Mixed
In heart failure with reduced ejection fraction (HFrEF), higher adiposity measured by waist-to-height ratio is associated with a significantly higher risk of heart failure hospitalization, and the 'obesity-survival paradox' (where higher BMI appeared protective) is eliminated when adjusting for natriuretic peptides and other prognostic variables.
For patients with heart failure and reduced ejection fraction, relying on BMI to assess risk is misleading. Higher waist-to-height ratio (indicating central adiposity) is linked to a significantly higher risk of hospitalization. The idea that being 'overweight' is protective in heart failure is a statistical artifact; once you account for fluid retention and biomarkers like natriuretic peptides, higher adiposity clearly increases risk. Focus on healthy body composition rather than just scale weight.
This paradox was less evident for waist-to-height ratio (as an exemplar of indices not incorporating weight) and eliminated by adjustment... However, both BMI and waist-to-height ratio showed that greater adiposity was associated with a higher risk of the primary outcome and HF hospitalization; this was more evident for waist-to-height ratio and persisted after adjustment e.g. the aHR for HF hospitalization for quintile 5 vs. quintile 1 of waist-to-height ratio was 1.39 (95% CI 1.06–1.81).
Why this rating
Large-scale randomized controlled trial (PARADIGM-HF) with extensive adjustment for confounders, though it is a secondary analysis of anthropometric measures rather than a primary intervention trial.
Source
Anthropometric measures and adverse outcomes in heart failure with reduced ejection fraction: revisiting the obesity paradox
Jawad H. Butt et al. · European Heart Journal · 2023
DOI 10.1093/eurheartj/ehad083
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