To Lose Weight or Not to Lose Weight, That Is the Big Question—in Obesity-Related Heart Failure

Obesity and heart failure (HF) are twin public health problems. Moreover, obesity can contribute to HF (1). Each contributes to increased mortality. Conversely, weight loss in obese patients without HF improves diastolic function and decreases oxygen requirements and left ventricular (LV) mass (2,3). In two large studies, surgery-induced weight loss reduced cardiac death and improved survival in humans (4,5), but it is unknown how many suffered from HF. So physicians should recommend weight loss, right? The problem is—there is a paradox. That is “the rub.” The “obesity paradox” is based on outcomes data that show that patients who are obese and have HF live longer than patients who are not obese (Fig. 1). There are multiple possible reasons for the paradox (recently reviewed by Lavie et al. [6]). Patients with obesity-related HF may be diagnosed earlier; they do not suffer from cachexia; they may also have an advantage because they are starting from a higher body weight before the cachexia of chronic disease (HF) begins; and/or there may be other benefits from adipose and lean muscle tissue. Regardless of the mechanism, the paradox leaves us with a conundrum: to recommend weight loss or not for patients …