Reports among patients with coronary heart disease regarding the association between
body mass index (BMI) and long-term mortality are inconsistent, ranging among linear,
U-shaped, or inverse (the “obesity paradox”) associations. BMI and mortality data
were available for 12,466 men with chronic coronary heart disease. BMI was classified
as <20 (lean), 20.0 to 22.99, 23.0 to 24.99 (reference), 25.0 to 26.99, 27.0 to 29.99,
and ≥30 kg/m2 (obese). Age-adjusted (direct methods) mortality was investigated within risk factor
categories. Adjusted hazard ratios compared with the reference group were estimated
using a Cox proportional-hazards model. Two thirds of the patients had BMIs ≥25 kg/m2. A number of risk factors were progressively more frequent with increasing BMI (age,
diabetes, past smoking, and metabolic components). Over a median follow-up period
of 12 years, adjusted mortality rates per 1,000 patient-years followed a U-shaped
association with BMI. The highest risk was noted in 148 lean (hazard ratio 1.41, 95%
confidence interval 1.08 to 1.85) and 1,788 obese (hazard ratio 1.28, 95% confidence
interval 1.15 to 1.42) patients. Mortality hazard in patients with BMIs of 20.0 to
29.99 kg/m2 (84% of patients) did not significantly differ from the reference group (lowest risk).
Risk factor presence was associated with higher mortality in every BMI category. Lean
patients had a particularly poor prognosis in the presence of past myocardial infarction,
smoking, or renal insufficiency. A U-shaped association was found in most subgroups
examined. In conclusion, BMI ≥25 kg/m2 is common in patients with coronary heart disease. A U-shaped association, with highest
risk among lean and obese patients, is persistent regardless of risk factor presence.
Further data are required to support the need of aggressive weight reduction in patients
with BMIs <30 kg/m2.
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Article info
Publication history
Accepted:
March 10,
2010
Received in revised form:
March 10,
2010
Received:
December 19,
2009
Identification
Copyright
© 2010 Elsevier Inc. Published by Elsevier Inc. All rights reserved.
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- The “Obesity Paradox” in Coronary Heart DiseaseAmerican Journal of CardiologyVol. 106Issue 11
- PreviewWe read with great interest the well-written and well-done study from Israel by Benderly et al1 from the Bezafibrate Infarction Prevention (BIP) database examining the relation of body mass index (BMI) to mortality in men with coronary heart disease (CHD). Importantly, in their study, they demonstrated a U-shaped association, with the highest risk in the lean (BMI <20 kg/m2) and in the obese (BMI ≥30 kg/m2) groups. It is critical to point out that these results are different from those of many other studies and meta-analyses, in which overweight (BMI 25 to 30 kg/m2) and obese (or at least mildly obese; BMI 30 to 35 kg/m2) patients have lower mortality than “normal”-BMI patients.
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