title: Metabolically-healthy obesity and coronary artery calcification.
abstract: OBJECTIVE
  The purpose of this study was to compare the coronary artery calcium (CAC) scores of metabolically-healthy obese (MHO) and metabolically healthy normal-weight individuals in a large sample of apparently healthy men and women.
  
  
  BACKGROUND
  The risk of cardiovascular disease among obese individuals without obesity-related metabolic abnormalities, referred to as MHO, is controversial.
  
  
  METHODS
  We conducted a cross-sectional study of 14,828 metabolically-healthy adults with no known cardiovascular disease who underwent a health checkup examination that included estimation of CAC scores by cardiac tomography. Being metabolically healthy was defined as not having any metabolic syndrome component and having a homeostasis model assessment of insulin resistance <2.5.
  
  
  RESULTS
  MHO individuals had a higher prevalence of coronary calcification than normal weight subjects. In multivariable-adjusted models, the CAC score ratio comparing MHO with normal-weight participants was 2.26 (95% confidence interval: 1.48 to 3.43). In mediation analyses, further adjustment for metabolic risk factors markedly attenuated this association, which was no longer statistically significant (CAC score ratio 1.24; 95% confidence interval: 0.79 to 1.96). These associations did not differ by clinically-relevant subgroups.
  
  
  CONCLUSIONS
  MHO participants had a higher prevalence of subclinical coronary atherosclerosis than metabolically-healthy normal-weight participants, which supports the idea that MHO is not a harmless condition. This association, however, was mediated by metabolic risk factors at levels below those considered abnormal, which suggests that the label of metabolically healthy for obese subjects may be an artifact of the cutoff levels used in the definition of metabolic health.
authors.affiliation: Center for Cohort Studies, Total Healthcare Center, Kangbuk Samsung Hospital, Sungkyunkwan University, School of Medicine, Seoul, South Korea; Department of Occupational and Environmental Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University, School of Medicine, Seoul, South Korea.
authors.forename: Yoosoo
authors.initials: Y
authors.lastname: Chang
authors.affiliation: Center for Cohort Studies, Total Healthcare Center, Kangbuk Samsung Hospital, Sungkyunkwan University, School of Medicine, Seoul, South Korea.
authors.forename: Bo-Kyoung
authors.initials: BK
authors.lastname: Kim
authors.affiliation: Center for Cohort Studies, Total Healthcare Center, Kangbuk Samsung Hospital, Sungkyunkwan University, School of Medicine, Seoul, South Korea.
authors.forename: Kyung Eun
authors.initials: KE
authors.lastname: Yun
authors.affiliation: Departments of Epidemiology and Medicine and Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland; Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences and Technology, Sungkyunkwan University, Seoul, South Korea.
authors.forename: Juhee
authors.initials: J
authors.lastname: Cho
authors.affiliation: Departments of Epidemiology and Medicine and Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland.
authors.forename: Yiyi
authors.initials: Y
authors.lastname: Zhang
authors.affiliation: Departments of Epidemiology and Medicine and Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland; Department of Social and Preventive Medicine, Julius Centre University of Malaya, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
authors.forename: Sanjay
authors.initials: S
authors.lastname: Rampal
authors.affiliation: Departments of Epidemiology and Medicine and Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland.
authors.forename: Di
authors.initials: D
authors.lastname: Zhao
authors.affiliation: Center for Cohort Studies, Total Healthcare Center, Kangbuk Samsung Hospital, Sungkyunkwan University, School of Medicine, Seoul, South Korea.
authors.forename: Hyun-Suk
authors.initials: HS
authors.lastname: Jung
authors.affiliation: Center for Cohort Studies, Total Healthcare Center, Kangbuk Samsung Hospital, Sungkyunkwan University, School of Medicine, Seoul, South Korea.
authors.forename: Yuni
authors.initials: Y
authors.lastname: Choi
authors.affiliation: Center for Cohort Studies, Total Healthcare Center, Kangbuk Samsung Hospital, Sungkyunkwan University, School of Medicine, Seoul, South Korea.
authors.forename: Jiin
authors.initials: J
authors.lastname: Ahn
authors.affiliation: Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: João A C
authors.initials: JA
authors.lastname: Lima
authors.affiliation: Department of Family Medicine, Kangbuk Samsung Hospital and Sungkyunkwan University School of Medicine, Seoul, South Korea.
authors.forename: Hocheol
authors.initials: H
authors.lastname: Shin
authors.affiliation: Departments of Epidemiology and Medicine and Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland.
authors.forename: Eliseo
authors.initials: E
authors.lastname: Guallar
authors.affiliation: Center for Cohort Studies, Total Healthcare Center, Kangbuk Samsung Hospital, Sungkyunkwan University, School of Medicine, Seoul, South Korea; Department of Occupational and Environmental Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University, School of Medicine, Seoul, South Korea. Electronic address: sh703.yoo@gmail.com.
authors.forename: Seungho
authors.initials: S
authors.lastname: Ryu
mesh_terms: D000328:Adult; D003324:Coronary Artery Disease / Q000175:diagnosis* / Q000453:epidemiology / Q000378:metabolism*; D003430:Cross-Sectional Studies; D005260:Female; D006304:Health Status; D006801:Humans; D008297:Male; D008875:Middle Aged; D009765:Obesity / Q000175:diagnosis* / Q000453:epidemiology / Q000378:metabolism*; D056910:Republic of Korea / Q000453:epidemiology; D061205:Vascular Calcification / Q000175:diagnosis* / Q000453:epidemiology / Q000378:metabolism*
keywords: cardiovascular disease; coronary artery calcium score; coronary artery disease; metabolically-healthy obesity; obesity