Two-thirds of Americans are obese or overweight, and the Centers for Disease Control has declared that obesity

is at epidemic proportions in the United States.[ ! "besity is a ris# factor for many diseases, s$ch as diabetes mellit$s, hypertension, stro#e, and heart and renal disease. Despite this relationship, obese people with these diseases live longer than their normal-weight co$nterparts. This con$ndr$m has been called the %obesity parado&.%['! ($t before yo$ postpone yo$r diet or have that e&tra )elly don$t, let*s e&amine the data. The "besity +arado& is best st$died in congestive heart fail$re, showing that obese patients have a better prognosis than leaner ones.[,--! "f note, none of the congestive heart fail$re trials have fo$nd obesity to worsen the prognosis. The obesity parado& has also been described for other diseases, incl$ding coronary artery disease, hypertension, and stro#e, and in dialysis patients.[., /! Cache&ia from advanced disease was at first tho$ght to be the e&planation. These findings, however, show a contin$o$s dose-response red$ction in mortality across a gradation of body mass inde& levels. And in many of these st$dies, the lowest body mass inde& was calc$lated to have a healthy percentage of body fat and not at levels consistent with a malno$rished state. 0ow do we e&plain the obesity parado&1 2n short, the answer is $n#nown, b$t there are several possibilities. 3irst, obese patients may present earlier with less disease b$rden. Second, obese patients may be more aggressively treated. Third, adipose tiss$e may secrete protective cyto#ines and other hormonal prod$cts. 3inally, these findings are associative, b$t do not prove a ca$se-and-effect relationship. So can we have o$r ca#e and eat it too1 (ased on the data at hand, it is li#ely that the obesity parado& is a real association, b$t what it means for the recommendations and treatment of o$r patients is food for tho$ght. That*s my opinion. 2*m Dr. 4eorge 4riffing, +rofessor of 5edicine at St 6o$is University and 7ditor-inChief for 2nternal 5edicine at e5edicine.