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Association of metabolically healthy obesity in young adulthood with myocardial structure and function



Obesity is major cause of cardiovascular diseases. Metabolically healthy obesity (MHO) may increase heart failure risk early in life, and may be reflected in impaired cardiac structure and function. Therefore, we aimed to examine the relationship between MHO in young adulthood and cardiac structure and function.


A total of 3066 participants from the Coronary Artery Risk Development in Young Adults (CARDIA) study were included, who completed echocardiography in young adulthood and middle age. The participants were grouped by obesity status (body mass index ≥30 kg/m2) and poor metabolic health (≥2 criteria for metabolic syndrome) into four metabolic phenotypes as follows: metabolically healthy non-obesity (MHN), MHO, metabolically unhealthy non-obesity (MUN), metabolically unhealthy obesity (MUO). The associations of the metabolic phenotypes (MHN serving as the reference) with left ventricular (LV) structure and function were evaluated using multiple linear regression models.


At baseline, mean age was 25 years, 56.4% were women, and 44.7% were black. After a follow-up 25 years, MUN in young adulthood was associated with worse LV diastolic function (E/é ratio, β [95% CI], 0.73 [0.18, 1.28]), worse systolic function (global longitudinal strain [GLS], 0.60 [0.08, 1.12]) in comparison with MHN. MHO and MUO were associated with LV hypertrophy (LV mass index, 7.49 g/m2 [4.63, 10.35]; 18.23 g/m2 [12.47, 23.99], respectively), worse diastolic function (E/é ratio, 0.67 [0.31, 1.02]; 1.47 [0.79, 2.14], respectively), and worse systolic function (GLS, 0.72 [0.38, 1.06]; 1.35 [0.64, 2.05], respectively) in comparison with MHN. These results were consistent in several sensitivity analyses.


In this community-based cohort using data from the CARDIA study, obesity in young adulthood was significantly associated with LV hypertrophy, worse systolic and diastolic function regardless of metabolic status.

Relationship of Baseline Metabolic Phenotypes with Young Adulthood and Midlife Cardiac Structure and Function. Adjusted for year 0 covariates: age, sex, race, educational level, smoking status, drinking status, and physical activity; metabolically healthy non-obesity was used as a reference category for comparison. Criteria for metabolic syndrome are listed in Supplementary Table S6. MUN metabolically unhealthy non-obesity, MHO metabolically healthy obesity, LVMi left ventricular mass index, LVEF left ventricular ejection fraction, E/A early to late peak diastolic mitral flow velocity ratio, E/é mitral inflow velocity to early diastolic mitral annular velocity, CI confidence interval.

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Fig. 1: Flowchart of selection of study participants.
Fig. 2: Relationship of metabolic phenotypes at year 0 with year-5 cardiac structure and function.
Fig. 3: Relationship of metabolic phenotypes at year 0 with year-25 cardiac structure and function.

Data availability

The data used and/or analyzed in this study are available to all researchers upon reasonable request.


  1. Afshin A, Forouzanfar MH, Reitsma MB, Sur P, Estep K, Lee A, et al. Health effects of overweight and obesity in 195 countries over 25 years. N Engl J Med. 2017;377:13–27.

    Article  PubMed  Google Scholar 

  2. Kivimäki M, Kuosma E, Ferrie JE, Luukkonen R, Nyberg ST, Alfredsson L, et al. Overweight, obesity, and risk of cardiometabolic multimorbidity: pooled analysis of individual-level data for 120 813 adults from 16 cohort studies from the USA and Europe. Lancet Public Health. 2017;2:e277–e85.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Neeland IJ, Poirier P, Després JP. Cardiovascular and metabolic heterogeneity of obesity: clinical challenges and implications for management. Circulation. 2018;137:1391–406.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Wildman RP, Muntner P, Reynolds K, McGinn AP, Rajpathak S, Wylie-Rosett J, et al. The obese without cardiometabolic risk factor clustering and the normal weight with cardiometabolic risk factor clustering: prevalence and correlates of 2 phenotypes among the US population (NHANES 1999-2004). Arch Internal Med. 2008;168:1617–24.

    Article  Google Scholar 

  5. Blüher M. Metabolically healthy obesity. Endocr Rev. 2020;41:bnaa004.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Commodore-Mensah Y, Lazo M, Tang O, Echouffo-Tcheugui JB, Ndumele CE, Nambi V, et al. High burden of subclinical and cardiovascular disease risk in adults with metabolically healthy obesity: the atherosclerosis risk in communities (ARIC) study. Diabetes Care. 2021;44:1657–63.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  7. Zhou Z, Macpherson J, Gray SR, Gill JMR, Welsh P, Celis-Morales C, et al. Are people with metabolically healthy obesity really healthy? A prospective cohort study of 381,363 UK Biobank participants. Diabetologia. 2021;64:1963–72.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022;145:e895–e1032.

    PubMed  Google Scholar 

  9. Wang YC, Liang CS, Gopal DM, Ayalon N, Donohue C, Santhanakrishnan R, et al. Preclinical systolic and diastolic dysfunctions in metabolically healthy and unhealthy obese individuals. Circ Heart Fail. 2015;8:897–904.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  10. Dobson R, Burgess MI, Sprung VS, Irwin A, Hamer M, Jones J, et al. Metabolically healthy and unhealthy obesity: differential effects on myocardial function according to metabolic syndrome, rather than obesity. Int J Obesity. 2016;40:153–61.

    Article  CAS  Google Scholar 

  11. Lee HJ, Kim HL, Lim WH, Seo JB, Kim SH, Zo JH, et al. Subclinical alterations in left ventricular structure and function according to obesity and metabolic health status. PloS One. 2019;14:e0222118.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Wang Y, Liang J, Zheng S, He A, Chen C, Zhao X, et al. Combined associations of obesity and metabolic health with subclinical left ventricular dysfunctions: Danyang study. ESC Heart Fail. 2021;8:3058–69.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Tsai MC, Lee CC, Liu SC, Tseng PJ, Chien KL. Combined healthy lifestyle factors are more beneficial in reducing cardiovascular disease in younger adults: a meta-analysis of prospective cohort studies. Sci Rep. 2020;10:18165.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. Friedman GD, Cutter GR, Donahue RP, Hughes GH, Hulley SB, Jacobs DR Jr, et al. CARDIA: study design, recruitment, and some characteristics of the examined subjects. J Clin Epidemiol. 1988;41:1105–16.

    Article  CAS  PubMed  Google Scholar 

  15. Physical status: the use and interpretation of anthropometry. Report of a WHO Expert Committee. World Health Organ Tech Rep Ser. 1995;854:1–452.

    Google Scholar 

  16. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the third report of the National Cholesterol Education Program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III). JAMA. 2001;285:2486–97.

    Article  Google Scholar 

  17. Armstrong AC, Ricketts EP, Cox C, Adler P, Arynchyn A, Liu K, et al. Quality control and reproducibility in M-mode, two-dimensional, and speckle tracking echocardiography acquisition and analysis: the CARDIA study, year 25 examination experience. Echocardiography. 2015;32:1233–40.

    Article  PubMed  Google Scholar 

  18. Gidding SS, Xie X, Liu K, Manolio T, Flack JM, Gardin JM. Cardiac function in smokers and nonsmokers: the CARDIA study. The Coronary Artery Risk Development in Young Adults Study. J Am Coll Cardiol. 1995;26:211–6.

    Article  CAS  PubMed  Google Scholar 

  19. Ward ZJ, Bleich SN, Cradock AL, Barrett JL, Giles CM, Flax C, et al. Projected U.S. state-level prevalence of adult obesity and severe obesity. N Engl J Med. 2019;381:2440–50.

    Article  PubMed  Google Scholar 

  20. Kishi S, Armstrong AC, Gidding SS, Colangelo LA, Venkatesh BA, Jacobs DR Jr, et al. Association of obesity in early adulthood and middle age with incipient left ventricular dysfunction and structural remodeling: the CARDIA study (Coronary Artery Risk Development in Young Adults). JACC Heart Fail. 2014;2:500–8.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Wormser D, Kaptoge S, Di Angelantonio E, Wood AM, Pennells L, Thompson A, et al. Separate and combined associations of body-mass index and abdominal adiposity with cardiovascular disease: collaborative analysis of 58 prospective studies. Lancet. 2011;377:1085–95.

    Article  PubMed  Google Scholar 

  22. Lanoye A, Brown KL, LaRose JG. The transition into young adulthood: a critical period for weight control. Curr Diab Rep. 2017;17:114.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Visseren FLJ, Mach F, Smulders YM, Carballo D, Koskinas KC, Bäck M, et al. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J. 2021;42:3227–337.

    Article  PubMed  Google Scholar 

  24. Kuk JL, Ardern CI. Are metabolically normal but obese individuals at lower risk for all-cause mortality? Diabetes Care. 2009;32:2297–9.

    Article  PubMed  PubMed Central  Google Scholar 

  25. van Vliet-Ostaptchouk JV, Nuotio ML, Slagter SN, Doiron D, Fischer K, Foco L, et al. The prevalence of metabolic syndrome and metabolically healthy obesity in Europe: a collaborative analysis of ten large cohort studies. BMC Endocrine Disorders. 2014;14:9.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Slagter SN, Corpeleijn E, van der Klauw MM, Sijtsma A, Swart-Busscher LG, Perenboom CWM, et al. Dietary patterns and physical activity in the metabolically (un)healthy obese: the Dutch Lifelines cohort study. Nutr J. 2018;17:18.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Velho S, Paccaud F, Waeber G, Vollenweider P, Marques-Vidal P. Metabolically healthy obesity: different prevalences using different criteria. Eur J Clin Nutr. 2010;64:1043–51.

    Article  CAS  PubMed  Google Scholar 

  28. Lin H, Zhang L, Zheng R, Zheng Y. The prevalence, metabolic risk and effects of lifestyle intervention for metabolically healthy obesity: a systematic review and meta-analysis: a PRISMA-compliant article. Medicine. 2017;96:e8838.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Mulye TP, Park MJ, Nelson CD, Adams SH, Irwin CE Jr, Brindis CD. Trends in adolescent and young adult health in the United States. J Adolesc Health. 2009;45:8–24.

    Article  PubMed  Google Scholar 

  30. Eckel N, Li Y, Kuxhaus O, Stefan N, Hu FB, Schulze MB. Transition from metabolic healthy to unhealthy phenotypes and association with cardiovascular disease risk across BMI categories in 90 257 women (the Nurses’ Health Study): 30 year follow-up from a prospective cohort study. Lancet Diabetes Endocrinol. 2018;6:714–24.

    Article  PubMed  Google Scholar 

  31. Lee YB, Kim DH, Kim SM, Kim NH, Choi KM, Baik SH, et al. Hospitalization for heart failure incidence according to the transition in metabolic health and obesity status: a nationwide population-based study. Cardiovasc Diabetol. 2020;19:77.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Bray GA, Heisel WE, Afshin A, Jensen MD, Dietz WH, Long M, et al. The science of obesity management: an endocrine society scientific statement. Endocr Rev. 2018;39:79–132.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Khera R, Pandey A, Chandar AK, Murad MH, Prokop LJ, Neeland IJ, et al. Effects of weight-loss medications on cardiometabolic risk profiles: a systematic review and network meta-analysis. Gastroenterology. 2018;154:1309–19.e7.

    Article  PubMed  Google Scholar 

  34. Kramer CK, Zinman B, Retnakaran R. Are metabolically healthy overweight and obesity benign conditions? A systematic review and meta-analysis. Ann Internal Med. 2013;159:758–69.

    Article  Google Scholar 

  35. Eckel N, Meidtner K, Kalle-Uhlmann T, Stefan N, Schulze MB. Metabolically healthy obesity and cardiovascular events: a systematic review and meta-analysis. Eur J Prev Cardiol. 2016;23:956–66.

    Article  PubMed  Google Scholar 

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We thank all the staff and participants of the CARDIA study for their contributions. This study was supported by the National Natural Science Foundation of China (81870195, 82070384 to XL; 81900329 to YG), Guangdong Basic and Applied Basic Research Foundation (2019A1515011582, 2021A1515011668 to XL; 2019A1515011098, 2022A1515010416 to YG).

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XL, LP, PW and ML conceived and designed the study. XL, LP, PW, ML, XZ, ZX, YG, LH, ZZ and ZC contributed to the acquisition, analysis and interpretation of the data. PW and ML were responsible for writing the manuscript. All authors contributed to revising the manuscript draft for important intellectual content and approved the final submitted manuscript.

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Correspondence to Longyun Peng or Xinxue Liao.

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Wang, P., Liu, M., Zhuang, X. et al. Association of metabolically healthy obesity in young adulthood with myocardial structure and function. Int J Obes (2023).

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