Obesity paradox can be a fact: unveiling the hidden role of adipose tissue

This commentary refers to ‘Anthropometric measures and adverse outcomes in heart failure with reduced ejection fraction: revisiting the obesity paradox’, by J.H. Butt et al., https://doi.org/10.1093/eurheartj/ehad083 and the discussion piece ‘Obesity paradox can be a fact: unveiling the hidden role of adipose tissue’, by D.-H. Lee, https://doi.org/10.1093/eurheartj/ehae236.

Duk-Hee Lee suggests that because patients with a body mass index of ≥35 kg/m² (or the highest waist-to-height ratio category) did not exhibit an elevated mortality risk, as might have been expected, there may still be an obesity survival paradox in heart failure. The hypothesis made is that adipose tissue might serve as a store for toxins that would otherwise poison mitochondria, i.e. that adipose tissue has a protective effect. Indeed, it is postulated that the release of these toxins as a consequence of weight loss might be harmful. While intriguing, we know of no clinical data supporting this hypothesis, and, notably, greater obesity was associated with a higher risk of worsening heart failure. The absence of an association with a higher risk of death may simply be a matter of time, with such a consequence not yet apparent during the relatively short follow-up period in the current study.

Declarations

Disclosure of Interest

J.H.B. reports advisory board honoraria from Bayer; consultant honoraria from Novartis and AstraZeneca; and travel grants from AstraZeneca. J.J.V.M. reports payments through Glasgow University from work on clinical trials, consulting, and other activities from Amgen, AstraZeneca, Bayer, Cardurion, Cytokinetics, GSK, KBP Biosciences, and Novartis; personal consultancy fees from Alnylam Pharma, Bayer, BMS, George Clinical PTY Ltd, Ionis Pharma, Novartis, Regeneron Pharma, and River 2 Renal Corporation; and personal lecture fees from Abbott, Alkem Metabolics, AstraZeneca, Blue Ocean Scientific Solutions Ltd, Boehringer Ingelheim, Canadian Medical and Surgical Knowledge, Emcure Pharma Ltd, Eris Lifesciences, European Academy of CME, Hikma Pharmaceuticals, Imagica Health, Intas Pharma, J.B. Chemicals & Pharma Ltd, Lupin Pharma, Medscape/Heart.Org, ProAdWise Communications, Radcliffe Cardiology, Sun Pharma, The Corpus, Translation Research Group, and Translational Medicine Academy. He is a director of Global Clinical Trial Partners Ltd.