Metabolically healthy obesity is independently associated with 20-year incidence of cardiovascular disease: findings from the ATTICA cohort study (2002–2022)

Background Individuals with excess body weight do not share the same risk for cardiovascular disease (CVD). The phenotype of metabolically healthy obesity (MHO) has drawn the attention of the scientific community due to a potentially reduced CVD risk compared with the phenotype of metabolically unhealthy obesity (MUO). Methods A prospective cohort study was conducted involving 3042 participants from the Attica region in Greece. Baseline demographic, clinical, and lifestyle characteristics were assessed, with participants categorized by their obesity and metabolic health status. Cox proportional hazards models were used to analyze the association between obesity/metabolic health status and 20-year CVD incidence, adjusting for relevant covariates. Results The sample at baseline comprised 38% individuals who were metabolically healthy without obesity (MHWO), 44% individuals who were metabolically unhealthy without obesity (MUWO), 6% individuals with MHO, and 12% individuals with MUO. Over the 20-year follow-up, 718 participants experienced a CVD event; participants with MUO demonstrated the highest incidence rate (61.1%). Cox regression analyses revealed that individuals with MUO had an 85% higher risk of developing CVD compared with individuals having the MHWO phenotype (HR = 1.85, 95% CI = 1.02–3.58). Individuals with MHO had a 39% elevated risk compared with individuals having the MHWO phenotype (HR = 1.39, 95% CI = 1.06–3.42). Groups with MHO and MUO had independently increased CVD risk, even after multivariable adjustment. Conclusions Individuals with MUO exhibit the highest risk, but individuals with MHO also have an independently increased CVD risk, emphasizing the significant impact of both obesity and metabolic health status on long-term CVD incidence.