Clinical obesity flags higher risk in heart failure with preserved ejection fraction

A single-center prospective cohort study from China reports that clinical obesity, as defined by the Lancet Diabetes & Endocrinology Commission, is far more common among hospitalized patients with heart failure with preserved ejection fraction (HFpEF) than obesity measured by body mass index alone, and that it marks a substantially higher risk of heart failure-related events.

The study enrolled 426 hospitalized Chinese HFpEF patients between November 2020 and July 2024. Because all participants already had established HFpEF, which the Commission framework considers an obesity-related organ dysfunction, classification of clinical obesity within the cohort depended on confirmation of excess adiposity. The researchers assessed this using body mass index, waist circumference, waist-to-hip ratio and body fat percentage measured by bioelectrical impedance.

Clinical obesity was present in 74.9 percent of the patients. That figure far exceeds the 15.0 percent prevalence of BMI-defined obesity in the same cohort, using the threshold of a body mass index of 28 kg/m2 or higher that is commonly applied in Asian populations. Notably, clinical obesity was common even among patients whose body mass index fell in the normal range, underscoring the study’s central argument that BMI alone inadequately reflects excess adiposity and its clinical consequences.

The primary endpoint was a composite of worsening heart failure or cardiovascular death. Over a median follow-up of 907 days, patients with clinical obesity experienced composite endpoint events at a rate of 35.24 per 100 person-years, compared with 15.82 per 100 person-years among patients without clinical obesity.

After statistical adjustment, clinical obesity was associated with an increased risk of the composite endpoint, with an adjusted hazard ratio of 2.04 and a 95 percent confidence interval of 1.42 to 2.95. The association with worsening heart failure alone was similar in magnitude, at an adjusted hazard ratio of 2.24 with a 95 percent confidence interval of 1.51 to 3.31. In contrast, BMI-defined obesity showed no significant prognostic value in this cohort.

The authors also tested whether clinical obesity could improve risk prediction beyond an existing tool. A Cox regression model incorporating age, atrial fibrillation and clinical obesity improved one- and two-year risk discrimination compared with the published HFpEF-ABA score. The model yielded significant net reclassification improvement and integrated discrimination improvement at one, two and three years, with all reported p values below 0.05.

The motivation for the study lies in a recognized limitation of body mass index. As the authors note, BMI tends to be lower in Asian populations despite prevalent central adiposity, meaning that a substantial burden of excess adiposity can be missed when obesity is defined by BMI thresholds alone. The Lancet Commission’s definition of clinical obesity, a chronic disease characterized by excess adiposity together with obesity-related organ dysfunction, was designed to capture these cases more directly.

The study’s conclusion is that clinical obesity is highly prevalent among Chinese HFpEF patients and identifies individuals at significantly higher risk for heart failure-related events, offering prognostic value beyond conventional BMI and helping refine risk stratification in HFpEF. As a single-center study of 426 hospitalized patients, its findings describe this specific cohort, and the reported associations are observational rather than evidence of causal effects.

Subject of Research: Prevalence and prognostic impact of clinical obesity in heart failure with preserved ejection fraction

Article Title: Prevalence and prognostic impact of clinical obesity in heart failure with preserved ejection fraction: a prospective cohort study

Article References: Chen, J., Cai, T., Liu, J., Xiao, R., Kleeberger, J. A., Venanzio, L. D., Wang, Y., Zhang, Y., He, S., Gao, L., Paneni, F., & Zhang, D. (2026). Prevalence and prognostic impact of clinical obesity in heart failure with preserved ejection fraction: a prospective cohort study. Cardiovascular Diabetology. https://doi.org/10.1186/s12933-026-03405-8

Image Credits: AI Generated

DOI: 10.1186/s12933-026-03405-8

Keywords: clinical obesity, HFpEF, heart failure, body mass index, adiposity, risk stratification, cardiovascular death, worsening heart failure, prospective cohort, bioelectrical impedance, Prevalence, prognostic