Original Article
Obesity and the Risk of Heart Failure
N Engl J Med 2002; 347:305-313August 1, 2002
- Abstract
Background
Extreme obesity is recognized to be a risk factor for heart failure. It is unclear whether overweight and lesser degrees of obesity also pose a risk.
Methods
We investigated the relation between the body-mass index (the weight in kilograms divided by the square of the height in meters) and the incidence of heart failure among 5881 participants in the Framingham Heart Study (mean age, 55 years; 54 percent women). With the use of Cox proportional-hazards models, the body-mass index was evaluated both as a continuous variable and as a categorical variable (normal, 18.5 to 24.9; overweight, 25.0 to 29.9; and obese, 30.0 or more).
Results
During follow-up (mean, 14 years), heart failure developed in 496 subjects (258 women and 238 men). After adjustment for established risk factors, there was an increase in the risk of heart failure of 5 percent for men and 7 percent for women for each increment of 1 in body-mass index. As compared with subjects with a normal body-mass index, obese subjects had a doubling of the risk of heart failure. For women, the hazard ratio was 2.12 (95 percent confidence interval, 1.51 to 2.97); for men, the hazard ratio was 1.90 (95 percent confidence interval, 1.30 to 2.79). A graded increase in the risk of heart failure was observed across categories of body-mass index. The hazard ratios per increase in category were 1.46 in women (95 percent confidence interval, 1.23 to 1.72) and 1.37 in men (95 percent confidence interval, 1.13 to 1.67).
Conclusions
In our large, community-based sample, increased body-mass index was associated with an increased risk of heart failure. Given the high prevalence of obesity in the United States, strategies to promote optimal body weight may reduce the population burden of heart failure.
Media in This Article
Figure 2
Risk of Heart Failure in Obese Subjects, According to Category of Body-Mass Index at the Base-Line Examination.Figure 1
Cumulative Incidence of Heart Failure According to Category of Body-Mass Index at the Base-Line Examination.Article Activity
- Article
Heart failure is a major health problem that is increasing in scope.1 Despite recent therapeutic advances, morbidity and mortality after the onset of heart failure remain substantial.1 Consequently, prevention of heart failure through identification and management of risk factors and preclinical phases of the disease is a priority.2 In this context, several studies have evaluated body-mass index (the weight in kilograms divided by the square of the height in meters) as a risk factor for left ventricular remodeling and overt heart failure. In these investigations, obesity has been consistently associated with left ventricular hypertrophy and dilatation,3-6 which are known precursors of heart failure.7,8 Whereas extreme obesity has been associated with heart failure,9 data are limited regarding the influence of overweight and lesser degrees of obesity on the risk of heart failure.10-12 Accordingly, we investigated the relation of body-mass index with the risk of heart failure in a community-based sample.
Methods
Participants
The design and selection criteria of the Framingham Heart Study have been described previously.13,14 Participants in the 15th biennial examination of the original cohort (1976 through 1979, 2632 subjects) and the second offspring study examination (1979 through 1983, 3863 subjects) were eligible for the present investigation. We excluded 614 attendees (9.5 percent) for the following reasons: age under 30 years (271 subjects), underweight (body-mass index less than 18.5 [85 subjects]),15,16 heart failure at base-line examination (84 subjects), missing information on covariates (172 subjects), and lack of follow-up data (2 subjects). After these exclusions, 5881 subjects (3177 women and 2704 men) remained eligible. Written informed consent was obtained from the study participants, and the research protocol was reviewed and approved by the institutional review board of the Boston University School of Medicine.
Estimation of Adiposity and Covariates
At each examination, a medical history was taken, a physical examination (including anthropometric measurements and measurement of blood pressure) was performed, a 12-lead electrocardiogram was obtained, and risk factors for cardiovascular disease were assessed. Height and weight were measured according to a standardized protocol. The body-mass index was calculated and was used as an estimate of overweight and obesity.16 The criteria and methods of measurement of all covariates have been described previously.17
Outcome
Surveillance for the development of cardiovascular events was continuous for all participants. A panel of three experienced physicians reviewed suspected cardiovascular events by examining hospital records and information from outside physicians.17 In this investigation, the primary outcome of interest was the occurrence of a first episode of heart failure, as defined by the Framingham Heart Study criteria.18 The simultaneous presence of at least two major criteria or one major criterion in conjunction with two minor criteria was required to establish a diagnosis of heart failure. Major criteria included paroxysmal nocturnal dyspnea or orthopnea, jugular venous distention, pulmonary rales, radiographic cardiomegaly, acute pulmonary edema, a third heart sound, central venous pressure above 16 cm of water, hepatojugular reflux, and weight loss of at least 4.5 kg in five days in response to treatment for heart failure. Minor criteria included bilateral ankle edema, nocturnal cough, dyspnea on ordinary exertion, hepatomegaly, pleural effusion, and a heart rate of at least 120 beats per minute. Minor criteria were acceptable only if they could not be attributed to another medical condition (such as chronic lung disease, cirrhosis, ascites, or the nephrotic syndrome).
Statistical Analysis
We used Cox proportional-hazards regression models,19 stratified according to cohort (original or offspring), to examine the relation of body-mass index to the incidence of heart failure. We performed both sex-specific and sex-stratified analyses. Body-mass index was evaluated as both a continuous variable (with increases in risk calculated per increment of 1) and a categorical variable. Subjects with values of 18.5 to 24.9 were classified as normal (the reference group), those with values of 25.0 to 29.9 as overweight, and those with values of 30.0 or more as obese.15,16 We adjusted for the following base-line covariates: age, smoking status, alcohol consumption, total serum cholesterol level, and presence or absence of valve disease, hypertension, diabetes mellitus, electrocardiographic left ventricular hypertrophy, and myocardial infarction (all defined at base line). We constructed trend models to determine whether there was a continuous gradient of heart-failure risk across categories of body-mass index. To evaluate the risk of heart failure associated with varying degrees of obesity, we performed analyses that categorized the obese group into three classes with body-mass indexes of 30.0 to 34.9 (group 1), 35.0 to 39.9 (group 2), and 40.0 or more (group 3).15,16 We also evaluated models with body-mass index and all covariates treated as time-dependent variables (updated every four years, including adjustment for the occurrence of interim myocardial infarction).
Elevated body-mass index could predispose persons to heart failure by promoting atherogenic traits such as hypertension, diabetes mellitus, and dyslipidemia, which, in turn, could result in myocardial infarction. Therefore, we constructed hierarchical statistical models using covariates defined at base line, with adjustment for potential confounders (age, cigarette smoking, alcohol consumption, and valve disease) and for all these variables plus covariates that are known to be along the causal pathway from excess weight to heart failure (e.g., hypertension, electrocardiographic left ventricular hypertrophy, diabetes mellitus, high total serum cholesterol level, and myocardial infarction). We also evaluated stepwise models with body-mass index, systolic blood pressure, alcohol intake, and total serum cholesterol as continuous measures (other covariates were dichotomous).
We examined models incorporating interaction terms to evaluate variation in the effect of body-mass index on the risk of heart failure according to age, sex, smoking status, alcohol consumption, and the presence or absence of valve disease, hypertension, diabetes mellitus, and myocardial infarction (all defined at base line).
We estimated the category-specific population attributable risk (PAR), expressed as a percentage, as a function of the proportion of cases occurring in a given category of body-mass index (pd) and the multivariable-adjusted relative risk (RR, equivalent to hazard ratios from models with covariates defined at base line) with the following equation:20
PAR = pd [(RR – 1) / RR] × 100.
To obtain insight into the type of heart failure (systolic vs. diastolic) associated with increasing body-mass index, we reviewed echocardiographic reports for a subgroup of participants who underwent evaluation of left ventricular systolic function within 30 days after their first hospitalization for heart failure between 1989 and 1998. Heart failure was presumed to be due to systolic dysfunction (systolic heart failure) if the estimated left ventricular ejection fraction was less than 50 percent, whereas a left ventricular ejection fraction of 50 percent or more was considered to be consistent with diastolic heart failure.21 The proportion of patients with heart failure who had a left ventricular ejection fraction under 40 percent, indicating moderate or severe left ventricular systolic dysfunction, was also examined.
Although underweight subjects were excluded from the primary analyses, we performed supplementary analyses comparing the risk of heart failure in these subjects with that in subjects with a normal body-mass index.
A two-sided P value of less than 0.05 was considered to indicate statistical significance. All analyses were performed with SAS software (version 6.12).22
Results
Clinical Characteristics
A third of the women and half the men in our sample were overweight. The prevalence of obesity was similar in the two sexes (about 16 percent). The prevalence of hypertension and diabetes mellitus increased with increasing body-mass index (Table 1Table 1
Base-Line Characteristics According to the Category of Body-Mass Index.).Body-Mass Index and the Risk of Heart Failure
During a mean follow-up of 14 years (maximum, 21.8), heart failure developed in 496 participants (258 women and 238 men). The crude cumulative incidence (Figure 1Figure 1
Cumulative Incidence of Heart Failure According to Category of Body-Mass Index at the Base-Line Examination.) and the age-adjusted incidence rates (Table 2Table 2
Cumulative Incidence of Heart Failure among Study Participants According to the Category of Body-Mass Index at Base Line.) of heart failure increased across categories of body-mass index for both men and women.After adjustment for known risk factors, there was an increase in the risk of heart failure of 5 percent for men and 7 percent for women for each increment of 1 in body-mass index (Table 3Table 3
Results of Multivariable Cox Proportional-Hazards Models Examining the Relation of Body-Mass Index to the Risk of Heart Failure., model IA). As compared with women who have a normal body-mass index, overweight women had a 50 percent greater risk of heart failure, and obese women had a doubling of the risk of heart failure (Table 3, model IB). Whereas overweight men had a nonsignificant 20 percent increase in heart-failure risk over men with a normal body-mass index, obese men had a statistically significant 90 percent increase in the risk of heart failure. In sex-stratified analyses, an increased risk of heart failure was evident for both overweight subjects (a 34 percent increase) and obese subjects (a 104 percent increase) and there was a 43 percent greater risk of heart failure per category increase in body-mass index. Among obese subjects, the risk of heart failure increased in a graded fashion with increasing severity of obesity (Figure 2Figure 2Risk of Heart Failure in Obese Subjects, According to Category of Body-Mass Index at the Base-Line Examination.). Men with class 3 obesity were excluded from this analysis because of the small sample (eight subjects). The association of body-mass index with the risk of heart failure remained robust in models incorporating body-mass index and other risk factors as time-dependent variables (Table 3, models IIA and IIB).In models adjusted only for age, smoking status, alcohol consumption, and valve disease, the hazard ratios for heart failure per increase of 1 in the body-mass index were 1.08 (95 percent confidence interval, 1.06 to 1.11) in women and 1.07 (95 percent confidence interval, 1.04 to 1.11) in men. In these models, in comparison with subjects with a normal body-mass index, the hazard ratios for heart failure were 1.53 (95 percent confidence interval, 1.15 to 2.04) for overweight women, 2.24 (95 percent confidence interval, 1.62 to 3.11) for obese women, 1.35 (95 percent confidence interval, 0.99 to 1.85) for overweight men, and 2.34 (95 percent confidence interval, 1.60 to 3.41) for obese men. Additional adjustment for hypertension, diabetes mellitus, high total serum cholesterol level, electrocardiographic left ventricular hypertrophy, and myocardial infarction (variables along the causal pathway) led to a slight attenuation of the hazard ratios in men but not in women (Table 3, models IA and IB). In models with stepwise selection of covariates (at an alpha level of <0.05), age, myocardial infarction, valve disease, and systolic blood pressure entered ahead of body-mass index. The hazard ratio for heart failure associated with body-mass index was nearly identical to that shown in model IA in Table 3.
Effect Modification
The effect of body-mass index on the risk of heart failure did not vary with age, sex, smoking status, alcohol consumption, or the presence or absence of valve disease or diabetes mellitus (P>0.10). However, we noted effect modification with hypertension (P=0.03) and myocardial-infarction status (P=0.02). The hazard ratio for the trend in the risk of heart failure across body-mass index categories was lower in subjects with hypertension (1.30; 95 percent confidence interval, 1.11 to 1.52) than in subjects without hypertension (1.66; 95 percent confidence interval, 1.33 to 2.07). Increased body-mass index was not associated with an increased risk of heart failure in those with myocardial infarction at base line (148 subjects; hazard ratio for trend across categories, 0.80; 95 percent confidence interval, 0.50 to 1.30) as compared with those without myocardial infarction (5733 subjects; hazard ratio, 1.50; 95 percent confidence interval, 1.31 to 1.71). The statistical power to detect hazard ratios of 1.5, 2.0, and 2.5 for heart failure (for trend across body-mass index categories at an alpha level of <0.05) in subjects with myocardial infarction at base line was 0.38, 0.81, and 0.96, respectively.
Population Attributable Risk
The population attributable risk of heart failure due to overweight was 14.0 percent in women and 8.8 percent in men. The corresponding population attributable risks due to obesity were 13.9 percent in women and 10.9 percent in men.
Echocardiographic Evaluation
Of the 120 participants who underwent echocardiographic evaluation within 30 days of their first hospitalization for heart failure (24 percent of those with heart failure), 75 percent (21 of 28) of those with a normal body-mass index, 65 percent (37 of 57) of overweight subjects, and 66 percent (23 of 35) of obese subjects had a left ventricular ejection fraction of less than 50 percent (indicative of systolic heart failure). The proportions of subjects with heart failure who had a left ventricular ejection fraction of less than 40 percent in the normal, overweight, and obese groups were 53.6 percent, 52.6 percent, and 42.9 percent, respectively.
Risk of Heart Failure in Underweight Subjects
Only 3 of the 76 underweight subjects (64 women and 12 men) had heart failure on follow-up. In sex-stratified models, underweight subjects had a multivariable-adjusted hazard ratio of 0.95 (95 percent confidence interval, 0.37 to 2.45) as compared with those with a normal body-mass index.
Discussion
Elevated body-mass index was associated with an increased risk of heart failure, without evidence of a threshold. This increased risk was evident in both sexes and was not limited to persons with extreme obesity. Although the hazard ratio for heart failure in overweight men did not achieve statistical significance, analyses evaluating body-mass index as a continuous variable and findings of trend models support the existence of a continuous gradient of heart-failure risk with increasing body-mass index in both sexes. The finding of an increased risk of heart failure associated with elevated body-mass index remained robust in analyses incorporating body-mass index and other covariates as time-dependent variables. It is important to note that statistical models in which adjustment is made for all risk factors underestimate the effects of adiposity on the risk of heart failure.
The smaller effect of body-mass index on the risk of heart failure in subjects with hypertension probably indicates a decreased contribution of obesity to the risk of heart failure in the presence of this major risk factor. The lack of effect of body-mass index on the risk of heart failure in subjects with myocardial infarction, however, must be interpreted with caution because of the small sample. In a subgroup of subjects who underwent echocardiographic evaluation within 30 days after their first hospitalization for heart failure, obesity was associated with both systolic and diastolic heart failure.
Three prior community-based studies reported an association of increased body-mass index with an increased risk of heart failure.10-12 However, they did not use the contemporary body-mass index classification,15,16 and ascertainment of heart failure was based primarily on hospital-discharge codes or death certificates. Furthermore, none of these studies assessed the entire range of body-mass index values or modeled covariates as time-dependent variables. Only one study10 adjusted for the occurrence of an interim myocardial infarction.
Other investigators have reported that a low body-mass index is associated with increased mortality among patients with heart failure.23,24 Our study had limited power to evaluate the risk of heart failure in underweight subjects. In this context, it is important to draw a distinction between the role of elevated body-mass index as a risk factor for heart failure and its effect on survival after the onset of heart failure.
The strength of the association, the stepwise increase in the risk of heart failure across increasing categories of body-mass index, the demonstration of a temporal sequence (with increased body-mass index preceding the development of heart failure), and the consistency of results in multiple analyses suggest a causal relation between increased body-mass index and heart failure. There are several plausible mechanisms for such an association. Increased body-mass index is a risk factor for hypertension,25 diabetes mellitus,26,27 and dyslipidemia,16 all of which augment the risk of myocardial infarction,28,29 an important antecedent of heart failure.10-12,30 In addition, hypertension and diabetes mellitus independently increase the risk of heart failure.10-12,30,31 Elevated body-mass index is associated with altered left ventricular remodeling,3-6,8 possibly owing to increased hemodynamic load,32,33 neurohormonal activation,34 and increased oxidative stress.35 Recently, Zhou et al. raised the possibility of a direct effect of obesity on the myocardium by demonstrating cardiac steatosis and lipoapoptosis in an animal model of obesity.36
The strengths of our investigation include the large community-based sample, standardized assessment of body-mass index, consistent use of the same diagnostic criteria for heart failure, and the long period of follow-up. Nonetheless, it is important to acknowledge several limitations. Although a diagnosis of heart failure was made only after a careful review of the records by a panel of three physicians, it is still possible that symptoms (such as dyspnea) and signs (such as ankle edema) may be misconstrued as indicating heart failure more often in obese persons.37 Pedal edema was more common among obese subjects with heart failure, but the distributions of major and all other minor heart-failure criteria were similar among subjects with heart failure in the three categories of body-mass index (data not shown). Exclusion of pedal edema as a minor criterion in the obese subjects did not alter the diagnosis of heart failure by the Framingham Heart Study adjudication panel in any instance. Other evidence against misclassification of subjects with heart failure as the explanation for the observed association includes the substantial increase in the risk of heart failure among those who were overweight and those with lesser degrees of obesity, and the finding in a subgroup analysis that 43 percent of obese subjects with heart failure had moderately or severely impaired left ventricular systolic function. Finally, because our sample was predominantly white, we avoided confounding by race but at the same time, we reduced the generalizability of our findings to other races and ethnic groups.
Our findings suggest that obesity is an important risk factor for heart failure in both women and men. Approximately 11 percent of cases of heart failure among men and 14 percent among women in the community are attributable to obesity alone. The contribution of obesity to the risk of heart failure has not been adequately recognized, and our observational data suggest that efforts to promote optimal body weight may reduce the risk of heart failure. Our results are particularly relevant given the alarming trend toward increasing obesity in the United States.16
Supported in part by a contract (N01-HC-25195) with the National Heart, Lung, and Blood Institute; by grants from Roche Laboratories (to Dr. Wilson) and Servier Amérique (to Dr. Kannel); and by a Research Career Award (1K24 HL04334) from the National Heart, Lung, and Blood Institute (to Dr. Vasan).
Source Information
From the Framingham Heart Study, Framingham, Mass. (S.K., J.C.E., D.L., P.W.F.W., E.J.B., M.G.L., W.B.K., R.S.V.); the Section of Preventive Medicine (D.L., E.J.B., M.G.L., W.B.K., R.S.V.) and the Cardiology Section (E.J.B., R.S.V.), Boston University School of Medicine, Boston; the Cardiology Division, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston (D.L.); and the National Heart, Lung, and Blood Institute, Bethesda, Md. (D.L.).
Address reprint requests to Dr. Vasan at the Framingham Heart Study, 73 Mt. Wayte Ave., Suite 2, Framingham, MA 01702, or at vasan@fram.nhlbi.nih.gov.
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