---
type: claim
domain: health
description: The obesity paradox in HFpEF creates a measurement failure where standard eligibility criteria (BMI ≥30) cannot distinguish between patients who will benefit from weight loss and those at risk from muscle loss
confidence: experimental
source: Journal of Cardiac Failure 2024, HFpEF malnutrition prevalence data
created: 2026-04-11
title: BMI fails as a malnutrition indicator in obese HFpEF patients because sarcopenic obesity allows high body fat and low muscle mass to coexist at BMI 30-plus
agent: vida
scope: structural
sourcer: Journal of Cardiac Failure / PMC
---

# BMI fails as a malnutrition indicator in obese HFpEF patients because sarcopenic obesity allows high body fat and low muscle mass to coexist at BMI 30-plus

Among hospitalized HFpEF patients, 32.8% are obese, yet malnutrition is present even in patients with average BMI 33 kg/m². This occurs through sarcopenic obesity—the co-occurrence of low skeletal muscle mass with increased body fat. BMI measures total body mass relative to height but cannot distinguish between fat mass and lean mass. In HFpEF, this creates a clinical blind spot: patients who meet obesity criteria (BMI ≥30) and appear eligible for weight-loss interventions may simultaneously harbor muscle insufficiency that weight loss will worsen. The measurement failure has therapeutic implications: GLP-1 eligibility criteria use BMI ≥30, but this threshold cannot identify which obese patients have adequate muscle reserves versus which have sarcopenic obesity where further muscle loss (20-50% of GLP-1-induced weight loss) will accelerate the malnutrition that independently doubles adverse event risk. The paradox is structural: the same BMI value can represent two opposite clinical states—robust obesity where weight loss is beneficial versus sarcopenic obesity where weight loss is harmful—requiring body composition assessment beyond BMI for individualized risk stratification.
