Physicians' Academy for Cardiovascular Education

“Obesity paradox”: Better prognosis for overweight and obese patients with CVD

Literature - Lavie CJ, et al. JACC 2014 - JACC 2014

Obesity and Cardiovascular Diseases - Implications Regarding Fitness, Fatness, and Severity in the Obesity Paradox

Lavie CJ, McAuley PA, Church TS, et al.
J Am Coll Cardiol 2014;63:1345–54


Obesity has been increasing in epidemic proportions in both adults and children over many decades, with a disproportionately higher increase in morbid or class III obesity. Recently, the proportion of the population with more severe, or morbid, obesity has increased to a greater extent than has overweight and mild obesity [1–3]. Nearly 70% of adults are currently classified as either overweight or obese as compared with fewer than 40% just 40 years ago [3].
Recent data have suggested obesity may account for nearly 20% of overall mortality [4].
Obesity adversely affects cardiovascular (CV) hemodynamics, structure, and function, as well as increases the prevalence of most CV diseases [3,5,6]. Progressive declines in physical activity over 5 decades have occurred and have primarily caused the obesity epidemic. Despite the potential adverse impact of overweight and obesity, recent epidemiological data have demonstrated an association of mild obesity and, particularly, overweight on improved survival (the “obesity paradox”, where overweight and at least mildly obese patients with most CV diseases seem to have a better prognosis than do their leaner counterparts) [3,5].
This state-of-the-art paper reviews the obesity paradox in CV diseases. The implications of cardiorespiratory fitness with prognosis are discussed, along with the joint impact of fitness and adiposity on the obesity paradox. Finally, in light of the obesity paradox, the potential value of purposeful weight loss and increased physical activity to affect levels of fitness is reviewed.

Main outcomes

  • Overweight and obesity have many adverse effects on hemodynamics and CV structure and function [5].
  • Reductions in occupation-related activity and energy expenditure largely explain the marked increased prevalence in obesity noted during recent decades [7].
  • In a large meta-analysis [8], the optimal survival occurred at the overweight BMI (25 to 30 kg/m2); these patients had a statistically significant 6% lower mortality than did the normal BMI cohort.
  • Several studies demonstrate an obesity paradox in hypertensive subjects [9], CHD [10-13], HF [5, 14-16] and AF [17] – overweight and obese patients with the condition have a considerably better prognosis than patients with normal BMI.
  • An obesity paradox does not apply to more morbid obesity, where prognosis is adversely affected [18-23]. This level of severe obesity is a major risk factor for development of CV diseases and is associated with poor prognosis when CV diseases become manifest. Efforts to prevent and treat morbid obesity are therefore urgently needed.
  • Fitness remains very predictive and largely negates the adverse effects of body fatness, as well as other traditional CV risk factors, including overweight/obesity, metabolic syndrome/type II diabetes mellitus, and hypertension [24-29]. Although ideal prevention of both age-associated loss in fitness and increase in adiposity may be useful, maintaining or improving fitness is more important than preventing increased adiposity with regard to long-term health outcomes.
  • Although better large-scale weight loss intervention trials are needed, the constellation of data still supports purposeful weight reduction in patients with CV diseases, especially in the more severely obesity (probably BMI >35 kg/m2 and especially BMI >40 kg/m2). Because fitness is important to improve prognosis, incorporating exercise training and efforts to improve fitness into weight loss programs appears to be particularly beneficial [30,31].


Overweight and obese patients with CV diseases have a better prognosis than do their leaner counterparts. This obesity paradox seems largely apparent in patients with low fitness, whereas those with better fitness have a good prognosis, and no clear obesity paradox is apparent. Although better long-term intervention studies are needed, purposeful weight reduction, and especially incorporating exercise training and improvements in fitness, seems to be beneficial.
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