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• W2034349672 abstract "Many studies indicate that overweight and obesity are extremely prevalent in Westernized societies, and during recent decades, the prevalence has been markedly increasing, especially in the United States.1Lavie CJ Milani RV Obesity and cardiovascular disease: the Hippocrates paradox?.J Am Coll Cardiol. 2003; 42: 677-679Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar If current trends continue, obesity will soon overtake cigarette smoking as the leading cause of preventable death in the United States.1Lavie CJ Milani RV Obesity and cardiovascular disease: the Hippocrates paradox?.J Am Coll Cardiol. 2003; 42: 677-679Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar Substantial evidence documents the “heavy” cardiovascular (CV) burden of obesity. Overweight/obesity is a strong risk factor for the development and progression of hypertension, dyslipidemia (especially elevated triglycerides and low levels of high-density lipoprotein cholesterol), metabolic syndrome, and type 2 diabetes mellitus, and increases systemic inflammation (eg, high levels of C-reactive protein).1Lavie CJ Milani RV Obesity and cardiovascular disease: the Hippocrates paradox?.J Am Coll Cardiol. 2003; 42: 677-679Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar, 2Lavie CJ Milani RV Ventura HO et al.Disparate effects of left ventricular geometry and obesity on mortality in patients with preserved left ventricular ejection fraction.Am J Cardiol. 2007; 100: 1460-1464Abstract Full Text Full Text PDF PubMed Scopus (104) Google Scholar, 3Lavie CJ Morshedi-Meibodi A Milani RV Impact of cardiac rehabilitation on coronary risk factors, inflammation, and the metabolic syndrome in obese coronary patients.J Cardiometab Syndr. 2008; 3: 136-140Crossref PubMed Scopus (44) Google Scholar Although hypertension is a strong risk factor for left ventricular hypertrophy, obesity contributes to left ventricular hypertrophy and other ventricular structural abnormalities independent of arterial pressure.1Lavie CJ Milani RV Obesity and cardiovascular disease: the Hippocrates paradox?.J Am Coll Cardiol. 2003; 42: 677-679Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar, 2Lavie CJ Milani RV Ventura HO et al.Disparate effects of left ventricular geometry and obesity on mortality in patients with preserved left ventricular ejection fraction.Am J Cardiol. 2007; 100: 1460-1464Abstract Full Text Full Text PDF PubMed Scopus (104) Google Scholar Although all of these factors contribute to atherosclerosis and coronary heart disease (CHD), obesity is probably an independent risk factor.1Lavie CJ Milani RV Obesity and cardiovascular disease: the Hippocrates paradox?.J Am Coll Cardiol. 2003; 42: 677-679Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar, 2Lavie CJ Milani RV Ventura HO et al.Disparate effects of left ventricular geometry and obesity on mortality in patients with preserved left ventricular ejection fraction.Am J Cardiol. 2007; 100: 1460-1464Abstract Full Text Full Text PDF PubMed Scopus (104) Google Scholar, 3Lavie CJ Morshedi-Meibodi A Milani RV Impact of cardiac rehabilitation on coronary risk factors, inflammation, and the metabolic syndrome in obese coronary patients.J Cardiometab Syndr. 2008; 3: 136-140Crossref PubMed Scopus (44) Google Scholar Additionally, obesity has adverse affects on both systolic and diastolic ventricular function, and is associated with an increased risk of heart failure (HF).1Lavie CJ Milani RV Obesity and cardiovascular disease: the Hippocrates paradox?.J Am Coll Cardiol. 2003; 42: 677-679Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar, 4Lavie CJ Mehra MR Milani RV Obesity and heart failure prognosis: paradox of reverse epidemiology?.Eur Heart J. 2005; 26: 5-7Crossref PubMed Scopus (104) Google Scholar Therefore, the prevention and treatment of overweight/obesity are major societal concerns. Despite the association of obesity with CV risk factors and increased CV risk, numerous studies1Lavie CJ Milani RV Obesity and cardiovascular disease: the Hippocrates paradox?.J Am Coll Cardiol. 2003; 42: 677-679Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar, 2Lavie CJ Milani RV Ventura HO et al.Disparate effects of left ventricular geometry and obesity on mortality in patients with preserved left ventricular ejection fraction.Am J Cardiol. 2007; 100: 1460-1464Abstract Full Text Full Text PDF PubMed Scopus (104) Google Scholar, 3Lavie CJ Morshedi-Meibodi A Milani RV Impact of cardiac rehabilitation on coronary risk factors, inflammation, and the metabolic syndrome in obese coronary patients.J Cardiometab Syndr. 2008; 3: 136-140Crossref PubMed Scopus (44) Google Scholar, 4Lavie CJ Mehra MR Milani RV Obesity and heart failure prognosis: paradox of reverse epidemiology?.Eur Heart J. 2005; 26: 5-7Crossref PubMed Scopus (104) Google Scholar, 5Lavie CJ Artham SM Milani RV et al.The obesity paradox: impact of obesity on the prevalence and prognosis of cardiovascular diseases.Postgrad Med. 2008; 120: 34-41Crossref PubMed Scopus (85) Google Scholar, 6Lavie CJ Milani RV Ventura HO Obesity, heart disease, and favorable prognosis: truth or paradox?.Am J Med. 2007; 120: 825-826Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar have now documented a strong “obesity paradox,” in which obese patients with CV disease, including hypertension, CHD, and, especially, HF have a better prognosis than do their lean counterparts. In a large study2Lavie CJ Milani RV Ventura HO et al.Disparate effects of left ventricular geometry and obesity on mortality in patients with preserved left ventricular ejection fraction.Am J Cardiol. 2007; 100: 1460-1464Abstract Full Text Full Text PDF PubMed Scopus (104) Google Scholar of patients who had been referred for echocardiography with normal systolic function, we have also demonstrated a strong obesity paradox. The reasons for this surprising paradox have been difficult to elucidate. Potential contributors have included nonpurposeful weight loss prior to study entry (due to unrecognized non-CV diseases), obese patients presenting earlier due to increased dyspnea due to non-CV causes, such as deconditioning and restrictive lung disease, and reduced expression of atrial natriuretic peptides, which has been documented in cases of obesity.1Lavie CJ Milani RV Obesity and cardiovascular disease: the Hippocrates paradox?.J Am Coll Cardiol. 2003; 42: 677-679Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar, 2Lavie CJ Milani RV Ventura HO et al.Disparate effects of left ventricular geometry and obesity on mortality in patients with preserved left ventricular ejection fraction.Am J Cardiol. 2007; 100: 1460-1464Abstract Full Text Full Text PDF PubMed Scopus (104) Google Scholar, 3Lavie CJ Morshedi-Meibodi A Milani RV Impact of cardiac rehabilitation on coronary risk factors, inflammation, and the metabolic syndrome in obese coronary patients.J Cardiometab Syndr. 2008; 3: 136-140Crossref PubMed Scopus (44) Google Scholar, 4Lavie CJ Mehra MR Milani RV Obesity and heart failure prognosis: paradox of reverse epidemiology?.Eur Heart J. 2005; 26: 5-7Crossref PubMed Scopus (104) Google Scholar, 5Lavie CJ Artham SM Milani RV et al.The obesity paradox: impact of obesity on the prevalence and prognosis of cardiovascular diseases.Postgrad Med. 2008; 120: 34-41Crossref PubMed Scopus (85) Google Scholar, 6Lavie CJ Milani RV Ventura HO Obesity, heart disease, and favorable prognosis: truth or paradox?.Am J Med. 2007; 120: 825-826Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar Although some have also suggested7Romero Corral A Lopez-Jimenez F Sierra-Johnson J et al.Differentiating between body fat and lean mass: how should we measure obesity?.Nat Clin Pract Endocrinol Metab. 2008; 4: 322-333Crossref PubMed Google Scholar that part of the explanation of the obesity paradox may be the limitations of the body mass index (BMI) to define at-risk obesity, suggesting that other measures such as waist circumference, waist/hip ratio, or percentage of body fat determinations would be more accurate, we have demonstrated that a higher percentage of body fat predicted better prognosis in patients with HF8Lavie CJ Osman AF Milani RV et al.Body composition and prognosis in chronic systolic heart failure: the obesity paradox.Am J Cardiol. 2003; 91: 891-894Abstract Full Text Full Text PDF PubMed Scopus (397) Google Scholar; preliminary data from our institution have suggested the same regarding CHD and mortality. In the current issue of CHEST (see page 925), Galal and colleagues9Galal W van Gestel Y Hoeks SE et al.The obesity paradox in patients with peripheral arterial disease.Chest. 2008; 134Abstract Full Text Full Text PDF PubMed Scopus (133) Google Scholar assessed 4.4-year mortality in 2,392 patients with peripheral arterial disease (PAD) from the Netherlands who had undergone major vascular surgery and had a high risk of mortality during follow-up. That study demonstrated a powerful obesity paradox in patients with PAD, with progressive reductions in mortality in normal-BMI, overweight, and obese groups of patients compared with an underweight group of patients. Although lower BMI was an independent predictor of higher mortality in the entire population, the increased risk in the underweight patients was almost completely explained statistically by a high prevalence of moderate-to-severe COPD. Nevertheless, adjusting for the severity of COPD did not abolish the relationship between BMI and mortality in the overweight and obese groups. The contributions of the study by Galal et al9Galal W van Gestel Y Hoeks SE et al.The obesity paradox in patients with peripheral arterial disease.Chest. 2008; 134Abstract Full Text Full Text PDF PubMed Scopus (133) Google Scholar are noteworthy, particularly regarding extending the obesity paradox to patients with PAD as well as documenting the contribution of COPD to this paradox, especially in underweight PAD patients. Nevertheless, the fact that the underweight patients had higher mortality and more COPD is of no major surprise, and many studies1Lavie CJ Milani RV Obesity and cardiovascular disease: the Hippocrates paradox?.J Am Coll Cardiol. 2003; 42: 677-679Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar, 2Lavie CJ Milani RV Ventura HO et al.Disparate effects of left ventricular geometry and obesity on mortality in patients with preserved left ventricular ejection fraction.Am J Cardiol. 2007; 100: 1460-1464Abstract Full Text Full Text PDF PubMed Scopus (104) Google Scholar, 4Lavie CJ Mehra MR Milani RV Obesity and heart failure prognosis: paradox of reverse epidemiology?.Eur Heart J. 2005; 26: 5-7Crossref PubMed Scopus (104) Google Scholar, 5Lavie CJ Artham SM Milani RV et al.The obesity paradox: impact of obesity on the prevalence and prognosis of cardiovascular diseases.Postgrad Med. 2008; 120: 34-41Crossref PubMed Scopus (85) Google Scholar, 6Lavie CJ Milani RV Ventura HO Obesity, heart disease, and favorable prognosis: truth or paradox?.Am J Med. 2007; 120: 825-826Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar have documented higher mortality rates among underweight persons. Importantly, this population may be different than other populations, such as cohorts of hypertensive, CHD, and HF patients, in that smoking, as the authors state, appears to be an especially potent contributor to PAD.1Lavie CJ Milani RV Obesity and cardiovascular disease: the Hippocrates paradox?.J Am Coll Cardiol. 2003; 42: 677-679Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar, 9Galal W van Gestel Y Hoeks SE et al.The obesity paradox in patients with peripheral arterial disease.Chest. 2008; 134Abstract Full Text Full Text PDF PubMed Scopus (133) Google Scholar Nevertheless, other studies5Lavie CJ Artham SM Milani RV et al.The obesity paradox: impact of obesity on the prevalence and prognosis of cardiovascular diseases.Postgrad Med. 2008; 120: 34-41Crossref PubMed Scopus (85) Google Scholar have also attempted to correct for smoking as a risk factor, and still lower BMI is an independent predictor of higher risk. Likewise, even in the present study,9Galal W van Gestel Y Hoeks SE et al.The obesity paradox in patients with peripheral arterial disease.Chest. 2008; 134Abstract Full Text Full Text PDF PubMed Scopus (133) Google Scholar which corrects for smoking status as well as COPD, lung disease did not completely explain this paradox in the subgroups of overweight and obese patients, who had the best prognosis. Considering this surprising paradox, how should clinicians proceed at present? In fact, some experts9Galal W van Gestel Y Hoeks SE et al.The obesity paradox in patients with peripheral arterial disease.Chest. 2008; 134Abstract Full Text Full Text PDF PubMed Scopus (133) Google Scholar, 10Allison DB Zannolli R Faith MS et al.Weight loss increases and fat loss decreases all-cause mortality rates: results from two independent cohort studies.Int J Obes Relat Metab Disord. 1999; 23: 603-611Crossref PubMed Scopus (189) Google Scholar have even questioned the safety and efficacy of purposeful weight loss in patients with CV diseases. However, we and others have reported1Lavie CJ Milani RV Obesity and cardiovascular disease: the Hippocrates paradox?.J Am Coll Cardiol. 2003; 42: 677-679Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar, 3Lavie CJ Morshedi-Meibodi A Milani RV Impact of cardiac rehabilitation on coronary risk factors, inflammation, and the metabolic syndrome in obese coronary patients.J Cardiometab Syndr. 2008; 3: 136-140Crossref PubMed Scopus (44) Google Scholar, 4Lavie CJ Mehra MR Milani RV Obesity and heart failure prognosis: paradox of reverse epidemiology?.Eur Heart J. 2005; 26: 5-7Crossref PubMed Scopus (104) Google Scholar, 5Lavie CJ Artham SM Milani RV et al.The obesity paradox: impact of obesity on the prevalence and prognosis of cardiovascular diseases.Postgrad Med. 2008; 120: 34-41Crossref PubMed Scopus (85) Google Scholar, 6Lavie CJ Milani RV Ventura HO Obesity, heart disease, and favorable prognosis: truth or paradox?.Am J Med. 2007; 120: 825-826Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar, 11Eilat-Adar S Eldar M Goldbourt U Association of intentional changes in body weight with coronary heart disease event rates in overweight subjects who have an additional coronary risk factor.Am J Epidemiol. 2005; 161: 352-358Crossref PubMed Scopus (97) Google Scholar that purposeful weight loss improves left ventricular systolic and diastolic function, reduces CHD risk factors, and is associated with the most favorable CV prognosis. Certainly, efforts to increase physical activity and overall physical fitness in our society are desperately needed, as many studies12Blair SN Church TS The fitness, obesity, and health equation: is physical activity the common denominator?.JAMA. 2004; 292: 1232-1234Crossref PubMed Scopus (209) Google Scholar have clearly demonstrated that a reduced level of fitness is a powerful predictor of mortality and increased fitness is protective in patients with obesity and other CV risk factors. As we continue to investigate the mechanisms for this puzzling obesity paradox, the “weight” of evidence clearly supports purposeful weight loss, particularly with therapies that do not reduce lean body mass, such as exercise training in addition to caloric restriction, for the primary and secondary prevention of CV diseases." @default.
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