Obesity and Risk of Heart Failure: Causal Relation and Therapeutic Implications

By Ambarish Pandey, M.D., M.S.

Associate Professor of Internal Medicine

The burden of obesity is increasing in the community and is a major public health concern. Epidemiological studies have demonstrated a significant association between higher body mass index (BMI) and risk of heart failure (HF); e.g., with every 1 kg/m² increase in BMI, there is a 5-7% higher risk of developing HF. While higher BMI is the most common but crude measure of obesity, not all obesity affects heart health similarly. Specifically, different types of fat distribution affect the risk of HF differently. Visceral fat (fat around internal organs) and pericardial fat (fat around the heart) appear to be more deleterious for HF risk than subcutaneous fat (fat under the skin). This differential risk is especially true for a specific type of HF known as heart failure with preserved ejection fraction (HFpEF), which is increasing in prevalence and typically affects older adults. Moreover, genetic epidemiological studies have demonstrated a causal link between obesity, specifically visceral adiposity, and the risk of HF. These observations suggest that targeting obesity may be an important strategy to reduce the growing burden of HF, especially HFpEF.

At #AHA24, I presented an overview of recent work from our group and others demonstrating that HF risk associated with obesity is modifiable through weight loss. Multiple studies, including those of surgical and lifestyle interventions, have shown that intentional weight loss can significantly reduce HF risk. The Look AHEAD trial, which studied more than 5,000 participants with diabetes and obesity, found that a 10% reduction in BMI was associated with significant improvements in HF risk, particularly for HFpEF. These improvements appear to be mediated through favorable changes in cardiac hemodynamics, showing that weight loss has direct beneficial effects on heart function. Further, medical advances with the development of novel weight loss pharmacotherapies offer new hope in addressing the obesity-related burden of HFpEF. Recently, the FDA approved the first weight-loss medication to reduce cardiovascular risk in adults with obesity or overweight conditions. This represents a significant step forward in treating obesity as a medical condition that affects heart health.

Together, the growing body of evidence underscores the importance of obesity in the development of HF, particularly HFpEF. Addressing obesity through various interventions, including lifestyle, surgical interventions, and weight loss pharmacotherapies, can have meaningful benefits for cardiovascular health, potentially preventing or reducing the risk of HF.