Cardiovascular disease outcomes in metabolically healthy obesity in communities of Beijing cohort study

Risk of Cardiovascular Events in Metabolically Healthy Overweight or Obese Adults: Role of LDL-Cholesterol in the Stratification of Risk

The objective of this study was to investigate the longitudinal association of metabolically healthy overweight/obese adults with major adverse cardiovascular events (MACE) and the effect of LDL-cholesterol levels on this association. This study was conducted with 15,904 participants from the URRAH study grouped according to BMI and metabolic status. Healthy metabolic status was identified with and without including LDL-cholesterol. The risk of MACE during 11.8 years of follow-up was evaluated with multivariable Cox regressions. Among the participants aged <70 years, high BMI was associated with an increased risk of MACE, whereas among the older subjects it was associated with lower risk. Compared to the group with normal weight/healthy metabolic status, the metabolically healthy participants aged <70 years who were overweight/obese had an increased risk of MACE with an adjusted hazard ratio of 3.81 (95% CI, 1.34-10.85, p = 0.012). However, when LDL-cholesterol < 130 mg/dL was included in the definition of healthy metabolic status, no increase in risk was found in the overweight/obese adults compared to the normal weight individuals (hazard ratio 0.70 (0.07-6.71, p = 0.75). The present data show that the risk of MACE is increased in metabolically healthy overweight/obese individuals identified according to standard criteria. However, when LDL-cholesterol is included in the definition, metabolically healthy individuals who are overweight/obese have no increase in risk.

A Bayesian Network Analysis of the Probabilistic Relationships Between Various Obesity Phenotypes and Cardiovascular Disease Risk in Chinese Adults: Chinese Population-Based Observational Study

BACKGROUND

Cardiovascular disease (CVD) risk among individuals with different BMI levels might depend on their metabolic health. The extent to which metabolic health status and BMI affect CVD risk, either directly or through a mediator, in the Chinese population remains unclear.

OBJECTIVE

In this study, the Bayesian network (BN) perspective is adopted to characterize the multivariable probabilistic connections between CVD risk and metabolic health and obesity status and identify potential factors that influence these relationships among Chinese adults.

METHODS

The study population comprised 6276 Chinese adults aged 30 to 74 years who participated in the China Health and Nutrition Survey 2009. BMI was used to categorize participants as normal weight, overweight, or obese, and metabolic health was defined by the Adult Treatment Panel-3 criteria. Participants were categorized into 6 phenotypes according to their metabolic health and BMI categorization. The 10-year risk of CVD was determined using the Framingham Risk Score. BN modeling was used to identify the network structure of the variables and compute the conditional probability of CVD risk for the different metabolic obesity phenotypes with the given structure.

RESULTS

Of 6276 participants, 64.67% (n=4059), 20.37% (n=1279), and 14.95% (n=938) had a low, moderate, and high 10-year CVD risk. An averaged BN with a stable network structure was constructed by learning 300 bootstrapped networks from the data. Using BN reasoning, the conditional probability of high CVD risk increased as age progressed. The conditional probability of high CVD risk was 0.43% (95% CI 0.2%-0.87%) for the 30 to 40 years age group, 2.25% (95% CI 1.75%-2.88%) for the 40 to 50 years age group, 16.13% (95% CI 14.86%-17.5%) for the 50 to 60 years age group, and 52.02% (95% CI 47.62%-56.38%) for those aged ≥70 years. When metabolic health and BMI categories were instantiated to their different statuses, the conditional probability of high CVD risk increased from 7.01% (95% CI 6.27%-7.83%) for participants who were metabolically healthy normal weight to 10.47% (95% CI 7.63%-14.18%) for their metabolically healthy obese (MHO) counterparts and up to 21.74% and 34.48% among participants who were metabolically unhealthy normal weight and metabolically unhealthy obese (MUO), respectively. Sex was a significant modifier of the conditional probability distribution of metabolic obesity phenotypes and high CVD risk, with a conditional probability of high CVD risk of only 2.02% and 22.7% among MHO and MUO women, respectively, compared with 21.92% and 48.21% for their male MHO and MUO counterparts, respectively.

CONCLUSIONS

BN modeling was applied to investigate the relationship between CVD risk and metabolic health and obesity phenotypes in Chinese adults. The results suggest that both metabolic health and obesity status are important for CVD prevention; closer attention should be paid to BMI and metabolic status changes over time.

Comparison of the Incidence of Cardiovascular Diseases in Weight Groups with Healthy and Unhealthy Metabolism

BACKGROUND

We aimed to identify the relationship between metabolically healthy obesity (MHO), a special subtype of obesity, and the incidence of cardiovascular disease (CVD) in rural Xinjiang.

METHODS

Body mass index (BMI) and the Joint Interim Statement criteria were utilized to define obesity and metabolic status, respectively. A baseline survey was conducted between 2010 and 2012. The cohort was followed-up until 2017, including 5059 participants (2953 Uyghurs and 2106 Kazakhs) in the analysis.

RESULTS

During 6.78 years of follow-up, 471 individuals developed CVD, 10.8% (n=545) of whom were obese, and the prevalence of MHO and MHNW was 5.2% and 54.5%, respectively. Compared with metabolically healthy normal weight subjects, the subjects with MHO had an increased risk of CVD (hazard ratio [HR]=1.76, 95% confidence interval [CI]: 1.23-2.51), while the metabolically unhealthy obesity (MUO) group had an even higher risk (HR=3.80, 95% CI: 2.87-5.03). Additionally, there were sex differences in the relationship between BMI-metabolic status and incident CVD (P _interaction =0.027). Compared with the subjects with MHO, those with MUO had an increased risk of CVD (HR=1.84, 95% CI: 1.26-2.71).

CONCLUSION

MHO was associated with a high risk of CVD among adults in rural Xinjiang. In each BMI category, metabolically unhealthy subjects had a higher risk of developing CVD than did metabolically healthy subjects.

Metabolically healthy obesity, transition to unhealthy metabolic status, and vascular disease in Chinese adults: A cohort study

BACKGROUND

Metabolically healthy obesity (MHO) and its transition to unhealthy metabolic status have been associated with risk of cardiovascular disease (CVD) in Western populations. However, it is unclear to what extent metabolic health changes over time and whether such transition affects risks of subtypes of CVD in Chinese adults. We aimed to examine the association of metabolic health status and its transition with risks of subtypes of vascular disease across body mass index (BMI) categories.

METHODS AND FINDINGS

The China Kadoorie Biobank was conducted during 25 June 2004 to 15 July 2008 in 5 urban (Harbin, Qingdao, Suzhou, Liuzhou, and Haikou) and 5 rural (Henan, Gansu, Sichuan, Zhejiang, and Hunan) regions across China. BMI and metabolic health information were collected. We classified participants into BMI categories: normal weight (BMI 18.5-23.9 kg/m²), overweight (BMI 24.0-27.9 kg/m²), and obese (BMI ≥ 28 kg/m²). Metabolic health was defined as meeting less than 2 of the following 4 criteria (elevated waist circumference, hypertension, elevated plasma glucose level, and dyslipidemia). The changes in obesity and metabolic health status were defined from baseline to the second resurvey with combination of overweight and obesity. Among the 458,246 participants with complete information and no history of CVD and cancer, the mean age at baseline was 50.9 (SD 10.4) years, and 40.8% were men, and 29.0% were current smokers. During a median 10.0 years of follow-up, 52,251 major vascular events (MVEs), including 7,326 major coronary events (MCEs), 37,992 ischemic heart disease (IHD), and 42,951 strokes were recorded. Compared with metabolically healthy normal weight (MHN), baseline MHO was associated with higher hazard ratios (HRs) for all types of CVD; however, almost 40% of those participants transitioned to metabolically unhealthy status. Stable metabolically unhealthy overweight or obesity (MUOO) (HR 2.22, 95% confidence interval [CI] 2.00-2.47, p < 0.001) and transition from metabolically healthy to unhealthy status (HR 1.53, 1.34-1.75, p < 0.001) were associated with higher risk for MVE, compared with stable healthy normal weight. Similar patterns were observed for MCE, IHD, and stroke. Limitations of the analysis included lack of measurement of lipid components, fasting plasma glucose, and visceral fat, and there might be possible misclassification.

CONCLUSIONS

Among Chinese adults, MHO individuals have increased risks of MVE. Obesity remains a risk factor for CVD independent of major metabolic factors. Our data further suggest that metabolic health is a transient state for a large proportion of Chinese adults, with the highest vascular risk among those remained MUOO.

The Relationship between Metabolically Healthy Obesity and the Risk of Cardiovascular Disease: A Systematic Review and Meta-Analysis

Cardiovascular disease (CVD) risk in individuals with metabolically healthy obesity (MHO) is unclear. We searched databases from inception to May 2019. Data were pooled using a random effects model. Newcastle-Ottawa Scale assessment was performed. Primary and secondary outcomes were CVD risk and all-cause mortality. Forty-three studies involving 4,822,205 cases were included. The median percentage of females, age and duration of follow-up was 52%, 49.9 years and 10.6 years, respectively. The mean Newcastle-Ottawa Scale score of the articles was 7.9 ± 1.0. Compared to individuals with a metabolically healthy normal weight, individuals with MHO had higher adjusted risk of CVD and all-cause mortality. We identified a significant linear dose-response relationship between body mass index (BMI) and CVD risk among metabolically healthy individuals (p < 0.001); every unit increase in BMI increased the CVD risk. Multivariate meta-regression analysis showed that an increased proportion of women and age resulted in the risk of CVD affected by MHO reduction (p = 0.014, p = 0.030, respectively). Age and sex explained the observed heterogeneity and reported the adjusted R². MHO resulted in a significantly increased risk for CVD; therefore, long-term weight loss should be encouraged.

Testing, Testing. 1, 2, 3. Is This Mic On?

This issue of the International Journal of Clinical Practice includes 4 articles regarding testing in medicine. Our Associate Editor for Cardiovascular Disease Prevention and Metabolic Diseases, Anthony Wierzbicki, together with Timothy Reynolds, start us off with a thoughtful extended editorial/perspective with the title (translated) "first, do no harm.". This article is protected by copyright. All rights reserved.