Healthy Weight and Obesity Prevention: JACC Health Promotion Series

Age-specific modifiable risk factor profiles for cardiovascular disease and all-cause mortality: a nationwide, population-based, prospective cohort study

Background

National investigations on age-specific modifiable risk factor profiles for cardiovascular disease (CVD) and mortality are scarce in China, the country that is experiencing a huge cardiometabolic burden exacerbated by population ageing.

Methods

This is a nationwide prospective cohort study of 193,846 adults in the China Cardiometabolic Disease and Cancer Cohort Study, 2011-2016. Among 139,925 participants free from CVD at baseline, we examined hazard ratios and population-attributable risk percentages (PAR%s) for CVD and all-cause mortality attributable to 12 modifiable socioeconomic, psychosocial, lifestyle, and metabolic risk factors by four age groups (40-<55 years, 55-<65 years, 65-<75 years, and ≥75 years).

Findings

Metabolic risk factors accounted for 52·4%, 47·2%, and 37·8% of the PAR% for CVD events in participants aged 40-<55 years, 55-<65 years, and 65-<75 years, respectively, with hypertension being the largest risk factor. While in participants aged ≥75 years, lifestyle risk factors contributed to 34·0% of the PAR% for CVD, with inappropriate sleep duration being the predominant risk factor. Most deaths were attributed to metabolic risk factors (PAR% 25·3%) and lifestyle risk factors (PAR% 24·6%) in participants aged 40-<55 years, with unhealthy diet and diabetes being the main risk factors. While in participants aged ≥55 years, most deaths were attributed to lifestyle risk factors (PAR% 26·6%-41·0%) and socioeconomic and psychosocial risk factors (PAR% 26·1%-27·7%). In participants aged ≥75 years, lifestyle risk factors accounted for 41·0% of the PAR% for mortality, with inappropriate sleep duration being the leading risk factor.

Interpretation

We identified age-specific modifiable risk profiles for CVD and all-cause mortality in Chinese adults, with remarkable differences between adults aged ≥75 years and their younger counterparts.

Funding

National Natural Science Foundation of China.

Obesity and Its Impact on Adverse In-Hospital Outcomes in Hospitalized Patients With COVID-19

BACKGROUND

An increasing level of evidence suggests that obesity not only is a major risk factor for cardiovascular diseases (CVDs) but also has adverse outcomes during COVID-19 infection.

METHODS

We used the German nationwide inpatient sample to analyze all hospitalized patients with confirmed COVID-19 diagnosis in Germany from January to December 2020 and stratified them for diagnosed obesity. Obesity was defined as body mass index ≥30 kg/m² according to the WHO. The impact of obesity on in-hospital case fatality and adverse in-hospital events comprising major adverse cardiovascular and cerebrovascular events (MACCE), acute respiratory distress syndrome (ARDS), venous thromboembolism (VTE), and others was analyzed.

RESULTS

We analyzed data of 176,137 hospitalizations of patients with confirmed COVID-19 infection; among them, 9,383 (5.3%) had an additional obesity diagnosis. Although COVID-19 patients without obesity were older (72.0 [interquartile range (IQR) 56.0/82.0] vs. 66.0 [54.0/76.0] years, p < 0.001), the CVD profile was less favorable in obese COVID-19 patients (Charlson comorbidity index 4.44 ± 3.01 vs. 4.08 ± 2.92, p < 0.001). Obesity was independently associated with increased in-hospital case fatality (OR 1.203 [95% CI 1.131-1.279], p < 0.001) and MACCE (OR 1.168 [95% CI 1.101-1.239], p < 0.001), ARDS (OR 2.605 [95% CI 2.449-2.772], p < 0.001), and VTE (OR 1.780 [95% CI 1.605-1.973], p < 0.001) and also associated with increased necessity of treatment on intensive care unit (OR 2.201 [95% CI 2.097-2.310], p < 0.001), mechanical ventilation (OR 2.277 [95% CI 2.140-2.422], p < 0.001), and extracorporeal membrane oxygenation (OR 3.485 [95% CI 3.023-4.017], p < 0.001).

CONCLUSIONS

Obesity independently affected case fatality, MACCE, ARDS development, VTE, and other adverse in-hospital events in patients with COVID-19 infection. Obesity should be taken into account regarding COVID-19 prevention strategies, risk stratification, and adequate healthcare planning. Maintaining a healthy weight is important not only to prevent cardiometabolic diseases but also for better individual outcomes during COVID-19 infection.

Clinical and school-based intervention strategies for youth obesity prevention: A systematic review

Introduction

In the last couple of decades, numerous intervention strategies (ISs) have been formulated in school/community or clinical sectors using physical activity (PA) in order to prevent youth obesity because they have been highly effective in addressing this issue. These two sectors have revealed some interesting information in terms of efficient results and best practice mechanisms, but comparisons between them to learn about their functioning have been rare.

Methods

Therefore, the aim of this systematic review was to analyze and synthesize PA ISs from school/community or clinical domains for the period 2013-2017, in French or English, targeting youths aged 5-19 years old through primary, secondary, and tertiary prevention.

Results

In total, 68 full articles were reserved for data extraction and synthesis and 617 were excluded because they did not meet eligibility criteria (61 of 68 were kept for the final analysis). The results identified a number of differences between the studies of the various IS sectors and also a third type of IS, mixed sector. Mixed ISs (clinical and school-community) have a special advantage because they can benefit from the strengths of both school/community-based and clinical-based ISs. Mixed ISs showed the most promising results. This review also highlighted the differences between sectors and their ISs in terms of intervention teams, prevention objectives, duration, materials, and efficiency.

Conclusion

Future studies should focus on establishing a prevention program in a given geographical area involving all stakeholders with their respective skills/knowledge, in the area of decision-making and in the development of ISs, to ensure that the program is the most efficient and best adapted to its environment.

Factors Associated with Severity of Acute Kidney Injury and Adverse Outcomes in Critically Ill Patients with COVID-19

BACKGROUND

Acute kidney injury (AKI) is a well-recognized complication of coronavirus disease 2019 (COVID-19). The short and long-term outcomes of patients who develop AKI have not been well characterized.

METHODS

In this multicenter retrospective cohort study, we describe the clinical characteristics and outcomes of critically ill adults with severe COVID-19 and AKI. Patient-level variables were extracted from the electronic medical record. Using nadir-to-peak serum creatinine, AKI was defined using the KDIGO definition. Multivariable logistic regression analyses examined factors associated with development of moderate-to-severe (stage 2-3) AKI, severe (stage-3) AKI, and the composite of renal replacement therapy (RRT) or in-hospital death.

RESULTS

Among 459 critically ill adults with COVID-19, 371 (80.1%) developed AKI, with 179 (37.9%) developing stage-3 AKI. Male gender, black and Asian/Native American race, lower baseline estimated glomerular filtration rate (eGFR), higher body mass index (BMI), and higher Acute Physiology and Chronic Health Evaluation (APACHE) IV score were more prevalent among patients with severe AKI, as were systemic markers of inflammation. On multivariable analysis, male gender, black and Asian/Native American race, higher APACHE IV score, lower baseline eGFR, and higher BMI (mainly the highest BMI stratum ≥35 kg/m2) were independently associated with higher stages of AKI severity. Male gender, lower baseline eGFR, and higher APACHE IV score were also independently associated with the composite of RRT or in-hospital death. Moderate-to-severe AKI and severe AKI were independently associated with in-hospital death, and there was a significant interaction between BMI and moderate-to-severe AKI for the outcome of in-hospital death. Among 83 (18.1%) patients who required RRT, 27 (32.5%) survived, and 12 (44.4%) remained dialysis-dependent at discharge. At 3 and 6 months, 5 (41.7%) and 4 (33.3%) remained dialysis-dependent, respectively.

CONCLUSIONS

AKI is common in critically ill adults with COVID-19. Several patient-level risk factors are associated with higher stages of AKI severity. BMI might be an effect modifier of AKI severity for in-hospital death. Among AKI survivors, there is a high rate of short- and long-term dialysis dependence.

Effect of childhood phthalates exposure on the risk of overweight and obesity: A nested case-control study in China

BACKGROUND

There was growing interest in endocrine disrupting chemicals that might have effect on the obesity epidemic, but few studies on the association of phthalates (PAEs) with childhood overweight and obesity in China based on longitudinal cohort study were available, which was the purpose of the present study.

METHODS

A nested case-control study was conducted in a prospective cohort of 2298 children aged 7-13 years from October 2017 to October 2020 with five waves visits in Xiamen city, China. A total of 829 children remained in the first wave of follow up with collection of urine for measuring seven PAEs metabolites, including mono-methyl phthalate (MMP), mono-ethyl phthalate (MEP), mono-n-butyl phthalate (MBP), mono-iso-butyl phthalate (MiBP), mono-2-ethylhexyl phthalate (MEHP), mono-2-ethyl-5-oxohexyl phthalate (MEOHP) and mono-2-ethyl-5-hydroxyhexyl phthalate (MEHHP), utilizing ultra high performance liquid chromatography-triple quadrupole mass spectrometry. Overweight and obesity, defined by WHO classifications, were allocated to the cases group, and those of all normal weight and matched cases with normal weight in each wave of follow-up as two control groups. Logistic regression models after adjusting for confounders were utilized to analyze the effect of PAEs on overweight and obesity in children with divided four groups based on the quartile distribution of each and total PAEs concentration.

RESULTS

The detection rates of children for each PAEs metabolite were 99.4% for MMP, 99.4% for MEP, 99.8% for MBP, 54.5% for MEHP, 84.4% for MEOHP, 99.9% for MEHHP, and 97.2% for MiBP. The geometric mean of concentrations of PAEs, MMP, MEP, MBP, MEHP, MEHHP, and MiBP were 310.085, 34.658, 9.127, 166.347, 7.043, 3.400, 18.571, and 24.093 (ng/ml), respectively. The total PAEs and seven metabolites concentrations were positively associated with childhood BMI Z-Scores with statistically significant slope rates and correlation coefficients, and were higher in the cases group than those in two controls groups in each wave of follow-up. The PAEs concentrations in the cases group was 5.90 (95 %CI: 5.79, 6.01) ng/ml in the first wave of survey, which was higher than those normal controls group (5.68 (95 %CI: 5.61, 5.75) ng/ml, P < 0.001) and matched controls group (5.72 (95 %CI: 5.61, 5.84) ng/ml, P = 0.018). The prevalence and ORs of overweight and obesity increased with quartile group of each and total PAEs concentrations accompanying a dose-response relationship. Compared with the quartile1 reference group with lowest total PAEs concentrations, the ORs of overweight and obesity in quartile2, quartile3 and quartile4 group increased gradually and reached at 1.20 (0.74-1.95), 1.49 (0.93-2.38) and 2.22 (1.41-3.48), respectively (P_trend < 0.001). The strength of the associations between PAEs and overweight and obesity was sex-specific in children.

DISCUSSION

Children in China were extensively exposed to PAEs, and the exposure to PAEs during childhood could significantly increase the risk of overweight and obesity with a dose-response relationship, particularly in girls. While limiting the exposure of PAEs products, the determination of exposure limit of plasticizer should be further strengthened.

Association between obesity grade and the age of the first acute coronary syndrome: A cross-sectional observational study

BACKGROUND

The study evaluates how obesity grade is associated with age during the first acute coronary syndrome (ACS) and examines the effect of cardiovascular (CV) risk factors and the age of first ACS in patients with severe obesity.

METHODS

We enrolled consecutive patients diagnosed with first episode of ACS between 2014 and 2019, and categorized them by body mass indices (BMI). Severe obesity was defined as BMI ≥35 kg/m². Independent variables affecting the age of first ACS were examined by linear regression analysis.

RESULTS

A total of 1005 patients (mean age, 57.5 ± 12.3 years; 19.3% female) were included. Approximately 6% and 12% of obese patients and normal weight patients had no other risk factors. Patients with ACS with severe obesity were younger than those with ACS in the grade-I obesity, overweight, and normal-weight groups (52.8 ± 9.9 vs. 55.3 ± 10.9, 56.8 ± 11.4, and 61.4 ± 14.2, respectively, p < 0.001). BMI had a strong, inverse linear relationship with earlier age of first ACS. The number of patients with no risk factors was significantly high in normal-weight individuals compared with patients with severe obesity (11.6% vs 5.6%, p = 0.037). After adjusting for CV risk factors, patients with overweight, grade-I obesity, and severe obesity may experience first ACS sooner than those with normal-weight by 3.9, 6.1, and 7.7 years, respectively (p < 0.001). However, males and females with severe obesity without CV risk factors experienced the first ACS episode 16 and 22 years later than those with the highest number of risk factors, respectively.

CONCLUSION

Patients with severe obesity experience first ACS episode 7.7 years earlier than those with normal-weight. Absence of CV risk factors in people with obesity can improve the potential negative effect of obesity on the ACS age.

TRIAL REGISTRATION

NCT04578964, 08 October 2020.

Synergistic Assessment of Mortality Risk According to Body Mass Index and Exercise Ability and Capacity in Patients Referred for Radionuclide Stress Testing

OBJECTIVE

To determine the interrelationship between body mass index (BMI), mode of stress testing (exercise or pharmacological), exercise capacity, and all-cause mortality in patients referred for stress-rest single photon emission computed tomography myocardial perfusion imaging.

PATIENTS AND METHODS

We evaluated all-cause mortality in 21,638 patients undergoing stress-rest single photon emission computed tomography myocardial perfusion imaging between January 2, 1991, and December 31, 2012. Patients were divided into exercise and pharmacologically tested groups and 9 BMI categories. The median follow-up was 12.8 years (range, 5.0-26.8 years).

RESULTS

In exercise patients, mortality was increased with both low and high BMI vs patients with a normal referent BMI of 22.5 to 24.9 kg/m². In pharmacologically tested patients, only low BMI, but not high BMI, was associated with increased mortality vs normal BMI. When exercise and pharmacologically tested groups were compared directly, pharmacologically tested patients manifested a marked increase in mortality risk vs exercise patients within each BMI category, ranging from an approximately 4-fold increase in mortality in those with normal or high BMI to a 12.3-fold increase in those with low BMI values. Similar findings were observed in a cohort of 4804 exercise and 4804 pharmacologically tested patients matched to have similar age and coronary artery disease risk factor profiles. In exercise patients, further risk stratification was achieved when considering both BMI and metabolic equivalent tasks of achieved exercise.

CONCLUSION

The combined assessment of BMI and exercise ability and capacity provides synergistic and marked risk stratification of future mortality risk in patients referred for radionuclide stress testing, providing considerable insights into the "obesity paradox" that is observed in populations referred for stress testing.

Obesity phenotypes and their relationships with atrial fibrillation

Background

This study assessed the associations of metabolic obesity phenotypes with the risk of atrial fibrillation (Afib).

Methods

This prospective cohort study categorized Taiwanese adults according to their body mass index (BMI) and metabolic health status at baseline. We assigned the participants to the underweight (BMI < 18.5 kg/m²), normal weight (BMI = 18.5-23.9 kg/m²), and overweight/obesity groups (BMI ≥ 24 kg/m²). Metabolically healthy was defined as absence of hypertension, diabetes, and hyperlipidemia and the presence of healthy metabolic profiles.

Results

In total, 5,742 adults were included. During a median follow-up of 13.7 years, 148 patients developed Afib. Compared to the metabolically healthy normal weight group, the risk of Afib was significantly higher than those in the metabolically unhealthy overweight/obesity (hazard ratio = 2.20, 95% confidence interval [1.12-4.33]) and metabolically unhealthy normal weight groups (HR = 2.64, 95% CI [1.34-5.17]). Additionally, the point estimate suggested a 1.97-fold greater risk among the metabolically healthy overweight/obesity group, although this difference was not significant given the wide confidence interval (HR = 1.97, 95% CI [0.80-4.86]).

Conclusion

Our results demonstrated the relationships of metabolic health and weight regarding the risk of Afib in Taiwanese adults. The Afib risk among metabolic and obesity phenotypes is associated with a metabolically unhealthy status. A trend toward a higher Afib risk with obesity among metabolically healthy subjects was observed. However, the result was not robust and it still suggested further study.

Myocardial Geometry and Dysfunction in Morbidly Obese Adolescents (BMI 35-40 kg/m2)

This study evaluated the preclinical effect of obesity on the ventricular remodeling in adolescents with morbid obesity, and determined if subjects labelled as metabolically healthy obesity (MHO) presented better heart index than those with metabolically unhealthy obesity (MUO). Prospective case-control research of 45 adolescents (14-year-old) with morbid obesity and 25 normal weight adolescents' gender- and age-matched with Tanner stage 4-5. Left ventricle (LV) was evaluated by conventional Doppler echocardiography, tissue Doppler imaging and two-dimensional speckle tracking echocardiography. Compared to normal-weight subjects, adolescents with morbid obesity presented a high percentage of pathological LV geometry (87%; p<0.01), and systolic and diastolic dysfunctions only detected by E/A ratio (2.0 vs 1.7, p<0.01), global longitudinal strain (-21.0% vs -16.5%, p<0.01), and early diastolic strain rate (3.2 vs 2.2, p<0.01). A correlation was found between impaired cardiac index and body mass index (BMI), high blood pressure, hyperglycemia, low HDL-cholesterol and hypertriglyceridemia. BMI and HDL-cholesterol were the most significant independent variables. No significant differences were found in structural and functional cardiac index when MHO and MUO subjects were compared (global longitudinal strain: -17.0% vs -16.4%, p0.79). Morbidly obese adolescents have an abnormal LV geometry, closely related to BMI, and systolic and diastolic LV dysfunctions. Adolescents labelled as MHO, despite exhibiting better BMI and insulin-resistance values, present the same pathological heart changes as MUO.

Reduction of Major Adverse Cardiovascular Events (MACE) after Bariatric Surgery in Patients with Obesity and Cardiovascular Diseases: A Systematic Review and Meta-Analysis

Cardiovascular diseases (CVDs) are the leading cause of death worldwide and obesity is a major risk factor that increases the morbidity and mortality of CVDs. Lifestyle modifications (e.g., diet control, physical exercise and behavioral changes) have been the first-line managements of obesity for decades. Nonetheless, when such interventions fail, pharmacotherapies and bariatric surgery are considered. Interestingly, a sudden weight loss (e.g., due to bariatric surgery) could also increase mortality. Thus, it remains unclear whether the bariatric surgery-associated weight reduction in patients with obesity and CVDs is beneficial for the reduction of Major Adverse Cardiovascular Events (MACE). Here, we performed a systematic literature search and meta-analysis of published studies comparing MACE in patients with obesity and CVDs who underwent bariatric surgery with control patients (no surgery). Eleven studies, with a total of 1,772,305 patients, which consisted of 74,042 patients who underwent any form of bariatric surgery and 1,698,263 patients with no surgery, were included in the systematic review. Next, the studies' data, including odds ratio (OR) and adjusted hazard ratio (aHR), were pooled and analyzed in a meta-analysis using a random effect model. The meta-analysis of ten studies showed that the bariatric surgery group had significantly lower odds of MACE as compared to no surgery (OR = 0.49; 95% CI 0.40-0.60; p < 0.00001; I² = 93%) and the adjustment to confounding variables in nine studies revealed consistent results (aHR = 0.57; 95% CI 0.49-0.66; p < 0.00001; I² = 73%), suggesting the benefit of bariatric surgery in reducing the occurrence of MACE in patients with obesity and CVDs (PROSPERO ID: CRD42021274343).

Normal weight obesity and unaddressed cardiometabolic health risk-a narrative review

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.

Novel insights on the role of spexin as a biomarker of obesity and related cardiometabolic disease

Spexin (SPX) is a 14-amino acid neuropeptide, discovered recently using bioinformatic techniques. It is encoded by the Ch12:orf39 gene that is widely expressed in different body tissues/organs across species, and secreted into systemic circulation. Recent reports have highlighted a potentially important regulatory role of SPX in obesity and related comorbidities. SPX is also ubiquitously expressed in human tissues, including white adipose tissue. The circulating concentration of SPX is significantly lower in individuals with obesity compared to normal weight counterparts. SPX's role in obesity appears to be related to various factors, such as the regulation of energy expenditure, appetite, and eating behaviors, increasing locomotion, and inhibiting long-chain fatty acid uptake into adipocytes. Recent reports have also suggested SPX's relationship with novel biomarkers of cardiovascular disease (CVD) and glucose metabolism and evoked the potential role of SPX as a key biomarker/player in the early loss of cardiometabolic health and development of CVD and diabetes later in life. Data on age-related changes in SPX and SPX's response to various interventions are also emerging. The current review focuses on the role of SPX in obesity and related comorbidities across the life span, and its response to interventions in these conditions. It is expected that this article will provide new ideas for future research on SPX and its metabolic regulation, particularly related to cardiometabolic diseases.

Gender Difference in the Relationship Between Pulse Pressure and Visceral Adiposity Index in Korean Adults

Background: This study was conducted to assess the association of pulse pressure (PP) and visceral adiposity index (VAI) by gender in Korean adults. Methods: This study used the data of 4960 adults at age ≥20 years, from the 2015 Korean National Health and Nutrition Examination Survey. Results: In the overall population (n = 4960), after adjustment for related variables and with quartile 1 of VAI as a reference, the odds ratios of high PP (PP >60 mmHg) was significantly higher in quartile 3 [1.32 (95% confidence interval [CI], 1.02-1.71)] and quartile 4 of VAI [1.40 (95% CI, 1.07-1.83)]. In women (n = 2784), the OR of high PP, with quartile 1 of VAI as a reference, was significantly higher in quartile 3 [2.36 (95% CI, 1.55-3.61)] and quartile 4 of VAI [2.70 (95% CI, 1.77-4.12)]. In men (n = 2176), high PP was not associated with the quartiles of VAI. In addition, after adjustment for related variables, the PP level was positively associated with the quartiles of VAI in the overall population (P < 0.001) and women (P < 0.001), but not in men (P = 0.316). Conclusions: VAI was positively associated with PP in Korean women, but not in Korean men.

Melatonin ameliorates endocrine dysfunction and defective sperm integrity associated with high-fat diet-induced obesity in male Wistar rats

Obesity (OBS) has been established as a link to male hypogonadism with consequent infertility. Previous studies have shown that melatonin (MEL) modulates hypothalamic-pituitary-gonadal function. The present study therefore investigated the hypothesis that MEL supplementation would attenuate spermatogenic and steroidogenic dysfunctions associated with obesity induced by high-fat diet (HFD). Twenty-four adult male Wistar rats (n = 6/group) were used: control group received vehicle (normal saline), obese group received 40% high-fat diet and distilled water, MEL-treated group received MEL (4 mg/kg), and OBS + MEL group received MEL and 40% HFD and the treatment lasted for 12 weeks. HFD caused increased body weight, glucose intolerance, plasma triglyceride and low-density lipoprotein cholesterol/ very low-density lipoprotein cholesterol and malondialdehyde, as well as decreased antioxidant capacity, high-density lipoprotein cholesterol, gonadotrophin-releasing hormone, follicle-stimulating hormone and testosterone and altered sperm parameters. However, all these alterations were attenuated when supplemented with MEL. Taken together, these results indicate that HFD exposure causes endocrine dysfunction and disrupted sperm parameters in obese animals, which are accompanied by lipid peroxidation/defective antioxidant capacity. In addition, the present results suggest that melatonin supplementation restores endocrine function and sperm integrity in obese rat model by suppression of oxidative stress-dependent mechanism.

Metabolic Health, Obesity, and Renal Function: 2013-2018 National Health and Nutrition Examination Surveys

Rising rates of metabolic syndrome, obesity, and mortality from chronic kidney disease (CKD) have prompted further investigation into the association between metabolic phenotypes and CKD. Purpose: To report the frequency of strictly defined metabolic phenotypes, renal function within each phenotype, and individual risk factors associated with reduced renal function. We utilized the 2013-2018 National Health and Nutrition Examination Surveys (NHANES) and complex survey sample weighting techniques to represent 220 million non-institutionalized U.S. civilians. Metabolic health was defined as having zero of the risk factors defined by the National Cholesterol Education Program with the exception of obesity, which was defined as BMI ≥ 30 kg/m2 in non-Asians and BMI ≥ 25 kg/m2 in Asians. The metabolically healthy normal (MUN) phenotype comprised the highest proportion of the population (38.40%), whereas the metabolically healthy obese (MHO) was the smallest (5.59%). Compared to the MHN reference group, renal function was lowest in the strictly defined MUN (B = -9.60, p < 0.001) and highest in the MHO (B = 2.50, p > 0.05), and this persisted when an increased number of risk factors were used to define metabolic syndrome. Systolic blood pressure had the strongest correlation with overall eGFR (r = -0.25, p < 0.001), and individuals with low HDL had higher renal function compared to the overall sample. The MUN phenotype had the greatest association with poor renal function. While the MHO had higher renal function, this may be due to a transient state caused by renal hyperfiltration. Further research should be done to investigate the association between dyslipidemia and CKD.

Medical and Surgical Obesity Treatments and Atherosclerosis: Mechanisms beyond Typical Risk Factors

PURPOSE OF REVIEW

This study aims to discuss the mechanisms by which GLP-1 agonists and bariatric surgery improve cardiovascular outcomes in severely obese patients.

RECENT FINDINGS

Recent studies have demonstrated that both GLP-1 agonist use and bariatric surgery reduce adverse cardiovascular outcomes. Improvements in traditional atherosclerosis risk factors in association with weight loss likely contribute, but weight loss-independent mechanisms are also suggested to have roles. We review the clinical and preclinical evidence base for cardiovascular benefit of LP-1 agonists and bariatric surgery beyond traditional risk factors, including improvements in endothelial function, direct impacts on atherosclerotic plaques, and anti-inflammatory effects.

Efficacy of dapagliflozin in heart failure with reduced ejection fraction according to body mass index

Aims

In heart failure with reduced ejection fraction (HFrEF), there is an ‘obesity paradox’, where survival is better in patients with a higher body mass index (BMI) and weight loss is associated with worse outcomes. We examined the effect of a sodium–glucose co‐transporter 2 inhibitor according to baseline BMI in the Dapagliflozin And Prevention of Adverse‐outcomes in Heart Failure trial (DAPA‐HF).

Methods and results

Body mass index was examined using standard categories, i.e. underweight (<18.5 kg/m²); normal weight (18.5–24.9 kg/m²); overweight (25.0–29.9 kg/m²); obesity class I (30.0–34.9 kg/m²); obesity class II (35.0–39.9 kg/m²); and obesity class III (≥40 kg/m²). The primary outcome in DAPA‐HF was the composite of worsening heart failure or cardiovascular death. Overall, 1348 patients (28.4%) were under/normal‐weight, 1722 (36.3%) overweight, 1013 (21.4%) obesity class I and 659 (13.9%) obesity class II/III. The unadjusted hazard ratio (95% confidence interval) for the primary outcome with obesity class 1, the lowest risk group, as reference was: under/normal‐weight 1.41 (1.16–1.71), overweight 1.18 (0.97–1.42), obesity class II/III 1.37 (1.10–1.72). Patients with class I obesity were also at lowest risk of death. The effect of dapagliflozin on the primary outcome and other outcomes did not vary by baseline BMI, e.g. hazard ratio for primary outcome: under/normal‐weight 0.74 (0.58–0.94), overweight 0.81 (0.65–1.02), obesity class I 0.68 (0.50–0.92), obesity class II/III 0.71 (0.51–1.00) (P‐value for interaction = 0.79). The mean decrease in weight at 8 months with dapagliflozin was 0.9 (0.7–1.1) kg (P < 0.001).

Conclusion

We confirmed an ‘obesity survival paradox’ in HFrEF. We showed that dapagliflozin was beneficial across the wide range of BMI studied.

Clinical Trial Registration: ClinicalTrials.gov NCT03036124.

Impact of Body Composition Indices on Ten-year Mortality After Revascularization of Complex Coronary Artery Disease (From the Syntax Extended Survival Trial)

Numerous studies have demonstrated a paradoxical association between higher baseline body mass index (BMI) and lower long-term mortality risk after coronary revascularization, known as the "obesity paradox", possibly relying on the single use of BMI. The current study is a post-hoc analysis of the SYNTAX Extended Survival (SYNTAXES) trial, which is the extended follow-up of the SYNTAX trial comparing percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) in patients with left-main coronary artery disease (LMCAD) or three-vessel disease (3VD). Patients were stratified according to baseline BMI and/or waist circumference (WC). Out of 1,800 patients, 1,799 (99.9%) and 1,587 (88.2%) had available baseline BMI and WC data, respectively. Of those, 1,327 (73.8%) patients had High BMI (≥25 kg/m²), whereas 705 (44.4%) patients had High WC (>102 cm for men or >88 cm for women). When stratified by both BMI and WC, 10-year mortality risk was significantly higher in patients with Low BMI/Low WC (adjusted hazard ratio [HR]: 1.65; 95% confidence interval [CI]: 1.09 to 2.51), Low BMI/ High WC (adjusted HR: 2.74; 95% CI: 1.12 to 6.69), or High BMI/High WC (adjusted HR: 1.59; 95% CI: 1.11 to 2.27) compared to those with High BMI/Low WC. In conclusion, the "obesity paradox" following coronary revascularization would be driven by low long-term mortality risk of the High BMI/Low WC group. Body composition should be assessed by the combination of BMI and WC in the appropriate evaluation of the long-term risk of obesity in patients with LMCAD or 3VD.

Health-related behaviors and health insurance status among US adults: Findings from the 2017 behavioral risk factor surveillance system

Health insurance coverage has increased overtime in the US. This study examined the associations between health insurance status and adoption of health-related behaviors among US adults. Using data collected through the 2017 Behavioral Risk Factor Surveillance System on health insurance coverage and type of insurance, we examined four health-related behaviors (i.e., no tobacco use, nondrinking or moderate drinking, meeting aerobic physical activity recommendations, and having a healthy body weight) and their associations with health insurance status. We conducted log-linear regression analyses to assess the associations with adjustment for potential confounders. Results showed the percentages of adults who reported no tobacco use or meeting physical activity recommendations were significantly higher, and the percentages of adults with a healthy body weight were significantly lower among those who were insured versus uninsured, or among adults with private insurance versus uninsured. Adults with health insurance also had a higher prevalence of reporting all 4 health-related behaviors than those uninsured. These patterns persisted after multivariable adjustment for potential confounders including sociodemographics, routine checkup, and number of chronic diseases. Adults with public insurance were 7% more likely to report no tobacco use than adults who were uninsured. Additionally, adults with private insurance were 8% and 7% more likely to report no tobacco use and meeting physical activity recommendations, respectively, but 10% less likely to report nondrinking or moderate drinking than adults with public insurance. In conclusion, we found significant associations existed between having health insurance coverage and engaging in some health-related behaviors among US adults.

Interactions of hypertension, obesity, left ventricular hypertrophy, and heart failure

PURPOSE OF REVIEW

Hypertension (HTN) and obesity are major risk factors for cardiac remodeling and dysfunction, leading to left ventricular hypertrophy (LVH) and heart failure (HF). In this review, we discuss the complex mechanisms and effects of HTN and obesity, and their treatments in LVH, ventricular function, and HF.

RECENT FINDINGS

Obesity and HTN impact the heart through overlapping neurohormonal pathways. However, the relationship between obesity and cardiomyopathy is more complex, and additional metabolic and hemodynamic pathways seem to contribute to cardiac dysfunction in these patients. Weight loss and blood pressure (BP) control help to prevent and reverse at least some of the damage caused by obesity and HTN even beyond what would be expected from solely the hemodynamic changes.

SUMMARY

Obesity and HTN cause maladaptive changes in the heart that can lead to LVH and HF. Weight loss and BP control help to, at least partially, reverse some of these changes and improve clinical outcomes in patients with HF.

Obesity prevalence in large US cities: association with socioeconomic indicators, race/ethnicity and physical activity

BACKGROUND

Obesity has a complex association with socioeconomic factors. Further clarification of this association could guide population interventions.

METHODS

To determine the relationship between obesity prevalence, socioeconomic indicators, race/ethnicity, and physical activity, we performed a cross-sectional, multivariable linear regression, with data from large US cities participating in the Big Cities Health Inventory.

RESULTS

Increased household income was significantly associated with decreased obesity prevalence, for White (-1.97% per 10 000USD), and Black (-3.02% per 10 000USD) populations, but not Hispanic. These associations remained significant when controlling for the proportion of the population meeting physical activity guidelines. Educational attainment had a co-linear relationship with income, and only a bachelor's degree or higher was associated with a lower prevalence of obesity in White (-0.30% per percentage) and Black (-0.69% per percentage) populations. No association was found between obesity prevalence and the proportion of the population meeting physical activity guidelines for any race/ethnicity grouping.

CONCLUSION

At the population level of large US cities, obesity prevalence is inversely associated with median household income in White and Black populations. Strategies to increase socioeconomic status may also decrease obesity. Targeting attainment of physical activity guidelines as an obesity intervention needs further appraisal.

Body mass index and severity/fatality from coronavirus disease 2019: A nationwide epidemiological study in Korea

OBJECTIVE

Obesity has been reported as a risk factor for severe coronavirus disease 2019 (COVID-19) in recent studies. However, the relationship between body mass index (BMI) and COVID-19 severity and fatality are unclear.

RESEARCH DESIGN AND METHODS

This study included 4,141 COVID-19 patients who were released from isolation or had died as of April 30, 2020. This nationwide data was provided by the Korean Centers for Disease Control and Prevention Agency. BMI was categorized as follows; < 18.5 kg/m2, 18.5-22.9 kg/m2, 23.0-24.9 kg/m2, 25.0-29.9 kg/m2, and ≥ 30 kg/m2. We defined a fatal illness if the patient had died.

RESULTS

Among participants, those with a BMI of 18.5-22.9 kg/m2 were the most common (42.0%), followed by 25.0-29.9 kg/m2 (24.4%), 23.0-24.9 kg/m2 (24.3%), ≥ 30 kg/m2 (4.7%), and < 18.5 kg/m2 (4.6%). In addition, 1,654 (41.2%) were men and 3.04% were fatalities. Multivariable analysis showed that age, male sex, BMI < 18.5 kg/m2, BMI ≥ 25 kg/m2, diabetes mellitus, chronic kidney disease, cancer, and dementia were independent risk factors for fatal illness. In particular, BMI < 18.5 kg/m2 (odds ratio [OR] 3.97, 95% CI 1.77-8.92), 25.0-29.9 kg/m2 (2.43, 1.32-4.47), and ≥ 30 kg/m2 (4.32, 1.37-13.61) were found to have higher ORs than the BMI of 23.0-24.9 kg/m2 (reference). There was no significant difference between those with a BMI of 18.5-22.9 kg/m2 (1.59, 0.88-2.89) and 23.0-24.9 kg/m2.

CONCLUSIONS

This study demonstrated a non-linear (U-shaped) relationship between BMI and fatal illness. Subjects with a BMI of < 18.5 kg/m2 and those with a BMI ≥ 25 kg/m2 had a high risk of fatal illness. Maintaining a healthy weight is important not only to prevent chronic cardiometabolic diseases, but also to improve the outcome of COVID-19.

Analysis of probable lipotoxic damage and myocardial fibrosis in epicardial obesity

Myocardial fibrosis is considered a key pathological process in the development of cardiovascular diseases. In epicardial obesity (EO), the main cause of fibrosis development is lipotoxic myocardial damage. It is important to detect myocardial fibrosis at an early stage, using non-invasive diagnostic methods. According to the results of echocardiography (ECG), 110 men with general obesity were divided into the following two groups: Group I with epicardial fat thickness (tEAT) ≥ 7 mm (n = 70) and Group II with tEAT < 7 mm (n = 40) without diastolic dysfunction. The levels of metabolic factors, pro-inflammatory cytokines, adipokines, and free fatty acids (FFA), profibrotic markers were determined in both groups. In Group I, the level of interleukin (IL)-6, C-reactive protein, and tumor necrosis factor (TNF)-α increased and that of leptin and adiponectin decreased compared with those in Group II. There was an increase in the level of all studied profibrotic factors in Group I. The level of TNF-α and IL-6 showed a positive correlation with the level of leptin and FFA and a negative correlation with the level of adiponectin. We also observed a relationship between the level of collagen, transforming growth factor (TGF)-β, and metalloproteinase (MMP)-3 and EO. Our results showed that confirmed EO correlates with not only disadipocytosis and increased levels of pro-inflammatory cytokines, but also increased levels of profibrotic factors. This suggests that the studied markers of fibrosis may be used to determine preclinical cardiac fibrosis with lipotoxic myocardial damage in patients with EO.

Distinct whole-blood transcriptome profile of children with metabolic healthy overweight/obesity compared to metabolic unhealthy overweight/obesity

BACKGROUND

Youth populations with overweight/obesity (OW/OB) exhibit heterogeneity in cardiometabolic health phenotypes. The underlying mechanisms for those differences are still unclear. This study aimed to analyze the whole-blood transcriptome profile (RNA-seq) of children with metabolic healthy overweight/obesity (MHO) and metabolic unhealthy overweight/obesity (MUO) phenotypes.

METHODS

Twenty-seven children with OW/OB (10.1 ± 1.3 years, 59% boys) from the ActiveBrains project were included. MHO was defined as having none of the following criteria for metabolic syndrome: elevated fasting glucose, high serum triglycerides, low high-density lipoprotein-cholesterol, and high systolic or diastolic blood pressure, while MUO was defined as presenting one or more of these criteria. Inflammatory markers were additionally determined. Total blood RNA was analyzed by 5'-end RNA-sequencing.

RESULTS

Whole-blood transcriptome analysis revealed a distinct pattern of gene expression in children with MHO compared to MUO children. Thirty-two genes differentially expressed were linked to metabolism, mitochondrial, and immune functions.

CONCLUSIONS

The identified gene expression patterns related to metabolism, mitochondrial, and immune functions contribute to a better understanding of why a subset of the population remains metabolically healthy despite having overweight/obesity.

IMPACT

A distinct pattern of whole-blood transcriptome profile (RNA-seq) was identified in children with metabolic healthy overweight/obesity (MHO) compared to metabolic unhealthy overweight/obesity (MUO) phenotype. The most relevant genes in understanding the molecular basis underlying the MHO/MUO phenotypes in children could be: RREB1, FAM83E, SLC44A1, NRG1, TMC5, CYP3A5, TRIM11, and ADAMTSL2. The identified whole-blood transcriptome profile related to metabolism, mitochondrial, and immune functions contribute to a better understanding of why a subset of the population remains metabolically healthy despite having overweight/obesity.

The impact of weight loss related to risk of new-onset atrial fibrillation in patients with type 2 diabetes mellitus treated with sodium-glucose cotransporter 2 inhibitor

Background

Sodium–glucose cotransporter 2 inhibitor (SGLT2i) use reduces body weight (BW) in patients with type 2 diabetes mellitus (T2DM). Obesity and T2DM are strong risk factors of new-onset atrial fibrillation (AF). However, whether BW loss following SGLT2i treatment reduces AF risk in patients with T2DM remains unclear.

Methods

We used a medical database from a multicenter health care provider in Taiwan, which included 10,237 patients with T2DM, from June 1, 2016 to December 31, 2018, whose BW data at baseline and at 12 weeks of SGLT2i treatment were available. Patients were followed up from the drug index date until the occurrence of new-onset AF, discontinuation of the SGLT2i, or the end of the study period, whichever occurred first.

Results

The patients’ baseline body mass index (BMI) was 28.08 \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\pm$$\end{document}± 4.88 kg/m². SGLT2i treatment was associated with a BW loss of 1.35 \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\pm$$\end{document}± 3.28 kg (1.78%\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\pm$$\end{document}± 4.47%). There were 37.4%, 47.0%, and 15.6% of patients experienced no-BW loss (n = 3832), BW loss 0.0–4.9% (n = 4814), and \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\ge$$\end{document}≥ 5.0% (n = 1591) following SGLT2i treatment, respectively. Compared with patients with baseline BMI < 23 kg/m², AF risk significantly increased in patients with baseline BMI \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\ge$$\end{document}≥ 27.5 kg/m² (P for trend = 0.015). Compared with those without BW loss after SGLT2i treatment, AF risk significantly decreased with a BW loss of \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\ge$$\end{document}≥ 5.0% (adjusted hazard ratios [95% confidence intervals]: 0.39[0.22–0.68]). Use of diuretics, old age, high-dose SGLT2i, higher estimated glomerular filtration rate, and baseline BMI were independent factors associated with a BW loss of \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\ge$$\end{document}≥ 5.0% following SGLT2i initiation. By contrast, neither baseline BMI nor BW loss after SGLT2i treatment predicted major cardiovascular adverse events or heart failure hospitalization risk (P for trend > 0.05).

Conclusion

BW loss of ≥ 5.0% following SGLT2i treatment was associated with a lower risk of new-onset AF in patients with T2DM in real-world practice.

Long-term body mass index changes in overweight and obese adults and the risk of heart failure, cardiovascular disease and mortality: a cohort study of over 260,000 adults in the UK

Background

Although obesity is a well-recognised risk factor for cardiovascular disease (CVD), the impact of long-term body mass index (BMI) changes in overweight or obese adults, on the risk of heart failure, CVD and mortality has not been quantified.

Methods

This population-based cohort study used routine UK primary care electronic health data linked to secondary care and death-registry records. We identified adults who were overweight or obese, free from CVD and who had repeated BMI measures. Using group-based trajectory modelling, we examined the BMI trajectories of these individuals and then determined incidence rates of CVD, heart failure and mortality associated with the different trajectories. Cox-proportional hazards regression determined hazards ratios for incident outcomes.

Results

264,230 individuals (mean age 49.5 years (SD 12.7) and mean BMI 33.8 kg/m² (SD 6.1)) were followed-up for a median duration of 10.9 years. Four BMI trajectories were identified, corresponding at baseline, with World Health Organisation BMI classifications for overweight, class-1, class-2 and class-3 obesity respectively. In all four groups, there was a small, stable upwards trajectory in BMI (mean BMI increase of 1.06 kg/m² (± 3.8)). Compared with overweight individuals, class-3 obese individuals had hazards ratios (HR) of 3.26 (95% CI 2.98–3.57) for heart failure, HR of 2.72 (2.58–2.87) for all-cause mortality and HR of 3.31 (2.84–3.86) for CVD-related mortality, after adjusting for baseline demographic and cardiovascular risk factors.

Conclusion

The majority of adults who are overweight or obese retain their degree of overweight or obesity over the long term. Individuals with stable severe obesity experience the worst heart failure, CVD and mortality outcomes. These findings highlight the high cardiovascular toll exacted by continuing failure to tackle obesity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10606-1.

Association of Metabolic Phenotypes With Coronary Artery Disease and Cardiovascular Events in Patients With Stable Chest Pain

OBJECTIVE

Obesity and metabolic syndrome are associated with major adverse cardiovascular events (MACE). However, whether distinct metabolic phenotypes differ in risk for coronary artery disease (CAD) and MACE is unknown. We sought to determine the association of distinct metabolic phenotypes with CAD and MACE.

RESEARCH DESIGN AND METHODS

We included patients from the Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE) who underwent coronary computed tomography (CT) angiography. Obesity was defined as a BMI ≥30 kg/m2 and metabolically healthy as less than or equal to one metabolic syndrome component except diabetes, distinguishing four metabolic phenotypes: metabolically healthy/unhealthy and nonobese/obese (MHN, MHO, MUN, and MUO). Differences in severe calcification (coronary artery calcification [CAC] ≥400), severe CAD (≥70% stenosis), high-risk plaque (HRP), and MACE were assessed using adjusted logistic and Cox regression models.

RESULTS

Of 4,381 patients (48.4% male, 60.5 ± 8.1 years of age), 49.4% were metabolically healthy (30.7% MHN and 18.7% MHO) and 50.6% unhealthy (22.3% MUN and 28.4% MUO). MHO had similar coronary CT findings as compared with MHN (severe CAC/CAD and HRP; P > 0.36 for all). Among metabolically unhealthy patients, those with obesity had similar CT findings as compared with nonobese (P > 0.10 for all). However, both MUN and MUO had unfavorable CAD characteristics as compared with MHN (P ≤ 0.017 for all). A total of 130 events occurred during follow-up (median 26 months). Compared with MHN, MUN (hazard ratio [HR] 1.61 [95% CI 1.02-2.53]) but not MHO (HR 1.06 [0.62-1.82]) or MUO (HR 1.06 [0.66-1.72]) had higher risk for MACE.

CONCLUSIONS

In patients with stable chest pain, four metabolic phenotypes exhibit distinctly different CAD characteristics and risk for MACE. Individuals who are metabolically unhealthy despite not being obese were at highest risk in our cohort.

Longitudinal Associations of Fitness and Obesity in Young Adulthood With Right Ventricular Function and Pulmonary Artery Systolic Pressure in Middle Age: The CARDIA Study

Background Low cardiorespiratory fitness (CRF) and obesity are risk factors for heart failure but their associations with right ventricular (RV) systolic function and pulmonary artery systolic pressure (PASP) are not well understood. Methods and Results Participants in the CARDIA (Coronary Artery Risk Development in Young Adults) study who underwent maximal treadmill testing at baseline and had a follow-up echocardiographic examination at year 25 were included. A subset of participants had repeat CRF and body mass index (BMI) assessment at year 20. The associations of baseline and changes in CRF and BMI on follow-up (baseline to year 20) with RV systolic function parameters (tricuspid annular plane systolic excursion, RV Doppler systolic velocity of the lateral tricuspid annulus), and PASP were assessed using multivariable-adjusted linear regression models. The study included 3433 participants. In adjusted analysis, higher baseline BMI but not CRF was significantly associated with higher PASP. Among RV systolic function parameters, higher baseline CRF and BMI were significantly associated with higher tricuspid annular plane systolic excursion and RV systolic velocity of the lateral tricuspid annulus. In the subgroup of participants with follow-up assessment of CRF or BMI at year 20, less decline in CRF was associated with higher RV systolic velocity of the lateral tricuspid annulus and lower PASP, while greater increase in BMI was significantly associated with higher PASP in middle age. Conclusions Higher CRF in young adulthood and less decline in CRF over time are each significantly associated with better RV systolic function. Higher baseline BMI and greater age-related increases in BMI are each significantly associated with higher PASP in middle age. These findings provide insights into possible mechanisms through which low fitness and obesity may contribute toward risk of heart failure.

Cardiovascular Risk Factors in Childhood and Left Ventricular Diastolic Function in Adulthood

BACKGROUND AND OBJECTIVES

Cardiovascular risk factors, such as obesity, blood pressure, and physical inactivity, have been identified as modifiable determinants of left ventricular (LV) diastolic function in adulthood. However, the links between childhood cardiovascular risk factor burden and adulthood LV diastolic function are unknown. To address this lack of knowledge, we aimed to identify childhood risk factors associated with LV diastolic function in the participants of the Cardiovascular Risk in Young Finns Study.

METHODS

Study participants (N = 1871; 45.9% men; aged 34-49 years) were examined repeatedly between the years 1980 and 2011. We determined the cumulative risk exposure in childhood (age 6-18 years) as the area under the curve for systolic blood pressure, adiposity (defined by using skinfold and waist circumference measurements), physical activity, serum insulin, triglycerides, total cholesterol, and high- and low-density lipoprotein cholesterols. Adulthood LV diastolic function was defined by using E/é ratio.

RESULTS

Elevated systolic blood pressure and increased adiposity in childhood were associated with worse adulthood LV diastolic function, whereas higher physical activity level in childhood was associated with better adulthood LV diastolic function (P < .001 for all). The associations of childhood adiposity and physical activity with adulthood LV diastolic function remained significant (both P < .05) but were diluted when the analyses were adjusted for adulthood systolic blood pressure, adiposity, and physical activity. The association between childhood systolic blood pressure and adult LV diastolic function was diluted to nonsignificant (P = .56).

CONCLUSIONS

Adiposity status and the level of physical activity in childhood are independently associated with LV diastolic function in adulthood.

From NAFLD to MAFLD: Implications of a Premature Change in Terminology

Despite the substantial gains in our understanding of NAFLD/NASH over the past 2 decades, there has been some dissatisfaction with the terminology "non-alcoholic" which overemphasizes "alcohol" and underemphasizes the root cause of this liver disease, namely, the predisposing metabolic risk factors. As a potential remedy, a name change from NAFLD to metabolic associated fatty liver disease (MAFLD) has been proposed. Although MAFLD reflects the relevant risk factors for this liver disease, this term is still suboptimal, leaving a great deal of ambiguity. Here, we caution that changing the name without understanding its broad implications can have a negative impact on the field. In this context, changing the terminology without new understanding of the molecular basis of the disease entity, new insights in risk stratification or other important aspect of this liver disease, can create unnecessary confusion which could negatively impact the field. At a time when the field is facing substantial challenges around disease awareness as well as clarity of acceptable endpoints for drug development and biomarker discovery, changing the terminology from one suboptimal name to another suboptimal name without full assessment is expected to deepen these challenges. In the context of this debate about terminology, we recommend the creation of a true international consensus group to include all the relevant scientific liver societies (AASLD, EASL, ALEH, APASL), patient advocacy organizations, bio-pharmaceutical industry, regulatory agencies and policy makers. A consensus meeting must assess the impact and consequences of changing the terminology based on the available evidence and make recommendations that will move the field forward. By this approach, a true collaborative international and inclusive consensus can be adopted by all stakeholders dealing with this important global liver disease.

Predicting the risk of type 2 diabetes through anthropometric indices in Pakistani adults- A sub-analysis of second National diabetes survey of Pakistan 2016-2017 (NDSP-07)

BACKGROUND AND AIM

Excess adiposity is associated with an increased risk of diabetes. Amongst the various measures of adiposity, the most appropriate one to predict the risk of diabetes remains debatable. Therefore, the aim of this study was to compare the ability of body mass index (BMI), waist circumference (WC), and waist-to-hip ratio (WHR) in predicting type 2 diabetes mellitus (DM) among Pakistani adults.

SUBJECTS AND METHODS

This was the sub-analysis of a large population based Second National Diabetes Survey of Pakistan (NDSP) 2016-2017. With this survey, 10834 individuals were recruited and 4788 individuals fulfilled the inclusion criteria for this sub-analysis (subjects with missing anthropometric details were excluded). Participants were categorized into two groups; subjects with type 2 DM and subjects without DM. Data of participants was collected via pre-designed detailed questionnaire. Clinical and anthropometric measurements were measured using standardized techniques.

RESULTS

Out of 4788 individuals, 3085(64.4%) were non-DM subjects and 1703(35.6%) were type 2 DM subjects with mean age of 39.78 ± 13.79 and 50.38 ± 11.33 years, respectively. Logistic regression analysis revealed a significant association of WC with type 2 diabetes after adjustment for possible confounders. Area under the curve (AUC) of WC was found higher than AUC of BMI and WHR.

CONCLUSION

The findings from second NDSP (2016-2017) demonstrated that WC is a better marker than WHR and BMI in predicting type 2 DM for Pakistani population.

Diverse Adiposity and Atrio-Ventricular Dysfunction across Obesity Phenotypes: Implication of Epicardial Fat Analysis

Obesity has been conceptualized as a highly heterogeneous condition. We aim to investigate chamber-specific effects of obesity on the heart and relevant outcomes. A total of 2944 symptom-free individuals (age: 47.5 ± 10.0 years), free of known cardiovascular diseases were classified into four categories based on body mass index (BMI) (as normal-weight (NW) vs. overweight/obese (O)) and metabolic status (metabolically-healthy (MH) vs. unhealthy (MU)). Epicardial adipose thickness (EAT) using echocardiography method. Speckle-tracking based atrio-ventricular (LA/LV) deformations including global longitudinal strain (GLS) and peak atrial longitudinal strain (PALS) were also analyzed. MUNW had higher cardiometabolic risks and more impaired diastolic and GLS/PALS than MHNW phenotype. Both MHO and MUO phenotypes exhibited worst atrial functions. Greater EAT was independently associated with worse GLS and PALS after correcting for various anthropometrics, LV mass and LA volume, respectively, with unfavorable LA effects from EAT being more pronounced in the NW phenotypes (both p interactions < 0.05). During a median follow-up period of 5.3 years, BMI/EAT improved the reclassification for atrial fibrillation (AF) incidence (p for net reclassification improvement < 0.05) mainly in the NW phenotypes (p interaction < 0.001). Categorization of clinical obesity phenotypes based on excessive visceral adiposity likely provides increment prognostic impacts on atrial dysfunction, particularly in non-obese phenotypes.

Metabolic Phenotypes and Chronic Kidney Disease: A Cross-Sectional Assessment of Patients from a Large Federally Qualified Health Center

The purpose of this study is to determine if renal function varies by metabolic phenotype. A total of 9599 patients from a large Federally Qualified Health Center (FQHC) were included in the analysis. Metabolic health was classified as the absence of metabolic abnormalities defined by the National Cholesterol Education Program Adult Treatment Panel III criteria, excluding waist circumference. Obesity was defined as body mass index >30 kg/m2 and renal health as an estimated glomerular filtration rate (eGFR) >60 mL/min/1.73 m2. Linear and logistic regressions were used to analyze the data. The metabolically healthy overweight (MHO) phenotype had the highest eGFR (104.86 ± 28.76 mL/min/1.72 m2) and lowest unadjusted odds of chronic kidney disease (CKD) (OR = 0.46, 95%CI = 0.168, 1.267, p = 0.133), while the metabolically unhealthy normal weight (MUN) phenotype demonstrated the lowest eGFR (91.34 ± 33.28 mL/min/1.72 m2) and the highest unadjusted odds of CKD (OR = 3.63, p < 0.0001). After controlling for age, sex, and smoking status, the metabolically unhealthy obese (MUO) (OR = 1.80, 95%CI = 1.08, 3.00, p = 0.024) was the only phenotype with significantly higher odds of CKD as compared to the reference. We demonstrate that the metabolically unhealthy phenotypes have the highest odds of CKD compared to metabolically healthy individuals.

Adipose Tissue Macrophage Polarization in Healthy and Unhealthy Obesity

Over 650 million adults are obese (body mass index ≥ 30 kg/m²) worldwide. Obesity is commonly associated with several comorbidities, including cardiovascular disease and type II diabetes. However, compiled estimates suggest that from 5 to 40% of obese individuals do not experience metabolic or cardiovascular complications. The existence of the metabolically unhealthy obese (MUO) and the metabolically healthy obese (MHO) phenotypes suggests that underlying differences exist in both tissues and overall systemic function. Macrophage accumulation in white adipose tissue (AT) in obesity is typically associated with insulin resistance. However, as plastic cells, macrophages respond to stimuli in their microenvironments, altering their polarization between pro- and anti-inflammatory phenotypes, depending on the state of their surroundings. The dichotomous nature of MHO and MUO clinical phenotypes suggests that differences in white AT function dictate local inflammatory responses by driving changes in macrophage subtypes. As obesity requires extensive AT expansion, we posit that remodeling capacity with adipose expansion potentiates favorable macrophage profiles in MHO as compared with MUO individuals. In this review, we discuss how differences in adipogenesis, AT extracellular matrix deposition and breakdown, and AT angiogenesis perpetuate altered AT macrophage profiles in MUO compared with MHO. We discuss how non-autonomous effects of remote organ systems, including the liver, gastrointestinal tract, and cardiovascular system, interact with white adipose favorably in MHO. Preferential AT macrophage profiles in MHO stem from sustained AT function and improved overall fitness and systemic health.

Effect of a 12-Week Concurrent Training Intervention on Cardiometabolic Health in Obese Men: A Pilot Study

The present study aimed to investigate the effects of a 12-week concurrent training intervention on cardiometabolic health in obese men. Twelve obese men (42.5 ± 5.3 years old) participated in the current 12−week randomized controlled trial with a parallel group design. The participants were randomly assigned to a concurrent training group or to a no-exercise control group. Anthropometry and body composition assessment were determined by electrical bio-impedance. Blood samples were obtained and a cardiometabolic risk Z-Score was calculated. Energy metabolism-related parameters [i.e., resting metabolic rate (RMR), respiratory quotient (RQ), and substrate oxidation in both resting conditions and during exercise] were determined by indirect calorimetry. Echocardiographic studies were performed using an ultrasound system equipped with a transducer to measure cardiac function. A significant decrease of weight (Δ = −4.21 kg; i.e., primary outcome), body mass index (Δ = −1.32 kg/m²), fat mass (FM; Δ = −3.27 kg), blood pressure (BP; Δ = −10.81 mmHg), and cardiometabolic risk Z-Score (Δ = −0.39) was observed in the exercise group compared with the control group (all P < 0.05), while no significant changes were noted in waist circumference (WC), lean mass (LM), bone mineral content, glycemic and lipid profiles, liver function, nor in energy metabolism-related parameters (all P > 0.1). Moreover, a significant increment of left ventricular (LV) end diastolic diameter (Δ = −4.35 mm) was observed in the exercise group compared with the control group (P = 0.02). A 12-week concurrent training intervention is an effective strategy to induce weight and fat loss with simultaneous reductions of BP and cardiometabolic risk, and improving cardiac function in obese men.

Metabolic Health, Obesity, and Cardiovascular Disease: 2015-2016 National Health and Nutrition Examination Survey

BACKGROUND

The metabolically unhealthy normal weight (MUN) and metabolically healthy obese (MHO) phenotypes are abnormal metabolic states. The purpose of this study was to report the frequency of the strictly defined MHO and MUN phenotypes and the association between metabolic phenotype and 10-year Framingham cardiovascular disease (CVD) risk score using a sample taken from the 2015-2016 National Health and Nutrition Examination Survey.

METHODS

A cross-sectional sample of 2,316 participants age 18-79 years with complete metabolic health information were selected from the 2015-2016 dataset and included in the present analysis. Metabolic health was defined as the absence of all metabolic abnormalities as outlined by the National Cholesterol Education Program Adult Treatment Panel III criteria, excluding waist circumference. Obesity was defined as body mass index ≥30 kg/m² or waist > 88.9 cm for females or > 101.6 cm for males.

RESULTS

Frequency of the MHO phenotype was 5.5% and the MUN was 44.3%. After adjustment for all covariates, Framingham CVD risk score was higher in the MUN (b = 1.74,p < 0.001) and metabolically unhealthy obese (b = 3.32,p < 0.001) phenotypes that used BMI to define obesity, and the MHO phenotype had a slight protective effect (b = -2.25,p < 0.001) when waist circumference was used as the measure of obesity.

CONCLUSIONS

Metabolically unhealthy phenotypes had higher CVD risk, while the MHO phenotype was not at any greater risk than the metabolically healthy normal weight.

Obesity as a multisystem disease: Trends in obesity rates and obesity-related complications

Obesity is a chronic multisystem disease associated with increased morbidity and mortality. The increasing prevalence of obesity makes it a major healthcare challenge across both developed and developing countries. Traditional measures such as body mass index do not always identify individuals at increased risk of comorbidities, yet continue to be used in deciding who qualifies for weight loss treatment. A better understanding of how obesity is associated with comorbidities, in particular non-metabolic conditions, is needed to identify individuals at risk in order to prioritize treatment. For metabolic disorders such as type 2 diabetes (T2D), weight loss can prevent T2D in individuals with prediabetes. It can improve and reverse T2D if weight loss is achieved early in the course of the disease. However, access to effective weight loss treatments is a significant barrier to improved health for people with obesity. In the present paper, we review the rising prevalence of obesity and why it should be classed as a multisystem disease. We will discuss potential mechanisms underlying its association with various comorbidities and how these respond to treatment, with a particular focus on cardiometabolic disease, malignancy and mental health.

Body mass index and all-cause mortality in patients with percutaneous coronary intervention: A dose-response meta-analysis of obesity paradox

The association between body mass index (BMI) and mortality of patients with percutaneous coronary intervention (PCI) is still controversial. We hope to explore whether the 'obesity paradox' really exists through this dose-response meta-analysis. PubMed, Embase and Cochrane databases were systematically searched for eligible studies up to April 2020. The random-effects restricted cubic spline models were used to evaluate the potential non-linear relationship between BMI and all-cause mortality of patients undergoing PCI. Fifteen studies were identified and included total 138 592 participants. The pooled hazard ratio of all-cause mortality was 0.60 (95% confidence interval: 0.45-0.82) when compared the highest category (mean = 33.32 kg m^-2 ) of BMI with the lowest category (mean = 18.89 kg m^-2 ). A non-linear U-shaped dose-response curve between BMI and the risk of all-cause mortality was found, with higher mortality rate at BMI lower than 27 kg m^-2 and higher than 32 kg m^-2 . The 'obesity paradox' does exist after PCI. The association between BMI and the risk of all-cause mortality for patients undergoing PCI is U shaped, with a nadir of risk at a BMI of 27 to 32 kg m^-2 and the highest risk at patients with underweight. The relationship between other prognostic indicators and BMI is worthy of further research.

Relationship of Weight Change Patterns From Young to Middle Adulthood With Incident Cardiovascular Diseases

CONTEXT

The effect of weight change patterns on cardiovascular diseases (CVD) remains uncertain.

OBJECTIVE

We aim to examine the relation of weight change patterns and absolute weight change from young adulthood to midlife with incident CVD.

DESIGN

Retrospective cohort study.

SETTING

National Health and Nutrition Examination Survey 1999-2016.

PARTICIPANTS

A total of 20 715 US adults aged 40 through 79 with recalled weight at young adulthood (25 years) and midlife (10 years before baseline).

MAIN OUTCOME MEASURE

CVD status was determined by self-report of a prior diagnosis, and age at diagnosis was used to establish time of CVD onset. CVD events was defined as the first occurrence of a congestive heart failure, coronary heart disease, angina pectoris, heart attack, or stroke.

RESULTS

After 9.76 years of follow-up, compared with participants who remained at normal weight, those in maximum overweight, changing from nonobese to obese, changing from obese to nonobese, maintaining obesity between young and middle adulthood had a 39% (hazard ratio [HR], 1.39; 95% confidence interval [CI], 1.19-1.62), 93% (HR, 1.93; 95% CI, 1.64-2.28), 125% (HR, 2.25; 95% CI, 1.29-3.94), and 132% (HR, 2.32; 95% CI, 1.68-3.20) higher risk of CVD, respectively. In addition, compared with weight change within 2.5 kg, weight gain ≥ 10.0 kg was associated with higher risk of CVD.

CONCLUSIONS

Both nonobese to obese, obese to nonobese, and stable obese from young to middle adulthood were associated with increased risks of CVD. The findings emphasize the importance of maintaining normal weight throughout the adulthood for preventing CVD in later life.

Polygenic Risk, Fitness, and Obesity in the Coronary Artery Risk Development in Young Adults (CARDIA) Study

Importance

Obesity is a major determinant of disease burden worldwide. Polygenic risk scores (PRSs) have been posited as key predictors of obesity. How a PRS can be translated to the clinical encounter (especially in the context of fitness, activity, and parental history of overweight) remains unclear.

Objective

To quantify the relative importance of a PRS, fitness, activity, parental history of overweight, and body mass index (BMI) (calculated as weight in kilograms divided by height in meters squared) in young adulthood on BMI trends over 25 years.

Design, Setting, and Participants

This population-based prospective cohort study at 4 US centers included white individuals and black individuals with assessments of polygenic risk of obesity, fitness, activity, and BMI in young adulthood (in their 20s) and up to 25 years of follow-up. Data collected between March 1985 and August 2011 were analyzed from April 25, 2019, to September 29, 2019.

Main Outcomes and Measures

Body mass index at the initial visit and 25 years later.

Results

This study evaluated an obesity PRS from a recently reported study of 1608 white individuals (848 women [52.7%]) and 909 black individuals (548 women [60.3%]) across the United States. At baseline (year 0), mean (SD) overall BMI was 24.2 (4.5), which increased to 29.6 (6.9) at year 25. Among white individuals, the PRS (combined with age, sex, self-reported parental history of overweight, and principal components of ancestry) explained 11.9% (at year 0) and 13.6% (at year 25) of variation in BMI. Although the addition of fitness increased the explanatory capability of the model (24.0% variance at baseline and up to 18.1% variance in BMI at year 25), baseline BMI in young adulthood was the strongest factor, explaining 52.3% of BMI in midlife in combination with age, sex, and self-reported parental history of overweight. Accordingly, models that included baseline BMI (especially BMI surveillance over time) were better in predicting BMI at year 25 compared with the PRS. In fully adjusted models, the effect sizes for fitness and the PRS on BMI were comparable in opposing directions. The added explanatory capacity of the PRS among black individuals was lower than among white individuals. Among white individuals, addition of baseline BMI and surveillance of BMI over time was associated with improved precision of predicted BMI at year 25 (mean error in predicted BMI 0 kg/m2 [95% CI, -11.4 to 11.4] to 0 kg/m2 [95% CI, -8.5 to 8.5] for baseline BMI and mean error 0 kg/m2 [95% CI, -5.3 to 5.3] for BMI surveillance).

Conclusions and Relevance

Cardiorespiratory fitness in young adulthood and a PRS are modestly associated with midlife BMI, although future BMI is associated with BMI in young adulthood. Fitness has a comparable association with future BMI as does the PRS. Caution should be exercised in the widespread use of polygenic risk for obesity prevention in adults, and close clinical surveillance and fitness may have prime roles in limiting the adverse consequences of elevated BMI on health.