Although obesity ) was also an independent risk factor for the development of HF, its results were attenuated with the addition of interleukin-6 or C-reactive protein to the model, suggesting that the effects of obesity may be partially mediated through inflammatory pathways.199 Role of the Metabolic Syndrome in Patients With Established HF The prevalence and effects of the metabolic syndrome in the established HF population are less well studied. Because the metabolic syndrome is an independent risk factor for the development of HF, it is not surprising that its prevalence in the HF population is higher than in the general adult population. The 2 studies from the United States, 1 study done in a hospitalized HF popula- tion (without restriction of EF with modified ATP III using and the other focused on an outpa- tient population with HFrEF,297 reported a prevalence of 68.3% and 40%, respectively. The prevalence of the metabolic syndrome in a Japanese HF cohort was 37%, which is more than double the prevalence found in the general Japanese population.298 Lastly, a small Turkish study of HFrEF reported a prevalence of 51%.299 These studies uniformly found a higher prevalence of the meta- bolic syndrome in women than in men. Hispanics had the highest prevalence of the metabolic syndrome (78.8%) followed by whites (69.5%) and blacks (60.9%).296 In the 2 studies that did not restrict EF, the prevalence of HF- pEF was higher in those with the metabolic syndrome. The effect of the metabolic syndrome on mortality in the HF population has been assessed in 2 studies with discrepant results. Hassan et al296 reported a lower mortality in patients with HF with compared with those without the metabolic syndrome (43.8% versus 57.6%) in a retrospective cohort of patients (n=625) admitted with HF. 