Send to

Choose Destination
PLoS Med. 2019 Sep 24;16(9):e1002916. doi: 10.1371/journal.pmed.1002916. eCollection 2019 Sep.

Association of obesity with heart failure outcomes in 11 Asian regions: A cohort study.

Author information

National Heart Centre Singapore, Singapore, Singapore.
University Medical Center Groningen, Groningen, Netherlands.
Changi General Hospital, Singapore, Singapore.
MacKay Memorial Hospital, Taipei, Taiwan.
CIMS Hospital, Ahmedabad, Gujarat, India.
Dayanand Medical College and Hospital, Ludhiana, Punjab, India.
Sir Gangaram Hospital, New Delhi, India.
Cardiovascular Research Institute, Singapore, Singapore.
Veterans Affairs Medical Center, Minneapolis, Minnesota, United States of America.
Duke-NUS Medical School, Singapore, Singapore.



Asians are predisposed to a lean heart failure (HF) phenotype. Data on the 'obesity paradox', reported in Western populations, are scarce in Asia and have only utilised the traditional classification of body mass index (BMI). We aimed to investigate the association between obesity (defined by BMI and abdominal measures) and HF outcomes in Asia.


Utilising the Asian Sudden Cardiac Death in Heart Failure (ASIAN-HF) registry (11 Asian regions including Taiwan, Hong Kong, China, India, Malaysia, Thailand, Singapore, Indonesia, Philippines, Japan, and Korea; 46 centres with enrolment between 1 October 2012 and 6 October 2016), we prospectively examined 5,964 patients with symptomatic HF (mean age 61.3 ± 13.3 years, 26% women, mean BMI 25.3 ± 5.3 kg/m2, 16% with HF with preserved ejection fraction [HFpEF; ejection fraction ≥ 50%]), among whom 2,051 also had waist-to-height ratio (WHtR) measurements (mean age 60.8 ± 12.9 years, 24% women, mean BMI 25.0 ± 5.2 kg/m2, 7% HFpEF). Patients were categorised by BMI quartiles or WHtR quartiles or 4 combined groups of BMI (low, <24.5 kg/m2 [lean], or high, ≥24.5 kg/m2 [obese]) and WHtR (low, <0.55 [thin], or high, ≥0.55 [fat]). Cox proportional hazards models were used to examine a 1-year composite outcome (HF hospitalisation or mortality). Across BMI quartiles, higher BMI was associated with lower risk of the composite outcome (ptrend < 0.001). Contrastingly, higher WHtR was associated with higher risk of the composite outcome. Individuals in the lean-fat group, with low BMI and high WHtR (13.9%), were more likely to be women (35.4%) and to be from low-income countries (47.7%) (predominantly in South/Southeast Asia), and had higher prevalence of diabetes (46%), worse quality of life scores (63.3 ± 24.2), and a higher rate of the composite outcome (51/232; 22%), compared to the other groups (p < 0.05 for all). Following multivariable adjustment, the lean-fat group had higher adjusted risk of the composite outcome (hazard ratio 1.93, 95% CI 1.17-3.18, p = 0.01), compared to the obese-thin group, with high BMI and low WHtR. Results were consistent across both HF subtypes (HFpEF and HF with reduced ejection fraction [HFrEF]; pinteraction = 0.355). Selection bias and residual confounding are potential limitations of such multinational observational registries.


In this cohort of Asian patients with HF, the 'obesity paradox' is observed only when defined using BMI, with WHtR showing the opposite association with the composite outcome. Lean-fat patients, with high WHtR and low BMI, have the worst outcomes. A direct correlation between high WHtR and the composite outcome is apparent in both HFpEF and HFrEF.


Asian Sudden Cardiac Death in HF (ASIAN-HF) Registry Identifier: NCT01633398.

Conflict of interest statement

I have read the journal's policy and the authors of this manuscript have the following competing interests: CSPL served as a guest editor on PLOS Medicine's Cardiovascular Disease Special Issue. Unrelated to present work, CSPL is supported by a Clinician Scientist Award from the National Medical Research Council Singapore, non-financial support from Boston Scientific, non-financial support from Bayer, non-financial support from Thermofisher, non-financial support from Vifor Pharma, other from Bayer, other from Novartis, other from Takeda, other from Merck, other from Astra Zeneca, other from Janssen Research & Development, other from LLC, other from Menarini, other from Boehringer Ingelheim, other from Abbott Diagnostics, from DC Devices, outside the submitted work; In addition, CSPL has a patent PCT/SG2016/050217 pending. AMR is supported by a Singapore Translational Research (STaR) award from the National Medical Research Council Singapore, is a named investigator on projects supported by grants from Boston Scientific, Bayer, Astra Zeneca, Roche Diagnostics and has received research support in kind Thermo Fisher, Roche Diagnostics and Abbott Laboratories and other from Novartis. All other authors report no conflict of interest, financial or otherwise.

Supplemental Content

Full text links

Icon for Public Library of Science Icon for PubMed Central
Loading ...
Support Center