Visceral obesity is associated with metabolic abnormalities that increase the risk of type 2 diabetes and coronary heart disease. Obese patients with a substantial accumulation of visceral adipose tissue are characterized by higher insulinaemic and glycaemic responses during an oral glucose challenge as well as by a deteriorated plasma lipoprotein-lipid profile compared with individuals with normal body weights or obese subjects with low levels of visceral adipose tissue. Results of the Quebec Cardiovascular Study have shown that the cluster of metabolic disturbances observed among subjects with visceral obesity (hyperinsulinaemia, hyperapolipoprotein B and small, dense low-density lipoprotein (LDL) particles) is associated with a 20-fold increase in the risk of coronary heart disease in a sample of middle-aged men followed over 5 years. Therefore, we have developed a simple screening approach in order to help physicians and health professionals identify at low cost individuals who would be characterized by this cluster of atherogenic abnormalities. We found that the simultaneous presence of an elevated waist girth combined with moderate hypertriglyceridaemia ('hypertriglyceridaemic waist') could adequately identify a large proportion (approximately 80%) of carriers of the above triad of atherogenic metabolic abnormalities (hyperinsulinaemia, hyperapolipoprotein B and small, dense LDL particles). Finally, there is evidence suggesting that the risk of an acute coronary syndrome in these viscerally obese patients may not always be related to the extent of coronary artery stenosis, providing further support to the notion that additional markers of thrombosis/inflammation should be considered. Thus, the stabilization of the atherosclerotic plaque, rather than its regression may even become a more legitimate and feasible therapeutic objective for the management of the coronary heart disease risk in the viscerally obese patient. Although these notions are based on a plausible metabolic rationale, randomized trials with proper end-points will be needed to determine the clinical benefits associated with the management of visceral obesity and related metabolic complications.