Critical appraisal of the obesity paradox in cardiovascular disease: how to manage patients with overweight in heart failure?

Overweight has been shown in multiple studies to carry a survival benefit in heart failure (HF) patients. This finding is, of course, counterintuitive to the well-established role of obesity as a modifiable risk factor for incident cardiovascular disease. The debate on the relevance of this obesity paradox is on-going, and clinical, methodological and teleological aspects are discussed. Particularly, younger age and a seemingly favourable clinical status of obese patients are repeatedly discussed together with the lack of prospective data to question the validity of the observed survival advantage in obese HF patients. Recent risk score calculators, however, have included body weight as an inverse risk factor, i.e. higher body mass index is predicting better outcome. Emerging prospective interventional trials support the concept that in patients with established disease, intentional weight reduction may not necessarily translate into improved outcome. The clinically most relevant consequence from the emerging data is, of course, the practical recommendation on body weight management that we may give our (overweight) patients. While the terminology as a paradox is critically discussed, a more differentiated concept for weight management should be emphasized that distinguishes between healthy subjects and those with an established cardiovascular disease such as heart failure.