Open Access Highly Accessed Research article

Beyond BMI: The “Metabolically healthy obese” phenotype & its association with clinical/subclinical cardiovascular disease and all-cause mortality -- a systematic review

Lara L Roberson1, Ehimen C Aneni1, Wasim Maziak3, Arthur Agatston1, Theodore Feldman1, Maribeth Rouseff2, Thinh Tran2, Michael J Blaha4, Raul D Santos5, Andrei Sposito6, Mouaz H Al-Mallah7, Ron Blankstein8, Matthew J Budoff9 and Khurram Nasir11034*

Author Affiliations

1 Center for Prevention and Wellness Research, Baptist Health Medical Group, Michigan Ave Suite 500, Miami Beach, Florida

2 Baptist Health South Florida, Miami, Florida

3 Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, Miami, Florida

4 The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland

5 Lipid Clinic Heart Institute, University of Sao Paulo Medical School Hospital, Sao Paulo, Brazil

6 Department of Cardiology, Faculty of Medical Sciences, State University of Campinas (Unicamp), Campinas, São Paulo, Brazil

7 King Abdul Aziz Cardiac Center, Riyadh, Saudi Arabia

8 Brigham and Women’s Hospital, Harvard School of Medicine, Boston, Massachusetts, USA

9 Los Angeles Biomedical Research Institute, Torrance, California, USA

10 Department of Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida

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BMC Public Health 2014, 14:14  doi:10.1186/1471-2458-14-14

Published: 8 January 2014



A subgroup has emerged within the obese that do not display the typical metabolic disorders associated with obesity and are hypothesized to have lower risk of complications. The purpose of this review was to analyze the literature which has examined the burden of cardiovascular disease (CVD) and all-cause mortality in the metabolically healthy obese (MHO) population.


Pubmed, Cochrane Library, and Web of Science were searched from their inception until December 2012. Studies were included which clearly defined the MHO group (using either insulin sensitivity and/or components of metabolic syndrome AND obesity) and its association with either all cause mortality, CVD mortality, incident CVD, and/or subclinical CVD.


A total of 20 studies were identified; 15 cohort and 5 cross-sectional. Eight studies used the NCEP Adult Treatment Panel III definition of metabolic syndrome to define “metabolically healthy”, while another nine used insulin resistance. Seven studies assessed all-cause mortality, seven assessed CVD mortality, and nine assessed incident CVD. MHO was found to be significantly associated with all-cause mortality in two studies (30%), CVD mortality in one study (14%), and incident CVD in three studies (33%). Of the six studies which examined subclinical disease, four (67%) showed significantly higher mean common carotid artery intima media thickness (CCA-IMT), coronary artery calcium (CAC), or other subclinical CVD markers in the MHO as compared to their MHNW counterparts.


MHO is an important, emerging phenotype with a CVD risk between healthy, normal weight and unhealthy, obese individuals. Successful work towards a universally accepted definition of MHO would improve (and simplify) future studies and aid inter-study comparisons. Usefulness of a definition inclusive of insulin sensitivity and stricter criteria for metabolic syndrome components as well as the potential addition of markers of fatty liver and inflammation should be explored. Clinicians should be hesitant to reassure patients that the metabolically benign phenotype is safe, as increased risk cardiovascular disease and death have been shown.