Author + information
- Carl J. Lavie, MD∗ (, )
- Francisco B. Ortega, PhD and
- Peter Kokkinos, PhD
- ↵∗John Ochsner Heart and Vascular Institute, Ochsner Clinical School - The University of Queensland School of Medicine, 1514 Jefferson Highway, New Orleans, Louisiana 70121
We read with great interest the recent report from Caleyachetty et al. (1) from the “huge” THIN (The Health Improvement Network) cohort, suggesting that obesity can never be “healthy,” as even those with metabolically healthy obesity (MHO) have increased risk of most cardiovascular diseases (CVD). Clearly, substantial evidence has already indicated that overweight and obese have markedly increased risk of heart failure (HF) despite being metabolically healthy (2), and obesity and weight gain particularly increases the prevalence of HF with preserved ejection fraction (EF) more so than HF with reduced EF. However, the impact of MHO on other CVD has been controversial. In this THIN paper, the authors make the case that MHO is still associated with increased coronary heart disease (1), but we would like to point out that for this important endpoint, the increase is relatively small (only 30% and 49% for overweight and obese, respectively), and those with MHO actually have lower coronary heart disease risk compared with those who have normal weight and only 1 metabolic risk factor (who have a >60% increased risk), whereas for HF, MHO has almost a 2-fold increase in risk.
The major weakness of this extremely powerful study, however, is lack of information on physical activity (PA), exercise, and/or cardiorespiratory fitness (CRF). We have previously demonstrated that, when CRF is included in the models, individuals with MHO and moderate-to-high CRF truly have an excellent prognosis (3,4) because fitness may be more important than fatness for predicting long-term prognosis (2–4). Therefore, we strongly suspect that only MHO with low PA and reduced CRF have significantly increased risk of coronary heart disease and most CVD, except for HF with reduced EF. Indeed, in a systematic review published by Roberson et al. (5), in 7 of 7 studies that included adjustments for PA/exercise or CRF, MHO was not associated with increased risk of CVD mortality, and 6 of these 7 studies showed no increased risk of nonfatal CVD.
In a perfect world, everyone would remain lean and fit throughout their lifespan. Considering that this is hardly the case currently in our Westernized society, emphasis is needed to increase PA, exercise, and CRF, even more so than emphasis merely on weight.
Please note: Dr. Lavie is the author of the book The Obesity Paradox. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- 2018 American College of Cardiology Foundation