The obesity paradox: is it really a paradox? Hypertension

  • Alessandro LechiEmail author
Part of the following topical collections:
  1. Obesity Paradox


This article is a narrative overview of the role of hypertension on the relationships between obesity, morbidity, and mortality. We used as sources MEDLINE/PubMed, CINAHL, EMBASE, and Cochrane Library, from inception to March 2016. Key words include overweight, obesity, visceral obesity, obesity paradox, and hypertension. In addition, we hand-searched references from the retrieved articles. This work is one of the works of the topical collection “Obesity Paradox”. The positive association between overweight, obesity, and cardiovascular diseases is well established, though this relation is typically U shaped with an increased risk in low-weight subjects or even a beneficial effect of overweight and obesity, the so-called “obesity paradox”. In addition, the relationship between obesity and arterial hypertension has been demonstrated in both children and adults by many epidemiological studies. Moreover, weight reduction is followed by a decrease in blood pressure in many patients and ameliorates the cardiovascular risk profile. Recent studies using more appropriate obesity indices raise some doubt about the real significance of obesity paradox and there are several studies that central obesity shows either no protective or even a worse effect. These observations raise the question: what kind of obesity is protective and what kind of obesity is harmful? The studies of obesity paradox suffer from several methodological limitations: most of these are retrospective analyses or were not specifically designed to study obesity paradox as a primary goal; a few studies have data on preceding unintentional weight loss and on some particular confounding variables. In conclusion, more prospective and accurate studies are necessary to better elucidate the clinical importance of obesity paradox. When weight loss is functional to reduce hypertension and cardiovascular risk, it should be encouraged, while an unintentional weight in a patient with chronic diseases may indicate an unfavorable course.


Obesity Hypertension Cardiovascular risk Weight loss Diet Paradox 


Compliances with ethical standards

Conflict of interest

The author states that there is no conflict of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Informed consent

For this type of study formal consent is not required.


  1. 1.
    Ostchega Y, Hughes JP, Terry A, Fakhouri TH, Miller I (2012) Abdominal obesity, body mass index, and hypertension in US adults: NHANES 2007–2010. Am J Hypertens 25:1271–1278. doi: 10.1038/ajh.2012.120 CrossRefPubMedGoogle Scholar
  2. 2.
    Lee SK, Kim SH, Cho GY, Baik I, Lim HE et al (2013) Obesity phenotype and incident hypertension: a prospective community-based cohort study. J Hypertens 31:145–151. doi: 10.1097/HJH.0b013e32835a3637 CrossRefPubMedGoogle Scholar
  3. 3.
    Berrington de Gonzalez A, Hartge P, Cerhan JR, Flint AJ, Hannan L, MacInnis RJ, Moore SC et al (2010) Body-mass index and mortality among 1.46 million white adults. N Engl J Med 363:2211–2219. doi: 10.1056/NEJMoa1000367 CrossRefPubMedGoogle Scholar
  4. 4.
    Romero-Corral A, Montori VM, Somers VK, Korinek J, Thomas RJ, Allison TG et al (2006) Association of bodyweight with total mortality and with cardiovascular events in coronary artery disease: a systematic review of cohort studies. Lancet 368:666–678. doi: 10.1016/S0140-6736(06)69251-9 CrossRefPubMedGoogle Scholar
  5. 5.
    Uretsky S, Messerli FH, Bangalore S, Champion A, Cooper-Dehoff RM, Zhou Q, Pepine CJ (2007) Obesity paradox in patients with hypertension and coronary artery disease. Am J Med 120:863–870CrossRefGoogle Scholar
  6. 6.
    Myers J, Lata K, Chowdhury S, McAuley P, Jain N, Froelicher V (2011) The obesity paradox and weight loss. Am J Med 124:924–930. doi: 10.1016/j.amjmed.2011.04.018 CrossRefPubMedGoogle Scholar
  7. 7.
    Lavie CJ, Milani RV, Ventura HO (2007) Obesity, heart disease and favorable prognosis—truth or pradox? Am J Med 120:825–826. doi: 10.1016/j.jacc.2008.12.068 CrossRefPubMedGoogle Scholar
  8. 8.
    Chen X, Wang Y (2008) Tracking of blood pressure from childhood to adulthood: a systematic review and metaregression analysis. Circulation 117:3171–3180. doi: 10.1161/CIRCULATIONAHA.107.730366 CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Ostchega Y, Carroll M, Prineas RJ, McDowell MA, Louis T, Tilert T (2009) Trends of elevated blood pressure among children and adolescents: data from the National Health and Nutrition Examination Survey 1988–2006. Am J Hypertens 22:59–67. doi: 10.1038/ajh.2008.312 CrossRefPubMedGoogle Scholar
  10. 10.
    Parker ED, Sinaiko AR, Kharbanda EO et al (2016) Change in weight status and development of hypertension. Pediatrics 137:1–9. doi: 10.1542/peds.2015-1662 CrossRefGoogle Scholar
  11. 11.
    Suglia SF, Clark CJ, Gary-Webb TL (2013) Adolescent obesity, change in weight status, and hypertension: racial/ethnic variations. Hypertension 61:290–295. doi: 10.1161/HYPERTENSIONAHA.111.00214
  12. 12.
    Crump C, Sundquist J, Winkleby MA, Sundquist K (2016) Interactive effects of physical fitness and body mass index on the risk of hypertension. JAMA Intern Med 176:210–216. doi: 10.1001/jamainternmed.2015.7444 CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Neter JE, Stam BE, Kok FJ, Grobbee DE, Geleijnse JM (2003) Influence of weight reduction on blood pressure: a meta-analysis of randomized controlled trials. Hypertension 42:878–884. doi: 10.1161/01.HYP.0000094221.86888.AE CrossRefGoogle Scholar
  14. 14.
    Jordan J, Yumuk V, Schlaich M, Nilsson PM, Zahorska-Markiewicz B, Grassi G, Schmieder RE, Engeli S, Finer N (2012) Joint statement of the European Association for the Study of Obesity and the European Society of Hypertension: obesity and difficult to treat arterial hypertension. J Hypertens 30:1047–1055. doi: 10.1097/HJH.0b013e3283537347 CrossRefPubMedGoogle Scholar
  15. 15.
    Molenaar EA, Hwang SJ, Vasan RS, Grobbee DE, Meigs JB, D’Agostino RB et al (2008) Burden and rates of treatment and control of cardiovascular disease risk factors in obesity: the Framingham Heart Study. Diabetes Care 31:1367–1372. doi: 10.2337/dc07-2413 CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Kotsis V, Nilsson V, Grassi G, Mancia G, Redon J, Luft F, On behalf of the WG on Obesity, Diabetes, the High Risk Patient, European Society Hypertension et al (2015) New developments in the pathogenesis of obesity induced hypertension. J Hypertens 33:1499–1508. doi: 10.1097/HJH.0000000000000645
  17. 17.
    Prospective Studies Collaboration (2009) Body-mass index and cause-specific mortality in 900,000 adults: collaborative analysis of 57 prospective studies. Lancet 373:1083–1096. doi: 10.1016/S0140-6736(09)60318-4 CrossRefPubMedCentralGoogle Scholar
  18. 18.
    Flegal KM, Kit BK, Orpana H, Graubard BI (2013) Association of all-cause mortality with overweight and obesity using standard body mass index categories. A systematic review and meta-analysis. JAMA 309:71–82. doi: 10.1001/jama.2012.113905 (Review) CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Asferg CL, Nielsen SJ, Andersen UB et al (2013) Relative atrial natriuretic peptide deficiency and inadequate renin and angiotensin II suppression in obese hypertensive men. Hypertension 62:147–53. doi: 10.1161/HYPERTENSIONAHA.111.00791
  20. 20.
    Lambert E, Straznicky N, Schlaich M, Esler M, Dawood T, Hotchkin E et al (2007) Differing pattern of sympathoexcitation in normal-weight and obesity-related hypertension. Hypertension 50:862–868. doi: 10.1161/HYPERTENSIONAHA.107.094649 CrossRefPubMedGoogle Scholar
  21. 21.
    Grassi G, Mark A, Esler M (2015) The sympathetic nervous system alterations in human hypertension. Circ Res 116:976–990. doi: 10.1161/CIRCRESAHA.116.303604 CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Hall JE, do Carmo JM, da Silva AA, Wang Z, Hall ME (2015) Obesity-induced hypertension: interaction of neurohumoral and renal mechanisms. Circ Res 116:991–1006. doi: 10.1161/CIRCRESAHA.116.305697 CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Messerli FH, Christie B, DeCarvalho JG, Aristimuno GG, Suarez DH, Dreslinski GR, Frohlich ED (1981) Obesity and essential hypertension. Hemodynamics, intravascular volume, sodium excretion, and plasma renin activity. Arch Intern Med 141:81–85. doi: 10.1001/archinte.1981.00340010073016 CrossRefGoogle Scholar
  24. 24.
    Alpert MA, Terry BE, Mulekar M, Cohen MV, Massey CV, Fan TM et al (1997) Cardiac morphology and left ventricular function in normotensive morbidly obese patients with and without congestive heart failure, and effect of weight loss. Am J Cardiol 80:736–740CrossRefGoogle Scholar
  25. 25.
    Kotsis V, Stabouli S, Toumanidis S, Tsivgoulis G, Rizos Z et al (2010) Obesity and daytime pulse pressure are predictors of left ventricular hypertrophy in true normotensives. J Hypertens 28:1065–1073. doi: 10.1097/HJH.0b013e3283370e5e
  26. 26.
    Kenchaiah S, Evans JC, Levy D, Wilson PWF, Benjamin EJ, Larson MG (2002) Obesity and the risk of heart failure. N Engl J Med 347:305–313. doi: 10.1056/NEJMoa020245 CrossRefGoogle Scholar
  27. 27.
    Peterson LR, Waggoner AD, Schechtman KB, Meyer T, Gropler RJ, Barzilai B, Dávila-Román VG (2004) Alterations in left ventricular structure and function in young healthy obese women. J Am Coll Cardiol 43:1399–1404. doi: 10.1016/j.jacc.2003.10.062 CrossRefPubMedGoogle Scholar
  28. 28.
    He J, Ogden LG, Bazzano LA, Vupputuri S, Loria C, Whelton PK (2001) Risk factors for congestive heart failure in US men and women: NHANES I epidemiologic follow-up study. Arch Intern Med 161:996–1002. doi: 10.1001/archinte.161.7.996 CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Messerli FH, Nunez BD, Ventura HO, Snyder DW. (1987) Overweight and sudden death. Increased ventricular ectopy in cardiopathy of obesity. Arch Intern Med 147:1725–1728. doi: 10.1001/archinte.1987.00370100039008
  30. 30.
    Middlemiss JE, Miles KL, McDonnell BJ, Yasmin, Maki-Petaja KM, On behalf of the Enigma study investigators et al (2016) Mechanisms underlying elevated SBP differ with adiposity in young adults: the Enigma study. J Hypertens 34:290–297. doi: 10.1097/HJH.0000000000000798
  31. 31.
    Niedziela J, Hudzik B, Niedziela N, Gąsior M, Gierlotka M, Wasilewski J, Myrda K et al (2014) The obesity paradox in acute coronary syndrome: a meta-analysis. Eur J Epidemiol 29:801–812. doi: 10.1007/s10654-014-9961-9 CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Chase PJ, Davis PG, Bensimhon DR (2014) The obesity paradox in chronic heart failure: what does it mean? Curr Heart Fail Rep 11:111–117. doi: 10.1007/s11897-013-0184-2 CrossRefPubMedGoogle Scholar
  33. 33.
    Gupta PP, Fonarow GC, Horwich TB (2015) Obesity and the obesity paradox in heart failure. Can J Cardiol 31:195–202. doi: 10.1016/j.cjca.2014.08.004 CrossRefPubMedGoogle Scholar
  34. 34.
    Chrysant SG, Chrysant GS (2013) New insights into the true nature of the obesity paradox and the lower cardiovascular risk. J Am Soc Hypertens 7:85–94. doi: 10.1016/j.jash.2012.11.008 CrossRefPubMedGoogle Scholar
  35. 35.
    Dorresteijn JAN, Spiering W, Van Der Graaf Y, Visseren FLJ, On behalf of the SMART Study Group (2012) Relation between adiposity and hypertension persists after onset of clinically manifest arterial disease. J Hypertens 30:2271–2275. doi: 10.1097/HJH.0b013e328357f18a CrossRefGoogle Scholar
  36. 36.
    Stamler R, Ford CE, Stamler J (1991) Why do lean hypertensives have higher mortality rates than other hypertensives? Findings of the Hypertension Detection and Follow-up Program. Hypertension 17:553–564. doi: 10.1161/01.HYP.17.4.553 CrossRefPubMedGoogle Scholar
  37. 37.
    Tuomilehto J (1991) Body mass index and prognosis in elderly hypertensive patients: a report from the European Working Party on High Blood Pressure in the Elderly. Am J Med 90(Suppl. 3):S34–S41CrossRefGoogle Scholar
  38. 38.
    Wassertheil-Smoller S, Fann C, Allman RM, Black HR, Camel GH, Davis B et al (2000) Relation of low body mass to death and stroke in the Systolic Hypertension in the Elderly Program. Arch Intern Med 160:494–500. doi: 10.1001/archinte.160.4.494 CrossRefPubMedGoogle Scholar
  39. 39.
    Shah RV, Abbasi SA, Yamal J-M, Davis BR, Barzilay J, Einhorn PT, Goldfine AB, For the ALLHAT Collaborative Research Group (2014) Impaired fasting glucose and body mass index as determinants of mortality in ALLHAT: is the obesity paradox real? J Clin Hypertens (Greenwich) 16:451–458. doi: 10.1111/jch.12325 CrossRefGoogle Scholar
  40. 40.
    Coutinho T, Goel K, Corrêa de Sá D, Kragelund C, Kanaya AM, Zeller M et al (2011) Central obesity and survival in subjects with coronary artery disease a systematic review of the literature and collaborative analysis with individual subject data. J Am Coll Cardiol 57:1877–1886. doi: 10.1016/j.jacc.2010.11.058 CrossRefPubMedGoogle Scholar
  41. 41.
    Sahakyan KR, Somers VK, Rodriguez-Escudero JP, Hodge DO, Carter RE et al (2015) Normal-weight central obesity: implications for total and cardiovascular mortality. Ann Intern Med 163:827–835. doi: 10.7326/M14-2525 CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Vest AR, Wu Y, Hachamovitch R, Young JB, Cho L (2015) The heart failure overweight/obesity survival paradox: the missing sex link. JACC Heart Fail 3:917–926. doi: 10.1016/j.jchf.2015.06.009 CrossRefPubMedGoogle Scholar
  43. 43.
    McAuley PA, Kokkinos PF, Oliveira RB, Emerson BT, Myers JN (2010) Obesity paradox and cardiorespiratory fitness in 12,417 male veterans aged 40 to 70 years. Mayo Clin Proc 85:115–121. doi: 10.4065/mcp.2009.0562 CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Yerrakalva D, Mullis R, Mant J (2015) The associations of “fatness”, “fitness”, and physical activity with all-cause mortality in older adults: a systematic review. Obesity 23:1944–1956. doi: 10.1002/oby.21181 CrossRefPubMedGoogle Scholar
  45. 45.
    O’Brien EC, Thomas LE (2016) Untangling the paradox: obesity as prognostic marker in prevalent cardiovascular disease. Am Heart J 172:170–172. doi: 10.1016/j.ahj.2015.11.005 CrossRefPubMedGoogle Scholar
  46. 46.
    Pack QR, Rodriguez-Escudero JP, Thomas RJ, Ades PA et al (2014) The prognostic importance of weight loss in coronary artery disease: a systematic review and meta-analysis. Mayo Clin Proc 89:1368–1377. doi: 10.1016/j.mayocp.2014.04.033 CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Ades PA, Savage PD (2010) The obesity paradox: perception vs knowledge. Mayo Clin Proc 85:112–114. doi: 10.4065/mcp.2009.0777 CrossRefPubMedPubMedCentralGoogle Scholar
  48. 48.
    Banack HR, Kaufman JS (2015) Does selection bias explain the obesity paradox among individuals with cardiovascular disease? Ann Epidemiol 25(5):342–349. doi: 10.1016/j.annepidem.2015.02.008 CrossRefPubMedGoogle Scholar
  49. 49.
    Ferreira I, Stehouwer CDA (2012) Obesity paradox or inappropriate study designs? Time for life-course epidemiology. J Hypertens 30:2271–2275. doi: 10.1097/HJH.0b013e32835b4fe0 CrossRefPubMedGoogle Scholar
  50. 50.
    Bosello O, Donataccio MP, Cuzzolaro M (2016) Obesity or obesities? Controversies on the association between body mass index and premature mortality. Eat Weight Disord Stud Anorex Bulim Obesity 21(2):165–174Google Scholar
  51. 51.
    Dixon JB, Lambert GW (2013) The obesity paradox–a reality that requires explanation and clinical interpretation. Atherosclerosis 226:47–48. doi: 10.1016/j.atherosclerosis.2012.11.005 CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  1. 1.Department of MedicineUniversity of VeronaVeronaItaly

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