[Editor’s note: The following editorial was first published in Missouri Medicine, January/February 2014 issue.]

By M. Javed Ashraf, MD, MPH

Overweight and obesity are the fastest-growing causes of morbidity and death in the United States. Obesity is a chronic metabolic disorder associated with increased cardiovascular morbidity and mortality. However, despite the fact that obesity is associated with increased health hazards, in recent years there have been some confusing and contradicting reports of “healthy obesity,” “benign obesity” and “obesity paradox.” These reports unfortunately have tried to undermine the severity of this alarming problem.

Dr. Caroline Kramer and colleagues highlighted the worsening obesity issue in their meta-analysis published December 2013 in Annals of Internal Medicine (Ann Intern Med. 2013;159:758-769). They reported increased incidences of cardiovascular disease and all-cause mortality among obese adults for both metabolically unhealthy and metabolically “healthy” people of various weights and emphasized “there is no such thing as healthy obesity.”

The authors compared the cardiovascular and all-cause mortality for healthy and unhealthy obese groups. In their meta-analysis with a follow-up of 10 years, metabolically healthy obese adults had an increased risk for all-cause mortality and cardiovascular disease. The data for their study came from eight prospective studies published during the past decade. Metabolic health was defined by the presence or absence of metabolic syndrome as per Adult Treatment Panel III (ATP III) criteria or by the International Diabetes Federation. Excess weight is associated initially with subclinical metabolic and vascular dysfunction that ultimately leads to increased cardiovascular events and mortality.

The concept of “benign obesity” originated from reports that evaluated metabolically healthy obese individuals over a short period of time. The authors claim their results do not support this concept of benign obesity. I applaud Dr. Kramer and her colleagues on their excellent work to clarify that there is no healthy pattern of obesity. In fact, the metabolically unhealthy adults, including those of mild obesity, exhibited the highest relative risk for cardiovascular events and all-cause mortality.

My colleague and I also highlighted the increased cardiovascular risks in obesity as well as among “normal weight obese” (NWO) individuals in our review article recently published in Missouri Medicine (2013;110:499-504). NWO adults have increased atherosclerotic plaques in their arteries and worse clinical outcomes than those who have normal or smaller waist-to-hip ratios. NWO individuals have an increased risk for diabetes and cardiovascular disease compared with individuals who are metabolically healthy and of normal weight.

I strongly suggest that clinicians pay more attention to this group of NWO individuals as they are likely to perceive themselves as healthy. Irrespective of metabolic status, if someone is obese or has normal weight obesity, he or she should be considered at risk. The data from Kramer et al’s meta-analysis further strengthen the fact that obesity at any level or severity is not a benign condition and is never healthy.


Dr. Ashraf is a cardiologist at the University of Missouri-Kansas City School of Medicine.