Prevalence of obesity.Body composition & body shape (body fat distribution ) and CVD risk .Mechanisms linking obesity with cardiovascular disease.Fat-but-Fit Paradigm and CVD,The Relationship of Metabolic Risk Factors and Cardiorespiratory Fitness. Metabolically Healthy but Obese ( MHO ) Phenotype and CVD.Obesity Paradox in Patients With CVD

1. Magdy El-Masry.
Prof. of Cardiology.
Tanta University.
Controversies in cardiovascular medicine

2. Prevalence of obesity

3. Without any shade of doubt, the biggest and more powerful study describing the
current prevalence of obesity worldwide in adults and in children, as well as how
this prevalence has changed over the past decades, is the systematic review
conducted by Ng et al.

4. LAUREL &
HARDY
The prevalence of obesity, measured by BMI, has
risen to unacceptable levels in both men and
women in the United States and worldwide

5. Half of all obese people in the world live in these 10
countries, according to a study published in the Lancet.
(May 2014)

7. What Does Obesity Really Mean
and How Is Associated With CVD?
Body composition & body shape (body fat distribution ) and
CVD risk

8. Fat mass
Fat-free mass
Our bodies are made up of fat-free mass and fat mass.
Fat-free mass includes bone, organs, tissue and water.
You cannot change the part of your body that is bones, tissues
and organs but you can change the ratio of fat to muscle.

9. 2kg of fat is soft, lumpy and sits right under the skin, and it
takes up around three times the space on the body as 2kg
of muscle, which is tightly packed and close to the bone.

10. Subcutaneous fat is located right
under the skin. Subcutaneous fat is
not as responsive to a good diet
and exercise
Visceral fat (sometimes referred to
as “deep” fat) grows around the
inner abdominal organs like the
stomach and liver.
Does this surprise you ? Visceral fat is the culprit
Visceral fat Subcutaneous fat
Higher
cardiometabolic
risk
Lower
cardiometabolic
risk

11. What Your Body Shape Says About Your Health (Body Fat Distribution : Good or Bad)
Less visceral fat
Lower cardiometabolic risk
More visceral fat
Higher cardiometabolic risk

12. Secretion of inflammatory adipokines from adipose tissue in obese state
In obese state, the enlarged adipose tissue leads to dysregulated secretion of adipokines and increased release of free fatty acids. The
free fatty acids and pro-inflammatory adipokines get to metabolic tissues, including skeletal muscle and liver, and modify inflammatory
responses as well as glucose and lipid metabolism, thereby contributing to metabolic syndrome. In addition, obesity induces a
phenotypic switch in adipose tissue from anti-inflammatory (M2) to pro-inflammatory (M1) macrophages. On the other hand, the
adipose production of insulin-sensitizing adipokines with anti-inflammatory properties, such as adiponectin, is decreased in obese state.
The red arrows indicate increased (when pointing upward) or decreased (when pointing downward) responses to obesity.
Adipose tissue
(an active
endocrine organ )

14. How is obesity measured?
Traditional measures:
Waist Circumference, body fat percentage and Body Mass Index

15. When can waist circumference become a risk?

16. For women, the ratio should be less than 0.85.
For men, the ratio should be less than 1.0.

18. Class
4
Class
5
BMI ≥50
kg/m ²
(super
obese)
BMI ≥60
kg/m ²
(super
super
obese)
BMI is still the most used anthropometric index in the literature
and persists as a strong predictor of CVD mortality
“BMI is not a good index of adiposity, but might
be a good index of cardio-metabolic risk.”

20. Body composition and body fat distribution for risk stratification in coronary heart disease. Body mass index (BMI) does
not provide information about body composition and body fat distribution. Therefore, it cannot distinguish between
individuals with high versus low lean body mass as well as lower body versus abdominal (visceral) obesity, which are
important predictors of cardiometabolic health. Alternative measurements such as %body fat, lean body mass, waist
circumference, waist-to-hip ratio or even quantification of adipose tissue by computed tomography imaging may be
needed to provide this information.

21. Cardiac complications of obesity

22. People who are overweight or obese
have more risk factors for CVD, and are
at increased risk of developing
hypertension, CAD , HF , and AF

23. Obesity is a foe! Mechanisms linking obesity with cardiovascular disease

24. Duration of Obesity and CVD

25.  For every 2 years additionally lived with
obesity, the risk of CVD mortality significantly
increased 7%.
“I think our findings really suggest that if we don’t measure obesity
duration in addition to BMI and waist circumference, we may be
underestimating the health risks of obesity,” Reis says.
Reis et al JAMA. 2013;310(3):280-288.
Duration of Obesity May Affect Heart Disease
Delaying the onset of
obesity can contribute to
lower the risk of
developing future CVD.

26. Fat-but-Fit Paradigm and CVD
The Fit/Fat Phenotype

27. In this context, we will focus on the fat-but-fit paradigm, which
refers to those individuals whom in spite of being obese have a
relatively good cardiorespiratory fitness level.
Can you be fat but fit?

28. These 2 studies can be considered as the foundation of
the fat-but-fit concept.

29. Men who were obese but fit had a higher risk of CVD mortality than normal-weight
and fit men although this risk difference was of borderline significance. On the
contrary, this risk was 50% lower than that observed in normal-weight and unfit
men and was also dramatically lower than the risk observed in obese and unfit men.
fat but fit

30. Cardiorespiratory fitness (CRF) refers to the ability of the circulatory
and respiratory systems to supply oxygen to skeletal muscles during
sustained physical activity.

31. The Relationship of Metabolic Risk Factors and Cardiorespiratory Fitness
with Atherosclerotic Disease. Farooq, et al., J Metabolic Synd 2015, 4:2
The physiological explanation for the fat-but-fit paradigm is that fitter people have lower
levels of most of CVD risk factors, and this remains true within the obese individuals, so
that fitness is able to counteract the adverse effects of obesity on CVD risk factors reducing
therefore the risk of CVD mortality.

32. Metabolically Healthy but Obese
( MHO ) Phenotype and CVD
Can obesity be really healthy?
One of the Many Faces of Obesity : The MHO Phenotype

34. A patient would be
classified as MHO if
(1) being obese (BMI≥30
kg/m2 ); plus
(2) meeting 0 of the 4
MetS criteria (WC
excluded)
A patient would be
classified as MAO if
(1) being obese (BMI≥30
kg/m2 ); plus
(2) meeting 1–4 of the
MetS criteria (WC
excluded)
Metabolically Healthy Obese
(MHO)
Metabolically Unhealthy Obese
(MUO)=MetS

35. Metabolic Health as a Primary Risk Factor for Poor Outcome.
Farooq, et al., J Metabolic Synd 2015, 4:2
Normal
Weight
Normal
Weight
Metabolically
Healthy
Metabolically
Unhealthy
Metabolically Healthy
Obese (MHO)
Metabolically Healthy
Normal Weight (MHNW)
Metabolically Unhealthy
Normal Weight (MUNW)
Metabolically Unhealthy
Obese (MUO)=MetS
Obese
Obese
Different Metabolic
Phenotypes.

36. Metabolically
Healthy Normal
Weight
(MHNW)
Metabolically
Healthy
Obese (MHO)
Metabolically
Unhealthy
Obese
(MUO)=MetS
Metabolically
Unhealthy
Normal Weight
(MUNW)
Risk for cardiovascular disease displayed as a continuum. Farooq, et al., J Metabolic Synd 2015, 4:2

37. Is Metabolically Healthy Obese (MHO) a “Benign” Phenotype?
Metabolically Healthy
Normal Weight (MHNW)
Metabolically Healthy
Obese (MHO)

38. Obesity Paradox in Patients With CVD
“The obesity paradox” in CVD – is the protective effect of obesity true?

39. Patients with established CVD who are
overweight or obese have a better prognosis
than leaner patients with CVD,
a phenomenon known as the ‘obesity
paradox’
Yesterday’s enemy is today’s friend
Obesity paradox: can obesity be a friend?

40. Meta-Analysis
of 6 Studies (n =
22,807) on
Impact of BMI
on CV
Mortality, All-
Cause
Mortality, and
Hospitalizations
in Heart Failure
Am J Cardiol
(2015)115:1428
The highest risk of adverse events, including CV mortality,
all-cause mortality, and rehospitalizations, during a mean
2.9-year follow-up, were in those with low BMI, whereas
the lowest risk occurred in the overweight BMI
The Obesity
Paradox in
Heart Failure

41. New data challenge the obesity paradox with regard
to CVD morbidity and longevity
Conclusions and Relevance In this study, obesity was associated with shorter
longevity and significantly increased risk of cardiovascular morbidity and mortality
compared with normal BMI.
Despite similar longevity compared with normal BMI, overweight was associated
with significantly increased risk of developing CVD at an earlier age, resulting in a
greater proportion of life lived with CVD morbidity.

43. Despite the presence of the obesity paradox,
substantial evidence still supports weight loss
among patients with CVD who are obese , especially
when associated with increases in physical activity
and cardiorespiratory fitness levels

44. Obesity Treatment Pyramid