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‘Apple’-shaped women may have increased CVD risk vs. ‘pear’-shaped women
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An increased risk for CVD was seen in women who were postmenopausal and had BMI with higher trunk fat or lower leg fat, according to a study published in the European Heart Journal.
“These findings highlight the importance of fat distribution beyond overall fat mass in the development of CVD,” Guo-Chong Chen, PhD, postdoctoral fellow in the department of epidemiology and population health at Albert Einstein College of Medicine, and colleagues wrote.
Women’s Health Initiative data
Researchers analyzed data from 2,683 women from the Women’s Health Initiative who were postmenopausal, free from CVD at baseline and had a normal BMI, defined as a measurement between 18.5 kg/m2 and 25 kg/m2. Women underwent dual-energy X-ray absorptiometry to assess body composition including regional fat mass, whole-body fat mass, lean mass and bone mass.
The primary outcome of interest was the first occurrence of CVD, defined as stroke, CHD or both. Follow-up was conducted until February 2017, which included questionnaires on clinical outcomes.
There were 291 cases of incident CVD during a median follow-up of 17.9 years.
Both whole-body fat mass and fat percentage were not associated with CVD risk after adjusting for lifestyle, demographic and clinical risk factors.
An increased risk for CVD was seen in patients with a higher percent of trunk fat, or “apple” shape (HR = 1.91; 95% CI, 1.33-2.74). Those with a higher percent of leg fat, or “pear” shape, had a decreased risk for CVD (HR = 0.62; 95% CI, 0.43-0.89). Further adjustment for waist-to-hip ratio and waist circumference attenuated the association of trunk fat and the risk for CVD, although it remained significant.
A particularly higher risk for CVD was seen in women with a higher percent of trunk fat in addition to a lower percent of leg fat (HR = 3.33; 95% CI, 1.46-7.62).
“Our findings were derived in postmenopausal women who were predominantly whites and are yet to be investigated in men and in other age or ethnic groups,” Chen and colleagues wrote.
Possible mechanisms
“Taken together, an adverse fat distribution characterized by increased abdominal (trunk) and decreased lower body (leg) fat increases the ASCVD risk independently of body fat mass,” Matthias Blüher, MD, head of the obesity outpatient clinic for adults at the University of Leipzig in Germany, and Ulrich Laufs, MD, PhD, professor of cardiology at the University of Leipzig, wrote in a related editorial. “Therefore, an intact balance between potentially harmful ectopic fat depots and safer or even beneficial healthy fat storage seems to be cardioprotective, although the exact mechanisms for the development of adverse fat distribution and how it is linked to atherosclerosis needs to be explored.” – by Darlene Dobkowski
Disclosures: Chen reports no relevant financial disclosures. Blüher reports he received honoraria as a consultant and speaker from Amgen, AstraZeneca, Boehringer Ingelheim, Lilly, Novo Nordisk, Novartis and Sanofi. Laufs reports he was a consultant for Amgen, Esperion and Sanofi. Please see the study for all other authors’ relevant financial disclosures.
Perspective
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Ian J. Neeland, MD, FAHA
BMI in isolation is a suboptimal indicator of CVD risk. Use of body composition for CVD risk assessment should take into account abdominal adiposity (an indicator of visceral fat, abnormal fat accumulation in the abdomen around the organs which is linked with heart disease) in conjunction with BMI.
Furthermore, this study confirms prior observations that higher lower body fat (in the legs, hips and buttocks) is associated with lower CVD risk. Thus, individuals who preferentially store fat in the legs and buttocks rather than the abdomen (viscera) seem to be at lowest risk for CVD, and those with more fat in the abdomen and less in the legs have the highest risk for CVD.
This study confirms prior observations and suggests that body fat assessment beyond simple BMI measurement may inform clinical risk stratification and decision making with regard to preventive therapies.
Cardiologists can better assess patients' risk with more accurate "obesity-typing" such as combining BMI with waist circumference or a test of body composition, which can be done with dual energy X-ray absorptiometry as in this study or with MRI now. Cardiologists can focus preventive efforts on the highest risk-patients based on obesity typing (high visceral fat, low leg/buttock fat).
Further research needs to be done to elucidate why some individuals store fat preferentially in one area compared with another (why some have more in the abdomen compared with others in the legs, for example) and how we can alter body composition to shift fat from the abdomen to the legs to potentially improve CVD risk even without altering the total amount of fat/body weight.
This study adds to a growing evidence base showing that body fat/obesity is a heterogeneous disease and not all fat should be treated the same, and that advanced imaging techniques such as those used in this study are likely to improve patient care in the future of personalized medicine.
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