{'fraction_non_alphanumeric': 0.02230843840931135, 'fraction_numerical': 0.005819592628516004, 'mean_word_length': 5.386996904024768, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Tipping the scales toward fitness as a key modifier of the obesity paradox in heart failure

Obesity is an epidemic, with an ever-increasing proportion of the population at the upper end of the continuum of underweight, normal weight, overweight, obese, and severely obese. Regardless of the measures used to assess obesity, which include body mass index (BMI), waist circumference, and percentage body fat (BF), individuals with obesity are predisposed to various disease states. Obesity has harmful effects on physiological parameters such as lipid composition, glucose tolerance, and levels of inflammation. It also directly impacts cardiovascular health by increasing blood volume, stroke volume, and cardiac output, all of which lead to ventricular dilation and hypertrophy as well as atrial enlargement.1 Nevertheless, while obesity is a clear risk factor for heart failure (HF), substantial data demonstrate an ‘obesity paradox’ where higher BMI and waist circumference are associated with improved outcomes in both men and women with HF.2–4 While conclusions regarding BMI are blurred by the fact that this measure combines fat mass and muscle mass, the obesity paradox in HF is also demonstrated when adiposity is assessed by BF. Systolic HF patients were previously noted to have a 13% reduction in mortality or urgent transplantation for every 1% increase in BF.5 It remains unclear if BF provides direct benefits or if it primarily stimulates muscle mass development. A small study of patients with HF demonstrated that patients with higher BF generally have higher muscular fitness and muscle strength.6 On the opposite end of this spectrum, the catabolic state of cachexia is characterized by muscle wasting and inflammatory immune activation. Muscle wasting, represented by the established marker of low urinary creatinine, was associated with more severe HF and impaired survival in a study of 120 systolic HF patients.7 Cardiorespiratory fitness (CRF) has also demonstrated prognostic significance in HF. Cardiopulmonary exercise testing results