The "Obesity Paradox" Is Not a Paradox: Time to Focus on Effective Treatments.

I recently read the editorial comment by Lavie and Ventura (1) with interest but also with disappointment. My disappointment is because several papers from different authors have illustrated that the reported relationship between obesity and survival from heart failure occurs because all of the observational analyses suffer from a very serious bias if one is exploring causal effects—for 2 examples, see Banack and Kaufman (2) and Preston and Stokes (3). The explanation was even provided in a letter to the editor on a recent publication by Lavie that is cited in this editorial (4). Dr. Lavie did not respond to the letter and it remains unclear why he has not incorporated such a simple and plausible explanation into this recent editorial. As one example, one can divide causes of heart failure into those due to obesity and those not due to obesity. If the nonobese causes of heart failure (e.g., genetics, viral myocarditis) have a worse prognosis than obese causes of heart failure, one would expect to see the observed data even if obesity worsens survival in heart failure. This is expected and not a paradox. Heart failure is a tragic illness. Focusing attention on the unjustified fascination that obese patients with heart failure do better than nonobese patients with heart failure may be diverting attention from proper prevention and treatment. This is especially true given that Lavie himself reviewed research on weight reduction programs in heart failure patients and concluded that weight reduction improves outcomes (5). I look forward to future academic efforts toward best treatment practices rather than repeating a theory that promotes unnecessary confusion.