A subgroup of patients with heart failure characterized by low body mass index (BMI) and high waist-to-hip ratio (WHR) had substantially worse outcomes than patients with more generalized adiposity, according to findings presented at Heart Failure 2026. The phenotype, described as “lemon-on-sticks,” was associated with congestion, inflammatory biomarkers, and more than double the risk of all-cause mortality.
“Obesity is a risk factor for cardiovascular disease, yet paradoxically, in patients with established heart failure, a higher BMI is associated with better survival,” said presenter Camilla van der Hoef of University Medical Centre Groningen, Netherlands. She noted that BMI does not distinguish among fat, fluid, and muscle mass, while higher WHR may reflect adverse abdominal fat distribution.
The retrospective analysis included 1,467 patients from the Scottish BIOlogy Study to TAilored Treatment in Chronic Heart Failure (BIOSTAT-CHF) cohort. Patients were categorized according to median BMI and WHR cutoffs, generating four phenotypic groups. The low BMI/high WHR subgroup was termed the “lemon-on-sticks” phenotype, while the high BMI/low WHR subgroup represented “general adiposity.”
Patients with the “lemon-on-sticks” phenotype showed the strongest signs of congestion and had the highest concentrations of N-terminal pro-B-type natriuretic peptide (NT-proBNP), a marker of cardiac stress. The phenotype was also associated with a predominantly inflammatory biomarker profile.
Compared with the “general adiposity” phenotype, the “lemon-on-sticks” phenotype was associated with more than double the risk of all-cause mortality after adjustment for age and sex (hazard ratio [HR] 2.20; 95% confidence interval [CI] 1.59-3.03; p<0.001). Patients with both high BMI and high WHR also had significantly higher mortality risk (HR 1.50; 95% CI 1.09-2.07; p=0.013). Mortality risk did not significantly differ in patients with low BMI and low WHR.
“Our analyses suggest that BMI and WHR capture distinct biological and clinical phenotypes in heart failure,” van der Hoef said. She added that integrating these measures may help identify patients with disproportionate central fat distribution and a higher burden of adverse disease indicators.
The findings highlight the limitations of BMI alone in heart failure assessment and suggest that body composition measures such as WHR may improve risk stratification. However, the observational design does not establish causality, and further longitudinal studies are needed to determine whether body composition–guided management improves outcomes.
