Metabolic health is a stronger determinant than obesity for cardiovascular disease incidence: a meta-analysis of longitudinal cohort studies
In brief
Unhealthy obesity doubles cardiovascular risk, while metabolic health can outweigh BMI
In a meta-analysis of 44 cohort studies, people with metabolically unhealthy obesity had about twice the cardiovascular disease risk of metabolically healthy people of normal weight. Poor metabolic health in normal-weight people often carried more risk than obesity with healthy metabolism, and was the main factor linked to stroke; these observational findings show why weight alone may miss risk.
- Journal
- International journal of obesity (2005) (Q1)
- Published
- 17 October 2026
- Study design
- Systematic review of cohort studies
- Evidence level
- Level 2, Moderate (CEBM 2a)
- Authors
- Zeinab Ghorbani, Sepideh Soltani, Dagfinn Aune, Nafiseh Khandouzi, Morvarid Noormohammadi, Asma Kazemi
- PMID
- 42892649
- DOI
- 10.1038/s41366-026-02237-6
Why clinicians should know about it
- Picked for Epidemiology (top studies of the week, 25 October 2026): Meta-analysis evaluates metabolic health and chronic cardiovascular disease risk
Abstract
Overweight and obesity are established risk factors for cardiovascular diseases (CVDs), yet heterogeneity in metabolic health among individuals with varied body mass index (BMI) complicates risk assessment. This systematic-review and meta-analysis of cohort studies investigated the risk of combined BMI-metabolic health phenotypes in relation to CVDs. PubMed and Scopus were searched up to January 2025. Metabolic phenotypes were defined as individuals with metabolically healthy normal weight (MHNW), metabolically healthy overweight (MHOW), metabolically healthy obesity (MHO), and their metabolically unhealthy counterparts, were analyzed for associations with CVD, coronary heart disease (CHD), myocardial infarction (MI), stroke, and heart failure (HF). Hazard ratios (HRs) and 95%confidence intervals (95% CIs) were pooled using random-effects models. Fifty-one publications (44 studies) were included. Compared with MHNW individuals, individuals with metabolically unhealthy obesity exhibited significantly higher risks across all cardiovascular outcomes with HRs of 2.10 (1.85-2.40) for CVD, 1.97 (1.71-2.27) for CHD, 2.20 (1.75-2.76) for MI, 1.55 (1.38-1.78) for stroke, and 2.05 (1.65-2.54) for HF. There was a positive dose-response relationship between both higher BMI and poor metabolic health and risk of CVD, CHD, MI, and HF incidence, however, associations for metabolically unhealthy normal weight subjects often exceeded that of metabolically healthy obese subjects. For stroke, poor metabolic health appears to be a primary determinant of risk. In conclusion, worsening metabolic health and higher BMI independently associated with increased CVD, CHD, MI, and HF risk, with their combination posing the greatest risk, while stroke risk was mainly associated with metabolic health.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.