Diabetes Metab J > Volume 44(4); 2020 > Article
Kim: Obesity Degree and Glycemic Status: Factors That Should Be Considered in Heart Failure
Heart failure (HF) is associated with serious morbidity and mortality in patients with diabetes who experience more than two-fold the frequency of HF compared with the general population [1,2]. In a study of multi-ethnic comparisons of diabetic patients with HF, which included Korean and Japanese populations, diabetes increased the combined risk of morbidity and mortality in all ethnicities with HF requiring special attention [3]. In addition, because the beneficial effects of novel anti-diabetic agents on cardiovascular mortality and hospitalization due to HF, which are considered critical outcomes in patients with diabetes, have been shown in several cardiovascular outcome trials, HF is considered an important disease that requires proper treatment in diabetic patients [4,5].
Obesity, especially an increase in visceral adipose tissue, is associated with numerous comorbidities including insulin resistance, increased arterial stiffness, hypertension, and atherosclerotic cardiovascular disease [6]. In most studies, an increased risk of HF in obese individuals was reported, however, whether overweight can increase the risk of HF remains unclear [7]. Regarding mortality, a J-curved relationship between body mass index (BMI) and mortality due to HF, termed obesity paradox, was reported in some observational studies, indicating improved survival in overweight and obese people with established HF [8,9].
In this issue of Diabetes and Metabolism Journal, Rhee et al. [10] reported an association among obesity degree, glycemic status, and risk of HF using the Korean National Health Screening (KNHS) dataset. This population-based cohort study included 9,720,220 subjects who underwent KNHS and were followed up for 6.3 years for HF. The authors analyzed the risk of HF in participants based on baseline glycemic status and whether this risk was associated with obesity status. Similar to other studies, participants with impaired fasting glucose (IFG) and those with diabetes showed 1.08- and 1.86-fold, respectively, increased risk of HF compared with normoglycemic participants. When the risk was analyzed based on obesity degree and BMI, the underweight group with BMI <18.5 kg/m2 showed a 1.7-fold increased risk of HF, and those with class II obesity with BMI ≥30 kg/m2 had a 1.1-fold increased risk. Participants who were in the pre-obese range (BMI 23.0 to 24.9 kg/m2) and class I obesity (BMI 25.0 to 29.9 kg/m2) showed a lower risk of HF than the reference group (BMI 18.5 to 22.9 kg/m2). Conversely, the risk analysis of HF based on abdominal obesity determined by waist circumstance (WC) showed a linear risk increment in proportion to the degree of abdominal obesity. However, when these analyses were performed after dividing the participants based on glycemic status, a linear relationship was maintained only in the normoglycemia and IFG group, although a J-shape curve was observed in the diabetes group. Overall, the risk of HF was highest in underweight participants with the longest diabetes duration. The results of the present study provide evidence that abdominal adiposity is important for predicting development of HF and guidelines for the prevention of HF should be emphasized in obese individuals especially with abdominal obesity. In diabetics however, a different approach is needed to establish appropriate WC cutoffs and BMI for predicting the risk of HF and better clinical outcomes.
Although BMI calculated using anthropometrics is commonly used to define obesity, it is not representative of excess regional adiposity which potentially has predictive value for incident cardiovascular events and mortality [11]. Recently, Cho et al. [12] confirmed that WC is a better marker than BMI for predicting the incidence of myocardial infarction or ischemic stroke and suggested lower optimal WC cutoff values than currently recommended are needed for the prevention of atherosclerotic cardiovascular disease in the Korean population. Although a greater BMI increased the risk of HF, an increased risk of HF in the obese range was reported in most studies and whether overweight increased the risk of HF is unclear. Based on pooled analysis results from Asia and Pacific studies, the risk of HF mortality among obese individuals was increased; however, association among overweight subjects was not observed [13]. The results of the present study also showed the risk of HF was more prominent in underweight and class II or greater obese participants than in normal weight subjects. In addition, overweight or class I obese subjects had a significantly lower risk of HF than normal weight individuals. As a limitation stated by the authors, whether weight loss is a result of HF or a preceding factor cannot be clearly distinguished. Accurate analysis of body composition measurements using methods such as dual energy X-ray absorptiometry is necessary.
Population-based studies can contribute to the recognition of disease in the general population as well as specific disease groups and improve clinical outcome. Consequently, the results of the present study based on the KNHS have an important clinical significance for the Korean population. Additional prospective studies could provide evidence to establish guidelines for ideal BMI and WC, as well as improved lifestyles, including diet and exercise, to prevent HF and improve prognosis of HF in diabetic, obese, and underweight high-risk subjects.

NOTES

CONFLICTS OF INTEREST: No potential conflict of interest relevant to this article was reported.

REFERENCES

1. Lehrke M, Marx N. Diabetes mellitus and heart failure. Am J Cardiol 2017;120(1S):S37-S47.
crossref pmid
2. Neeland IJ, Poirier P, Despres JP. Cardiovascular and metabolic heterogeneity of obesity: clinical challenges and implications for management. Circulation 2018;137:1391-1406.
crossref pmid pmc
3. Cooper LB, Yap J, Tay WT, Teng TK, MacDonald M, Anand IS, Sharma A, O'Connor CM, Kraus WE, Mentz RJ, Lam CS. HF-ACTION and ASIAN-HF Investigators. Multi-ethnic comparisons of diabetes in heart failure with reduced ejection fraction: insights from the HF-ACTION trial and the ASIAN-HF registry. Eur J Heart Fail 2018;20:1281-1289.
crossref pmid
4. Fitchett D, Inzucchi SE, Cannon CP, McGuire DK, Scirica BM, Johansen OE, Sambevski S, Kaspers S, Pfarr E, George JT, Zinman B. Empagliflozin reduced mortality and hospitalization for heart failure across the spectrum of cardiovascular risk in the EMPA-REG OUTCOME trial. Circulation 2019;139:1384-1395.
crossref pmid
5. Neal B, Perkovic V, Mahaffey KW, de Zeeuw D, Fulcher G, Erondu N, Shaw W, Law G, Desai M, Matthews DR. CANVAS Program Collaborative Group. Canagliflozin and cardiovascular and renal events in type 2 diabetes. N Engl J Med 2017;377:644-657.
crossref pmid
6. Poirier P, Giles TD, Bray GA, Hong Y, Stern JS, Pi-Sunyer FX, Eckel RH. American Heart Association. Obesity Committee of the Council on Nutrition, Physical Activity, and Metabolism. Obesity and cardiovascular disease: pathophysiology, evaluation, and effect of weight loss: an update of the 1997 American Heart Association Scientific Statement on Obesity and Heart Disease from the Obesity Committee of the Council on Nutrition, Physical Activity, and Metabolism. Circulation 2006;113:898-918.
crossref
7. Aune D, Sen A, Norat T, Janszky I, Romundstad P, Tonstad S, Vatten LJ. Body mass index, abdominal fatness, and heart failure incidence and mortality: a systematic review and dose-response meta-analysis of prospective studies. Circulation 2016;133:639-649.
crossref pmid
8. Horwich TB, Fonarow GC, Hamilton MA, MacLellan WR, Woo MA, Tillisch JH. The relationship between obesity and mortality in patients with heart failure. J Am Coll Cardiol 2001;38:789-795.
crossref pmid
9. Lavie CJ, Alpert MA, Arena R, Mehra MR, Milani RV, Ventura HO. Impact of obesity and the obesity paradox on prevalence and prognosis in heart failure. JACC Heart Fail 2013;1:93-102.
crossref pmid
10. Rhee EJ, Kwon H, Park SE, Han KD, Park YG, Kim YH, Lee WY. Associations among obesity degree, glycemic status, and risk of heart failure in 9,720,220 Korean adults. Diabetes Metab J 2020;44:592-601.
crossref pmid pmc
11. Pandey A, LaMonte M, Klein L, Ayers C, Psaty BM, Eaton CB, Allen NB, de Lemos JA, Carnethon M, Greenland P, Berry JD. Relationship between physical activity, body mass index, and risk of heart failure. J Am Coll Cardiol 2017;69:1129-1142.
crossref pmid pmc
12. Cho JH, Rhee EJ, Park SE, Kwon H, Jung JH, Han KD, Park YG, Park HS, Kim YH, Yoo SJ, Lee WY. Taskforce Team of the Obesity Fact Sheet of the Korean Society for the Study of Obesity. The risk of myocardial infarction and ischemic stroke according to waist circumference in 21,749,261 Korean adults: a nationwide population-based study. Diabetes Metab J 2019;43:206-221.
crossref pmid
13. Schneider HJ, Friedrich N, Klotsche J, Pieper L, Nauck M, John U, Dorr M, Felix S, Lehnert H, Pittrow D, Silber S, Volzke H, Stalla GK, Wallaschofski H, Wittchen HU. The predictive value of different measures of obesity for incident cardiovascular events and mortality. J Clin Endocrinol Metab 2010;95:1777-1785.
crossref pmid pdf


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