By Michael H. Crawford, MD
Professor of Medicine, Lucy Stern Chair in Cardiology, University of California, San Francisco
SYNOPSIS: Compared to normal-weight workers, overweight or obese employees in Spain exhibited a higher prevalence of risk factors for cardiovascular disease, which can be partially mitigated by regular exercise.
SOURCE: Valenzuela PL, Santao-Lozano A, Saco-Ledo G, et al. Obesity, cardiovascular risk, and lifestyle: Cross-sectional and prospective analyses in a nationwide Spanish cohort. Eur J Prev Cardiol 2023; Jun 15: zwad204. doi: 10.1093/eurjpc/zwad204. [Online ahead of print].
Controversy exists over whether being overweight or obese (OVO) independently predicts cardiovascular disease (CVD) risk factors, such as diabetes, hypercholesterolemia, and hypertension, and whether a healthy lifestyle can mitigate the development of such risk factors among OVO patients.
Investigators from Spain performed a cross-sectional study with prospective, longitudinal follow-up of Spanish workers age 18 to 64 years. These employees were covered by a health insurance company and had undergone initial medical exams, as well as two or more subsequent medical evaluations. In addition to medical information, the evaluations included questions about their frequency and intensity of aerobic physical activity as categorized by the World Health Organization. Researchers also collected data about sleep habits, smoking, and alcohol consumption.
Objective data included body mass index, total blood cholesterol (higher than 240 mg/dL = hypercholesterolemia), diabetes (fasting glycemia greater than 125 mg/dL), and hypertension (blood pressure higher than 140/90 mmHg). Participants’ cardiometabolic conditions were considered unhealthy if they exhibited one or more of these risk factors.
At baseline, the authors enrolled 596,111 workers (mean age = 44 years; 67% were men). The median follow-up for 302,061 workers was two years. The baseline prevalence of overweight and obese workers was 30% and 27%, respectively. Compared to normal-weight workers, overweight workers demonstrated a higher prevalence (OR, 1.67; 95% CI, 1.61-1.67) and incidence (OR, 1.62; 95% CI, 1.59-1.67) of an unhealthy cardiometabolic status. The authors reported similar results for obese workers (prevalence: OR, 2.70; 95% CI, 2.69-2.78 and incidence: OR, 2.7; 95% CI, 2.63-2.78). The OVO workers who met physical activity guidelines were at a lower risk of receiving an unhealthy cardiometabolic label at baseline (OR, 0.87; 95% CI, 0.85-0.88) and were less likely to transition from a healthy status to an unhealthy status during follow-up (OR, 0.87; 95% CI, 0.84-0.94). Not smoking carried a similar baseline association (OR, 0.88; 95% CI, 0.86-0.90), but other lifestyle factors did not provide this baseline protective effect. The incidence of developing an unhealthy cardiometabolic status over time was only attenuated by physical activity (OR, 0.87; 95% CI, 0.84-0.94). The authors concluded OVO status is independently associated with the prevalence and incidence of CVD risk factors. Regular physical activity attenuates both.
COMMENTARY
It is uncertain if obesity is the direct cause of CVD, although obesity often is considered one risk factor for developing CVD. A healthy lifestyle can lower the odds of developing CVD. Regular exercise is a proven technique for healthy living, but little evidence exists regarding the effects of other factors, such as sleep habits, smoking, and alcohol consumption.
Valenzuela et al addressed some of these issues by showing that carrying excess weight and obesity are independently associated with the prevalence and incidence of CVD risk factors, regardless of lifestyle. In addition, staying more physically active partially prevented the development of risk factors, especially among the overweight group. Surprisingly, other lifestyle factors were not associated with risk factor development during follow-up, but smoking was associated with risk factors at baseline.
The strengths of this study include its large size and the variety of lifestyles represented in a nationwide sample. Notably, the baseline prevalence data are crucial because only 1.3% of participants changed their cardiometabolic status over the short two-year median follow-up.
A prominent weakness was that lifestyle was self-reported. Also, there were no anthropometric data, such as waist circumference or body fat percentage. In addition, there were no data regarding diet or CV events. Nevertheless, this study strongly supports the CVD risk of living overweight or obese. Regular exercise is vital, especially among overweight patients, for preventing the development of CVD risk factors.
Compared to normal-weight workers, overweight or obese employees in Spain exhibited a higher prevalence of risk factors for cardiovascular disease, which can be partially mitigated by regular exercise.
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