicated that CRF markedly alters the relationship between fatness and prognosis in both CHD²⁹ and HF,⁶⁹ as well as in veterans referred for stress testing.58., 70., 71. In a study of nearly 10,000 patients with CHD followed for almost 14 years, only those in the bottom tertile of age- and gender-related levels of CRF demonstrated an obesity paradox, which was present by BMI, % BF, and even by WC or central obesity in the unfit (Fig 3).²⁹ On the other hand, CHD patients

Potential benefits of purposeful weight reduction

Despite the obesity paradox, there are still potential beneficial effects of purposeful weight reduction.3., 4., 5., 6., 78., 79. Whereas weight loss has been questioned, with weight loss being associated with increased mortality in some studies,⁸⁰ purposeful weight loss during increased PA and exercise training is associated with considerable benefits in patients with CVD,3., 4., 5., 6., 78., 79. although a recent large study in DM did not demonstrate survival benefits from small amounts of

Conclusion

Obesity, generally assessed by BMI, adversely impacts CV risk factors and CV structure and function and is associated with increased risk of most CVD.90., 91. In 2016, however, one cannot discount that an obesity paradox clearly exists, even more so in the elderly population,⁹² meaning that overweight and, at least, mildly obese patients with most CVD have a better short- and medium-term prognosis than do leaner patients, particularly underweight and those in the lower end of the “normal” BMI

Financial disclosure/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 XX.

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Obesity and Prevalence of Cardiovascular Diseases and Prognosis—The Obesity Paradox Updated

Abstract

Section snippets

Causes of weight gain, obesity, and energy balance

Impact of obesity on hemodynamics and CV structure and function

Obesity and impact on CVD and prognosis—the obesity paradox

Mechanisms of the obesity paradox

Impact of severity of obesity

Impact of cardiorespiratory fitness

Impact of CRF on the obesity paradox

Potential benefits of purposeful weight reduction

Conclusion

Financial disclosure/conflict of interest

Prog Cardiovasc Dis

Lancet

J Am Coll Cardiol

Prog Cardiovasc Dis

JACC Heart Fail

JACC Heart Fail

Prog Cardiovasc Dis

Prog Cardiovasc Dis

Mayo Clin Proc

Am J Clin Nutr

Mayo Clin Proc

Prog Cardiovasc Dis

Mayo Clin Proc

Mayo Clin Proc

Am J Med

Prog Cardiovasc Dis

Mayo Clin Proc

Am J Med

J Am Coll Cardiol

Mayo Clin Proc

Lancet

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

Prog Cardiovasc Dis

Prog Cardiovasc Dis

Am J Cardiol

J Am Coll Cardiol

JACC Heart Fail

Prog Cardiovasc Dis

Prog Cardiovasc Dis

Prog Cardiovasc Dis

Am Heart J

J Am Coll Cardiol

Am J Med

Am J Cardiol

Am J Cardiol

Prog Cardiovasc Dis

Prog Cardiovasc Dis

Prog Cardiovasc Dis

Prog Cardiovasc Dis

Prog Cardiovasc Dis

Mayo Clin Proc

Mayo Clin Proc

Mayo Clin Proc

Am J Cardiol