Still, it is important to Bozkurt et al note that although obese patients have lower levels of brain natriuretic peptide than nonobese patients, brain natriuretic peptide levels predict worse symptoms, im- paired hemodynamics, and higher mortality in any BMI category, even in obese patients.222 It has also been proposed that obese patients may simply have less ad- vanced illness, earlier diagnosis, or competing diagno- ses with excess symptoms such as fatigue and dyspnea caused part by their excess body weight. Treatment of Obesity in Patients Without Established HF and Potential Beneficial Effects to Prevent HF There are multiple beneficial effects of weight reduction in obesity on the cardiovascular system, including decreas- ing LV mass, decreased arterial pressure, decreased fill- ing pressures of the left and right sides of the heart, and improvement in indexes of diastolic and systolic cardiac The role of intentional weight loss in obesity as a means of preventing CVD has been the subject of multiple previous studies and reviews218,219,222,226 229 and is beyond the scope of this document. The recent 2013 AHA/ACC/The Obesity Society Guideline for the Manage- ment of Overweight and Obesity in Adults underlines the importance of the prevention and treatment of overweight and obesity on risk factors for CVD and type 2 diabetes mellitus, as well as CVD morbidity and mortality, but did not have specific comments on the prevention of HF or treatment of obesity in patients with HF.6 Given the strong association between obesity and incident HF discussed above, it is plausible that intentional weight loss via di- etary intervention, physical activity, approved pharma- cotherapy, or surgery may reduce the incidence of HF, although there are no prospective studies of weight loss specifically studying clinical HF as an outcome (Table 8). 