{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,29]],"date-time":"2026-09-29T01:14:54Z","timestamp":1790644494778,"version":"4.1.0"},"reference-count":40,"publisher":"Public Library of Science (PLoS)","issue":"2","license":[{"start":{"date-parts":[[2026,2,3]],"date-time":"2026-02-03T00:00:00Z","timestamp":1770076800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:sec id=\"sec001\">\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Obesity is a risk factor for incident heart failure, but patients with excess weight and heart failure have lower mortality. This \u201cobesity paradox\u201d may be explained either by a favourable effect of the adipose tissue or by confounding.<\/jats:p>\n                    <jats:p>We aimed to assess if body mass index (BMI) is associated with lower mortality after extensive adjustment for prognostic factors in patients with reduced (HFrEF) or preserved (HFpEF) ejection fraction.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec002\">\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Prospective, observational study including consecutive patients hospitalized for acute heart failure. Two years hazard of mortality was assessed in a multivariable Cox model, in the whole population and separately for HFrEF and HFpEF.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec003\">\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Among 957 included patients (mean age 76 years, 41% women), 500 (47%) had HFrEF and 443 (53%) HFpEF. Four hundred (39%) were in the normoweight, 301(30%) in the overweight, and 256(25%) in the obese category (Class I obesity:144 patients; class II or III: 112). Corresponding mortality was 37%, 26% and 22%. Unadjusted hazard ratio (HR) for mortality was 0.96 (95% CI 0.94\u20130.98) for each BMI point in the whole population, 0.97 (95% CI 0.94\u20131.02) in patients with HFrEF, and 0.94 (95% CI 0.92\u20130.97) in HFpEF. After adjustment for age, sex, atrial fibrillation, diabetes, chronic obstructive pulmonary disease, chronic anaemia, hypertension, glomerular filtration rate, and NT-proBNP, HR was 1.00 (95% CI 0.96\u20131.02) in the whole population, 1.02 (0.96\u20131.07) in HFrEF, and 0.98 (95% CI 0.94\u20131.01) in HFpEF.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec004\">\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Excess weight was associated with an apparent survival benefit in patients with acute heart failure, particularly in patients with HFpEF. This advantage disappeared completely after adjustment for confounding factors including NT-proBNP. The obesity paradox can be completely explained by differences in demographics, co-morbidities, and severity of heart failure.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1371\/journal.pone.0341606","type":"journal-article","created":{"date-parts":[[2026,2,3]],"date-time":"2026-02-03T18:22:06Z","timestamp":1770142926000},"page":"e0341606","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":1,"title":["Overweight and obesity association with mortality in patients with heart failure and reduced or preserved ejection fraction-a cohort study"],"prefix":"10.1371","volume":"21","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-4712-6666","authenticated-orcid":true,"given":"Nicolas","family":"Garin","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3212-1272","authenticated-orcid":true,"given":"David","family":"Carballo","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jonathan","family":"Dash","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"J\u00e9r\u00f4me","family":"Stirnemann","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jean-Luc","family":"Reny","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nicolas","family":"Vuilleumier","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sebastian","family":"Carballo","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2026,2,3]]},"reference":[{"key":"pone.0341606.ref001","doi-asserted-by":"crossref","first-page":"101850","DOI":"10.1016\/j.eclinm.2023.101850","article-title":"Trends and predictions of malnutrition and obesity in 204 countries and territories: an analysis of the global burden of disease study 2019","volume":"57","author":"B Chong","year":"2023","journal-title":"EClinicalMedicine"},{"issue":"7","key":"pone.0341606.ref002","doi-asserted-by":"crossref","first-page":"639","DOI":"10.1161\/CIRCULATIONAHA.115.016801","article-title":"Body mass index, abdominal fatness, and heart failure incidence and mortality: a systematic review and dose-response meta-analysis of prospective studies","volume":"133","author":"D Aune","year":"2016","journal-title":"Circulation"},{"issue":"1","key":"pone.0341606.ref003","doi-asserted-by":"crossref","first-page":"58","DOI":"10.1136\/heartjnl-2019-314770","article-title":"Complex interaction of obesity, intentional weight loss and heart failure: a systematic review and meta-analysis","volume":"106","author":"R Mahajan","year":"2020","journal-title":"Heart"},{"issue":"8","key":"pone.0341606.ref004","doi-asserted-by":"crossref","first-page":"778","DOI":"10.1016\/j.jacc.2013.09.072","article-title":"Body mass index and mortality in acutely decompensated heart failure across the world: a global obesity paradox","volume":"63","author":"R Shah","year":"2014","journal-title":"J Am Coll Cardiol"},{"issue":"1","key":"pone.0341606.ref005","doi-asserted-by":"crossref","first-page":"55","DOI":"10.1001\/archinte.165.1.55","article-title":"The obesity paradox: body mass index and outcomes in patients with heart failure","volume":"165","author":"JP Curtis","year":"2005","journal-title":"Arch Intern Med"},{"issue":"3","key":"pone.0341606.ref006","doi-asserted-by":"crossref","first-page":"233","DOI":"10.1016\/j.jchf.2017.11.011","article-title":"Impact of body mass index on heart failure by race\/ethnicity from the get with the guidelines-heart failure (GWTG-HF) registry","volume":"6","author":"TM Powell-Wiley","year":"2018","journal-title":"JACC Heart Fail"},{"issue":"1","key":"pone.0341606.ref007","doi-asserted-by":"crossref","first-page":"74","DOI":"10.1016\/j.ahj.2006.09.007","article-title":"An obesity paradox in acute heart failure: analysis of body mass index and inhospital mortality for 108,927 patients in the Acute Decompensated Heart Failure National Registry","volume":"153","author":"ADHERE Scientific Advisory Committee and Investigators","year":"2007","journal-title":"Am Heart J"},{"issue":"5","key":"pone.0341606.ref008","doi-asserted-by":"crossref","first-page":"711","DOI":"10.1002\/ejhf.2832","article-title":"Better pharmacotherapy in heart failure with reduced ejection fraction may partly explain the obesity paradox","volume":"25","author":"S Carbone","year":"2023","journal-title":"Eur J Heart Fail"},{"issue":"12","key":"pone.0341606.ref009","doi-asserted-by":"crossref","first-page":"2271","DOI":"10.1097\/HJH.0b013e32835b4fe0","article-title":"Obesity paradox or inappropriate study designs? 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