Physicians' Academy for Cardiovascular Education

There is no such thing as 'metabolically healthy obese', as it increases CHD risk

Separate and combined associations of obesity and metabolic health with coronary heart disease: a pan-European case-cohort analysis

Literature - Lassale C, Tzoulake I, Moons KGM et al., - Eur Heart J, 2018: 39: 397–406

Main results


This prospective case-cohort study in participants from 8 European countries showed higher CHD risks associated with both general (BMI) and central (WC) obesity, with adjusted analyses suggesting that the effect of WC obesity is stronger. Metabolically healthy overweight and obese individuals showed a higher risk of CHD compared with those with normal weight and without MetS. Metabolically unhealthy individuals in all tested BMI categories were at higher CHD risk than their metabolically healthy counterparts. Although MetS aggravates the elevated CHD risk, these data show that ‘metabolically healthy obese’ is not a benign condition.

Editorial comment

Garcia-Moll [6] reiterates that obesity is a major epidemic, with up to about half of the populations of western countries being overweight or obese. In this context, he calls the concept of a metabolically healthy obese phenotype a sunbeam in a dark landscape of increased risk of T2DM, CHD and mortality. MHO individuals were initially thought to have prognoses similar to those with normal weight. More recent reports with longer follow-up challenge this finding. The carefully carried out study by Lassale and colleagues in a large study cohort that allowed complex statistical analysis and exhaustive adjustment with potential confounders also challenges the concept of MHO.

As acknowledged by the authors, this study was limited by the use of only the most frequently used definitions of MHO and MetS. Moreover, there is no longitudinal follow-up on evolution of weight and metabolic status. Also, the design of the EPIC-CVD study makes that some centers only recruited women, or a high proportion of vegetarians, which may limit the external validity of these finding. Nevertheless, the conclusions of this study that obesity increases CHD risk regardless of metabolic status are relevant. And metabolic abnormalities confer extra CHD risk to both normal weight and overweight/obese individuals. Considering that obesity also increases the risk for other risk factors such as hypertension, T2DM and cardiac conditions, studies with longer follow-up may find further support of the CV risk associated with obesity.


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