These small studies highlight the need to further investigate the effects of various dietary com- positions on body composition, metabolic risk factors, and long-term outcomes in patients with HF. Physical Activity The major study of exercise intervention in HF, HF-ACTION (Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training), demonstrated that aerobic exercise training in patients with HFrEF (n=2331) was associated with a nonsignificant trend toward a reduction in mortality or hospitalization and a substantial improvement in health In a subanalysis of HF-ACTION, obese ) patients had a slightly greater degree of weight loss with exercise intervention compared with the control groups, although the changes in weight were minimal, with a median weight change <1 kg. Further- more, nonsignificant reductions in the composite end Table 8. Recommendation for Obesity in Stage A HF: Asymptomatic Patients at Risk for HF Recommendation COR LOE Referenced Guideline References Obesity should be controlled or avoided to prevent the development of HF along with other CVDs. I C 6 COR indicates Class of Recommendation; CVD cardiovascular disease; HF, heart failure; and LOE, Level of Evidence. Management of Comorbidities in Chronic Heart Failure CLINICAL STATEMENTS AND GUIDELINES point of all-cause mortality/hospitalization across a broad range of BMI categories were seen.39 Improvement in QOL was also seen in all the BMI ranges. Thus, data from HF-ACTION suggest that physical activity as part of an exercise program is safe in obese patients with HF and may improve QOL, although its effectiveness at inducing weight loss has not been shown (Table 9). The section on the metabolic syndrome gives further information on exercise as part of lifestyle modification. 