The single use of body mass index for the obesity paradox is misleading and should be used in conjunction with other obesity indices

Overweight and obesity in children and adults have significantly risen in the US and worldwide due to biological, environmental, and cultural drivers and account for about 2.1 billion people. In addition, obesity, even metabolically healthy, is a major risk factor for the metabolic syndrome, diabetes mellitus, dyslipidemia, and hypertension, all significant causes of cardiovascular disease (CVD), coronary heart disease (CHD) heart failure (HF) and stroke. However, despite these causative effects, overweight and obesity frequently, confer protection in patients with established CVD, CHD, HF, and hypertension, compared to normal weight persons, the so-called 'obesity paradox'. This phenomenon though is not unique, because other studies have not shown a protective effect of overweight and obesity in such patients. These controversial effects of obesity are mostly due to the use of different indices of obesity by the various studies. Most studies have used the body mass index (BMI) as an index of obesity, which is a poor index for total fat or fat distribution. In order to get a better perspective on the true nature of the obesity paradox, a Medline and Embase search of the English language literature was contacted from 2012 to 2018, using the terms, overweight, obesity, obesity paradox, CVD, HF, and hypertension. From this search, 37 pertinent papers were selected and their findings together with collateral literature will be discussed in this review. The analysis of data suggests that the existence of the obesity paradox is questionable based on the single use of BMI as a measure of obesity. The use of waist circumference and waist to hip ratio are better indices of obesity and should be used together with the BM.