Obesity or bmi paradox? beneath the tip of the iceberg
Open accessAbstract
The obesity paradox refers to extant evidence showing that obesity in older subjects or in patients with several chronic diseases may be protective and associated with decreased mortality. A number of mechanisms have been postulated to support the existence of obesity paradox; however, marked heterogeneity was found across studies and this has cast doubt on the actual presence of this phenomenon. The aim of the present narrative review is to summarize evidence underlying the concept of obesity paradox, focusing on limitations and bias related to this phenomenon, with emphasis on the use of body mass index (BMI). A major cause of the discrepancy between studies may be related to the use of BMI in the definition of obesity, that should consider, instead, excess body fat as the main characteristic of this disease and as the unique determinant of its complications. In addition, the adjustment for potential confounders (e.g., stage and grade of diseases, smoking habit, inability to capture the presence of signs of undernutrition in the normal-weight comparative group, consideration of body composition) may significantly scale down the protective role of obesity in terms of mortality. However, it is still necessary to acknowledge few biases (e.g., reverse causation, attrition bias, selection bias of healthy obese subjects or resilient survivors) that would still apply to obesity even when defined according with body composition. Further research should be prompted in order to promote correct phenotyping of patients in order to capture properly the trajectories of mortality in a number of diseases.
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There is a well-known paradox that obesity is related to a lower risk of mortality.
“There is a well-known paradox that obesity is related to a lower risk of mortality (31).”
From The role of obesity in sarcopenia and the optimal body composition to prevent against sarcopenia and obesity (2023) · cites this paper as [31]
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Cites
The effect of age on the association between body-mass index and mortality
Stevens, J., Cai, J., Pamuk, E. R., Williamson, D. F., Thun, M. J., & Wood, J. L. (1998) · New England Journal of Medicine · doi:10.1056/nejm199801013380101 · Cited by 1,611 · see citing works
Reverse epidemiology of cardiovascular risk factors in maintenance dialysis patients
Kalantar‐Zadeh, K., Block, G., Humphreys, M. H., & Kopple, J. D. (2003) · Kidney International · doi:10.1046/j.1523-1755.2003.00803.x · Cited by 1,248 · see citing works
BMI-related errors in the measurement of obesity
Rothman, K. J. (2008) · International Journal of Obesity · doi:10.1038/ijo.2008.87 · Cited by 1,140 · see citing works
Gruberg, L., Weissman, N. J., Waksman, R., Fuchs, S., Deible, R., Pinnow, E. E., Ahmed, L. M., Kent, K. M., Pichard, A. D., Suddath, W. O., et al. (2002) · Journal of the American College of Cardiology · doi:10.1016/s0735-1097(01)01802-2 · Cited by 696 · see citing works
Kalantar‐Zadeh, K., Block, G., Horwich, T. B., & Fonarow, G. C. (2004) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2003.11.039 · Cited by 689 · see citing works
The Obesity Paradox in Cancer: a Review
Lennon, H., Sperrin, M., Badrick, E., & Renehan, A. G. (2016) · Current Oncology Reports · doi:10.1007/s11912-016-0539-4 · Cited by 608 · see citing works
Plasma Adiponectin, Body Mass Index, and Mortality in Patients With Chronic Heart Failure
Kistorp, C., Faber, J., Galatius, S., Gustafsson, F., Frystyk, J., Flyvbjerg, A., & Hildebrandt, P. (2005) · Circulation · doi:10.1161/circulationaha.104.530972 · Cited by 605 · see citing works
Villareal, D. T., Apovian, C. M., Kushner, R. F., & Klein, S. (2005) · Obesity Research · doi:10.1038/oby.2005.228 · Cited by 579 · see citing works
Defining Obesity Cut Points in a Multiethnic Population
Razak, F. A., Anand, S. S., Shannon, H. S., Vuksan, V. V. V., Davis, B. C., Jacobs, R., Teo, K. K., McQueen, M., & Yusuf, S. (2007) · Circulation · doi:10.1161/circulationaha.106.635011 · Cited by 558 · see citing works
Hainer, V., & Aldhoon-Hainerová, I. (2013) · Diabetes Care · doi:10.2337/dcs13-2023 · Cited by 503 · see citing works
Obesity and Atrial Fibrillation Prevalence, Pathogenesis, and Prognosis
Lavie, C. J., Pandey, A., Lau, D. H., Alpert, M., & Sanders, P. (2017) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2017.09.002 · Cited by 477 · see citing works
Central Obesity and Survival in Subjects With Coronary Artery Disease
Coutinho, T. A., Goel, K., de Sa, D. C., Kragelund, C., Kanaya, A. M., Zeller, M., Park, J., Køber, L., Torp-Pedersen, C. T., Cottin, Y., et al. (2011) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2010.11.058 · Cited by 408 · see citing works
Caan, B. J., Meyerhardt, J. A., Kroenke, C. H., Alexeeff, S., Xiao, J., Weltzien, E. K., Feliciano, E. M. C., Castillo, A., Quesenberry, C. P., Kwan, M. L., et al. (2017) · Cancer Epidemiology Biomarkers & Prevention · doi:10.1158/1055-9965.epi-17-0200 · Cited by 354 · see citing works
Nutritional Deficiencies in Morbidly Obese Patients: A New Form of Malnutrition?: Part A: Vitamins
Kaidar-Person, O., Person, B., Szomstein, S., & Rosenthal, R. J. (2008) · Obesity Surgery · doi:10.1007/s11695-007-9349-y · Cited by 325 · see citing works
Obesity paradox in cancer: new insights provided by body composition
González, M. C., Pastore, C. A., Orlandi, S. P., & Heymsfield, S. B. (2014) · American Journal of Clinical Nutrition · doi:10.3945/ajcn.113.071399 · Cited by 312 · see citing works
Role of adipokines in cardiovascular disease
Mattu, H. S., & Randeva, H. S. (2012) · Journal of Endocrinology · doi:10.1530/joe-12-0232 · Cited by 292 · see citing works
An Epidemiologic and Genomic Investigation Into the Obesity Paradox in Renal Cell Carcinoma
Hakimi, A. A., Furberg, H. F., Zabor, E. C., Skanderup, A. J., Schultz, N. D., Ciriello, G., Mikklineni, N., Fiegoli, B., Kim, P. H., Voss, M. H., et al. (2013) · JNCI Journal of the National Cancer Institute · doi:10.1093/jnci/djt310 · Cited by 291 · see citing works
Diagnostic accuracy of body mass index to identify obesity in older adults: NHANES 1999–2004
Batsis, J. A., Mackenzie, T. A., Bartels, S. J., Sahakyan, K. R., Somers, V. K., & Lopez-Jimenez, F. (2016) · International Journal of Obesity · doi:10.1038/ijo.2015.243 · Cited by 275 · see citing works
Body composition phenotypes in pathways to obesity and the metabolic syndrome
Dulloo, A. G., Jacquet, J., Solinas, G., Montani, J.-P., & Schutz, Y. (2010) · International Journal of Obesity · doi:10.1038/ijo.2010.234 · Cited by 268 · see citing works
Body Mass Index and Mortality in Chronic Obstructive Pulmonary Disease: A Meta-Analysis
Cao, C., Wang, R., Wang, J., Bunjhoo, H., Xu, Y., & Xiong, W. (2012) · PLoS ONE · doi:10.1371/journal.pone.0043892 · Cited by 247 · see citing works
Antonopoulos, A. S., Oikonomou, E. K., Antoniades, C. A., & Tousoulis, D. (2016) · Obesity Reviews · doi:10.1111/obr.12440 · Cited by 233 · see citing works
The Importance of Body Composition in Explaining the Overweight Paradox in Cancer—Counterpoint
Caan, B. J., Feliciano, E. M. C., & Kroenke, C. H. (2018) · Cancer Research · doi:10.1158/0008-5472.can-17-3287 · Cited by 225 · see citing works
Schutter, A. D., Lavie, C. J., & Milani, R. V. (2013) · Progress in Cardiovascular Diseases · doi:10.1016/j.pcad.2013.08.003 · Cited by 202 · see citing works
The obesity paradox in cancer-moving beyond BMI
Strulov Shachar, S., & Williams, G. R. (2017) · Cancer Epidemiology, Biomarkers & Prevention · doi:10.1158/1055-9965.epi-16-0439 · Cited by 198 · see citing works
Veronese, N., Cereda, E., Solmi, M., Fowler, S. A., Manzato, E., Maggi, S., Manu, P., Abe, E., Hayashi, K., Allard, J. P., et al. (2015) · Obesity Reviews · doi:10.1111/obr.12309 · Cited by 187 · see citing works
Body composition phenotypes and obesity paradox
Prado, C. M. M., González, M. C., & Heymsfield, S. B. (2015) · Current Opinion in Clinical Nutrition & Metabolic Care · doi:10.1097/mco.0000000000000216 · Cited by 157 · see citing works
Body weight and mortality in COPD: focus on the obesity paradox
Spelta, F., Pasini, A. M. F., Cazzoletti, L., & Ferrari, M. (2017) · Eating and Weight Disorders - Studies on Anorexia Bulimia and Obesity · doi:10.1007/s40519-017-0456-z · Cited by 150 · see citing works
Nutritional Deficiencies in Morbidly Obese Patients: A New Form of Malnutrition?
Kaidar‐Person, O., Person, B., Szomstein, S., & Rosenthal, R. J. (2008) · Obesity Surgery · doi:10.1007/s11695-007-9350-5 · Cited by 144 · see citing works
The obesity paradox in elderly patients with heart failure: Analysis of nutritional status
Casas-Vara, A., Santolaria, F., Fernández-Bereciartúa, A., González‐Reimers, E., García-Ochoa, A., & Martı́nez-Riera, A. (2012) · Nutrition · doi:10.1016/j.nut.2011.10.006 · Cited by 141 · see citing works
The Plausibility of Obesity Paradox in Cancer—Point
Park, Y., Peterson, L. L., & Colditz, G. A. (2018) · Cancer Research · doi:10.1158/0008-5472.can-17-3043 · Cited by 138 · see citing works
Is There a Paradox in Obesity?
Goyal, A., Nimmakayala, K. R., & Zonszein, J. (2014) · Cardiology in Review · doi:10.1097/crd.0000000000000004 · Cited by 127 · see citing works
Nigam, A., Wright, R. S., Allison, T. G., Williams, B. A., Kopecky, S. L., Reeder, G. S., Murphy, J. G., & Jaffe, A. S. (2006) · International Journal of Cardiology · doi:10.1016/j.ijcard.2005.06.040 · Cited by 98 · see citing works
Donini, L. M., Savina, C., Gennaro, E. D., Felice, M. R. D., Rosano, A., Pandolfo, M. M., del Balzo, V., CANNELLA, C., Ritz, P., & Chumlea, W. C. (2011) · The journal of nutrition health & aging · doi:10.1007/s12603-011-0073-x · Cited by 95 · see citing works
Self-citationBeyond the BMI: The Search for Better Guidelines for Bariatric Surgery
Pories, W. J., Dohm, L. G., & Mansfield, C. J. (2010) · Obesity · doi:10.1038/oby.2010.8 · Cited by 93 · see citing works
Wang, L., Liu, W., He, X., Chen, Y., Lu, J., Liu, K., Cao, K., & Yin, P. (2015) · International Journal of Obesity · doi:10.1038/ijo.2015.176 · Cited by 93 · see citing works
Paradoxical Preservation of Vascular Function in Severe Obesity
Biasucci, L. M., Graziani, F., Rizzello, V., Liuzzo, G., Guidone, C., Caterina, A. R. D., Brugaletta, S., Mingrone, G., & Crea, F. (2010) · The American Journal of Medicine · doi:10.1016/j.amjmed.2010.02.016 · Cited by 86 · see citing works
Cicoira, M., Maggioni, A. P., Latini, R., Barlera, S., Carretta, E., Jánosi, A., Soler‐Soler, J., Anand, I. S., Cohn, J. N., & Val-HeFT Investigators (2006) · European Journal of Heart Failure · doi:10.1016/j.ejheart.2006.10.016 · Cited by 84 · see citing works
Impact of Misclassification of Obesity by Body Mass Index on Mortality in Patients With CKD
Lin, T., Lim, P., & Hung, S. (2017) · Kidney International Reports · doi:10.1016/j.ekir.2017.12.009 · Cited by 83 · see citing works
Mascie‐Taylor, C. G. N., & Goto, R. (2007) · Journal of PHYSIOLOGICAL ANTHROPOLOGY · doi:10.2114/jpa2.26.109 · Cited by 76 · see citing works
Body composition analyses in normal weight obese women.
Renzo, L. D., del Gobbo, V., Bigioni, M., Premrov, M. G., Cianci, R., & LORENZO, A. D. (2006) · PubMed · Cited by 70 · see citing works
The obesity paradox in cancer: clinical insights and perspectives
Trestini, I., Carbognin, L., Bonaiuto, C., Tortora, G., & Bria, E. (2018) · Eating and Weight Disorders - Studies on Anorexia Bulimia and Obesity · doi:10.1007/s40519-018-0489-y · Cited by 68 · see citing works
Poggiogalle, E., Migliaccio, S., Lenzi, A., & Donini, L. M. (2014) · Endocrine · doi:10.1007/s12020-014-0315-x · Cited by 67 · see citing works
Self-citationDoes Being Overweight Really Reduce Mortality?
Tobias, D. K., & Hu, F. B. (2013) · Obesity · doi:10.1002/oby.20602 · Cited by 55 · see citing works
The Obesity Paradox: A Misleading Term That Should Be Abandoned
Flegal, K. M., & Ioannidis, J. P. A. (2018) · Obesity · doi:10.1002/oby.22140 · Cited by 42 · see citing works
Anand, N. (2013) · JOURNAL OF CLINICAL AND DIAGNOSTIC RESEARCH · doi:10.7860/jcdr/2013/5329.2907 · Cited by 40 · see citing works
Obesity paradox in heart failure: statistical artifact, or impetus to rethink clinical practice?
Charnigo, R. J., & Guglin, M. E. (2016) · Heart Failure Reviews · doi:10.1007/s10741-016-9577-0 · Cited by 40 · see citing works
Frankenstein, L., Zugck, C., Nelles, M., Schellberg, D., Katus, H. A., & Remppis, B. A. (2009) · European Journal of Heart Failure · doi:10.1093/eurjhf/hfp150 · Cited by 37 · see citing works
Cardioprotective effects of ghrelin in heart failure: From gut to heart
Khatib, M. N., Simkhada, P. P., & Gode, D. (2014) · Heart Views · doi:10.4103/1995-705x.144792 · Cited by 33 · see citing works
Reverse epidemiology in different stages of heart failure
Güder, G., Gelbrich, G., Edelmann, F., Wachter, R., Pieske, B. M., Pankuweit, S., Maisch, B., Prettin, C., Brenner, S., Morbach, C., et al. (2015) · International Journal of Cardiology · doi:10.1016/j.ijcard.2015.02.009 · Cited by 22 · see citing works
Yanek, L. R., Vaidya, D. M., Kral, B. G., Dobrosielski, D. A., Moy, T. F., Stewart, K. J., & Becker, D. M. (2015) · PubMed · Cited by 9 · see citing works
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Valenzuela, P. L., Carrera-Bastos, P., Castillo-García, A., Lieberman, D. E., Santos-Lozano, A., & Lucia, A. (2023) · Nature Reviews Cardiology · doi:10.1038/s41569-023-00847-5 · Cited by 452 · see citing works
Liu, C., Cheng, K. Y.-K., Tong, X., Cheung, W.-H., Chow, S. K.-H., Law, S. W., & Wong, R. M. Y. (2023) · Frontiers in Endocrinology · doi:10.3389/fendo.2023.1077255 · Cited by 88 · see citing works
“There is a well-known paradox that obesity is related to a lower risk of mortality (31).”
BackgroundReyes-Barrera, J., Sainz-Escárrega, V. H., Medina-Urritia, A. X., Jorge-Galarza, E., Osorio-Alonso, H., Torres-Tamayo, M., Leal-Escobar, G., Posadas-Romero, C., Torre-Villalvazo, I., & Juárez-Rojas, J. G. (2021) · Adipocyte · doi:10.1080/21623945.2021.1893452 · Cited by 36 · see citing works
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Self-citation
- Authors
- Donini, L. M., Pinto, A., Giusti, A. M., Lenzi, A., & Poggiogalle, E.
- Affiliations
- Sapienza University of Rome (IT)
- Corresponding author
- Donini, Lorenzo Maria
- Venue
- Frontiers in Nutrition
- Publisher
- Frontiers Media SA
- Published
- 2020-05-07
- Volume
- 7
- Pages
- 53-53
- ISSN
- 2296-861X (ISSN-L)
- PMC
- PMC7221058
- OpenAlex
- W3021972501
- Cited by
- 264
- References
- 50
- Citations by year
- 2026: 31 · 2025: 59 · 2024: 66 · 2023: 51 · 2022: 34 · 2021: 16 · 2020: 6
- FWCI
- 3.41
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- Frontiers in Nutrition (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- IRIS Research product catalog (Sapienza University of Rome) (submittedVersion, cc-by)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Topics
- Health Sciences › Medicine › Physiology › Nutrition and Health in Aging
- Health Sciences › Medicine › Physiology › Body Composition Measurement Techniques
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Obesity, Physical Activity, Diet
- Keywords
- obesity paradox, body mass index, body composition, excess body fat, mortality, chronic disease, malnutrition, confounding, reverse causality, selection bias, attrition bias, older adults
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