Author + information
- Steven E.S. Miner, MD∗ ( and )
- Lynne E. Nield, MD
- ↵∗Address for correspondence:
Southlake Regional Health Center, University of Toronto, 596 Davis Drive, Newmarket, Ontario L3Y 2P9, Canada
The authors of the VIRGO (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) study (1) deserve congratulations for their impressive work. The paper covers a lot of ground, but perhaps the most important finding is the notably high prevalence of obesity, particularly in young women.
“Obesity” is an imprecise term that reflects body mass index, but not necessarily the deposition and distribution of fat in metabolically sensitive body compartments, such as the abdomen. This may explain the confusion in the scientific community and lay press regarding the cardiovascular risks of obesity in women. In 1997, Barrett-Connor (2) used the term “female pattern obesity” to describe non-visceral adiposity. Superficial reading of this terminology might lead some to believe that obesity is not a risk factor for women. In fact Barrett-Connor (2) specifically hypothesized that visceral obesity is the causative factor for cardiovascular disease (CVD) and that women with visceral adiposity are at higher risk than men. This hypothesis has been conclusively proven. Specific measures of visceral adiposity have been shown to be powerful predictors of CVD in women.
What about the young women in the VIRGO study? Did they have visceral or peripheral adiposity? Data on waist circumference would be helpful if available. However, we know that in young women, but not older women, body mass index is a good predictor of visceral adiposity (3). In the absence of any other data, we can safely surmise that the young women experienced visceral obesity as an important risk factor for early CVD.
The VIRGO study also evaluated perceived risk and health care provider discussion of risk, and it found both wanting.
The VIRGO study reports that only 53% of the young patients believed that they were at risk for CVD and that obese women were significantly less likely than obese men to recognize this risk. This represents a compelling failure of public health education. In our current era, it is unlikely that there are any smokers unaware of the CVD risks of tobacco. It is shameful that the same efforts have not been put into obesity education.
The sociological stigma of obesity may also play a role. An obese woman is more likely to delay health care if she feels that her provider holds a bias against her weight. Similarly, physicians are less likely to perform diagnostic tests in obese patients based on the assumption that symptoms are due primarily to obesity (4). These factors are only exacerbated when mixed messages are received regarding the CVD risks of obesity.
This muddle of confusion and stigma leads to denial of risk, denial of care, and ultimately, delayed diagnosis. At Southlake Regional Health Center, we studied the angiographic results in 616 young women from 2012 through 2014. In nonobese patients, the prevalence of normal coronary arteries was 22%, whereas in obese young women, the prevalence of normal coronary arteries was only 14% (p = 0.01). Similarly, 3-vessel disease was seen in 8.7% of nonobese young women compared with 16% of obese young women (p = 0.005). Although these data have limitations, they are consistent with relatively delayed testing due to either health care avoidance or underestimation of patient risk.
On the basis of the totality of evidence, the chief medical officer of the United Kingdom has declared obesity to be a “national risk” (5). As a community, we have a duty to our patients to honestly recognize and inform them of the risks of obesity. The VIRGO study shows us that we are failing badly. Now is the time to have an honest discussion.
Please note: Both authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- 2016 American College of Cardiology Foundation
- Leifheit-Limson E.C.,
- D'Onofrio G.,
- Daneshvar M.,
- et al.
- Barrett-Connor E.
- ↵Davies SC. Annual Report of the Chief Medical Officer, 2014—The Health of the 51%: Women. 2014. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/484383/cmo-report-2014.pdf. Accessed March 15, 2016.