Design: Meta-analysis of 8 placebo-controlled RCTs, BMI-stratified
Population: 57,356 patients with heart failure, CKD and/or type 2 diabetes
Primary outcome: Cardiovascular death or heart failure hospitalisation
Effect: BMI <30 RR 0.80 (0.72–0.89); BMI ≥30 RR 0.80 (0.75–0.85)

This meta-analysis pooled eight placebo-controlled trials of SGLT2 inhibitors in heart failure, CKD and type 2 diabetes (57,356 patients, mean BMI about 30) that reported outcomes stratified at a BMI of 30.

Cardiovascular death or heart failure hospitalisation fell by 20% both below BMI 30 (RR 0.80, 95% CI 0.72–0.89) and at or above it (RR 0.80, 0.75–0.85), with no evidence of effect modification. Heart failure hospitalisation (RR 0.75 and 0.74) and all-cause death (RR 0.83 and 0.89) showed similar consistency. Heterogeneity came from disease category and drug, not BMI.

Some clinicians hesitate to start an SGLT2 inhibitor in lean patients — common among South Asians with CKD or diabetes — worrying about weight loss, or assume benefit is weaker in obesity. These data answer both: the cardiorenal benefit is the same. BMI should not decide who gets one.

Offer an SGLT2 inhibitor to eligible patients with CKD, heart failure or type 2 diabetes regardless of BMI.
Lower body weight is not a reason to withhold one; monitor weight and volume status in frail patients.
Expect an initial eGFR dip of a few mL/min — it is haemodynamic and not a reason to stop.
Give sick-day advice to pause the drug during acute illness, vomiting or fasting.

Why it matters

It removes BMI as a reason for hesitation, which matters in lean South Asian patients with CKD or diabetes.

The statistics, in plain English

Identical risk ratios (0.80) in both BMI groups, with a formal test finding no interaction, means BMI does not change how well the drugs work on this outcome.