Das Adipositas-Paradox/Paradigma bei kardiovaskulären Erkrankungen: Fakten und Kommentare

Zusammenfassung

Patienten mit kardiovaskulären Erkrankungen zeigen oft ein besseres Überleben bei Übergewicht und milder Adipositas als bei normalem Körpergewicht. Darüber hinaus ist bei solchen Patienten ein beobachteter Gewichtsverlust oft mit einer erhöhten Sterblichkeit assoziiert. Dieser Befund steht im Gegensatz zur fest etablierten Erkenntnis für Adipositas als kardiovaskulärer Risikofaktor und wird daher als Adipositas-Paradox beschrieben. Eine zunehmende Evidenz bestätigt die Erkenntnisse bei verschiedenen kardiovaskulären Erkrankungen. Insbesondere bei Patienten mit chronischer Herzinsuffizienz wurde die auch als inverse Epidemiologie beschriebene geringere Sterblichkeit bei höherem BMI umfangreich beschrieben. In Berechnungsmodellen zur Risikoabschätzung bei Herzinsuffizienz wie dem Seattle Heart Failure Model wird Adipositas daher mittlerweile als protektiver Faktor verwendet. Auch bei Patienten mit koronarer Herzerkrankung, akutem Herzinfarkt, Hypertonus, Vorhofflimmern, Schlaganfall, peripherer Gefäßerkrankung, mit Diabetes und kardiovaskulärem Risikoprofil oder dialysepflichtiger Niereninsuffizienz bestätigt sich ein besseres Überleben für Patienten mit Übergewicht und milder Adipositas, ebenso bei Patienten mit zahlreichen kardiovaskulären Interventionen wie Herzkatheter, Bypass-Chirurgie, TAVI, Klappenchirurgie oder Herztransplantation. In der vorliegenden Arbeit werden verschiedene methodische, statistische und konzeptionelle Aspekte diskutiert, die die Erkenntnisse kritisch bewerten und eine mutmaßlich fehlerhafte Interpretation der Befunde folgern. Dagegen gibt es auch mechanistische Erklärungen, die einen protektiven Effekt durch erhöhte Körpermasse beschreiben angesichts einer kardiovaskulären Erkrankung mit grundsätzlich gestörter Stoffwechselkontrolle im Sinne einer katabolen/anabolen Imbalance. Der Stellenwert und die Limitationen des Body-Mass-Index als grundlegende Methode zur Einschätzung des Körperbaus, die Besonderheiten eines ungewollten gegenüber eines gewollten Gewichtsverlustes, widersprüchliche Daten aus prospektiven, kontrollierten Studien wie auch der Einfluss des Alters sind Gegenstand der Diskussion. Der Artikel gibt eine Übersicht über die aktuelle Diskussion zum Adipositas-Paradox. Überlegungen zum Körpergewicht und zum Gewichtsmanagement sollten über die Erkenntnisse der Primärprävention hinaus eine differenziertere Sichtweise berücksichtigen, die individuelle Faktoren wie Alter und bestehende Erkrankungen der Patienten einbezieht.

Abstract

Patients with cardiovascular diseases who are overweight or mildly obese are repeatedly reported to have a lower mortality risk compared to patients with normal body weight. Moreover, observed weight loss is largely associated with increased mortality risk. These findings are at first glance in contrast to the compelling evidence of obesity as a cardiovascular risk factor, consequently the term ‘obesity paradox’ was quickly adopted in the literature. Increasing evidence has accumulated to confirm the inverse epidemiology of higher body weight with better survival prospects in a wide range of cardiovascular diseases and conditions. Particular confirmation has emerged in patients with heart failure (HF). Risk calculator tools for patients with HF based on multi-variable risk factor models include higher body weight now as a beneficial factor rather than a risk factor. In other cardiovascular diseases such as coronary artery disease, acute myocardial infarction, hypertension, atrial fibrillation, stroke, peripheral artery disease, diabetes with cardiovascular comorbidity and others the inverse epidemiology has been confirmed. Similar findings were further confirmed in multiple interventional settings such as percutaneous coronary intervention, bypass surgery, valvular surgery or TAVI intervention and heart transplantation. An intense debate has been triggered and is ongoing as to the validity and interpretation of the findings, potential bias or methodical concerns. Pathophysiologic insights in turn have provided convincing mechanistic explanations for potential protective effects of excessive body tissue in diseases that are characterized by metabolic imbalance involving anabolic blunting and catabolic over-activation. Evidence from prospective controlled interventional data is scarce and cannot convincingly confirm a prognostic benefit of intentional weight loss. The role and limits of the body mass index (BMI) as the most widely used tool to assess body weight is discussed in this review along with putative differences of intended and non-intended body weight change. The often overlooked relevance of advanced age on optimum body weight and further aspects will be discussed. The term ‘obesity paradox’ may prohibit wider application of the accumulating evidence in relevant clinical settings. The potential transition in terminology to an ‘obesity paradigm’ is discussed to promote a differentiated and up-to-date weight management with stronger distinction between primary prevention and secondary disease management.

Schlüsselwörter

Adipositas - Mortalität - Prävention - kardiovaskuläre Erkrankung - Herzinsuffizienz

Key words

Adipositas - Mortality - Prevention - cardiovascular disease - heart failure - Stroke

Publication History

Article published online:
12 March 2021

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