The Cardiovascular and Metabolic Heterogeneity of Obesity: Clinical Challenges and Implications for Management

By I. Neeland, P. Poirier, J. Despres. Circulation, 2018

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The prevalence of obesity has increased globally over the last two decades. Although the body mass index (BMI) has been a convenient and simple index of obesity at the population level, studies have shown that obesity defined by BMI alone is a remarkably heterogeneous condition with varying cardiovascular (CV) and metabolic manifestations across individuals. Adipose tissue is an exquisitely active metabolic organ engaged in cross-talk between various systems; perturbation of which results in a pathologic response to positive caloric balance in susceptible individuals that directly and indirectly contributes to CV and metabolic disease. Inadequate subcutaneous adipose tissue expansion in the face of dietary triglycerides leads to visceral and ectopic fat deposition, inflammatory/adipokine dysregulation, and insulin resistance. Conversely, preferential fat storage in the lower body depot may act as a metabolic buffer and protect other tissues from lipotoxicity caused by lipid overflow and ectopic fat. Translational, epidemiologic, and clinical studies over the past 30 years have clearly demonstrated a strong link between visceral and ectopic fat and the development of a clinical syndrome characterized by atherogenic dyslipidemia, hyperinsulinemia/glucose intolerance, hypertension, atherosclerosis, and adverse cardiac remodeling/heart failure. This relationship is even more nuanced when clinical entities such as metabolically healthy obesity phenotype and the obesity paradox are considered. Although it is clear that the accumulation of visceral/ectopic fat is a major contributor to CV and metabolic risk above and beyond the BMI, implementation of fat distribution assessment into clinical practice remains a challenge. Anthropometric indices of obesity are easily implemented but newer imaging-based methods offer improved sensitivity and specificity for measuring specific depots. Lifestyle, pharmacologic, and surgical interventions allow a multidisciplinary approach to overweight/obesity that may improve outcomes and align with a public health message to combat the growing epidemic of obesity worldwide and build healthier lives, free of cardiovascular diseases.

Subfields: Cardiology and Cardiovascular Medicine, Physiology

View Paper: https://www.semanticscholar.org/paper/4e236175c68a1ad4e19a4be9c6d48a5437bbc3a2

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