Obesity Paradox in Aging: From Prevalence to Pathophysiology

https://doi.org/10.1016/j.pcad.2018.07.011Get rights and content

Abstract

Recent advances in medical technology and health care have greatly improved the management for chronic diseases and prolonged human lifespan. Unfortunately, increased lifespan and the aging population impose a major challenge on the ever-rising prevalence of chronic diseases, in particular cardiometabolic stress associated with the pandemic obesity in our modern society. Although overweight and obesity are associated with incident cardiovascular diseases (CVD), including heart failure (HF), it paradoxically leads to a more favorable prognosis in patients with chronic HF, a phenomenon commonly defined as “obesity paradox”. Numerous population-based and clinical studies have suggested possible explanations such as better metabolic reserve, smoking and disease-associated weight loss for obesity paradox. Recent evidence noticed a shift in obesity paradox with aging. While some studies have reported a more pronounced “obesity paradox” in the older patients, others have seen diminished cardiac benefits with overweight and obesity in the elderly patients with CVD. These findings suggested that a complex relationship among aging, metabolism, and HF severity/chronicity, which may explain the shift in obesity paradox in the elderly. Aging negatively affects body metabolism and cardiac function although its precise impact on obesity paradox remains elusive. To develop new strategies for cardiovascular health in the elderly, it is imperative to understand the precise role for aging on obesity-related CVD.

Section snippets

Epidemiology, and clinical evidence for obesity paradox in heart failure (HF)

Obesity has reached an epidemic proportion and imposed substantial risks on both metabolic and cardiovascular (CV) diseases (CVD), contributing to the increased premature mortality.1., 2., 3., 4. Overweight and obesity adversely affect CV function and serve as an independent risk factor for both systolic and diastolic heart dysfunction, resulting in HF.4., 5., 6., 7. Several scenarios including oxidative stress, apoptosis, autophagy failure, lipotoxicity, inflammation, hemodynamic change,

Confounding influences of obesity paradox – focusing on aging

A number of confounding factors were implicated to influence the CV outcomes in obesity, thus affecting obesity paradox and prognosis of CVD. For example, gender, nutritional status, aging and therapeutic strategies, such as CRF and weight loss may all contribute to the presentation of obesity paradox.14,25,28 Here we will discuss gender, socioeconomic, nutrition and aging with a focus on how aging may alter the clinical prognosis.

Obesity paradox– pathophysiological aspects of aging, adiposity and CV health

Although obesity paradox may be affected by various factors such as age, gender, etiology of CVD and comorbidities, the pathophysiology underscoring the heterogeneous impact of aging on adiposity and CVD outcomes in obesity paradox remains largely obscure. Aging is an important independent risk factor for cardiometabolic incidents, resulting in unfavorable changes in CV system including cardiac remodeling, decrease in exercise capacity and pump function, endothelial dysfunction and vascular

Intervention targeting obesity in obesity paradox – weight loss and dietary restriction

For management of overweight and obese patients with CVD, it is suggested that clinical care should be focused on improvement and maintenance of physical function and quality of life as opposed to the prevention of obesity-related medical problems in younger aged patients.27 Although weight loss is beneficial for cardiac geometry and function, as well as symptom control in HF, definitive clinical guidelines are still lacking for the optimal body composition in patients with HF, especially in

Future perspectives, challenges and conclusions

Obesity paradox refers to the association between obesity (in particular class 1 obesity) and better survival with a given disease, such as HF or CHD. Because the data to support the obesity paradox are exclusively from clinical observations, it is still uncertain whether the obesity paradox is an artifact from observational studies. Paradoxical observations cause vexing clinical and epidemiological presentations to result in causal relationships. Compelling evidence has indicated a unique role

Statement of conflict of interest

There is no conflict of interest of any of the listed authors.

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