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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EThe obesity paradox can be described as the tendency for obese individuals, including those with chronic diseases, to survive longer than adults of normal weight as determined by body mass index. This article discusses data, as well as possible explanations.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EObesity\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EPrevention \u0026amp; Screening\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EObesity\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EEndocrinology\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EDiabetes \u0026amp; Metabolic Syndrome\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EPrevention \u0026amp; Screening\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EMercedes Carnethon, PhD, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA, discussed the obesity paradox\u2014the tendency for obese individuals, including those with chronic diseases, to survive longer than adults of normal weight as determined by body mass index (BMI).\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EThe data supporting the obesity paradox are strong. A recent meta-analysis based on 89 studies, using normal-weight individuals as the reference, reported a relative risk of all-cause mortality of 0.93 (95% CI, 0.89 to 0.95) for overweight individuals (BMI 25 to \u0026lt; 30 kg\/m\u003Csup\u003E2\u003C\/sup\u003E), 1.13 (95% CI, 1.06 to 1.19) for obese individuals (BMI 30 to \u0026lt; 35 kg\/m\u003Csup\u003E2\u003C\/sup\u003E), and 1.25 (95% CI, 1.13 to 1.39) for extremely obese individuals (BMI \u2265 35 kg\/m\u003Csup\u003E2\u003C\/sup\u003E) [Flegal KM et al. \u003Cem\u003EJAMA\u003C\/em\u003E. 2013]. Another meta-analysis of 9 studies that addressed BMI in patients with chronic heart failure reported lower all-cause and cardiovascular mortality rates in overweight (HR, 0.84; 95% CI, 0.79 to 0.90) and obese (HR, 0.67; 95% CI, 0.62 to 0.73) individuals [Oreopoulos A. \u003Cem\u003EAm Heart J.\u003C\/em\u003E 2008]. Another meta-analysis involving \u0026gt; 81 000 hemodialysis patients reported a crude hazard ratio for overweight versus normal-weight patients of 0.67 (95% CI, 0.65 to 0.68). Adjustment for age, sex, diabetes, smoking, cholesterol, and chronic kidney disease produced a hazard ratio of 0.94 (95% CI, 0.92 to 0.96) [Jialin W et al. \u003Cem\u003ENephron Clin Pract\u003C\/em\u003E. 2012]. Yet, another meta-analysis exploring weight and acute coronary syndrome that involved \u0026gt; 218 000 patients reported a reduced risk of death in individuals who were overweight (HR, 0.70; 95% CI, 0.64 to 0.76), obese (HR, 0.60; 95% CI, 0.53 to 0.68), and severely obese (HR, 0.70; 95% CI, 0.58 to 0.86) [Niedziela J et al. \u003Cem\u003EEur J Epidemiol\u003C\/em\u003E. 2014].\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003EThe list of chronic diseases linked with the obesity paradox is long and includes chronic kidney disease, chronic heart disease, heart failure, stroke, cancer, acquired immunodeficiency syndrome, rheumatoid arthritis, chronic obstructive pulmonary disease, diabetes, and hypertension.\u003C\/p\u003E\u003Cp id=\u0022p-5\u0022\u003EPossible explanations for the obesity paradox include reverse causation (ie, healthier patients with the aforementioned comorbidities may be more overweight or obese) or that weight per se does not fully represent the potential adverse effects of adipose tissue. For instance, the term \u003Cem\u003Emetabolically obese normal weight\u003C\/em\u003E (MONW) was coined in 1981 to describe individuals who are not considered obese based on their height and weight (BMI \u0026lt; 28 kg\/m\u003Csup\u003E2\u003C\/sup\u003E) but who are hyperinsulinemic, insulin resistant, and at risk of type 2 diabetes, hypertriglyceridemia, and premature coronary heart disease [Ruderman NB et al. \u003Cem\u003EAm J Clin Nutr\u003C\/em\u003E. 1981]. MONW is prevalent in Americans \u2265 50 years of age, with the prevalence exceeding 50% in those \u2265 65 years of age [Wildman RP et al. \u003Cem\u003EArch Intern Med.\u003C\/em\u003E 2008].\u003C\/p\u003E\u003Cp id=\u0022p-6\u0022\u003EThose affected tend to be nonwhite, less educated, cigarette smokers, and physically inactive, with habitually inadequate sleep and a family history of metabolic diseases. MONW has been linked with increased mortality [Kramer CK et al. \u003Cem\u003EAnn Intern Med.\u003C\/em\u003E 2013].\u003C\/p\u003E\u003Cp id=\u0022p-7\u0022\u003EMore than 85% of patients with type 2 diabetes are overweight or obese. The diabetes that develops in more normal-weight individuals, however, may be associated with a doubling of the risk of mortality (HR, 2.2; 95% CI, 1.4 to 3.4), including cardiovascular mortality [Carnethon MR et al. \u003Cem\u003EJAMA\u003C\/em\u003E. 2012]. In the Look AHEAD study [\u003Ca class=\u0022external-ref external-ref-type-clintrialgov\u0022 href=\u0022\/lookup\/external-ref?link_type=CLINTRIALGOV\u0026amp;access_num=NCT00017953\u0026amp;atom=%2Fspmdc%2F14%2F47%2F15.atom\u0022\u003ENCT00017953\u003C\/a\u003E; The Look AHEAD Research Group. \u003Cem\u003ENew Engl J Med.\u003C\/em\u003E 2013], 5145 overweight diabetics were randomized to receive intensive modifications in their lifestyle or education. The composite end point after up to 13.7 years of follow-up was fatal or nonfatal cardiovascular disease, stroke, or angina that required hospitalization. Even though the intensive lifestyle intervention focused on weight loss, improved fitness, lowered glycated hemoglobin, and reduced waist circumference, the rate of cardiovascular events was unaffected.\u003C\/p\u003E\u003Cp id=\u0022p-8\u0022\u003EThe plausibility of the obesity paradox can be assessed based on several factors. One is nutrition. Obesity, which results from overnutrition, has been linked with longer-term mortality. Wasting, which is due to undernutrition, is associated with short-term mortality. It may be that those with chronic disease do not live long enough to suffer from the adversities of overnutrition [Kalantar-Zadeh K et al. \u003Cem\u003ECurr Opin Clin Nutr Metab Care\u003C\/em\u003E. 2007]. In this scenario, a leaner body may reflect more advanced disease or increased comorbidities, whereas a heavier body type has greater metabolic wherewithal to withstand illnesses.\u003C\/p\u003E\u003Cp id=\u0022p-9\u0022\u003EA second plausibility factor is age-related loss of muscle mass and strength. Sarcopenia is associated with declining function and higher rate of mortality, and it can be accelerated by factors such as physical inactivity, poor diet, and kidney disease. In older people, increased fat and declining muscle and bone can reduce overall weight. In these people, BMI may be an inappropriate measure because it cannot discriminate the distribution of fat and bone, or body composition (ie, body fat vs muscle mass). Increased abdominal fat is associated with sarcopenia; whether the fat is subcutaneous or visceral is important in determining the risk of mortality.\u003C\/p\u003E\u003Cp id=\u0022p-10\u0022\u003EA third factor is the level of physical activity. Obese individuals who are physically active have a lower risk of mortality than lean individuals who are physically inactive. Fitness, regardless of weight, is associated with lower mortality [Barry VW et al. \u003Cem\u003EProg Cardiovasc Dis.\u003C\/em\u003E 2014].\u003C\/p\u003E\u003Cp id=\u0022p-11\u0022\u003EA fourth factor is smoking. Smokers tend to have a lower BMI, which has been linked with increased mortality, compared to normal-weight individuals [Tobias TK et al. \u003Cem\u003ENew Engl J Med.\u003C\/em\u003E 2014].\u003C\/p\u003E\u003Cp id=\u0022p-12\u0022\u003EGiven the emphasis on BMI in examining the obesity paradox, it is germane to consider that risk factors other than BMI that are difficult to measure, such as genetics and lifestyle, may be operative. If these other factors are associated with higher mortality, then BMI could appear to be inversely related with mortality (ie, a lower BMI would be linked with increased risk of mortality) [Lajous M et al. \u003Cem\u003EEpidemiology\u003C\/em\u003E. 2014].\u003C\/p\u003E\u003Cp id=\u0022p-13\u0022\u003ETo summarize, the obesity paradox is biologically plausible. In nonobese individuals, factors like diabetes may present a high risk due to underlying factors that cannot be measured. Smoking and physical inactivity may be confounders. On the other hand, the obesity paradox may not be real. Rather, it could reflect a selection bias in studies, with other factors like genetics and lifestyle being the true basis in diabetes and other chronic diseases.\u003C\/p\u003E\u003Cp id=\u0022p-14\u0022\u003EStudies suggesting that obesity is nonproblematic receive prominent coverage in the popular media. With obesity rates rising, there could be a tendency to wish for a normalization of obesity, rather than confront a reality that the present course is undesirable and that a societal change is required. Clearly, more studies are needed.\u003C\/p\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2014 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/14\/47\/15.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzlx1e\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}