• Metabolic Medicine

There has been a lot of controversy concerning the prognostic role of obesity on cardiovascular morbidity and mortality. Several studies with cardiovascular patients (heart failure, coronary, cerebrovascular and peripheral artery diseases, hypertension and atrial fibrillation) have reported better or similar risk of cardiovascular events and mortality among overweight and obese individuals as compared to lean ones.1 Since obesity is an independent risk factor for cardiovascular diseases, these findings initially surprised researchers, who coined the term ‘obesity paradox’. The increasingly debated ‘metabolically healthy’ or ‘metabolically benign’ obese phenotype might be an explanation to the ‘obesity paradox’ in cardiovascular diseases. In their article, van der Leeuw and colleagues add more fuel to the discussion by investigating the influence of adiposity and cardiometabolic dysfunction on recurrent major cardiovascular events (stroke, myocardial infarction, retinal infarction and vascular mortality) and mortality in a sample of the Secondary Manifestations of ARTerial disease (SMART) study population without diabetes.2

In a population of 5232 patients with previously diagnosed cardiovascular disease (58.5% coronary artery disease), the authors created six groups by the combination of adiposity, as defined by Body Mass Index (BMI) strata (normal weight, BMI 20–24.9 kg/m²; overweight, BMI 25–29.9 kg/m²; obesity, BMI≥30 kg/m²), and cardiometabolic dysfunction, which was based on the presence of at least three criteria of a modified National Cholesterol Education Program (NCEP) metabolic syndrome definition (waist circumference replaced by C-reactive protein). Over a mean follow-up time of 6 years, they found that, as compared to the normal weight without cardiometabolic dysfunction group, overweight and obesity without cardiometabolic dysfunction were not associated with a higher risk of recurrent major cardiovascular events and mortality, whereas, all groups with cardiometabolic dysfunction showed similarly increased risks of both outcomes. As expected, cardiometabolic dysfunction was highest within the obese category (75%), but the prevalence was high …