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Obesity Paradox

The 4 th national congress of obesity. Obesity Paradox. F. Hosseinpanah , M.D. Obesity Research Center Research Institute for Endocrine sciences Shahid Beheshti University of Medical Sciences December 6, 2013 Tehran. Agenda. Introduction OP in CAD OP in heart failure OP in diabetes

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Obesity Paradox

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  1. The 4thnational congress of obesity Obesity Paradox F. Hosseinpanah, M.D. Obesity Research Center Research Institute for Endocrine sciences ShahidBeheshti University of Medical Sciences December 6, 2013 Tehran

  2. Agenda • Introduction • OP in CAD • OP in heart failure • OP in diabetes • OP in stroke • How to explain OP? • Conclusions

  3. Introduction • Obesity is considered a major risk factor not only for type 2 diabetes, lipid disorders, and hypertension but also for coronary heart disease and certain cancers • Mortality increases as BMI increases above 25 kg/m2 and as BMI decreases below 25 kg/m2 JAMA 2005;293:1861–1867

  4. Observations at the primaryepidemiology level • Obesity is clearly a risk factor for developing CAD • Once CAD has been established, the correlation of obesity with total mortality, cardiovascular mortality, infarction, and revascularisation is less clear

  5. Prognosis of overweight and obese individuals seemed to be better than the prognosis of normal or low-weight subjects ? ?

  6. What does obesity paradox mean? • Overweight and obese individuals with established cardiovascular disease, heart failure, hypertension, diabetes, ESRD have a better prognosis compared with normal weight subjects

  7. Obesity Paradox • Coronary artery disease • Chronic heart failure • Hypertension • Stroke • Diabetes • ESRD • …..

  8. Objective: To determine the extent and nature of the association between obesity, and total mortality and cardiovascular events in patients with coronary artery disease (CAD) Lancet 2006;368:666–678

  9. Inclusion criteria • Reported total mortality and cardiovascular events in patients with established CAD, on the basis of bodyweight or other measures of fat distribution • Patients with CAD (defined as a history of PCI, CABG, or MI) at baseline • Cohort studies with 6 months or longer of f/U

  10. Exclusion Criteria • Studies defining CAD with non-invasive techniques • Studies with only in-hospital mortality data

  11. Included studies • Frothy studies were included • Sample size: N=250152 patients with CAD • Mean length of F/U : 3.8 years • Subgroups: MI,PCI, CABG

  12. Outcomes • Total mortality • Cardiovascular mortality

  13. Adjusted for age , sex, smoking, HTN, cardiac risk factor

  14. Key messages low BMI : • Long-term risk of total mortality • Long-term risk of Other cardiovascular events Overweight : • Better survival • Lower cardiovascular events Obesity : • Higher total mortality only in patients with history of CABG Severe obesity : • Significantly higher cardiovascular mortality

  15. Objective: To examine the relationship between increased BMI and mortality in patients with CHF Am Heart J 2008;156:13-22

  16. Included studies • Nine studies were included eligibility criteria • Total sample size = 28209 • Mean length of F/U :2.7 years

  17. Outcomes • Primary : all-cause mortality • Secondary : cardiovascular mortality

  18. Key messages • Obese and overweight with CHF have lower risk for death than normal body weight even after adjustment for baseline risk • Underweight individuals are at extremely high risk for death

  19. Objective:To test the association of weight status with mortality in adults with new onset diabetes JAMA. 2012 August 8; 308(6): 581–590.

  20. Included cohorts • Pooled analysis of five longitudinal cohort studies • 2,625 participants with incident diabetes • Participants contributed 27,125 person-years of F/U • Main outcomes :Total, cardiovascular, and non-cardiovascular mortality

  21. Adjusted HR, 2.08(1.5-2.85)

  22. Adjusted HR, 1.52(0.89-2.58) Adjusted HR, 2.08(1.5-2.85

  23. Adjusted HR, 2.32(1.55-3.48)

  24. Key messages • In this pooled longitudinal study, participants who were normal weight at the time of incident diabetes experienced higher total and non-cardiovascular mortality as compared with those who were overweight or obese. • Cardiovascular mortality was non-significantly elevated in participants who were normal weight as compared with those who were overweight or obese • Findings were consistent across demographic categories and smoking status and persisted following adjustment for known cardiovascular disease risk factors

  25. Objective: To evaluate the association of the body mass index (BMI) with mortality and with non-fatal functional outcome in patients with acute stroke or transient ischemic attack Eur Heart J. 2012 Oct 16

  26. Methods • Design: Post hoc analysis of TEMPis Trial • Sample size : 4428 patients with acute stroke or transient ischemic attack (TIA).BMI was available in 1521 patients • Length of F/U: 30 months • Outcomes: all-cause mortality ,recurrent stroke, need for institutional care, and functional impairment (Barthel index ,60, modified Rankin score .3)

  27. Key messages • Patients hospitalized for acute stroke or TIA who are overweight and obese have better survival and non-fatal functional outcomes when compared with patients with normal weight • It is noteworthy, that the risk of recurrent stroke was not higher in overweight or obese patients • The inverse associations remained after adjustment for confounding factors including age, gender, prior living situation, stroke subtype and severity, co-morbidities, and stroke treatment facility

  28. DIABETES CARE, VOLUME 36, SUPPLEMENT 2, AUGUST 2013 DIABETES CARE, VOLUME 36, SUPPLEMENT 2, AUGUST 2013

  29. How to explain obesity paradox? • Role of age and less risky obesity (selection bias) • Anabolic deficiency or the malnutrition-inflammation complex • Medical treatment • Body composition • Enlarged muscle mass and better nutritional status • Cardiorespiratory fitness • Increased muscle strength • Single body weight measurement • Central obesity and body fat distribution

  30. How to explain obesity paradox? • Endothelial progenitor cells • Thromboxane production • Ghrelin sensitivity • Soluble tumor necrosis factor receptor

  31. Von Haehlinget al. Obesity and the heart a weighty issue. J Am CollCardiol 2006;47:2274–2276.

  32. Conclusions • Observations at primary epidemiology levels provide conclusive evidence in favor of positive association between obesity and mortality • Obesity paradox requires a chronic disease in the first place such as CAD, Heart failure,.. • There are some reasons for the observed paradox • We have to keep in mind thatthe BMI is a crude and flawed anthropometric biomarker that does not take into account fat mass/fat-free mass ratio, nutritional status, cardiorespiratory fitness, body fat distribution, or other factors affecting health risks and the patient’s mortality

  33. Conclusions • The guidelines in both the US and Europe as they are right now suggest obesity as a major modifiable cardiovascular risk factor in secondary prevention?! • The discussion over the existence of the obesity paradox cannot lead to an underestimation of obesity as a crucial risk factor for the development of cardiovascular and metabolic diseases that requires comprehensive prevention and management strategies.

  34. Final solution • Prospective evaluation of weight loss/weight changes among patients who have already affected by diseases are needed • Obviously , RCTs would be the best design in this regard

  35. Thanks for your kind attention

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