Can the Complexity of Diagnosing Pulmonary Embolism in Patients With Obesity and Multiple Comorbidities Provide an Explanation of the Obesity Paradox?

This report describes three cases of patients with obesity who had chronic comorbidities and presented with documented causes of dyspnea before hospital admission. The challenges in recognising and diagnosing pulmonary embolism (PE) in these patients are highlighted and discussed in light of current literature. It is possible that delayed or missed diagnoses are common among patients with a history of dyspnea, a symptom frequently observed in individuals with obesity. A hypothesis is proposed based on existing medical literature to explain the so-called "obesity paradox." This hypothesis suggests that the seemingly lower relative risk of mortality from PE in patients with obesity, compared to their counterparts without obesity, may stem from a higher rate of missed diagnoses in the former who have multiple comorbidities, many of which often present with dyspnea, besides other symptoms. Such a situation could lead to misleading data indicating better outcomes due to selection bias, where healthier patients with obesity but without comorbid conditions are more easily identified and receive prompt treatment. In contrast, delays or missed diagnoses in more vulnerable patients with obesity who have multiple health issues may result in significantly worse outcomes, potentially explaining the increased all-cause mortality associated with obesity. While this paper specifically examines PE, the same principle may apply to other medical emergencies involving patients with obesity who present with acute dyspnea. Specific studies are needed to simultaneously assess the outcomes for both diagnosed and undiagnosed patients with obesity to prove or disprove this hypothesis.