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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/cdn\/css\/http\/css_Xg7z6oCTVgud_Q0huYz9x9iiD5H_2YPSJ5z2ZViSWdY.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 1999 consensus recommendations for heart failure (HF) stated that obese patients should lose weight [\u003Cem\u003EAm J Cardiol\u003C\/em\u003E 1999], and according to data from the Framingham Heart Study, even being overweight poses an increased risk for HF (5% for men and 7% for women for each increment of 1 in body mass index) [Kenchaiah S et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2002]. However, the current American College of Cardiology\/American Heart Association Heart Failure Guidelines [Hunt SA et al. \u003Cem\u003EJ Am Col Cardiol\u003C\/em\u003E 2005; Jessup M et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2009] contain no mention of weight loss for HF patients. Why? This article discusses clinical trials why fatter may be better in heart failure.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003Eheart failure\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Ecardiometabolic disorder\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eobesity\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \n         \u003Cp id=\u0022p-2\u0022\u003EThe 1999 consensus recommendations for heart failure (HF) stated that obese patients should lose weight [\u003Cem\u003EAm J Cardiol\u003C\/em\u003E 1999], and according to data from the Framingham Heart Study, even being overweight poses an increased risk for HF (5% for men and 7% for women for each increment of 1 in body mass index [BMI]) [Kenchaiah S et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2002]. However, the current American College of Cardiology\/American Heart Association Heart Failure Guidelines [Hunt SA et al. \u003Cem\u003EJ Am Col Cardiol\u003C\/em\u003E 2005; Jessup M et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2009] contain no mention of weight loss for HF patients. Why? According to Tamara Horwich, MD, UCLA, Los Angeles, CA, fatter is better in heart failure.\u003C\/p\u003E\n         \u003Cp id=\u0022p-3\u0022\u003EThe relationship between weight and HF was first investigated more than 10 years ago in a study that included 1203 patients with advanced systolic HF. The results of that study showed that obesity is not associated with increased mortality and, in fact, may confer a more favorable prognosis, despite the fact that the obese and overweight patient groups had significantly higher rates of hypertension and diabetes, as well as higher levels of cholesterol, triglycerides, and low-density lipoprotein cholesterol (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E) [Horwich TB et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2001]. These results were recently confirmed in a meta-analysis of nine observational studies (n=28,209) in which both obesity and being overweight were associated with lower all-cause and cardiovascular mortality rates compared with normal weight patients with CHF and were not associated with increased mortality in any study [Oreopoulos A et al. \u003Cem\u003EAm Heart J\u003C\/em\u003E 2008].\u003C\/p\u003E\n         \u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/2\/21\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Adjusted Survival Analysis: Overweight and Obese Fair Better.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1017977781\u0022 data-figure-caption=\u0022Adjusted Survival Analysis: Overweight and Obese Fair Better.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/2\/21\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/2\/21\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/2\/21\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11204\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-4\u0022 class=\u0022first-child\u0022\u003EAdjusted Survival Analysis: Overweight and Obese Fair Better.\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003ECopyright \u00a9 2001 American College of Cardiology. All rights reserved.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-5\u0022\u003EParadoxically, low body mass index (BMI) may be associated with poorer survival in patients with chronic heart failure (CHF). In the Candesartan in Heart failure: Reduction in Mortality and Morbidity (CHARM) study, CHF patients with \u22655% weight loss in 6 months had more than a 50% increase in mortality compared with those with stable weight. The risk increased more than four-fold for patients whose last recorded annual weight loss exceeded 10%. Weight loss accelerated in the year prior to death [Pocock SJ et al. \u003Cem\u003EEurt Heart J\u003C\/em\u003E 2008]. This reversal has been termed the \u201cobesity paradox.\u201d\u003C\/p\u003E\n         \u003Cp id=\u0022p-6\u0022\u003ESeveral explanations for the obesity paradox in HF patients have been offered: obese HF patients are simply less sick because they present at an earlier stage of disease; high BMI represents greater metabolic reserve in HF; and\/or obesity (increased fat or increased lean mass) is protective in terms of altering neurohormonal, inflammatory cytokine, and adipokine physiology [Von Haehling S et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2007].\u003C\/p\u003E\n         \u003Cp id=\u0022p-7\u0022\u003EThe neurohormonal connection has been evaluated in several studies. Obese individuals tend to have low levels of adiponectin, an adipocyte-derived peptide with insulin-desensitizing and anti-inflammatory properties. In the general population, low levels of adiponectin are associated with a higher risk of MI; however, in HF, the opposite is true\u2014low levels of adiponectin are associated with decreased mortality (\u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E) [Pischon T et al. \u003Cem\u003EJAMA\u003C\/em\u003E 2004]. Another neurohormone that is altered with respect to BMI is brain natriuretic peptide (BNP). HF patients with a BMI \u0026lt;25 have higher levels of BNP compared with overweight (BMI 25 to 29.9) and obese HF patients (BMI \u226530) [Horwich T et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2006]. However, in the general population, low BNP levels are generally associated with lean body mass [DAS SR et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2006]. This leads to the question of whether it is lean body mass that is offering cardiovascular protection in overweight and obese HF patients. The answer is important, because almost all of the studies of obesity and HF use BMI as a measure, and while BMI does correlate with fat mass, it can not discriminate between lean mass and fat mass [Romero-Corral A et al. \u003Cem\u003EInt J Obesity\u003C\/em\u003E 2008].\u003C\/p\u003E\n         \u003Cdiv id=\u0022F2\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/2\/21\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Adiponectin Levels.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1017977781\u0022 data-figure-caption=\u0022Adiponectin Levels.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 2.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/2\/21\/F2.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/2\/21\/F2.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 2.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/2\/21\/F2.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11207\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 2.\u003C\/span\u003E \n               \u003Cp id=\u0022p-8\u0022 class=\u0022first-child\u0022\u003EAdiponectin Levels.\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EReproduced with permission from T. Horwich, MD.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp\u003EIf the paradox implies that being overweight or obese is associated with improved outcomes and if unintentional weight loss portends poor prognosis in HF patients, what are the clinical implications? Dr. Horwich suggests that currently used HF medications, such as ACE inhibitors and beta-blockers, prevent weight loss (\u003Ca id=\u0022xref-fig-3-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F3\u0022\u003EFigure 3\u003C\/a\u003E), and traditional dietary advice that includes the restriction of fluids, salt, alcohol, high K foods, and sugar if the patient is also a diabetic, but not weight reduction. More specifically, for HF individuals with a BMI:\n\u003C\/p\u003E\u003Cul class=\u0022list-unord \u0022 id=\u0022list-1\u0022\u003E\u003Cli id=\u0022list-item-1\u0022\u003E\n                  \u003Cp id=\u0022p-10\u0022\u003E\u0026lt;30 kg\/m\u003Csup\u003E2\u003C\/sup\u003E \u2013 do not encourage weight loss\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-2\u0022\u003E\n                  \u003Cp id=\u0022p-11\u0022\u003E\u0026gt;40 kg\/m\u003Csup\u003E2\u003C\/sup\u003E \u2013 lose weight to BMI \u0026lt;40\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-3\u0022\u003E\n                  \u003Cp id=\u0022p-12\u0022\u003E30 to 40 kg\/m\u003Csup\u003E2\u003C\/sup\u003E \u2013 inconclusive evidence to make recommendation\u003C\/p\u003E\n               \u003C\/li\u003E\u003C\/ul\u003E\u003Cp\u003E\n         \u003C\/p\u003E\n         \u003Cp id=\u0022p-13\u0022\u003EThe best survival has been found for patients with a BMI of 30 to 32 kg\/m\u003Csup\u003E2\u003C\/sup\u003E [Riegel B et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2009].\u003C\/p\u003E\n         \u003Cdiv id=\u0022F3\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/2\/21\/F3.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Impact of ACEIs and Beta-Blockers.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1017977781\u0022 data-figure-caption=\u0022Impact of ACEIs and Beta-Blockers.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 3.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/2\/21\/F3.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/2\/21\/F3.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 3.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/2\/21\/F3.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11209\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 3.\u003C\/span\u003E \n               \u003Cp id=\u0022p-14\u0022 class=\u0022first-child\u0022\u003EImpact of ACEIs and Beta-Blockers.\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-3\u0022\u003EReproduced with permission from T. Horwich, MD.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-15\u0022\u003EThe findings of the obesity paradox extend beyond HF to other chronic conditions, such as end-stage renal disease, rheumatoid arthritis, chronic obstructive pulmonary disease, AIDS, malignancy, and coronary artery disease, as well as in the elderly in general. More studies are needed to determine whether weight loss promotion in patients with HF is a worthwhile goal or may even be harmful. In addition, we need studies to determine what impact intentional weight gain, exercise to increase muscle mass, and nutritional therapy have in HF patients with low BMI.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2010 MD Conference Express\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\/10\/2\/21.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_figures.js?nzmtg2\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzmtg2\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}