Cover Story | Obesity and Cardiovascular Disease Risk

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The rising prevalence of obesity is driving an increased focus on its role in promoting cardiovascular disease. Estimates of the age-adjusted prevalence of obesity and severe obesity increased significantly among adults, but not among children and adolescents, in the U.S. between 2001-2004 and 2013-2016.1,2 During 2013-2016, 38.9 percent of adults had obesity and 7.6 percent had severe obesity.2 The prevalence estimates for obesity and severe obesity in children and adolescents during that period were 17.8 percent and 5.8 percent, respectively.2

The Obesity Medicine Association defines obesity as a chronic, relapsing, multifactorial, neurobehavioral disease, wherein an increase in body fat promotes adipose tissue dysfunction and abnormal fat mass physical forces, resulting in adverse metabolic, biomechanical and psychosocial health consequences.3

Increased Cardiovascular Disease Risk

Obesity has consistently been associated with an increased risk for metabolic diseases and cardiovascular disease. “An increase in body fat can directly contribute to heart disease through atrial enlargement, ventricular enlargement and atherosclerosis,” says Harold Bays, MD, FACC. Further, increased body fat indirectly contributes to heart disease, “through promotion of sleep apnea, thromboembolic disease and onset or worsening of metabolic diseases that are major cardiovascular disease risk factors, including dyslipidemia, type 2 diabetes, high blood pressure and metabolic syndrome,” Bays says.

In the Cardiovascular Risk in Young Finns Study, repeated measurement of participants’ height and weight between 1980 and 2011 showed that trajectories of worsening or persisting obesity were associated with an increased risk of cardiovascular disease in adulthood.4 Participants who reduced their elevated childhood body mass index (BMI) to normal levels had a similar risk for dyslipidemia and hypertension compared with those who were never obese or overweight. Another study demonstrated that an increase in BMI between age seven and early adulthood was associated with an increased risk of type 2 diabetes.5

Cardiology Magazine Image"… increased body fat indirectly contributes to heart disease, through promotion of sleep apnea, thromboembolic disease and onset or worsening of metabolic diseases that are major cardiovascular disease risk factors, including dyslipidemia, type 2 diabetes, high blood pressure and metabolic syndrome." Harold Bays, MD, FACC

A longitudinal cohort study of 67,278 participants, half of whom were with obesity, found that those with obesity were significantly more likely to have hypertension and diabetes. Over eight years of follow-up, obesity was strongly associated with a new diagnosis of atrial fibrillation after controlling for age, gender, hypertension, and diabetes.6 As of 2015, an elevated BMI accounted for four million deaths globally.7 An analysis of data from 3,310 patients in the TOPCAT study found that the risk of all-cause mortality was significantly higher in patients with heart failure with preserved ejection fraction (HFpEF) with abdominal obesity than in those without abdominal obesity.8

Pathogenesis of Obesity

The etiology of obesity is multifactorial. Contributors to its pathogenesis include genetic, environmental, sociocultural, physiological, medical, behavioral and epigenetic factors.

  • More than 140 genetic chromosomal regions related to obesity have been identified. Genes related to BMI and general adiposity are highly expressed in the central nervous system.7
  • Obesity genes are thought to act within the hypothalamic homeostatic regulator of energy balance and within neural circuits related to reward-based decision making, learning and memory, delayed discounting and spatial orientation.7
  • Epigenetically increased risk for adult obesity can also be transmitted to future generations.7
  • Other factors include disrupted sleep, mental stress, neurologic dysfunction, viral infections and inflammation.3
  • Interactions among the causative factors can lead to excessive weight gain and obesity.7

Gut microbiota also have a role in promoting increased adiposity. Proinflammatory signaling generated in response to bacterial lipopolysaccharide may affect neurobehavioral brain centers and adversely affect adipocyte function, leading to adiposopathy and increased risk for metabolic disease.3

Obesity Algorithm3

Comprehensive evaluation

  • Medical, physical activity, and nutrition history including eating patterns, weight loss attempts, and a food and beverage diary
  • Physical exam, including height, weight, blood pressure, body composition analysis, waist measurement
  • Assess for presence of obesity, adiposopathy and fat mass disease: BMI, percent body fat, waist circumference, Edmonton Obesity Staging System
  • Adiposity-relevant blood testing, including fasting blood glucose, hemoglobin A1c, fasting lipid levels and liver enzymes
  • General and individualized laboratory testing
  • Individualized diagnostic testing, including body composition, imaging, sleep and metabolic studies

Treatment principles

  • Treat adipocyte and adipose tissue dysfunction, which treats adiposopathy
  • Treat excessive body fat, which treats fat mass disease
  • Treating diseases due to increased body fat and its adverse metabolic and biomechanical consequences may improve patient health, quality of life, body weight and body composition

Individualized treatment plans

  • Manage secondary and contributing causes of adiposopathy and fat mass disease
  • Manage concomitant medications that might alter body weight
  • Nutrition therapy: Use calorie restriction, carbohydrate restriction, food journaling, very low-calorie diet programs
  • Physical activity: Give exercise prescription, use pedometers, decrease sedentary time, initial goal of 150 minutes per week of moderate intensity physical activity
  • Counseling: Eliminate provider bias and stigma, identify self-sabotage, develop strong support, address stress management, sleep optimization, other psychological support as needed
  • Pharmacotherapy: Use as part of comprehensive program
  • Bariatric surgery if needed
  • Consider referral to obesity medicine specialist


Adiposopathy refers to the pathogenic enlargement of adipose cells and adipose tissue that results in anatomic and functional abnormalities, leading to metabolic disease and increased cardiovascular disease risk. “Given that adipose tissue has no less potential for disease than any other body organ, the term adiposopathy is intended to identify adipose tissue organ pathology similar with the ‘opathies’ of other body organs,” says Bays. Specifically, adiposopathy is defined as adipocyte and adipose tissue dysfunction caused by positive caloric balance and sedentary lifestyle in genetically and environmentally susceptible individuals.9

Anatomic manifestations of adiposopathy include:

  • Adipocyte hypertrophy
  • Increased visceral, pericardial, perivascular and other periorgan adiposity
  • Growth of adipose tissue beyond its vascular supply with ischemia, cellular death and inflammation
  • Increased adipose tissue immune cells
  • Ectopic fat deposits in other organs9

Pathophysiologic manifestations of adiposopathy include:

  • Impaired adipogenesis
  • Pathologic adipocyte organelle dysfunction
  • Increased circulating free fatty acids
  • Pathogenic adipose tissue endocrine and immune responses
  • Pathogenic interaction with other organs9

These anatomic and pathophysiologic changes result in various clinical manifestations, including high blood glucose, insulin resistance, hypertension, adiposopathic dyslipidemia, metabolic syndrome, atherosclerosis and a host of other pathologies. In his review of adiposopathic changes that occur with increased body fat, Bays wrote, “A clinical application of Ockham’s razor suggests adiposopathy as the primary cause of most cases of metabolic diseases such as high glucose levels, high blood pressure and dyslipidemia, as well as most cases of cardiovascular disease.”9

Obesity and Inflammation in Cardiovascular Disease

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Obesity promotes systemic inflammation, and inflammation can drive adipogenesis. Chronic systemic inflammation, along with increased accumulation of epicardial adipose tissue has been observed in people with obesity.10 “Most cardiologists are familiar with the ‘inside to in’ model of atherosclerosis, wherein atherogenic lipoproteins in the circulation become entrapped in the subendothelium and generate an inflammatory reaction that promotes atheromatous plaque,” Bays says. “It is increasingly recognized that the adiposopathic ‘sick fat’ surrounding the heart can also transmit inflammatory responses that promote heart disease. This is sometimes called the ‘outside to in’ model of atherosclerosis.”

Systemic inflammation promotes the expression of a proinflammatory phenotype in epicardial fat, particularly the adipose tissue surrounding the coronary arteries. Chronic inflammation and accumulation of epicardial fat is strongly associated with the presence, severity and progression of coronary artery disease, independent of visceral adiposity.10 Normal epicardial adipocytes are similar with adipocytes from brown adipose tissue, which burn fatty acids and nourish adjacent tissues. They secrete adiponectin, which minimizes inflammation and fibrosis in the coronary arteries and myocardium. In contrast, epicardial fat in obese people is more prone to lipolysis, leading to release of fatty acids and reactive inflammation. In obesity, adiponectin secretion from epicardial fat is reduced and proinflammatory adipokines are released, promoting infiltration of macrophages, destruction of microvascular systems and activation of fibrotic pathways (Figure).10

The most common myocardial disorder in people with obesity is HFpEF, characterized by ventricular fibrosis and decreased distensibility, along with modestly increased cardiac volume, relatively low natriuretic peptide levels and impaired renal function. Even modest volume overload leads to cardiac overfilling and disproportionate increase in cardiac filling pressures.10

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Metabolically Healthy Obesity

Metabolically healthy obesity (MHO) refers to obesity without the presence of metabolic syndrome. People with MHO typically have intermediate levels of visceral adiposity and cardiovascular risk between those with normal weight and those with obesity.11 However, studies have found that at least half of participants with MHO at baseline convert to metabolically unhealthy obesity with increased risk of cardiovascular disease.11,12

"Reports of patients who are metabolically healthy, but with obesity are highly dependent upon how healthy is defined. With more strict definitions, it is rare to find such individuals. In these rare cases, the addition of time often transforms the apparently ‘healthy’ patient with obesity into a patient who ultimately expresses the complications of obesity, and thus becomes unhealthy."

In the Nurses’ Health Study, 84 percent of 3,027 women with MHO at baseline converted to unhealthy phenotypes after 20 years of follow-up.12 The MESA study reported that 48 percent of participants with MHO developed metabolic syndrome and an increased risk of cardiovascular disease during a median 12.2 years of follow-up.

“Reports of patients who are metabolically healthy, but with obesity are highly dependent upon how healthy is defined. With more strict definitions, it is rare to find such individuals,” says Bays. “In these rare cases, the addition of time often transforms the apparently ‘healthy’ patient with obesity into a patient who ultimately expresses the complications of obesity, and thus becomes unhealthy,” he adds. “The concept of the obesity paradox is no longer as paradoxical when functionality of adipose tissue is the focus, as opposed to the amount of adipose tissue. The degree by which fat is functional or dysfunctional (from an endocrine and immune standpoint) is what helps determine the pathogenic potential of increased body fat. This is why the concept of adiposopathy or ‘sick fat’ is so important,” explains Bays.


Help Your Patients Move More

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Encourage your patients to create a plan to move more. Suggest they think of three ways to more naturally fit in time standing or moving. For example:

  • Opt for an activity break to stretch and move rather than a snack or coffee break
  • Walk around or do leg raises during the next conference call
  • Keep stretching bands and/or hand weights near the TV and use commercials as a cue to get up and move
  • Set an alarm at the top of every hour and get out of the chair at work and home (some fitness devices can be programmed to do this, too)

Send your patients to for more tips on increasing physical activity. Download the infographic pictured here to support your conversations with your patients. Post it on the office wall to signal to your patients the importance of being active – and to get up and move!

Weight loss is recommended for all overweight or obese patients with comorbid conditions such as prediabetes, diabetes, hypertension and dyslipidemia.6 “Recognizing the pathogenic potential of adipose tissue may afford a clearer rationale toward recommending weight reduction to overweight patients. In other words, discussing how fat weight gain causes fat to become ‘sick’ and how losing body weight causes fat to become more ‘healthy’ might prove to be more productive than discussing the individual diagnostic components defining the metabolic syndrome,” Bays says.

The goals for management of adults with overweight or obesity are to improve health, quality of life, and body weight and composition.3 Because of the heterogeneity of obesity etiology and pathophysiology, response to treatment varies among patients. The rate of initial weight loss is the most consistent factor that predicts long-term weight loss success.7 An initial weight goal of 5-10 percent over six months is recommended, with an emphasis on dietary changes, increased physical activity and behavior modification delivered by a multidisciplinary team. Additional interventions include weight loss medications, medical devices and bariatric surgery.7

Evidence suggests that added sugar and certain saturated fat-containing foods increase risk for cardiometabolic disease by metabolic mechanisms that are not mediated solely by positive energy balance and fat gain. Certain dietary patterns or components appear to increase “energy in” or “energy storage as fat” through mechanisms not explained solely by their specific caloric contribution to the “energy in” side of energy balance.13

Sufficient polyunsaturated fat in the diet, with corresponding decrease in saturated fat, results in major blood lipid reduction. Replacement of saturated fatty acids with n-6 fatty acids is associated with lower cardiovascular disease risk; replacement with refined carbohydrates has a neutral or adverse effect.13 Consumption of fructose, high-fructose corn syrup or sucrose leads to greater increases in risk factors for cardiometabolic disease than isocaloric amounts of starch.13

Bariatric surgery reduces body fat, including epicardial fat, decreases inflammation and improves adipocyte and adipose tissue function, leading to reduced lipid levels and improvements in metabolic diseases.10 Cardiovascular disease risk factors are improved, including glucose metabolism, blood pressure, factors related to thrombosis, kidney function, adipocyte and adipose tissue function, inflammatory markers and vascular markers. “Some bariatric surgeries not only substantially improve cardiovascular disease risk factors but also reduce overall cardiovascular disease mortality,” Bays notes. Candidates for bariatric surgery include patients with a BMI ≥35 with one or more adverse health consequences and those with a BMI ≥40 with or without adverse health consequences.3

The Obesity Algorithm developed by the Obesity Medicine Society is a good place to start in developing management strategies for patients with overweight or obesity. It is a free education and patient management resource formatted in over 300 downloadable PowerPoint slides. “The Obesity Algorithm is a simplified, yet comprehensive discussion of obesity management, which can help clinicians develop strategies for treatment of patients with obesity,” says Bays.


  1. Hales CM, Fryar CD, Carroll MD, et al. JAMA 2018;319:2419-29.
  2. Ogden CL, Fryar CD, Hales CM, et al. JAMA 2018;319:2410-8.
  3. Bays HE, Seger J, Primack C, et al. Obesity Algorithm, presented by the Obesity Medicine Association. Available at: Accessed June 10, 2018.
  4. Buscot MJ, Thomson RJ, Juonala M, et al. Eur Heart J 2018;Apr 4:[Epub ahead of print].
  5. Bjerregaard LG, Jensen BW, Angquist L, et al. New Engl J Med 2018;378:1302-12.
  6. Foy AJ, Mandrola J, Liu G, et al. Am J Cardiol 2018;121:1072-5.
  7. Gadde KM, Martin CK, Berthoud HR, et al. J Am Coll Cardiol 2018;69-84.
  8. Tsujimoto T, Kajio H. J Am Coll Cardiol 2017;70:2739-49.
  9. Bays H. Curr Atheroscler Rep 2014;16:409.
  10. Packer M. J Am Coll Cardiol 2018;71:2360-72.
  11. Mongraw-Chaffin M, Foster MC, Anderson CAM. J Am Coll Cardiol 2018;71:1857-65.
  12. Eckel N, Li Y, Kuxhous O, et al. Lancet Diabetes Endocrinol 2018;May 28:[Epub ahead of print].
  13. Stanhope KL, Goran MI, Bosy-Westphal A, et al. Obes Rev 2018;May 14:[Epub ahead of print].
  14. Bays HE, Jones PH, Jacobson TA, et al. J Clin Lipidol 2016;10:33-57.
  15. Bays H, Kothari SN, Azagury DE, et al. Surg Obes Relat Dis 2016;12:468-95.

Clinical Topics: Arrhythmias and Clinical EP, Cardiovascular Care Team, Diabetes and Cardiometabolic Disease, Dyslipidemia, Heart Failure and Cardiomyopathies, Prevention, Atherosclerotic Disease (CAD/PAD), Atrial Fibrillation/Supraventricular Arrhythmias, Lipid Metabolism, Acute Heart Failure, Heart Failure and Cardiac Biomarkers, Diet, Exercise, Hypertension, Sleep Apnea

Keywords: ACC Publications, Cardiology Magazine, Adipocytes, Adipogenesis, Adipokines, Adiponectin, Adipose Tissue, Adipose Tissue, Brown, Adiposity, Atherosclerosis, Atrial Fibrillation, Bariatric Surgery, Behavior Therapy, Blood Glucose, Blood Pressure, Body Mass Index, Cardiac Volume, Cardiovascular Diseases, Coronary Artery Disease, Decision Making, Diabetes Mellitus, Diabetes Mellitus, Type 2, Diet, Dyslipidemias, Epidemiologic Studies, Exercise, Factor X, Fatty Acids, Fatty Acids, Nonesterified, Fatty Acids, Omega-6, Follow-Up Studies, Fructose, Glucose, Heart Failure, Hypertension, Inflammation, Insulin Resistance, Lipolysis, Lipoproteins, Longitudinal Studies, Macrophages, Metabolic Syndrome, Myocardium, Natriuretic Peptides, Obesity, Obesity, Abdominal, Obesity, Morbid, Pediatric Obesity, Organelles, Overweight, Patient Care Team, Phenotype, Plaque, Atherosclerotic, Prediabetic State, Prevalence, Quality of Life, Risk Factors, Sleep Apnea Syndromes, Snacks, Social Responsibility, Stroke Volume, Sucrose, Thrombosis, Weight Gain, Weight Loss

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