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‘Obesity paradox’ misunderstands the biology of optimal weight throughout the life cycle


The ‘obesity paradox’ refers to observations that run counter to the thesis that normal weight (BMI 18.5–24.9 kg/m2) provides the lowest mortality and higher weight is associated with greater mortality. We argue that the weight of lowest mortality is influenced by aging and chronic disease, with mortality advantage extending into the overweight and even class I obese ranges under some circumstances. A focus on quality nutrition, physical activity, fitness, and maintaining function in these weight ranges may be preferable to a focus on intentional weight loss, which has uncertain effects. The ‘obesity paradox’ is no ‘paradox’ if one defines and interprets ‘ideal’ weight appropriately.

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  1. Flegal KM, Kit BK, Orpana H, Graubard BI . Association of all-cause mortality with overweight and obesity using standard body mass index categories: a systematic review and meta-analysis. JAMA 2013; 309: 71–82.

    Article  CAS  Google Scholar 

  2. Chan JM, Rimm EB, Colditz GA, Stampfer MJ, Willett WC . Obesity, fat distribution, and weight gain as risk factors for clinical diabetes in men. Diabetes Care 1994; 17: 961–969.

    Article  CAS  Google Scholar 

  3. Brown CD, Higgins M, Donato KA, Rohde FC, Garrison R, Obarzanek E et al. Body mass index and the prevalence of hypertension and dyslipidemia. Obes Res 2000; 8: 605–619.

    Article  CAS  Google Scholar 

  4. Armstrong ME, Spencer EA, Cairns BJ, Banks E, Pirie K, Green J et al. Body mass index and physical activity in relation to the incidence of hip fracture in postmenopausal women. J Bone Miner Res 2011; 26: 1330–1338.

    Article  Google Scholar 

  5. Bouchard DR, Langlois MF, Brochu M, Dionne IJ, Baillargeon JP . Metabolically healthy obese women and functional capacity. Metab Syndr Relat Disord 2011; 9: 225–229.

    Article  Google Scholar 

  6. Carnethon MR, De Chavez PJ, Biggs ML, Lewis CE, Pankow JS, Bertoni AG et al. Association of weight status with mortality in adults with incident diabetes. JAMA 2012; 308: 581–590.

    CAS  PubMed  PubMed Central  Google Scholar 

  7. Uretsky S, Messerli FH, Bangalore S, Champion A, Cooper-Dehoff RM, Zhou Q et al. Obesity paradox in patients with hypertension and coronary artery disease. Am J Med 2007; 120: 863–870.

    Article  Google Scholar 

  8. Morse SA, Gulati R, Reisin E . The obesity paradox and cardiovascular disease. Curr Hypertens Rep 2010; 12: 120–126.

    Article  Google Scholar 

  9. Oreopoulos A, Kalantar-Zadeh K, Sharma AM, Fonarow GC . The obesity paradox in the elderly: potential mechanisms and clinical implications. Clin Geriatr Med 2009; 25: 643–659 viii.

    Article  Google Scholar 

  10. Flegal KM, Graubard BI, Williamson DF, Cooper RS . Reverse causation and illness-related weight loss in observational studies of body weight and mortality. Am J Epidemiol 2011; 173: 1–9.

    Article  Google Scholar 

  11. Andres R, Elahi D, Tobin JD, Muller DC, Brant L . Impact of age on weight goals. Ann Intern Med 1985; 103 (Pt 2): 1030–1033.

    Article  CAS  Google Scholar 

  12. WHO. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet 2004; 363: 157–163.

    Article  Google Scholar 

  13. O'Carroll AM, Lolait SJ, Harris LE, Pope GR . The apelin receptor APJ: journey from an orphan to a multifaceted regulator of homeostasis. J Endocrinol 2013; 219: R13–R35.

    Article  CAS  Google Scholar 

  14. Kalantar-Zadeh K, Kopple JD . Obesity paradox in patients on maintenance dialysis. Contrib Nephrol 2006; 151: 57–69.

    Article  Google Scholar 

  15. Hong NS, Kim KS, Lee IK, Lind PM, Lind L, Jacobs DR et al. The association between obesity and mortality in the elderly differs by serum concentrations of persistent organic pollutants: a possible explanation for the obesity paradox. Int J Obes (Lond) 2012; 36: 1170–1175.

    Article  CAS  Google Scholar 

  16. Ozeke O, Ozer C, Gungor M, Celenk MK, Dincer H, Ilicin G . Chronic intermittent hypoxia caused by obstructive sleep apnea may play an important role in explaining the morbidity-mortality paradox of obesity. Med Hypotheses 2011; 76: 61–63.

    Article  Google Scholar 

  17. Lee M, Martin H, Firpo MA, Demerath EW . Inverse association between adiposity and telomere length: The Fels Longitudinal Study. Am J Hum Biol 2011; 23: 100–106.

    Article  CAS  Google Scholar 

  18. Simpson SJ, Raubenheimer D . Macronutrient balance and lifespan. Aging (Albany NY) 2009; 1: 875–880.

    Article  CAS  Google Scholar 

  19. Masoro EJ . Overview of caloric restriction and ageing. Mech Ageing Dev 2005; 126: 913–922.

    Article  CAS  Google Scholar 

  20. Sjostrom L, Narbro K, Sjostrom CD, Karason K, Larsson B, Wedel H et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med 2007; 357: 741–752.

    Article  Google Scholar 

  21. Adams TD, Gress RE, Smith SC, Halverson RC, Simper SC, Rosamond WD et al. Long-term mortality after gastric bypass surgery. N Engl J Med 2007; 357: 753–761.

    Article  CAS  Google Scholar 

  22. Maciejewski ML, Livingston EH, Smith VA, Kavee AL, Kahwati LC, Henderson WG et al. Survival among high-risk patients after bariatric surgery. JAMA 2011; 305: 2419–2426.

    Article  CAS  Google Scholar 

  23. Wing RR, Bolin P, Brancati FL, Bray GA, Clark JM, Coday M et al. Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. N Engl J Med 2013; 369: 145–154.

    Article  CAS  Google Scholar 

  24. Myers J, Lata K, Chowdhury S, McAuley P, Jain N, Froelicher V . The obesity paradox and weight loss. Am J Med 2011; 124: 924–930.

    Article  Google Scholar 

  25. Doehner W, Erdmann E, Cairns R, Clark AL, Dormandy JA, Ferrannini E et al. Inverse relation of body weight and weight change with mortality and morbidity in patients with type 2 diabetes and cardiovascular co-morbidity: an analysis of the PROactive study population. Int J Cardiol 2012; 162: 20–26.

    Article  Google Scholar 

  26. Stevens J, Juhaeri, Cai J . Changes in body mass index prior to baseline among participants who are ill or who die during the early years of follow-up. Am J Epidemiol 2001; 153: 946–953.

    Article  CAS  Google Scholar 

  27. Zheng H, Tumin D, Qian Z . Obesity and mortality risk: new findings from body mass index trajectories. Am J Epidemiol 2013; 178: 1591–1599.

    Article  Google Scholar 

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Correspondence to J B Dixon.

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Competing interests

JD has received research funding and support from Allergan Inc. He is on the Optifast® Medical Advisory Board for Nestlé Australia and has received consultancy fees from Allergan Inc, Metagenics, and iNova Pharmaceuticals. EF has acted as a consultant for Allergan Inc. in the past and currently does consulting work for Jenny Craig and Vivus Inc. G.L.’s laboratory currently receives commercial research grant funding from Medtronic (formerly ARDIAN Inc.), Servier Australia, Abbott (formerly Solvay) and Allergan Inc.; he has acted as a consultant for Medtronic and has received honoraria or travel support for presentations from Pfizer, Wyeth Pharmaceuticals, Servier and Medtronic. GE and JK have no conflict of interest to declare.

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Dixon, J., Egger, G., Finkelstein, E. et al. ‘Obesity paradox’ misunderstands the biology of optimal weight throughout the life cycle. Int J Obes 39, 82–84 (2015).

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  • healthy aging
  • reverse causation
  • obesity epidemic
  • survival advantage
  • body mass index

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