Although the concept of cardiomyopathy relating to obesity has been described the strong, independent, incremental re- lationship between obesity as indexed by body mass in- dex (BMI) and HF incidence was only more recently estab- lished. In a study of 5881 participants in the Framingham Heart Study, the increase in the risk of HF per 1-unit BMI increase was 5% for men and 7% for women, even after adjustment for demographics and known risk factors of MI, diabetes mellitus, hypertension, and cholesterol.192 The continuous gradient between higher BMI and risk of HF has been confirmed in larger prospective, cohort stud- In addition to BMI, other anthropometric indexes of obesity, including waist circumference, waist-to-hip ra- tio, and waist-to-height ratio, have been independently as- sociated with incident HF in large, population-based stud- ies; however, indexes such as waist circumference and waist-to-hip ratio have not been shown to perform better than BMI as predictors of HF.194 196 Although the relation- ship between overweight/obesity and incident HF may be associated with hemodynamic and anatomic cardiac changes related to excess body mass,197 recent evidence suggests that the relationship is also mediated by obesity- related metabolic, inflammatory, and hormonal changes. Obesity is highly correlated with insulin resistance, which may in part potentiate the link between obesity and HF. In the Uppsala study, insulin sensitivity, but not anthropo- metric indexes of obesity, was independently predictive of In a cohort study from Greece, individuals with normal BMI and metabolic syndrome were at substantially higher risk of HF at 6 years compared with obese individu- als without metabolic syndrome.198 Analyses from MESA (Multi-Ethnic Study of Atherosclerosis) suggest that inflam- mation may potentiate the link between obesity and the risk of developing HF. 