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Wijayatunga NN, Kim H, Hays HM, Kang M. Objectively Measured Physical Activity Is Lower in Individuals with Normal Weight Obesity in the United States. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:11747. [PMID: 36142017 PMCID: PMC9517524 DOI: 10.3390/ijerph191811747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 09/12/2022] [Accepted: 09/13/2022] [Indexed: 06/16/2023]
Abstract
The role of physical activity in normal weight obesity (NWO), which is associated with increased cardiometabolic risk, is not clear. This study aimed to determine body composition phenotype-specific differences in objectively measured physical activity and sedentary time in adults in the United States. A total of 2055 adults with a body mass index (BMI) ≥ 18.5 m2 were studied using 2003-2006 National Health and Nutrition Examination Surveys. Physical activity and percent body fat (BF%) were measured using accelerometer and dual-energy X-ray absorptiometry, respectively. A BF% > 23.1% and >33.3% for men and women, respectively, was considered excess. A BMI of 18.5-24.9 kg/m2 with excess BF% was defined as NWO, while those with normal BF%, as normal weight lean (NWL). A BMI of ≥25 kg/m2 with excess BF% was considered overweight/obesity (OB). Compared to NWL, moderate to vigorous physical activity was significantly lower by 8.3 min (95% confidence interval/CI = -15.20, -1.40) and 10.18 min (95% CI = -14.83, -5.54) per day in NWO and OB, respectively. Low-intensity physical activity was also significantly lower by 17.71 min (95% CI = -30.61, -4.81) per day in NWO compared to NWL. However, sedentary time was not different. Objectively measured physical activity is significantly lower in NWO compared to NWL, while sedentary time is not.
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Affiliation(s)
- Nadeeja N. Wijayatunga
- Department of Nutrition and Hospitality Management, University of Mississippi, University, MS 38677, USA
| | - Heontae Kim
- Institute of Child Nutrition, University of Mississippi, University, MS 38677, USA
| | - Harry M. Hays
- Department of Nutrition and Hospitality Management, University of Mississippi, University, MS 38677, USA
| | - Minsoo Kang
- Department of Health, Exercise Science and Recreation Management, University of Mississippi, University, MS 38677, USA
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Rakhmat II, Putra ICS, Wibowo A, Henrina J, Nugraha GI, Ghozali M, Syamsunarno MRAA, Pranata R, Akbar MR, Achmad TH. Cardiometabolic risk factors in adults with normal weight obesity: A systematic review and meta-analysis. Clin Obes 2022; 12:e12523. [PMID: 35412026 DOI: 10.1111/cob.12523] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 03/23/2022] [Accepted: 03/26/2022] [Indexed: 12/29/2022]
Abstract
Normal weight obesity (NWO) is a new emerging phenotype of obesity, defined as a normal body mass index with a high body fat percentage. While several studies have described the impact of NWO on cardiometabolic risk factors, the association between them remains uncertain. This meta-analysis systematically evaluated cardiometabolic risk factors in adults with NWO compared to adults with normal weight lean (NWL). A systematic literature search was performed from the inception until September 21, 2021 in order to comprehensively search for all observational studies that had three important variables, including adults (age ≥18 years old), NWO and cardiometabolic risk factors including metabolic syndrome, hypertension, diabetes mellitus, dyslipidaemia or all laboratory findings related to cardiometabolic risk factors. Twenty-four cross-sectional studies with a total of 75 201 subjects are included in the qualitative and quantitative analysis. Overall, older age and female sex are more likely in NWO population. Compared to NWL, NWO is significantly associated with cardiometabolic risk factors, including metabolic syndrome (OR = 2.24 [1.74, 2.89]; p < .001; I2 = 76%, Pheterogeneity < 0.001), hypertension (OR = 1.60[1.36, 1.89]; p < .001; I2 = 76%, Pheterogeneity < 0.001), diabetes mellitus (OR = 1.72[1.54, 1.92]; p < .001; I2 = 47%, Pheterogeneity < 0.001), dyslipidaemia (OR = 1.50 [1.03, 2.18]; p = .03; I2 = 94%, Pheterogeneity < 0.001) and other laboratory findings, except for C-reactive protein in both sexes group; and adiponectin levels in female group. Our meta-analysis showed that NWO was associated with cardiometabolic risk factors. Thus, the traditional definition of obesity using the BMI criteria should be challenged, as those with NWO might still be exposed to a heightened risk of cardiometabolic disorders. Nonetheless, further prospective cohort studies are needed better to understand this syndrome.
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Affiliation(s)
- Iis Inayati Rakhmat
- Department of Biochemistry, Faculty of Medicine, Jenderal Achmad Yani University, Kota Cimahi, Jawa Barat, Indonesia
| | - Iwan Cahyo Santosa Putra
- School of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia, Jakarta, Indonesia
| | - Arief Wibowo
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Padjadjaran University, Bandung, Indonesia
| | - Joshua Henrina
- School of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia, Jakarta, Indonesia
| | - Gaga Irawan Nugraha
- Department of Basic Medical Science, Faculty of Medicine, Padjajadran University, Bandung, Indonesia
| | - Mohammad Ghozali
- Department of Basic Medical Science, Faculty of Medicine, Padjajadran University, Bandung, Indonesia
| | - Mas Rizky A A Syamsunarno
- Department of Basic Medical Science, Faculty of Medicine, Padjajadran University, Bandung, Indonesia
| | - Raymond Pranata
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Padjadjaran University, Bandung, Indonesia
| | - Mohammad Rizki Akbar
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Padjadjaran University, Bandung, Indonesia
| | - Tri Hanggono Achmad
- Department of Basic Medical Science, Faculty of Medicine, Padjajadran University, Bandung, Indonesia
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Mohammadian Khonsari N, Khashayar P, Shahrestanaki E, Kelishadi R, Mohammadpoor Nami S, Heidari-Beni M, Esmaeili Abdar Z, Tabatabaei-Malazy O, Qorbani M. Normal Weight Obesity and Cardiometabolic Risk Factors: A Systematic Review and Meta-Analysis. Front Endocrinol (Lausanne) 2022; 13:857930. [PMID: 35399938 PMCID: PMC8987277 DOI: 10.3389/fendo.2022.857930] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 02/14/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Obesity is one of the most significant causes of morbidity and mortality worldwide. Current studies suggest a new type of obesity, normal weight obesity (NWO), which is defined as having a normal body mass index (BMI), but a high-fat percentage increases the risk of cardiometabolic risk factors (CMRFs). This systematic review and meta-analysis aimed to pool the association between NWO with CMRFs. METHODS A systematic search of the literature in all available electronic databases, including Scopus, Web of Science, EMBASE, and PubMed, was performed until October 2021. All English studies that assessed the association of NWOs [compared to normal weight non-obese (NWNO)] and the CMRFs were included. Two investigators extracted data and performed a quality assessment. The heterogeneity between studies was assessed with I-squared and Cochran's Q tests. Odds ratio (OR) was used as an effect size to pool the association of NWO with CMRFs. RESULTS Twenty-five articles that met the inclusion criteria entered the study. The total number of participants was 177,792, with an age range of 13 to 75 years. Most studies were conducted on the general population (adults) and were from China. The result of fixed-effect model meta-analysis indicated an increased odds of hyperglycemia (OR:1.50, 95%:1.23, 1.76), high TG (OR:1.90, 95% CH:1.44, 2.35), low HDL (OR: 1.28, 95% CI:1.06, 1.49) and diabetes (OR:1.39, 95% CI:1.30, 1.49). Moreover, the random effect meta-analysis showed that NWO increased the odds of dyslipidemia (OR:1.83, 95% CI:1.61, 20.4), HTN (OR:1.40, 95% CI:1.28, 1.51) and metabolic syndrome (OR:1.92, 95% CI:1.58, 2.26). Moreover, the mean of all CMRFs except plasma glucose in NWO subjects was statistically higher than NWNO subjects (p-value<0.05). CONCLUSION The present study showed that NWO increased the odds of CMRFs. These findings indicate the inadequacy of the BMI measurement and the need for body fat assessment for a better obesity risk assessment.
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Affiliation(s)
| | - Patricia Khashayar
- Center for Microsystems Technology, Imec & Ghent University, Zwijnaarde-Gent, Belgium
| | - Ehsan Shahrestanaki
- Social Determinants of Health Research Center, Alborz University of Medical Sciences, Karaj, Iran
| | - Roya Kelishadi
- Department of Pediatrics, Child Growth and Development Research Center, Research Institute for Primordial Prevention of Non-Communicable Disease, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Sahar Mohammadpoor Nami
- Non-Communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran
| | - Motahar Heidari-Beni
- Department of Nutrition, Child Growth and Development Research Center, Research Institute for Primordial Prevention of Non-Communicable Disease, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Zahra Esmaeili Abdar
- Non-Communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran
| | - Ozra Tabatabaei-Malazy
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
- *Correspondence: Mostafa Qorbani, ; Ozra Tabatabaei-Malazy,
| | - Mostafa Qorbani
- Non-Communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran
- *Correspondence: Mostafa Qorbani, ; Ozra Tabatabaei-Malazy,
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Normal weight obesity and unaddressed cardiometabolic health risk-a narrative review. Int J Obes (Lond) 2021; 45:2141-2155. [PMID: 34007010 DOI: 10.1038/s41366-021-00858-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 04/27/2021] [Accepted: 04/30/2021] [Indexed: 02/06/2023]
Abstract
Normal weight obesity (NWO) is defined as having a normal body mass index (BMI), but a high body fat mass. There is growing interest in individuals with NWO, which is an underdiagnosed and understudied group, because of their increased risk for cardiometabolic morbidity and mortality. In this review, we summarized the definition, prevalence, etiology, pathophysiology, and cardiovascular outcomes seen in NWO. We have also summarized the available literature on interventions for NWO. There is a wide variation in the body fat percent cutoffs used to diagnose excess body fat. Hence, the prevalence rates of NWO vary between different populations and studies. It is estimated that about 30 million Americans have NWO and the worldwide prevalence ranges from 4.5% to 22%. Genetics, diet, and physical activity are related to NWO. However, etiological factors are not clear. Changes in body composition, inflammation, oxidative stress are present in NWO in comparison to normal weight lean (NWL) who have a normal BMI and normal body fat amount. Furthermore, cardiometabolic changes are observed and some are subclinical. Thus, screening for NWO will enhance the primary prevention of cardiovascular disease. Due to the use of various body fat percent cutoffs and methods to measure body fat, it is challenging to compare between studies. Researchers working in this field should ideally work towards developing standard body fat percent cutoffs for diagnosing NWO. There are many gaps in the literature on NWO unlike for overt obesity and future studies should explore the etiology, molecular mechanisms, and adipose tissue changes of NWO as well as conduct well planned and executed randomized controlled trials testing dietary, physical, and behavioral interventions for NWO in both males and females of different racial and age groups.
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Bellissimo MP, Bettermann EL, Tran PH, Crain BH, Ferranti EP, Binongo JN, Hartman TJ, Jones DP, Ziegler TR, Alvarez JA. Physical Fitness but Not Diet Quality Distinguishes Lean and Normal Weight Obese Adults. J Acad Nutr Diet 2020; 120:1963-1973.e2. [PMID: 33011149 PMCID: PMC7686254 DOI: 10.1016/j.jand.2020.07.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 06/27/2020] [Accepted: 07/19/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Individuals with normal weight obesity (NWO) have increased cardiometabolic disease and mortality risk, but factors contributing to NWO development are unknown. OBJECTIVE The objective of this study was to determine whether diet quality scores and physical fitness levels differed between adults classified as lean, NWO, and overweight-obese. Secondary objectives of the study were to compare clinical biomarkers and food groups and macronutrient intakes between the three groups, and to test for associations between body composition components with diet quality scores and physical fitness levels. DESIGN This is a secondary data analysis from a cross-sectional study that included metropolitan university and health care system employees. Body composition was measured by dual energy x-ray absorptiometry. Individuals with a body mass index <25 kg/m2 and body fat >23% for men and >30% for women were classified as having NWO. Alternate Healthy Eating Index, Dietary Approaches to Stop Hypertension score, and Mediterranean Diet Score were calculated from Block food frequency questionnaires. Physical fitness was assessed by measuring maximal oxygen uptake (VO2 maximum) during treadmill testing. PARTICIPANTS/SETTING This study included 693 adults (65% women, mean age 48.9 ± 11.5 years) enrolled between 2007 and 2013 in Atlanta, GA. MAIN OUTCOME MEASURES The main outcome measures were Alternate Healthy Eating Index, Dietary Approaches to Stop Hypertension, and Mediterranean Diet Score diet quality scores and maximal oxygen uptake. STATISTICAL ANALYSES Multiple linear regression analyses with post hoc comparisons were used to investigate group differences in fitness, diet quality, and biomarkers. Regression analyses were also used to examine relationships between diet quality scores and fitness with body composition. RESULTS VO2 maximum was significantly lower in the NWO compared with the lean group (36.2 ± 0.8 mL/min/kg vs 40.2 ± 1.0 mL/min/kg; P < 0.05). Individuals with NWO reported similar diet quality to lean individuals and more favorable Alternate Healthy Eating Index and Dietary Approaches to Stop Hypertension scores than individuals with overweight-obesity (P < 0.05). Diet quality scores and physical fitness levels were inversely associated with percent body fat and visceral adipose tissue (P < 0.05), regardless of weight status. Individuals with NWO exhibited higher fasting blood insulin concentrations, insulin resistance, low-density lipoprotein cholesterol, and triglyceride levels, and significantly lower high-density lipoprotein cholesterol levels than lean individuals (P < 0.05). CONCLUSIONS Physical fitness was significantly decreased in individuals with NWO compared with lean individuals. Higher diet quality was associated with decreased total and visceral fat but did not distinguish individuals with NWO from lean individuals.
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Affiliation(s)
- Moriah P. Bellissimo
- Nutrition and Health Sciences Doctoral Program, Laney Graduate School, Emory University; Atlanta, GA, USA
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine; Atlanta, GA, USA
- Emory Center for Clinical and Molecular Nutrition, Emory University; Atlanta, GA, USA
| | - Erika L. Bettermann
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine; Atlanta, GA, USA
| | - Phong H. Tran
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine; Atlanta, GA, USA
| | - Benjamin H. Crain
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine; Atlanta, GA, USA
| | - Erin P. Ferranti
- Nell Hodgson School of Nursing, Emory University; Atlanta, GA, USA
| | - Jose N. Binongo
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University; Atlanta, GA, USA
| | - Terryl J. Hartman
- Department of Epidemiology, Rollins School of Public Health, Emory University; Atlanta, GA, USA
| | - Dean P. Jones
- Emory Center for Clinical and Molecular Nutrition, Emory University; Atlanta, GA, USA
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University School of Medicine; Atlanta, GA, USA
- Clinical Biomarkers Laboratory, Department of Medicine, Emory University School of Medicine; Atlanta, GA, USA
| | - Thomas R. Ziegler
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine; Atlanta, GA, USA
- Emory Center for Clinical and Molecular Nutrition, Emory University; Atlanta, GA, USA
- Section of Endocrinology, Atlanta Veterans Affairs Medical Center; Decatur, GA, USA
| | - Jessica A. Alvarez
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine; Atlanta, GA, USA
- Emory Center for Clinical and Molecular Nutrition, Emory University; Atlanta, GA, USA
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Correa-Rodríguez M, González-Ruíz K, Rincón-Pabón D, Izquierdo M, García-Hermoso A, Agostinis-Sobrinho C, Sánchez-Capacho N, Roa-Cubaque MA, Ramírez-Vélez R. Normal-Weight Obesity Is Associated with Increased Cardiometabolic Risk in Young Adults. Nutrients 2020; 12:E1106. [PMID: 32316150 PMCID: PMC7230158 DOI: 10.3390/nu12041106] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/03/2020] [Accepted: 04/03/2020] [Indexed: 12/11/2022] Open
Abstract
Normal-weight obesity (NWO) has been shown to be associated with cardiometabolic dysfunction. However, little is known regarding this potential relationship in early adulthood. The aim of this study was to investigate the associations between NWO and cardiometabolic risk factors in a large population of Colombian young adults. A cross-sectional study was conducted on 1354 subjects (61% women), aged from 18 to 30. Anthropometric data, including body mass index (BMI) and waist circumference (WC), were estimated, and the percentage of fat mass was measured through bioelectrical impedance analysis (BIA). Muscular fitness was determined by using a handgrip strength test and normalized grip strength (NGS = handgrip (kg)/body mass (kg)). A cardiometabolic risk Z-score was derived by assessing WC, triglycerides, high-density lipoprotein cholesterol (HDL-C) cholesterol, fasting glucose, and systolic blood pressure. NWO was defined by the combination of excess %BF (over 25.5% for men and 38.9% for women) and a BMI < 25 kg/m2. The overall prevalence of NWO was 29.1%. Subjects with NWO have an increased risk of cardiometabolic risk compared to the normal-weight lean group (OR = 3.10). Moreover, NWO was associated with an increased risk of presenting low HDL-C (OR = 2.34), high abdominal obesity (OR = 7.27), and low NGS (OR = 3.30), p < 0.001. There is a high prevalence of NWO in American Latin young adults and this condition is associated with an increased cardiovascular risk, high blood pressure, low HDL-C, high abdominal obesity, and low muscular strength early in life. Screening for adiposity in subjects with a normal BMI could help to identify young adults at a high risk of cardiometabolic abnormalities.
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Affiliation(s)
- María Correa-Rodríguez
- Faculty of Health, Department of Nursing, University of Granada, Av. Ilustración, 60, 18016 Granada, Spain;
| | - Katherine González-Ruíz
- Grupo de Ejercicio Físico y Deportes, Vicerrectoría de Investigaciones, Universidad Manuela Beltrán, Bogotá DC 110231, Colombia;
| | - David Rincón-Pabón
- ZIPATEFI (Zona de Investigaciones de Posgrados, Terapia Respiratoria y Fisioterapia de Areandina), Fundación Universitaria del Área Andina, Pereira 110231, Colombia;
| | - Mikel Izquierdo
- Department of Health Sciences, Public University of Navarra, Navarrabiomed- IdiSNA, Complejo Hospitalario de Navarra (CHN), 31008 Pamplona, Spain; (M.I.); (A.G.-H.)
- CIBER of Frailty and Healthy Aging (CIBERFES), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Antonio García-Hermoso
- Department of Health Sciences, Public University of Navarra, Navarrabiomed- IdiSNA, Complejo Hospitalario de Navarra (CHN), 31008 Pamplona, Spain; (M.I.); (A.G.-H.)
- Laboratorio de Ciencias de la Actividad Física, el Deporte y la Salud, Facultad de Ciencias Médicas, Universidad de Santiago de Chile, USACH, Santiago 7500618, Chile
| | | | - Nohora Sánchez-Capacho
- Facultad de Ciencias de la Salud- Universidad de Boyacá, Tunja 150003, Colombia; (N.S.-C.); (M.A.R.-C.)
| | | | - Robinson Ramírez-Vélez
- Department of Health Sciences, Public University of Navarra, Navarrabiomed- IdiSNA, Complejo Hospitalario de Navarra (CHN), 31008 Pamplona, Spain; (M.I.); (A.G.-H.)
- CIBER of Frailty and Healthy Aging (CIBERFES), Instituto de Salud Carlos III, 28029 Madrid, Spain
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Zegarra-Lizana PA, Ramos-Orosco EJ, Guarnizo-Poma M, Pantoja-Torres B, Paico-Palacios S, Del Carmen Ranilla-Seguin V, Lazaro-Alcantara H, Benites-Zapata VA. Relationship between body fat percentage and insulin resistance in adults with Bmi values below 25 Kg/M2 in a private clinic. Diabetes Metab Syndr 2019; 13:2855-2859. [PMID: 31425947 DOI: 10.1016/j.dsx.2019.07.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 07/23/2019] [Indexed: 12/19/2022]
Abstract
AIM To evaluate the association between elevated body fat percent (BF%) and the prevalence of insulin resistance (IR) in the adult population with body mass index (BMI) in the normal values. METHODS We carry out an analytical cross-sectional study. The participants attended outpatient from 2012 to 2016 in a private clinic in Lima-Peru between 18 and 60 years with a BMI between 19 and 24.9/Kg/m2. We defined elevated BF% if the values were greater than 25% in men and 30% in women and IR with a cut-off point of HOMA-IR based in the 75th percentile. We performed a generalized linear model from family Poisson (crude and adjusted) with robust standard errors to evaluate the association between BF% and the IR. We reported as association measure the prevalence ratio (PR) with their respective 95% confidence intervals (CI). RESULTS We included 284 participants, the average age was 33.77 ± 10.86 (SD) years and the percentage of women was 88.1%. The prevalence of elevated BF% was 71.13% and the prevalence of IR was 25%. We found an association between the elevated BF% and IR, PR = 3.17; 95% CI: 1.46-6.91. CONCLUSIONS Body fat percentage seems to be a good indicator of IR in patients with normal BMI and without endocrine comorbidities. Longitudinal prospective studies are recommended to corroborate our findings.
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Affiliation(s)
- Paolo A Zegarra-Lizana
- School of Medicine, Universidad Peruana de Ciencias Aplicadas, Lima, Peru; Sociedad Científica de Estudiantes de Medicina de la Universidad Peruana de Ciencias Aplicadas, Universidad Peruana de Ciencias Aplicadas, Lima, Peru.
| | - Elizabeth J Ramos-Orosco
- School of Medicine, Universidad Peruana de Ciencias Aplicadas, Lima, Peru; Sociedad Científica de Estudiantes de Medicina de la Universidad Peruana de Ciencias Aplicadas, Universidad Peruana de Ciencias Aplicadas, Lima, Peru.
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He H, Pan L, Liu F, Ma J, Hu Z, Wang L, Li Y, Shan G. Expanded normal weight obesity and blood pressure in Chinese adults: a community-based cross-sectional study. Aust J Prim Health 2019; 25:256-263. [PMID: 31196378 DOI: 10.1071/py18166] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 05/02/2019] [Indexed: 01/24/2023]
Abstract
The study aimed to explore the independent association between expanded normal weight obesity categories and blood pressure among adults aged 20-80 years in China. By cross-sectional design, a total of 4279 adults living in Shaanxi Province, China, were selected from communities via multi-stage stratified cluster sampling in 2014. Information on anthropometric, body composition and blood pressure was collected and analysed. Expanded normal weight obesity (ENWO) categories were used to identify the level of bodyweight based on the combination of body mass index (BMI) and body fat percentage (BFP) categories. The age- and sex-standardised prevalence of hypertension increased within ENWO groups, from 10.12% in the underweight-low body fat group to 45.92% in the obesity-high body fat group. In under or normal weight participants, body fat percentage was found independently associated with hypertension in men, with an adjusted odds ratio of 3.69 in the fourth quartile of BFP compared with the first one. However, this effect was not observed in women. BFP was independently associated with increased risk of hypertension, especially in men. People with normal BMI should be re-identified as a high-risk population based on BFP level when it comes to hypertension prevention in primary healthcare settings.
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Affiliation(s)
- Huijing He
- Department of Epidemiology and Statistics, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, Department of Epidemiology and Statistics, School of Basic Medicine, Peking Union Medical College, 5 Dongdansantiao, Dongcheng District, Beijing 100005, China
| | - Li Pan
- Department of Epidemiology and Statistics, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, Department of Epidemiology and Statistics, School of Basic Medicine, Peking Union Medical College, 5 Dongdansantiao, Dongcheng District, Beijing 100005, China
| | - Feng Liu
- Institute of Chronic Disease Control and Prevention, Shaanxi Provincial Center for Disease Control and Prevention, 3 Jiandong Street, Beilin District, Xi'an 710000, Shaanxi Province, China
| | - Jingang Ma
- Institute of Chronic Disease Control and Prevention, Shaanxi Provincial Center for Disease Control and Prevention, 3 Jiandong Street, Beilin District, Xi'an 710000, Shaanxi Province, China
| | - Zhiping Hu
- Institute of Chronic Disease Control and Prevention, Shaanxi Provincial Center for Disease Control and Prevention, 3 Jiandong Street, Beilin District, Xi'an 710000, Shaanxi Province, China
| | - Li Wang
- Department of Epidemiology and Statistics, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, Department of Epidemiology and Statistics, School of Basic Medicine, Peking Union Medical College, 5 Dongdansantiao, Dongcheng District, Beijing 100005, China
| | - Yajun Li
- Institute of Chronic Disease Control and Prevention, Shaanxi Provincial Center for Disease Control and Prevention, 3 Jiandong Street, Beilin District, Xi'an 710000, Shaanxi Province, China
| | - Guangliang Shan
- Department of Epidemiology and Statistics, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, Department of Epidemiology and Statistics, School of Basic Medicine, Peking Union Medical College, 5 Dongdansantiao, Dongcheng District, Beijing 100005, China; and Corresponding author
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9
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There is an association between body fat percentage and metabolic abnormality in normal weight subjects: Iranian large population. TRANSLATIONAL METABOLIC SYNDROME RESEARCH 2019. [DOI: 10.1016/j.tmsr.2019.08.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
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10
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Jia A, Xu S, Xing Y, Zhang W, Yu X, Zhao Y, Ming J, Ji Q. Prevalence and cardiometabolic risks of normal weight obesity in Chinese population: A nationwide study. Nutr Metab Cardiovasc Dis 2018; 28:1045-1053. [PMID: 30143410 DOI: 10.1016/j.numecd.2018.06.015] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 06/13/2018] [Accepted: 06/15/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND AIMS Several studies have reported increased cardiovascular risks in normal weight obesity (NWO) populations. We aimed to investigate the prevalence of NWO and its relationships with cardiometabolic risks in Chinese patients. METHODS AND RESULTS The data were from the 2007-2008 China National Diabetes and Metabolic Disorders Study. The body fat (BF) was measured using the biological impedance method. NWO was defined as a normal BMI (18.5-23.9 kg/m2) but with excess BF% (BF% ≥ 24% for men and ≥33% for women). 23,748 people (9633 males and 14,115 females) were enrolled and the prevalence of NWO was 9.5% for men, 6.06% for women. The prevalence risks of diabetes (odds ratio [OR]1.519, 95% confidence interval [CI] 1.262-1.828), Framingham risk score (FRS) ≥10% (OR 1.973, 95% CI 1.596-2.439), hypertension (OR 1.525, 95% CI 1.333-1.745), and metabolic syndrome Mets (OR 2.175, 95% CI 1.920-2.463) significantly increased in the NWO group compared with the normal group. Subgroup analyses showed that, after ruling out participants with abnormal waist circumference, the male group had similar findings to the overall population; but in the female group, the prevalence risks of FRS ≥10%, hypertension, and Mets increased, although the risk of diabetes did not. CONCLUSION NWO is in a relatively high prevalence in Chinese population, and the prevalence of NWO is higher in Chinese men compared to Chinese women. Cardiometabolic risks significantly increase in an NWO population, and such risks persist after excluding the effect of abdominal obesity.
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Affiliation(s)
- A Jia
- Department of Endocrinology, Xijing Hospital, Air Force Medical University, Xi'an, 710032, China; Department of Endocrinology, The First Hospital of Yulin, Yulin, 719000, China
| | - S Xu
- Department of Endocrinology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, 441021, China; Department of Health Statistics, Faculty of Preventive Medicine, Air Force Medical University, Xi'an, 710032, China
| | - Y Xing
- Department of Endocrinology, Xijing Hospital, Air Force Medical University, Xi'an, 710032, China
| | - W Zhang
- Department of Endocrinology, Xijing Hospital, Air Force Medical University, Xi'an, 710032, China
| | - X Yu
- Department of Endocrinology, Xijing Hospital, Air Force Medical University, Xi'an, 710032, China
| | - Y Zhao
- Department of Endocrinology, The First Hospital of Yulin, Yulin, 719000, China
| | - J Ming
- Department of Endocrinology, Xijing Hospital, Air Force Medical University, Xi'an, 710032, China.
| | - Q Ji
- Department of Endocrinology, Xijing Hospital, Air Force Medical University, Xi'an, 710032, China.
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11
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Do MH, Lee E, Oh MJ, Kim Y, Park HY. High-Glucose or -Fructose Diet Cause Changes of the Gut Microbiota and Metabolic Disorders in Mice without Body Weight Change. Nutrients 2018; 10:E761. [PMID: 29899272 PMCID: PMC6024874 DOI: 10.3390/nu10060761] [Citation(s) in RCA: 261] [Impact Index Per Article: 43.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 05/30/2018] [Accepted: 06/11/2018] [Indexed: 12/11/2022] Open
Abstract
High fat diet-induced changes in gut microbiota have been linked to intestinal permeability and metabolic endotoxemia, which is related to metabolic disorders. However, the influence of a high-glucose (HGD) or high-fructose (HFrD) diet on gut microbiota is largely unknown. We performed changes of gut microbiota in HGD- or HFrD-fed C57BL/6J mice by 16S rRNA analysis. Gut microbiota-derived endotoxin-induced metabolic disorders were evaluated by glucose and insulin tolerance test, gut permeability, Western blot and histological analysis. We found that the HGD and HFrD groups had comparatively higher blood glucose and endotoxin levels, fat mass, dyslipidemia, and glucose intolerance without changes in bodyweight. The HGD- and HFrD-fed mice lost gut microbial diversity, characterized by a lower proportion of Bacteroidetes and a markedly increased proportion of Proteobacteria. Moreover, the HGD and HFrD groups had increased gut permeability due to alterations to the tight junction proteins caused by gut inflammation. Hepatic inflammation and lipid accumulation were also markedly increased in the HGD and HFrD groups. High levels of glucose or fructose in the diet regulate the gut microbiota and increase intestinal permeability, which precedes the development of metabolic endotoxemia, inflammation, and lipid accumulation, ultimately leading to hepatic steatosis and normal-weight obesity.
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Affiliation(s)
- Moon Ho Do
- Research Division of Food Functionality, Korea Food Research Institute, Jeollabuk-do 55365, Korea.
| | - Eunjung Lee
- Research Division of Strategic Food Technology, Korea Food Research Institute, Jeollabuk-do 55365, Korea.
| | - Mi-Jin Oh
- Research Division of Food Functionality, Korea Food Research Institute, Jeollabuk-do 55365, Korea.
| | - Yoonsook Kim
- Research Division of Food Functionality, Korea Food Research Institute, Jeollabuk-do 55365, Korea.
| | - Ho-Young Park
- Research Division of Food Functionality, Korea Food Research Institute, Jeollabuk-do 55365, Korea.
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12
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Olafsdottir AS, Torfadottir JE, Arngrimsson SA. Health Behavior and Metabolic Risk Factors Associated with Normal Weight Obesity in Adolescents. PLoS One 2016; 11:e0161451. [PMID: 27560824 PMCID: PMC4999227 DOI: 10.1371/journal.pone.0161451] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Accepted: 08/06/2016] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE To explore health behaviors and metabolic risk factors in normal weight obese (NWO) adolescents compared with normal weight lean (NWL) peers. DESIGN AND METHODS A cross-sectional study of 18-year-old students (n = 182, 47% female) in the capital area of Iceland, with body mass index within normal range (BMI, 18.5-24.9 kg/m2). Body composition was estimated via dual energy X-ray absorptiometry, fitness was assessed with maximal oxygen uptake (VO2max) during treadmill test, dietary intake through 24-hour recall, questionnaires explained health behavior and fasting blood samples were taken. NWO was defined as normal BMI and body fat >17.6% in males and >31.6% in females. RESULTS Among normal weight adolescents, 42% (n = 76) were defined as NWO, thereof 61% (n = 46) male participants. Fewer participants with NWO were physically active, ate breakfast on a regular basis, and consumed vegetables frequently compared with NWL. No difference was detected between the two groups in energy- and nutrient intake. The mean difference in aerobic fitness was 5.1 ml/kg/min between the groups in favor of the NWL group (p<0.001). NWO was positively associated with having one or more risk factors for metabolic syndrome (Odds Ratio OR = 2.2; 95% confidence interval CI: 1.2, 3.9) when adjusted for sex. High waist circumference was more prevalent among NWO than NWL, but only among girls (13% vs 4%, p = 0.019). CONCLUSIONS High prevalence of NWO was observed in the study group. Promoting healthy lifestyle with regard to nutrition and physical activity in early life should be emphasized regardless of BMI.
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Affiliation(s)
- Anna S. Olafsdottir
- Research Center for Sport and Health Sciences, School of Education, University of Iceland, Reykjavik, Iceland
- * E-mail:
| | - Johanna E. Torfadottir
- Educational Research Institute, University of Iceland, Reykjavik, Iceland
- Unit for Nutrition Research, Faculty for Food Science and Nutrition, University of Iceland, Reykjavik, Iceland
| | - Sigurbjorn A. Arngrimsson
- Research Center for Sport and Health Sciences, School of Education, University of Iceland, Reykjavik, Iceland
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13
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Khazneh E, Hřibová P, Hošek J, Suchý P, Kollár P, Pražanová G, Muselík J, Hanaková Z, Václavík J, Miłek M, Legáth J, Šmejkal K. The Chemical Composition of Achillea wilhelmsii C. Koch and Its Desirable Effects on Hyperglycemia, Inflammatory Mediators and Hypercholesterolemia as Risk Factors for Cardiometabolic Disease. Molecules 2016; 21:404. [PMID: 27023504 PMCID: PMC6273470 DOI: 10.3390/molecules21040404] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 03/17/2016] [Accepted: 03/21/2016] [Indexed: 02/04/2023] Open
Abstract
This study was done to identify the content compounds of Achillea wilhelmsii (A. wilhelmsii) and to evaluate its hypoglycemic and anti-hypercholesterolemic activity and effect on inflammatory mediators. The extracts and fractions of A. wilhelmsii were thoroughly analyzed using high performance liquid chromatography (HPLC), and the total content of phenols and flavonoids was determined. The hypoglycemic activity was evaluated in vivo using alloxan-induced diabetic mice. The effect upon inflammatory mediators was evaluated in vitro using the human monocytic leukemia cell line (THP-1). The anti-hypercholesterolemic activity was evaluated in vitro using the 3-hydroxy-3-methylglutaryl-CoA (HMG-CoA) reductase assay kit. The water extract (WE)-treated group showed the highest reduction in the fasting blood glucose levels (FBGL). The chloroform fraction (CF) and ethyl acetate fraction (EAF) both showed a significant ability to reduce the secretion of tumor necrosis factor alpha (TNF-α). The EAF, however, also attenuated the levels of matrix metalloproteinase-2 (MMP-2) and matrix metalloproteinase-9 (MMP-9). The CF showed the most significant 3-hydroxy-3-methylglutaryl-CoA reductase (HMGR) inhibition activity. The five main compounds in the CF were isolated and identified. Out of the five compounds in the CF, 1β,10β-epoxydesacetoxymatricarin (CP1) and leucodin (CP2) showed the highest anti-hypercholesterolemic potential. A molecular docking study provided corresponding results.
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Affiliation(s)
- Elian Khazneh
- Department of Natural Drugs, Faculty of Pharmacy, University of Veterinary and Pharmaceutical Sciences, Palackého tř. 1, Brno 61242, Czech Republic.
| | - Petra Hřibová
- Department of Natural Drugs, Faculty of Pharmacy, University of Veterinary and Pharmaceutical Sciences, Palackého tř. 1, Brno 61242, Czech Republic.
| | - Jan Hošek
- Department of Molecular Biology and Pharmaceutical Biotechnology, Faculty of Pharmacy, University of Veterinary and Pharmaceutical Sciences, Palackého tř. 1, Brno 61242, Czech Republic.
| | - Pavel Suchý
- Department of Human Pharmacology and Toxicology, Faculty of Pharmacy, University of Veterinary and Pharmaceutical Sciences, Palackého tř. 1, Brno 61242, Czech Republic.
| | - Peter Kollár
- Department of Human Pharmacology and Toxicology, Faculty of Pharmacy, University of Veterinary and Pharmaceutical Sciences, Palackého tř. 1, Brno 61242, Czech Republic.
| | - Gabriela Pražanová
- Department of Human Pharmacology and Toxicology, Faculty of Pharmacy, University of Veterinary and Pharmaceutical Sciences, Palackého tř. 1, Brno 61242, Czech Republic.
| | - Jan Muselík
- Department of Pharmaceutics, Faculty of Pharmacy, University of Veterinary and Pharmaceutical Sciences, Palackého 1-3, Brno 61242, Czech Republic.
| | - Zuzana Hanaková
- Department of Natural Drugs, Faculty of Pharmacy, University of Veterinary and Pharmaceutical Sciences, Palackého tř. 1, Brno 61242, Czech Republic.
| | - Jiří Václavík
- Department of Natural Drugs, Faculty of Pharmacy, University of Veterinary and Pharmaceutical Sciences, Palackého tř. 1, Brno 61242, Czech Republic.
| | - Michał Miłek
- Department of Biotechnology and Bioinformatics, Faculty of Chemistry, Rzeszów University of Technology, Powstańców Warszawy 6, Rzeszów 35-959, Poland.
| | - Jaroslav Legáth
- Department of Biotechnology and Bioinformatics, Faculty of Chemistry, Rzeszów University of Technology, Powstańców Warszawy 6, Rzeszów 35-959, Poland.
- Department of Pharmacology and Toxicology, The University of Veterinary Medicine and Pharmacy in Košice, Komenského 73, Košice 04181, Slovakia.
| | - Karel Šmejkal
- Department of Natural Drugs, Faculty of Pharmacy, University of Veterinary and Pharmaceutical Sciences, Palackého tř. 1, Brno 61242, Czech Republic.
- Department of Molecular Biology and Pharmaceutical Biotechnology, Faculty of Pharmacy, University of Veterinary and Pharmaceutical Sciences, Palackého tř. 1, Brno 61242, Czech Republic.
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14
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Abbate R, Al-Daghri NM, Andreozzi P, Borregaard N, Can G, Caridi G, Carstensen-Kirberg M, Cioni G, Conte E, Cuomo R, Denis MA, Fakhfouri G, Fakhfouri G, Fiasse R, Glenthøj A, Goliasc G, Gremmel T, Herder C, Iemmolo M, Jing ZC, Krause R, Marrone O, Miazgowski B, Miazgowski T, Minchiotti L, Mousavizadeh K, Ndrepepa G, Niessner A, Ogayar Luque C, Onat A, Papassotiriou I, Ruiz Ortiz M, Sabico S, Schooling CM, Sakka SD, Sołtysiak P, Visseren FLJ, Wagner J, Wang XJ, Westerink J. Research update for articles published in EJCI in 2013. Eur J Clin Invest 2015; 45:1005-16. [PMID: 26394055 DOI: 10.1111/eci.12512] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 08/04/2015] [Indexed: 01/14/2023]
Affiliation(s)
- Rosanna Abbate
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Nasser M Al-Daghri
- Prince Mutaib Chair for Biomarkers of Osteoporosis, Biochemistry Department, College of Science, King Saud University, Riyadh, Saudi Arabia
| | - Paolo Andreozzi
- Department of Clinical Medicine and Surgery, 'Federico II' University, Naples, Italy
| | - Niels Borregaard
- The Granulocyte Research Laboratory, Department of Hematology, National University Hospital, Copenhagen, Denmark
| | - Günay Can
- Departments of Cardiology and Public Health, Cerrahpaşa Medical Faculty, University of Istanbul, Istanbul, Turkey
| | - Gianluca Caridi
- Laboratory on Pathophysiology of Uremia, Istituto Giannina Gaslini IRCCS, Genoa, Italy
| | - Maren Carstensen-Kirberg
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany.,German Center for Diabetes Research (DZD e.V.), Partner Düsseldorf, Düsseldorf, Germany
| | - Gabriele Cioni
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Enrico Conte
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Rosario Cuomo
- Department of Clinical Medicine and Surgery, 'Federico II' University, Naples, Italy
| | - Marie A Denis
- Department of Gastroenterology, St. Luc University Hospital, Brussels, Belgium
| | - Gohar Fakhfouri
- Department of Psychiatry and Neuroscience, Faculty of Medicine, Laval University, Québec City, QC, Canada
| | - G Fakhfouri
- Institut Universitaire en Santé Mentale de Québec, Québec City, QC, Canada
| | - Renné Fiasse
- Department of Gastroenterology, St. Luc University Hospital, Brussels, Belgium
| | - Andreas Glenthøj
- The Granulocyte Research Laboratory, Department of Hematology, National University Hospital, Copenhagen, Denmark
| | - Georg Goliasc
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Thomas Gremmel
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria.,Center for Platelet Research Studies, Division of Hematology/Oncology, Boston Children's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Christian Herder
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany.,German Center for Diabetes Research (DZD e.V.), Partner Düsseldorf, Düsseldorf, Germany
| | - Maria Iemmolo
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Zhi-Cheng Jing
- State Key Laboratory of Cardiovascular Disease, FuWai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Robert Krause
- Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Oreste Marrone
- Institute of Biomedicine and Molecular Immunology, National Research Council, Palermo, Italy
| | - Bartosz Miazgowski
- Department of Hypertension and Internal Medicine, Pomeranian Medical University, Szczecin, Poland
| | - Tomasz Miazgowski
- Department of Hypertension and Internal Medicine, Pomeranian Medical University, Szczecin, Poland
| | | | - Kazem Mousavizadeh
- Cellular and Molecular Research Center and Department of Molecular Medicine, Faculty of Advanced Technologies in Medicine, Iran University of Medical Sciences, Tehran, Iran
| | | | - Alexander Niessner
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | | | - Altan Onat
- Departments of Cardiology and Public Health, Cerrahpaşa Medical Faculty, University of Istanbul, Istanbul, Turkey
| | - Ioannis Papassotiriou
- Department of Clinical Biochemistry, "Aghia Sophia" Children's Hospital, Athens, Greece
| | - Martín Ruiz Ortiz
- Cardiology Department, Reina Sofía University Hospital, Córdoba, Spain
| | - Shaun Sabico
- Biomarkers Research Program, Biochemistry Department, College of Science, King Saud University, Riyadh, Saudi Arabia
| | - C Mary Schooling
- CUNY School of Public Health and Hunter College, New York, NY, USA
| | - Sophia D Sakka
- Department of Endocrinology and Diabetes, Birmingham Children's Hospital, Birmingham, UK
| | - P Sołtysiak
- Department of Hypertension and Internal Medicine, Pomeranian Medical University, Szczecin, Poland
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jasmin Wagner
- Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Xiao-Jian Wang
- State Key Laboratory of Cardiovascular Disease, FuWai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jan Westerink
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
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