Obesity and Atherosclerotic Cardiovascular Disease: A Review of Social and Biobehavioral Pathways

In the United States, two out of every five adults have obesity. The obesity epidemic is a significant public health concern and a major risk factor for atherosclerotic cardiovascular disease (ASCVD), contributing to its development through a complex interplay of social, biologic and behavioral mechanisms. It exacerbates traditional cardiovascular risk factors such as dyslipidemia, hypertension, and type 2 diabetes, while visceral and epicardial fat deposition promotes inflammation and insulin resistance, thereby accelerating atherosclerosis. Beyond traditional pathophysiologic pathways, social determinants of health (SDoH) significantly contribute to obesity-related disparities, particularly among racial and ethnic minorities. SDoH factors such as socioeconomic status, access to health care, and limited availability of nutritious food and safe spaces for physical activity not only increase obesity prevalence but also exacerbate its psychological toll, including stress and anxiety, which further elevate cardiovascular risk. Environmental factors, such as limited green spaces and air pollution, further promote obesogenic behaviors and worsen cardiovascular outcomes. In this review, we explore the association between obesity and ASCVD and key mediating pathways including the role of SDoH and environmental risk factors. We also discuss potential strategies-including patient education, community engagement to address SDoH, and establishment of dedicated cardiometabolic and cardiovascular prevention clinics-to mitigate the population burden of obesity and improve downstream cardiovascular outcomes.