New analysis revealed within the European Coronary heart Journal has debunked the “weight problems paradox,” which advised that obese or overweight coronary heart failure sufferers had a decrease danger of hospitalization or loss of life in comparison with these with regular weight. The examine discovered that utilizing waist-to-height ratio measurements as an alternative of physique mass index (BMI) eliminates the perceived survival benefit for people with a BMI of 25kg/m2 or extra.
Research exhibits ‘weight problems paradox’ doesn't exist: waist-to-height ratio is a greater indicator of outcomes in sufferers with coronary heart failure than BMI.
New analysis has debunked the concept there may be an “weight problems paradox,” whereby sufferers with coronary heart failure who're obese or overweight are considered much less prone to find yourself within the hospital or die than individuals of regular weight.
The examine, which was revealed within the European Coronary heart Journal[1] on March 22, exhibits that if medical doctors measure the ratio of waist to peak of their sufferers, quite than their physique mass index (BMI), the supposed survival benefit for individuals with a BMI of 25kg/m2 or extra disappears.
The “weight problems paradox” pertains to counter-intuitive findings suggesting that, though persons are at better danger of creating coronary heart issues if they're obese or overweight, as soon as an individual has developed a coronary heart situation, these with greater BMIs appeared to do higher and had been much less prone to die than these of regular weight. Varied explanations have been advised, together with the truth that as soon as somebody has developed coronary heart issues, some additional fats is by some means protecting in opposition to additional well being issues and loss of life, particularly as individuals who develop a extreme and continual sickness typically drop pounds.
John McMurray, Professor of Medical Cardiology on the College of Glasgow (UK), who led the newest analysis, stated: “It has been advised that residing with weight problems is an efficient factor for sufferers with coronary heart failure and diminished ejection fraction – which is when the primary chamber of the guts is unable to squeeze out the conventional quantities of blood. We knew this might not be appropriate and that weight problems have to be dangerous quite than good. We reckoned that a part of the issue was that BMI was a weak indicator of how a lot fatty tissue a affected person has.”
Physique Mass Index (BMI) is a broadly used measurement that calculates an individual’s weight in relation to their peak, offering an estimate of physique fats and total well being. It's calculated by dividing a person’s weight in kilograms by the sq. of their peak in meters (kg/m2). BMI is usually utilized to evaluate whether or not an individual is underweight, regular weight, obese, or overweight, but it surely has limitations because it doesn't account for elements comparable to muscle mass or distribution of fats. Consequently, it might not present a complete illustration of a person’s well being or danger for sure circumstances.
As Professor Stephan von Haehling, Advisor Heart specialist, and Dr. Ryosuke Sato, a analysis fellow, each on the College of Göttingen Medical Middle (Germany), write in an accompanying editorial,[2] BMI fails to take account of the physique’s composition of fats, muscle,[ and bone, or where the fat is distributed. “Would it be feasible to assume that an American professional wrestler (more muscle) and a Japanese sumo wrestler (more fat) with the same BMI would have a similar risk of cardiovascular disease? The same is true for persons such as Arnold Schwarzenegger in his younger years when he starred as the ‘Terminator’ with a BMI of ~30 kg/m2.”
The study published on Wednesday is the first to look at different ways of measuring the size and proportions of patients, including BMI, but also anthropometric measurements such as waist-to-height ratio, waist circumference and waist-to-hip ratio, and adjusting the patient outcomes to take into account other factors that play a role in, or predict, these outcomes, such as levels of natriuretic peptides – hormones that are secreted in the blood when the heart is under pressure, as with heart failure.
“Natriuretic peptides are the single most important prognostic variable in patients with heart failure. Normally, levels of natriuretic peptides rise in people with heart failure, but patients living with obesity have lower levels than those who are normal weight,” said Prof. McMurray.
Prof. McMurray and colleagues analyzed data from 1832 women and 6567 men with heart failure and reduced ejection fraction who were enrolled in the PARADIGM-HF international randomized controlled trial taking place in 47 countries on six continents.[3] When the sufferers had been randomized, medical doctors collected knowledge on BMI, blood stress, anthropometric measurements, outcomes from blood checks, medical histories, and coverings. The researchers had been during which sufferers had been hospitalized with coronary heart failure or who died from it.
An “obesity-survival paradox” confirmed decrease loss of life charges for individuals with BMIs of 25 kg/m2 or extra,[4] however this was eradicated when the researchers adjusted the outcomes to take account of all of the elements that may have an effect on outcomes, together with ranges of natriuretic peptides.
First creator of the examine, Dr. Jawad Butt, a analysis fellow from Copenhagen College Hospital—Rigshospitalet, Copenhagen (Denmark), who carried out the analyses, stated: ”The paradox was far much less evident once we checked out waist-to-height ratios, and it disappeared after adjustment for prognostic variables. After adjustment, each BMI and waist-to-height ratio confirmed that extra physique fats was related to a better danger of loss of life or hospitalization for coronary heart failure, however this was extra evident for waist-to-height ratio. When waist-to-height ratio, we discovered the highest 20% of individuals with essentially the most fats had a 39% elevated danger of being hospitalized for coronary heart failure in comparison with individuals within the backside 20% who had the least fats.”
Prof. McMurray stated: “Our examine exhibits there isn't a ‘weight problems survival paradox’ once we use higher methods of measuring physique fats. BMI doesn't take note of the situation of fats within the physique or its quantity relative to muscle or the burden of the skeleton, which can differ in keeping with intercourse, age, and race. In coronary heart failure particularly, retained fluid additionally contributes to physique weight. It's indices that don't embrace weight, comparable to waist-to-height ratio, which have clarified the true relationship between physique fats and affected person outcomes in our examine, exhibiting that better adiposity is definitely related to worse not higher outcomes, together with excessive charges of hospitalization and worse health-related high quality of life.
“Weight problems is just not good and is dangerous in sufferers with coronary heart failure and diminished ejection fraction. These observations elevate the query as as to whether weight reduction may enhance outcomes, and we'd like trials to check this. Within the UK, the Nationwide Institute for Well being and Care Excellence, NICE, now recommends that waist-to-height ratio as an alternative of BMI is used for the overall inhabitants, and we must always assist this for sufferers with coronary heart failure too.
“It is necessary as a result of the underdiagnosis of coronary heart failure in individuals residing with weight problems is a serious problem in major care. Sufferers’ signs of breathlessness are sometimes dismissed as due solely to weight problems. Weight problems is a danger issue and driver of coronary heart failure. Whereas up to now weight reduction could have been a priority for sufferers with coronary heart failure and diminished ejection fraction, as we speak it's weight problems.”
Prof. von Haehling and Dr. Sato write of their editorial: “The current findings elevate the alarm over the time period ‘weight problems paradox’, which has been claimed to be primarily based on BMI. Can we inform overweight HF [heart failure] sufferers simply to remain as they're? To adequately tackle this query, not solely ought to the weight problems paradox be revisited even in sufferers with HF with preserved ejection fraction (HFpEF) and in lean HF sufferers by WHtR [waist-to-height ratio], which higher displays pathophysiological processes of weight problems, but additionally additional checks are warranted to validate the impact of weight reduction in ‘actually’ overweight HF sufferers with a excessive WHtR.”
Limitations of the examine are that it may be tougher to precisely measure physique shapes, comparable to waist circumference, particularly when the measurements are carried out by totally different individuals; there could also be additional unknown elements that would have an effect on the outcomes; the evaluation was carried out on measurements and different knowledge taken on the time contributors joined the examine and didn't take account of any modifications in weight or waist circumference throughout the follow-up interval; there have been no knowledge on the cardiorespiratory health of the contributors, which might affect the hyperlink between anthropometric measurements and outcomes; and, lastly, solely 153 sufferers had been underweight, with a BMI of lower than 18.5 kg/m2, and 171 sufferers with a waist-to-height ratio of lower than 0.4 (0.5 is taken into account a wholesome ratio), so the examine’s findings can't be extrapolated to sufferers with low BMIs or waist-to-hip ratio.
Notes:
- “Anthropometric measures and hostile outcomes in coronary heart failure with diminished ejection fraction: revisiting the weight problems paradox” by Jawad H Butt, Mark C Petrie, Pardeep S Jhund, Naveed Sattar, Akshay S Desai, Lars Køber, Jean L Rouleau, Karl Swedberg, Michael R Zile, Scott D Solomon, Milton Packer and John J V McMurray, 22 March 2023, European Coronary heart Journal.
DOI: 10.1093/eurheartj/ehad083 - “Revisiting the weight problems paradox in coronary heart failure: what's the greatest anthropometric index to gauge weight problems?” by Ryosuke Sato and Stephan von Haehling, 22 March 2023, European Coronary heart Journal.
DOI: 10.1093/eurheartj/ehad079 - PARADIGM-HF (Prospective comparability of ARNI with ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure) was a randomized, double-blind, placebo-controlled trial in sufferers with continual coronary heart failure with diminished ejection fraction (HFrEF), evaluating the efficacy and security of angiotensin receptor-neprilysin inhibitor saubitril/valsartan in contrast with enalaparil, added to plain care.
- The examine used the World Well being Group BMI classes: <18.5 kg/m2 is underweight, 18.5-24.9 kg/m2 is regular weight, 25-29.9 kg/m2 is obese, and 30 kg/m2 upwards is overweight.
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