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Journal of the American College of Cardiology
© 2011 by the American College of Cardiology Foundation
Published by Elsevier Inc.
EDITORIAL COMMENT
Botero’s Fat Figures and
the Risk of Heart Failure*
Eileen Hsich, MD
Cleveland, Ohio
Is there such a thing as a “healthy fat” person? Can obesity
be less risky than maintaining normal weight? The answer is
yes, if the normal-weight individual has the metabolic
syndrome (MetS). With cardiovascular disease, this has
been referred to as the “obesity paradox” (1). As we further
understand the relationship between body mass index
(BMI) and cardiovascular risk, we realize that the excess
cardiovascular deaths observed in obese patients compared
with normal-weight patients (2) may be due to other factors
including a higher prevalence of MetS among obese patients
(2). In fact, the paper by Voulgari et al. (3) in this issue of
the Journal nicely demonstrates that MetS better correlates
with development of heart failure (HF) than BMI.
See page 1343
The association of obesity with HF has been known since at
least the 1950s when a 43-year-old “monstrously” obese man
died of biventricular heart failure, and the autopsy revealed a
heart weighing 600 g with dilated and hypertrophied ventricles
(right ⬎ left) (4). Since that case report, epidemiological
studies have shown a higher risk of the development of left
ventricular hypertrophy (5), left ventricular dilation (6), diastolic dysfunction (7), and clinical HF (8 –12) among obese
individuals compared with those of normal weight. In the
Framingham Heart Study involving 5,881 participants who
were followed for a mean of 14 years, there was a 5% increased
risk of HF in men and a 7% increased risk of HF in women for
every 1-U increase in BMI after adjusting for known risk
factors, such as hypertension and diabetes mellitus (9). The risk
of HF was present whether obesity was defined by BMI
(8 –12), waist circumference (8,10,13), or waist– hip ratio
(8,10). In studies that separated the cohort by sex (8 –10,14)
and/or race (8), this association was still present.
The obesity paradox in HF refers to the lower risk of urgent
transplantation and/or death observed among obese HF pa-
*Editorials publication in the Journal of the American College of Cardiology reflect
the views of the authors and do not necessarily represent the views of JACC or the
American College of Cardiology.
From the Cleveland Clinic, Cleveland, Ohio. Dr. Hsich has reported that she has
no relationships relevant to the contents of this paper to disclose.
Vol. 58, No. 13, 2011
ISSN 0735-1097/$36.00
doi:10.1016/j.jacc.2011.06.030
tients compared with those of low or normal weight. In acute
decompensated HF based on ADHERE (Acute Decompensated Heart Failure National Registry), which had 108,927
patients, there was a 10% lower risk-adjusted mortality (95%
confidence interval: 0.88 to 0.93, p ⬍ 0.0001) for every 5-unit
increase in BMI (15). In chronic HF based on the CHARM
(Candesartan in Heart failure: Assessment of Reduction in
Mortality and morbidity) cohort (N ⫽ 7,599), obese patients
with reduced and preserved left ventricular ejection fraction
(LVEF) had a lower mortality rate than lean and overweight
patients (16). Most of the studies noting this obesity paradox
have defined obesity by BMI (15–20) except for 1 study that
observed the “paradox” when obesity was defined by waist
circumference (WC) (21) and another that used percentage of
body fat (defined by the skinfold technique) and total body fat
(22). These last 2 studies have challenged the argument that
the obesity paradox is predominantly due to the limitations of
BMI, which are dependent on the percentage of body fat and
can vary based on age, sex, and race (23–25). However,
additional studies are needed to verify these results because the
studies involved small cohorts (WC study: N ⫽ 344; body fat
study: N ⫽ 201), few clinical events (WC study: 68 events;
body fat study: 28 events), and a limited patient population
(systolic HF only).
The Voulgari et al. (3) study did not demonstrate an
association between obesity defined by BMI and HF in the
subgroup of patients without MetS. Their study differs from
the other epidemiologic studies evaluating risk factors for HF
due to exclusion of patients with diabetes mellitus and macrovascular disease, separation of patients into those with and
without metabolic syndrome, and few cardiac events (HF
developed in 185 patients), limiting the power of the analysis.
The strength of their analysis was the use of the National
Cholesterol Education Program Adult Treatment Panel III
(NCEP-ATP III) criteria for MetS, cardiac catheterization in
about 83% of the cohorts to rule out subclinical coronary artery
disease, and few patients lost to follow-up. It was also a
prospective study with echocardiograms obtained for all patients. Although it was relatively small, the study did demonstrate that MetS better correlated with the development of HF
than just BMI. Their findings give credence to the existence of
a “metabolically healthy population” and raises concern about
those with MetS.
The metabolic syndrome is defined by abdominal obesity,
hypertension, high triglyceride level, and low levels of highdensity lipoprotein cholesterol, and insulin resistance. Different
definitions have been proposed by many organizations over the
years, and the one currently adopted is the NCEP-ATP III
criteria (2,26), which was used in the Voulgari et al. (3)
study. The metabolic syndrome, such as obesity, is considered a risk factor for the development of left ventricular
hypertrophy (27), left ventricular dilation (27), myocardial
dysfunction (27,28), and clinical HF (29 –32). In the Third
National Health and Nutrition Examination Survey, people
with MetS had almost twice the risk of the development of
1352
Hsich
Obesity, Metabolic Syndrome, and Heart Failure Risk
HF than those without MetS (31). Given the fact that the
components of MetS are known risk factors for HF (2), it is
not surprising that MetS is a stronger predictor of HF than
simply 1 variable such as the presence of obesity.
How should we incorporate this information into our daily
medical practices, especially given data showing that MetS is a
better predictor of cardiovascular outcome than obesity defined
by BMI (33)? We currently record patients’ weight and vital
signs and assess for cardiovascular risk factors such as diabetes
mellitus and hyperlipidemia when they come to our office. Do
we really need a scale or simply a measuring tape? How should
we advise obese patients without MetS given the lower
incidence of HF in the Voulgari et al. (3) study and a lower risk
of cardiovascular events in the ULSAM (Uppsala Longitudinal
Study of Adult Men) (33)? Do we tell them that they are
among the “metabolically healthy obese” population and suggest that eating cheeseburgers and French fries is okay as long
as they do not meet NCEP-ATP III criteria for MetS? The
answer lies in Fernando Botero’s paintings. He is a neofigurative Columbian artist who paints healthy-appearing
young and middle-age obese people dancing, wrestling, and
enjoying life. What is missing in his paintings and in our clinics
is healthy elderly obese women and men. At an older age, they
probably are no longer healthy.
Reprint requests and correspondence: Dr. Eileen Hsich, Kaufman Center for Heart Failure, Heart and Vascular Institute,
Cleveland Clinic, J3-4, 9500 Euclid Avenue, Cleveland, Ohio
44195. E-mail: [email protected].
REFERENCES
1. Despres JP. Excess visceral adipose tissue/ectopic fat the missing link
in the obesity paradox? J Am Coll Cardiol 2011;57:1887–9.
2. Heart Disease and Stroke Statistics—2011 Update: A Report From the
American Heart Association. Available at: http://circ.ahajournals.org/
content/123/4/e18.full.pdf. Accessed July 7, 2011.
3. Voulgari C, Tentolouris N, Dilaveris P, Tousoulis D, Katsilambros N,
Stefanadis C. Increased heart failure risk in normal-weight people with
metabolic syndrome compared with metabolically healthy obese individuals. J Am Coll Cardiol 2011;58:1343–50.
4. Seide MJ. Heart failure due to extreme obesity; report of a case, with
autopsy findings. N Engl J Med 1957;257:1227–30.
5. Lauer MS, Anderson KM, Kannel WB, Levy D. The impact of
obesity on left ventricular mass and geometry. The Framingham Heart
Study. JAMA 1991;266:231– 6.
6. Bazzano LA, Belame SN, Patel DA, et al. Obesity and left ventricular
dilatation in young adulthood: the Bogalusa Heart Study. Clin Cardiol
2011;34:153–9.
7. Russo C, Jin Z, Homma S, et al. Effect of obesity and overweight on
left ventricular diastolic function: a community-based study in an
elderly cohort. J Am Coll Cardiol 2011;57:1368 –74.
8. Loehr LR, Rosamond WD, Poole C, et al. Association of multiple
anthropometrics of overweight and obesity with incident heart failure: the
Atherosclerosis Risk in Communities study. Circ Heart Fail 2009;2:18–24.
9. Kenchaiah S, Evans JC, Levy D, et al. Obesity and the risk of heart
failure. N Engl J Med 2002;347:305–13.
10. Hu G, Jousilahti P, Antikainen R, Katzmarzyk PT, Tuomilehto J.
Joint effects of physical activity, body mass index, waist circumference,
and waist-to-hip ratio on the risk of heart failure. Circulation
2010;121:237– 44.
11. Kenchaiah S, Sesso HD, Gaziano JM. Body mass index and vigorous
physical activity and the risk of heart failure among men. Circulation
2009;119:44 –52.
JACC Vol. 58, No. 13, 2011
September 20, 2011:1351–2
12. Baena-Diez JM, Byram AO, Grau M, et al. Obesity is an independent
risk factor for heart failure: Zona Franca Cohort study. Clin Cardiol
2010;33:760 – 4.
13. Dagenais GR, Yi Q, Mann JF, Bosch J, Pogue J, Yusuf S. Prognostic
impact of body weight and abdominal obesity in women and men with
cardiovascular disease. Am Heart J 2005;149:54 – 60.
14. He J, Ogden LG, Bazzano LA, Vupputuri S, Loria C, Whelton PK. Risk
factors for congestive heart failure in US men and women: NHANES I
epidemiologic follow-up study. Arch Intern Med 2001;161:996–1002.
15. Fonarow GC, Srikanthan P, Costanzo MR, Cintron GB, Lopatin M. An
obesity paradox in acute heart failure: analysis of body mass index and
inhospital mortality for 108,927 patients in the Acute Decompensated Heart
Failure National Registry. Am Heart J 2007;153:74–81.
16. Kenchaiah S, Pocock SJ, Wang D, et al. Body mass index and
prognosis in patients with chronic heart failure: insights from the
Candesartan in Heart failure: Assessment of Reduction in Mortality
and morbidity (CHARM) program. Circulation 2007;116:627–36.
17. Curtis JP, Selter JG, Wang Y, et al. The obesity paradox: body mass
index and outcomes in patients with heart failure. Arch Intern Med
2005;165:55– 61.
18. Gastelurrutia P, Pascual-Figal D, Vazquez R et al. Obesity paradox and risk
of sudden death in heart failure results from the MUerte Subita en Insuficiencia cardiaca (MUSIC) study. Am Heart J 2011;161:158–64.
19. Kapoor JR, Heidenreich PA. Obesity and survival in patients with
heart failure and preserved systolic function: a U-shaped relationship.
Am Heart J 2010;159:75– 80.
20. Oreopoulos A, Padwal R, Kalantar-Zadeh K, Fonarow GC, Norris
CM, McAlister FA. Body mass index and mortality in heart failure: a
meta-analysis. Am Heart J 2008;156:13–22.
21. Clark AL, Fonarow GC, Horwich TB. Waist circumference, body
mass index, and survival in systolic heart failure: the obesity paradox
revisited. J Card Fail 2011;17:374 – 80.
22. Lavie CJ, Osman AF, Milani RV, Mehra MR. Body composition and
prognosis in chronic systolic heart failure: the obesity paradox. Am J
Cardiol 2003;91:891– 4.
23. Gallagher D, Heymsfield SB, Heo M, Jebb SA, Murgatroyd PR, Sakamoto
Y. Healthy percentage body fat ranges: an approach for developing guidelines
based on body mass index. Am J Clin Nutr 2000;72:694–701.
24. Kyle UG, Schutz Y, Dupertuis YM, Pichard C. Body composition
interpretation. Contributions of the fat-free mass index and the body
fat mass index. Nutrition 2003;19:597– 604.
25. Movsesyan L, Tanko LB, Larsen PJ, Christiansen C, Svendsen OL.
Variations in percentage of body fat within different BMI groups in
young, middle-aged and old women. Clin Physiol Funct Imaging
2003;23:130 –3.
26. Executive Summary of the Third Report of The National Cholesterol
Education Program (NCEP) Expert Panel on Detection, Evaluation,
And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). JAMA 2001;285:2486 –97.
27. Chinali M, Devereux RB, Howard BV, et al. Comparison of cardiac structure
and function in American Indians with and without the metabolic syndrome
(the Strong Heart Study). Am J Cardiol 2004;93:40–4.
28. Voulgari C, Moyssakis I, Papazafiropoulou A, et al. The impact of
metabolic syndrome on left ventricular myocardial performance. Diabetes Metab Res Rev 2010;26:121–7.
29. Ingelsson E, Arnlov J, Lind L, Sundstrom J. Metabolic syndrome and
risk for heart failure in middle-aged men. Heart 2006;92:1409 –13.
30. Wang J, Sarnola K, Ruotsalainen S, et al. The metabolic syndrome
predicts incident congestive heart failure: a 20-year follow-up study of
elderly Finns. Atherosclerosis 2010;210:237– 42.
31. Li C, Ford ES, McGuire LC, Mokdad AH. Association of metabolic
syndrome and insulin resistance with congestive heart failure: findings
from the Third National Health and Nutrition Examination Survey. J
Epidemiol Community Health 2007;61:67–73.
32. Suzuki T, Katz R, Jenny NS, et al. Metabolic syndrome, inflammation,
and incident heart failure in the elderly: the cardiovascular health
study. Circ Heart Fail 2008;1:242– 8.
33. Arnlov J, Ingelsson E, Sundstrom J, Lind L. Impact of body mass
index and the metabolic syndrome on the risk of cardiovascular disease
and death in middle-aged men. Circulation 2010;121:230 – 6.
Key Words: heart failure y inflammation y lifestyle y metabolic
syndrome y obesity.