Register
Forgot your password?

Causes of the reverse epidemiology of «obesity paradox» in patients with cardiovascular diseases

Authors: YakhyaevaK.B., Keren M.A., Volkovskaya I.V.

Company: Bakoulev National Medical Research Center for Cardiovascular Surgery, Moscow, Russian Federation

For correspondence:  Sign in or register.

Type:  Reviews


DOI: https://doi.org/10.24022/1997-3187- 2025-19-2-162-171

For citation: Yakhyaeva K.B., Keren M.A., Volkovskaya I.V. Causes of the reverse epidemiology of «obesity paradox» in patients with cardiovascular diseases. Creative Cardiology. 2025; 19 (2): 162–171 (in Russ.). DOI: 10.24022/1997-3187-2025-19-2-162-171

Received / Accepted:  30.03.2025 / 14.04.2025

Keywords: obesity cardiovascular diseases body mass index obesity paradox cardiovascular risk



Subscribe 🔒

 

Abstract

Obesity is one of the main components of metabolic syndrome and is one of the leading risk factors for the development of cardiovascular diseases (CVD). However, today its role in the prevention of adverse cardiovascular outcomes in patients with existing chronic pathology is not fully clarified. There are many studies describing a phenomenon called the “obesity paradox,” which suggests that the prognosis in this group of patients is improving if they are overweight or obese. This article presents the results of studies showing the “obesity paradox” in patients with cardiovascular diseases. The aim of the review is to analyze and summarize the available literature data regarding the impact of overweight and obesity on the prognosis in patients with CVD, as well as to analyze possible causes of the “obesity paradox”.

References

  1. Obesity and overweight/ World Health Organization (WHO). Fact Sheets. 2022. https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight (accessed March 1, 2025)
  2. Drapkina O.M., Shepel R.N., Eliashevich S.O. Does the “obesity paradox” really take place in coronary heart disease? Cardiovascular Therapy and Prevention. 2016; 15 (4): 75–79 (in Russ.). DOI: 10.15829/1728-8800-2016-4-75-79
  3. Shuvaev I.P., Asymbekova E.U., Sherstyannikova O.M., Akhmedyarova N.K., Rakhimov A.Z., Matskeplishvili S.T. The effect of fat metabolism disorders on severity of diastolic myocardial dysfunction in patients with ischemic heart diseases and metabolic syndrome. The Bulletin of Bakoulev Center. Cardiovascular Diseases. 2018; 19 (6): 800–810 (in Russ.). DOI: 10.24022/1810-0694-2018-19-6-800-810
  4. Shalov R.Z., Filatov A.G. Comorbid pathology and risk factors in patients with atrial fibrillation. Annals of Arrhythmology. 2023; 20 (1): 43–51 (in Russ.). DOI: 10.15275/annaritmol.2023.1.5
  5. Ades P.A., Savage P.D. The obesity paradox: perception vs knowledge. Mayo Clin. Proc. 2010; 85 (2): 112–114. DOI: 10.4065/mcp.2009.0777
  6. Gruberg L., Weissman N.J., Waksman R., Shmuel F., Regina D., Pinnow E. et al. The impact of obesity on the short-term and long-term outcomes after percutaneous coronary intervention: the obesity paradox? J. Am. Coll. Cardiol. 2002; 39 (4): 578–584. DOI: 10.1016/s0735-1097(01)01802-2
  7. Wang Z., Peng Y., Liu M. Age variation in the association between obesity and mortality in adults. Obesity (Silver Spring). 2017; 25 (12): 2137–2141. DOI: 10.1002/oby.21976
  8. Zhou D., Li Z., Shi G, Zhou J. Obesity paradox for critically ill patients may be modified by age: a retrospective observational study from one large database. Crit. Care. 2020; 24 (1): 425. DOI: 10.1186/s13054-020-03157-1
  9. Bogdanov A.R., Derbeneva S.A., Bogdanova A.A. Features basal metabolism and body composition in obese patients and diastolic heart failure. Creative Cardiology. 2019; 2: 20–29 (in Russ.). DOI: 10.15275/kreatkard.2015.02.02
  10. Brgdar A., Gharbin J., Elawad A., Khalafalla S., Bishaw A., Balogun A.F., Taha M.E. The effects of body mass index on in-hospital mortality and outcomes in patients with heart failure: a nationwide analysis. Cureus. 2022; 14 (2): e22691. DOI: 10.7759/cureus.22691
  11. Powell-Wiley TM A. Scientific statement from the American Heart Association. Circulation. 2021; 143 (21): e984–e1010. DOI: 10.1161/CIR.0000000000000973
  12. Clinical recommendations. Chronic heart failure. Russian Journal of Cardiology. 2017; 1 (141): 7–81 (in Russ.).
  13. Wang Z., Dong B., Hu J., Adegbija O., Arnold L.W. Exploring the non-linear association between BMI and mortality in adults with and without diabetes: the US National Health Interview Survey. Diabetic Medicine. 2020; 33 (12): 1691–1699. DOI: 10.1111/dme.13111
  14. Gurevitz C., Assali A., Mohsan J., Shirly F., Beigel R., Ovdat T. et al. The obesity paradox in patients with acute coronary syndromes over 2 decades – the ACSIS registry 2000–2018. Int. J. Cardiol. 2023; 380: 48–55. DOI: 10.1016/j.ijcard.2023.03.038
  15. Jiang X., Xu J., Zhen S., Zhu Y. Obesity is associated with postoperative outcomes in patients undergoing cardiac surgery: a cohort study. BMC Anesthesiol. 2023; 23 (1): 3. DOI: 10.1186/s12871-022-01966-1
  16. Terada T., Johnson J.A., Norris C., Padway R., Weiyu Q., Sharma A.M. et al. Severe obesity is associated with increased risk of early complications and extended length of stay following coronary artery bypass grafting surgery. J. Am. Heart Assoc. 2016; 5 (6): e003282. DOI: 10.1161/JAHA.116.003282
  17. Lv M., Gao F., Liu B., Pandey P., Feng Y., Wang Y. et al. The effects of obesity on mortality following coronary artery bypass graft surgery: a retrospective study from a single center in China. Med. Sci. Monit. 2021; 27: e929912. DOI: 10.12659/MSM.929912
  18. Muhyieddeen A., Sharif Z., Rasheed O., Ranasinghe S., Chang J., Saleh K. Investigating the obesity paradox: patient outcomes in common cardiac procedures with obesity. Am. Heart J. 2024; 267: 131. DOI: 10.1016/j.ahj.2023.08.040
  19. Golukhova E.Z., Keren M.A., Zavalikhina T.V., Bulaeva N.I., Marapov D.I., Sigaev I.Yu., et al. Prognosis of early outcomes after isolated coronary bypass surgery: results of a singlecenter cohort study. Annals of the Russian Academy of Medic al Sciences. 2023; 78 (3): 176–184 (in Russ.). DOI: 10.15690/vramn8086
  20. Keren M.A., Zavalikhina T.V., Bulayeva N.I., Sigaev I.Yu., Merzlyakov V.Yu., Alshibaya M.D. et al. Prediction of death after coronary bypass surgery. The Bulletin of Bakoulev Center. Cardiovascular Diseases. 2023; 24 (S3): 34 (in Russ.).
  21. Yeung E., Smith S., Scharf M., Wung C., Harsha S., Lawson S. et al. BMI disparities in coronary artery bypass grafting outcomes: A single center Society of Thoracic Surgeons (STS) database analysis. Surg. Pract. Sci. 2022; 10: 100110. DOI: 10.1016/j.sipas.2022.100110
  22. Beckmann A., Poehlmann M., Mayr P., Krane M., Boehm J. The Burden of obesity in cardiac surgery: a 14 years’ follow-up of 14.754 patients. J. Obes. 2024; 2024: 5564810. DOI: 10.1155/2024/5564810
  23. Golukhova E.Z., Keren M.A., Volkovskaya I.V., Yakhyaeva K.B., Zavalikhina T.V., Avakova S.A. et al. Is there “obesity paradox” in coronary surgery? Effect of body mass index on hospital outcomes and three-year survival after coronary bypass surgery. Creative Cardiology. 2023; 17(2): 247–255 (in Russ.). DOI: 10.24022/1997-3187-2023-17-2-247-255
  24. Golukhova E.Z. Report on the scientific and therapeutic work of the A.N. Bakulev National Medical Research Center for Cardiovascular Surgery of the Ministry of Health of the Russian Federation for 2023 and development prospects. The Bulletin of Bakoulev Center. Cardiovascular Diseases. 2024; 25 (S): 5–141 (in Russ.). DOI: 10.24022/1810-0694-2024-25S
  25. Chumakova G.A., Kuznetsova Т.Yu., Druzhilov М.А., Veselovskaya N.G. Visceral adiposity as a global factor of cardiovascular risk. Russian Journal of Cardiology. 2018; 23 (5): 7–14 (in Russ.). DOI: 10.15829/1560-4071-2018-5-7-14
  26. National Clinical Guidelines «Obesity in adults» 2024. Moscow; 2024 (in Russ.).
  27. Shibata R., Izumiya Y., Sato K., Papanicolaou K., Kihara S., Colucci W.S. et al. Adiponectin protects against the development of systolic dysfunction following myocardial infarction. J. Mol. Cell. Cardiol. 2007; 42 (6): 1065–1074. DOI: 10.1016/j.yjmcc.2007.03.808
  28. Maeda N., Takahashi M., Funahashi T., Kihara S., Nishizawa H., Kishida K. et al. PPARgamma ligands increase expression and plasma concentrations of adiponectin, an adipose-derived protein. Diabetes. 2001; 50 (9): 2094–2099. DOI: 10.2337/diabetes.50.9.2094
  29. Tao L., Gao E., Jiao X., Yuan Y., Shuzhuang Li., Christopher A. et al. Adiponectin cardioprotection after myocardial ischemia/reperfusion involves the reduction of oxidative/nitrative stress. Circulation. 2007; 115 (11): 1408–1416. DOI: 10.1161/CIRCULATIONAHA.106.666941
  30. Després J.P. Body fat distribution and risk of cardiovascular disease: an update. Circulation. 2012; 126 (10): 1301–1313. DOI: 10.1161/CIRCULATIONAHA.111.067264
  31. Kishore B.K. Reverse epidemiology of obesity paradox: Fact or fiction? Physiol. Rep. 2024; 12 (21): e70107. DOI:: 10.14814/phy2.70107
  32. Abramowitz M.K., Hall C.B., Amodu A., Sharma D., Androga L., Hawkins M. Muscle mass, BMI, and mortality among adults in the United States: A population-based cohort study. PLoS One. 2018; 13 (4): e0194697. DOI: 10.1371/journal.pone.0194697
  33. Carbone S., Elagizi A., Lavie C.J. Obesity and mortality risk in heart failure: when adipose tissue distribution matters. Eur. J. Heart Fail. 2018; 20 (9): 1278–1280. DOI: 10.1002/ejhf.1279
  34. Lang J.J., Prince S.A., Merucci K., Cadenas-Sanchez C., Chaput J.P., Fraser B.J. et al. Cardiorespiratory fitness is a strong and consistent predictor of morbidity and mortality among adults: an overview of meta-analyses representing over 20.9 million observations from 199 unique cohort studies. Br. J. Sports Med. 2024; 58 (10): 556–566. DOI: 10.1136/bjsports-2023-107849
  35. Pereira C., Diniz S.A., Ramiro P., Cabral P.C. Abdominal obesity and hydration status as protective factors against mortality in older adults: a prospective study. Nutrition. 2023; 116: 112155. DOI: 10.1016/j.nut.2023.112155
  36. Simati S., Kokkinos A., Dalamaga M., Argyrakopoulou G. Obesity paradox: fact or fiction? Curr. Obes. Rep. 2023; 2/ DOI: 10.1007/s13679-023-00497-1
  37. Osadnik T., Nowak D., Osadnik K., Gierlotka M., Windak A., Tomasik T. et al. Association of body mass index and long-term mortality in patients from nationwide LIPIDOGRAM 2004–2015 cohort studies: no obesity paradox? Cardiovasc. Diabetol. 2023; 22: 323. DOI: 10.1186/s12933-023-02059-0
  38. Adams K.F., Schatzkin A., Harris T.B., Kipnis V., Traci M., Rachel B. et al. Overweight, obesity, and mortality in a large prospective cohort of persons 50 to 71 years old. N. Engl. J. Med. 2006; 355: 763–778. DOI: 10.1056/NEJMoa055643
  39. Garcia G.R. 3rd, Coleman N.C., Pond Z.A., Pope C.A. 3rd. Shape of BMI-mortality risk associations: reverse causality and heterogeneity in a representative cohort of US Adults. Obesity (Silver Spring). 2021; 29 (4): 755–766. DOI: 10.1002/oby.23114
  40. Schenkeveld L., Magro M., Oemrawsingh R., Lenzen M., de Jaegere P., van Geuns R. et al. The influence of optimal medical treatment on the ‘obesity paradox’, body mass index and long-term mortality in patients treated with percutaneous coronary intervention: a prospective cohort study. BMJ Open. 2012; 2 (1): e000535. DOI: 10.1136/bmjopen-2011-000535
  41. Tan X.F., Shi J.X., Chen M.H. Prolonged and intensive medication use are associated with the obesity paradox after percutaneous coronary intervention: a systematic review and meta-analysis of 12 studies. BMC Cardiovasc. Disord. 2016; 16: 125. DOI: 10.1186/s12872-016-0310-7
  42. Lancefield T., Clark D.J., Andrianopoulos N., Angela L.B., Christopher M.R., Jennifer J. et al. Is there an obesity paradox after percutaneous coronary intervention in the contemporary era? An analysis from a multicenter Australian registry. JACC Cardiovasc. Interv. 2010; 3 (6): 660–668. DOI: 10.1016/j.jcin.2010.03.018
  43. Hira R.S., Kataruka A., Akeroyd J.M., Ramsey D.J., Pokharel Y., Gurm H.S. et al. Association of body mass index with risk factor optimization and guideline-directed medical therapy in US veterans with cardiovascular disease. Circ. Cardiovasc. Qual. Outcomes. 2019; 12 (1): e004817. DOI: 10.1161/CIRCOUTCOMES.118.004817
  44. Hansel B., Roussel R., Elbez Y., Marre M., Krempf M., Ikeda Y. et al. Cardiovascular risk in relation to body mass index and use of evidence- based preventive medications in patients with or at risk of atherothrombosis. Eur. Heart J. 2015; 36 (40): 2716–2728. DOI: 10.1093/eurheartj/ehv347
  45. Rubino F., Cummings D., Eckel R., Cohen R., Wilding J., Brown W. et al. Definition and diagnostic criteria of clinical obesity. Lancet Diabetes Endocrinol. 2025; 13 (3): 221–262. DOI: 10.1016/S2213-8587(24)00316-4
  46. Druzhilov М.А., Kuznetsova Т.Yu., Druzhilova О.Yu. “Obesity paradoxes”: main causes of an “inverse” cardiovascular epidemiology. Cardiovascular Therapy and Prevention. 2018; 17 (5): 92–98 (in Russ.). DOI: 10.15829/1728-8800-2018-5-92-98
  47. Keren M.A., Sheykina N.A., Sigaev I.Yu., Merzlyakov V.Yu., Alshibaya M.D., Arakelyan V.S. et al. Outcomes of coronary and carotid revascularization depending on the implemented surgical tactics: the experience of one center. Grudnaya i Serdechno-Sosudistaya Khirurgiya. 2023; 6 (65): 713–721 (in Russ.).
  48. Keren M.A., Sigaev I.Yu., Osipova A.I., Volkovskaya I.V., Zavalikhina T.V., Avakova S.A. et al. Impact of chronic kidney disease on type of coronary artery bypass grafting and on the structure of postoperative complications in patients with coronary artery disease. Grudnaya i Serdechno-Sosudistaya Khirurgiya. 2023; 65 (4): 414–423 (in Russ.). DOI: 10.24022/0236-2791-2023-65-4-414-423
  49. Zhalilov A.K., Merzlyakov V.Yu., Klyuchnikov I.V., Salomov M.A., Khaziev R.A., Shurupova I.V., Berdibekov B.Sh. Comparison of immediate outcomes of coronary artery bypass grafting in patients with acute coronary syndrome depending on the timing of myocardial revascularization. Grudnaya i Serdechno-Sosudistaya Khirurgiya. 2024; 66 (3): 311–321 (in Russ.). DOI: 10.24022/0236-2791-2024-66-3-311-321
  50. Golukhova E.Z., Keren M.A., Volkovskaya I.V., Yakhyaeva K.B., Zavalikhina T.V., Avakova S.A. et al. Is there “obesity paradox” in coronary surgery? Effect of body mass index on hospital outcomes and three-year survival after coronary bypass surgery. Creative Cardiology. 2023; 17(2): 247–255 (in Russ.). DOI: 10.24022/1997-3187-2023-17-2-247-255

About Authors

  • Kumushdzhan B. Yakhyaeva, Cardiologist; ORCID
  • Milena A. Keren, Dr. Med. Sci., Professor of Chair, Senior Researcher; ORCID
  • Irina V. Volkovskaya, Cand. Med. Sci., Head of Department; ORCID

Chief Editor

Elena Z. Golukhova, MD, PhD, DSc, Professor, Academician of Russian Academy of Sciences, Director of Bakoulev National Medical Research Center for Cardiovascular Surgery


Sort by