Obesity, physical activity, and cardiometabolic health: a non-resolved triangle

This editorial refers to ‘Obesity, cardiovascular risk, and lifestyle: cross-sectional and prospective analyses in a nationwide Spanish cohort’, by P.L. Valenzuela et al., https://doi.org/10.1093/eurjpc/zwad204. Overweight and obesity are a worldwide health concern, with North America and Europe being the regions with the highest obesity prevalence.1 Obesity is recognized as a chronic disease that poses significant risks to cardiometabolic health.2 Nevertheless, epidemiological data have shown that overweight or obese patients who are diagnosed with coronary heart disease or heart failure have improved prognosis compared with normal weight or underweight patients (i.e. obesity paradox3). The study from Valenzuela et al.,4 which included a large sample of working population from Spain, has shed light on the association between weight status and cardiometabolic health, as well as on the role of lifestyle factors in this relationship. The authors provide new evidence about the subgroup of individuals with obesity who exhibit a more favourable metabolic profile [i.e. metabolic healthy obesity (MHO)]. This editorial explores the intertwining topics of obesity, lifestyle factors, and cardiometabolic health, providing insights into strategies for improving health in people with overweight and obesity. Valenzuela et al.4 highlight a clear and independent association between overweight/obesity and an unhealthy cardiometabolic status. In fact, the magnitude of the association increases along with the bodyweight (higher for obesity than for overweight). Then, individuals classified as overweight had a higher prevalence and incidence of cardiovascular disease (CVD) risk factors, with obesity further exacerbating these risks. Although the cross-sectional analysis showed the presence of subjects with obesity and free of diabetes, hypercholesterolaemia, or hypertension, data from the follow-up period showed a significant increase in the incidence of those derangements among participants with overweight and obesity. Therefore, MHO likely represents a transient state, and individuals with MHO still require weight-loss interventions to avoid the onset and progression of cardiometabolic disorders. These findings underscore the urgent need to address the growing burden of excess weight and its impact on cardiometabolic health. The study also underlines the key role of lifestyle factors, particularly physical activity, in mitigating the cardiometabolic risks associated with overweight and obesity. Self-reported regular physical activity was found to reduce the odds of an unhealthy cardiometabolic status, both at baseline and during follow-up. This emphasizes the importance of promoting and facilitating physical activity as a protective measure against cardiometabolic disorders, especially among those with higher body mass index (BMI). It is worth mentioning that Valenzuela et al.4 have measured the relationship between body mass and CVD risk factors without including an analysis of body composition. However, adiposity and central obesity are anthropometric characteristics that have been independently linked to multiple risk factors such as hypertension, insulin resistance, inflammation and increased incidence of diabetes, cardiovascular events, heart failure, and atrial fibrillation.5 That is a non-negligible fact: among the subjects described with MHO, it is possible to find individuals with low adiposity and high muscle mass who usually have a lower cardiovascular and metabolic risk. The effect of adiposity can confound the analysis of the studied outcomes when only BMI is measured. Finally, the study from Valenzuela et al.4 did not include an analysis of CVD occurrence. Nevertheless, it is expected that the long-term follow-up of the cohort will provide interesting data about the relationship between obesity and the development of CVD and related mortality. For now, clinicians should focus on weight management, while also promoting regular physical activity to reduce CVD risk factors. It is essential to recognize the potential transient nature of MHO and to stress that individuals with MHO also require weight-loss interventions.