In addition to its own potential role as an independent coronary heart disease (CHD) risk factor, substantial evidence indicates that overweightness and obesity adversely impact many other CHD risk factors, including dyslipidaemia, hypertension/left ventricular hypertrophy, glucose intolerance, including metabolic syndrome and type 2 diabetes mellitus and physical inactivity.1 Clearly, the prevalence of almost every cardiovascular disease (CVD), including hypertension, heart failure (HF), peripheral arterial disease, atrial fibrillation as well as CHD, is markedly increased in the presence of obesity. However, despite these adverse effects of obesity, numerous studies and even large meta-analyses clearly demonstrate an ‘obesity paradox’, in which lean patients with established CVD have a worse clinical prognosis than do their more overweight/obese counterparts with the same CVD, including CHD.1 ,2

Despite the obesity paradox, several studies suggest that within the obese cohort, ‘heavier’ obese patients do not have a more favourable prognosis. In fact, in a large systematic review of over 250 000 CHD patients in 40 cohort studies followed for 3.8 years, Romero-Corral and colleagues2 reported that overweight and obese CHD patients had a lower cardiovascular and total mortality compared with underweight and normal-weight CHD patients; however, patients with class II obesity (body mass index (BMI) >35 kg/m²) were at excess risk of cardiovascular mortality but still no increase in total mortality. A recent report by Das et al3 showed a U-shaped inhospital mortality curve in a very large cohort with ST-segment myocardial infarction. Interestingly, those authors classified the class I obese (BMI 30–35 kg/m²) as the reference group and even suggested that in our ‘ever growing’ society, mild obesity may now be the ‘new normal’. Most importantly, however, is …