Medical research often details new treatment breakthroughs. Less often, a study will look at existing research and give it a novel reinterpretation.
Just such a paper was published recently in the Journal of Nutrition: it puts forward the counterintuitive medical reality that the same health advice that prevents you from becoming ill may actually harm you once you are already sick.
Named ‘Cuomo’s paradox’ by the scientific community, the author Prof Raphael Cuomo of the University of California, San Diego School of Medicine, looked at findings across numerous studies. His paper formalises the general principle that nutritional factors which help prevent cancer or cardiovascular disease can have the opposite effect on survival after diagnosis.
In other words, unhealthy behaviours such as carrying extra weight, drinking moderate amounts of alcohol, or having elevated cholesterol levels are associated with better survival in people who already have cancer or heart disease.
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Cuomo’s paradox doesn’t mean throwing prevention guidelines out the window. Rather, it argues for personalised nutrition after diagnosis and during treatment, with the aim of preserving strength and tolerating sometimes harsh treatments.
The obesity paradox is well documented in cardiovascular and cancer care. Obesity is well-established as a major risk factor for both cancer and cardiac disease. Studies consistently link a high body mass index (BMI) with an increased incidence of colorectal, breast, endometrial, kidney and pancreatic cancers. Obesity has been shown to trigger cardiovascular disease through increased blood pressure, insulin resistance and high cholesterol.
Paradoxically, once cancer or cardiac disease develops, individuals who are overweight often show improved survival compared with their normal-weight or underweight peers. What Cuomo has added is to link these paradoxes across multiple factors – weight, alcohol, cholesterol – and multiple diseases, creating a unified framework for stage-specific nutritional advice.
Before diagnosis, we should advise patients to maintain a healthy weight, limit alcohol intake and manage their cholesterol. After diagnosis, targets should be individualised to reflect disease stage, treatment and body composition
But how might extra weight help cancer survival? Chemotherapy, radiation and surgery assault the body, causing muscle and tissue breakdown. Patients with greater reserves – both fat and muscle mass – may be able to weather these assaults better and resist further weight loss.
Alcohol consumption offers another striking example of the risk-survival paradox, Cuomo says. Alcohol intake has been consistently linked to increased risk of several cancers, including those of the breast, large bowel, liver and upper digestive tract. On the other hand, some studies suggest light-to-moderate drinkers have better post-diagnosis outcomes compared with non-drinkers. This is true for breast and large bowel cancer but not for liver and head and neck cancers.
In cardiovascular disease, the paradox is even more consistent. Moderate alcohol consumers who develop cardiac disease often fare better than abstainers or former heavy drinkers.
Then we have the “cholesterol paradox”. LDL cholesterol (the bad cholesterol), plays a dual role in human health. Elevated LDL cholesterol is a major risk factor for arterial disease and heart attack, making it a key target of public-health intervention. However, once heart failure or late-stage cardiovascular disease develops, higher cholesterol concentrations are frequently associated with lower mortality.
For doctors, Cuomo’s paradox emphasises the need for more tailored messaging that separates prevention from survival goals. Before diagnosis, we should advise patients to maintain a healthy weight, limit alcohol intake and manage their cholesterol. After diagnosis, targets should be individualised to reflect disease stage, treatment and body composition.
Why is this important for patients today?
“Millions are living with advanced cancer or heart disease; Cuomo’s paradox gives clinicians a rationale to individualise recommendations for patients rather than copy prevention rules” the author says.
“The boundaries of this paradox have yet to be uncovered, though I expect that it will have applications outside of cancer and cardiovascular disease,” he added, while pointing out that there is less evidence that the paradox applies to people with diabetes or hypertension.
So what is the key message of his eponymous paradox? “It is that behaviour that helps you avoid disease may not be the behaviour that helps you live longer after diagnosis.”
