EDITORIAL Body fat and cardiovascular risk: understanding the obesity paradox

This editorial refers to ‘The influence of body mass index on mortality and bleeding among patients with or at high-risk of atherothrombotic disease’†, by K.-H. Mak et al., on page 857 Large studies of initially healthy men and women consistently link adiposity with an increased risk of cardiovascular events.1,2 Com-pared with a reference body mass index (BMI),25 kg/m2, the relative risk of dying during the next decade ranges from 1.2 for over-weight (25–29.9 kg/m2) to 3.8 for severely obese (40 kg/m2) sub-jects, after adjustment for age, smoking, alcohol, and physical activity.1 Abdominal fat, measured as the waist–hip ratio, more reliably predicts the risk of ischaemic heart disease and death than BMI, even within normal body weights and after additional adjust-ment for blood pressure and cholesterol.2,3 In striking contrast, among patients with known atherothrombo