In a meta-analysis of 21 cohort studies including .300 000 persons, the risks for cardiovascular events in patients who ) and obese (BMI ) compared with those of normal weight were 32% and 81% higher, respectively, after adjustment for age, sex, physical activity, and smoking.635 Cardiovascular risk is increased particularly in patients with central obesity, which can be identified by a waist circumference .102 cm (40 inches) in men or .88 cm (35 inches) in women,643,644 and in those with extreme obesity, defined as a BMI .40 kg/m2 Obesity likely contributes to increased cardiovascular risk through multiple pathophysiological pathways. Obesity is associated with traditional cardiovascular risk factors, such as diabetes mellitus, dyslipidemia, and hypertension, but in and of itself obesity increases sympathetic tone, induces a hyper- coagulable state, and is associated with markers of inflam- mation.646 Curiously, despite the strong association of BMI with cardiovascular risk in population studies, a similar relationship between BMI and death is not observed consis- tently in cohorts with established IHD.647 This could be due to weaknesses of BMI as a measure of adiposity; confounding factors such as age, smoking, or medications; or weight loss in association with advanced chronic illness. No clinical trials have examined specifically the effects of weight loss on cardiovascular event rates in patients with SIHD. In the SOS (Swedish Obese Subjects) study, however, weight losses of 20% to 32% at 1 year achieved with bariatric surgery were associated with a 24% reduction in mortality rate.648 The association of adiposity with other cardiovascular risk factors suggests that weight reduction is indicated in all overweight or obese patients. Reducing caloric intake is a cornerstone of weight management therapy. Referral to an experienced dietitian or to a reputable weight loss program for nutritional counseling and behavioral modification ther- apy can be helpful. 