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Low body-mass index with abdominal obesity is associated with worse heart failure outcomes in Asian

September 24, 2019

Having a lower body-mass index (BMI), but also having a higher waist-to-height ratio (WHtR), is associated with worse outcomes among Asian patients with heart failure, according to a study published September 24 in the open-access journal PLOS Medicine by Carolyn Lam of the National Heart Centre Singapore, and colleagues. As noted by the authors, the combined use of BMI and abdominal measures could potentially inform heart failure management better, especially among the particularly vulnerable patients with low BMI and high WHtR in Asia.

Among heart failure patients, Asian patients are more likely to be lean (have a low BMI, <24.5 kg/m2 ) than Western patients. The obesity paradox, in which higher BMI is associated with better heart failure outcomes, has been mainly reported in Western nations using the traditional classification of obesity (BMI), but little is known about this paradox in Asia. To address this gap in knowledge, Lam and colleagues investigated the association between obesity (defined by BMI and abdominal measures) and heart failure outcomes in Asia. Using a heart failure registry for 11 Asian regions, the researchers prospectively examined 5,964 patients with symptomatic heart failure, among whom 2,051 also had WHtR measurements, and examined one-year composite outcomes (i.e., heart failure hospitalization or mortality).

Higher BMI was associated with better outcomes but higher WhtR was associated with worse outcomes. In combined analysis, the "lean-fat" subgroup with low BMI and high WHtR (?0.55) made up 13.9% of the heart failure population in Asia, were more likely to be women (35.4%) from low-income countries (47.7%), predominantly in South/Southeast Asia, had the highest prevalence of diabetes (46%), worst quality-of-life scores (63.3 ± 24.2), and highest rate of composite events ([51/232], 22%), compared to other subgroups (p<0.05 for all). In addition, the lean-fat group had the highest adjusted risk of composite outcomes (hazard ratio [HR]: 1.93, 95%CI 1.17-3.18, p=0.01), compared to the obese-thin group with high BMI and low WHtR. Findings were consistent across both heart failure with preserved and reduced ejection fraction (HFpEF and HFrEF). Taken together, the findings suggest that the obesity paradox exists in Asia, but only when classified by BMI and not abdominal measures. A direct relationship between central obesity and heart failure outcomes is apparent in both HFpEF and HFrEF.

According to the authors, clear national policies that underscore the prevention of abdominal obesity and the promotion of a healthy BMI through awareness, education and lifestyle modification should be championed. The authors note that because these analyses were based on data from multinational registries, they may be affected by selection bias and unmeasured confounding.
Research Article


ASIAN HF Study was supported by research grants from Boston Scientific Investigator Sponsored Research Program, National Medical Research Council of Singapore [NMRC/CSA/0052/2013], A*STAR Biomedical Research Council ATTRaCT program [SPF2014/003] and Bayer. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing Interests:

I have read the journal's policy and the authors of this manuscript have the following competing interests: CSPL served as a guest editor on PLOS Medicine's Cardiovascular Disease Special Issue. Unrelated to present work, CSPL is supported by a Clinician Scientist Award from the National Medical Research Council Singapore, non-financial support from Boston Scientific, non-financial support from Bayer, non-financial support from Thermofisher, non-financial support from Vifor Pharma, other from Bayer, other from Novartis, other from Takeda, other from Merck, other from Astra Zeneca, other from Janssen Research & Development, other from LLC, other from Menarini, other from Boehringer Ingelheim, other from Abbott Diagnostics, from DC Devices, outside the submitted work; In addition, CSPL has a patent PCT/SG2016/050217 pending. AMR is supported by a Singapore Translational Research (STaR) award from the National Medical Research Council Singapore, is a named investigator on projects supported by grants from Boston Scientific, Bayer, Astra Zeneca, Roche Diagnostics and has received research support in kind Thermo Fisher, Roche Diagnostics and Abbott Laboratories and other from Novartis. All other authors report no conflict of interest, financial or otherwise.


Chandramouli C, Tay WT, Bamadhaj NS, Tromp J, Teng T-HK, Yap JJL, et al. (2019) Association of obesity with heart failure outcomes in 11 Asian regions: A cohort study. PLoS Med 16(9): e1002916.

Image Credit: Pexels, Pixabay

Author Affiliations:

National Heart Centre Singapore, Singapore, Singapore
University Medical Center Groningen, Groningen, Netherlands
Changi General Hospital, Singapore, Singapore
MacKay Memorial Hospital, Taipei, Taiwan
CIMS Hospital, Ahmedabad, Gujarat, India
Dayanand Medical College and Hospital, Ludhiana, Punjab, India
Sir Gangaram Hospital, New Delhi, India
Cardiovascular Research Institute, Singapore, Singapore
Veterans Affairs Medical Center, Minneapolis, Minnesota, United States of America
Duke-NUS Medical School, Singapore, Singapore

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