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J Obes Metab Syndr 2025; 34(1): 4-13

Published online January 30, 2025 https://doi.org/10.7570/jomes24043

Copyright © Korean Society for the Study of Obesity.

Obesity Phenotypes, Lifestyle Medicine, and Population Health: Precision Needed Everywhere!

Jean-Pierre Després1,2,3,*, Dominic J. Chartrand1,2, Adrien Murphy-Després1,2, Isabelle Lemieux1, Natalie Alméras1,2

1Québec Heart and Lung Institute Research Centre–Laval University (Centre de recherche de l’Institut universitaire de cardiologie et de pneumologie de Québec – Université Laval), Québec, QC; 2Department of Kinesiology, Faculty of Medicine, Laval University (Université Laval), Québec, QC; 3VITAM–Research Centre on Sustainable Health (VITAM – Centre de recherche en santé durable), Integrated University Health and Social Services Centre of the Capitale-Nationale (Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale), Québec, QC, Canada

Correspondence to:
Jean-Pierre Després
https://orcid.org/0000-0002-5193-583X
VITAM-Research Centre on Sustainable Health (VITAM – Centre de recherche en santé durable), Integrated University Health and Social Services Centre of the Capitale-Nationale (Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale), 2480, chemin de la Canardière, Room 112, Québec, QC, G1J 2G1, Canada
Tel: +1-418-663-5313 (ext. 12260)
E-mail: jean-pierre.despres.ciussscn@ssss.gouv.qc.ca

Received: November 11, 2024; Reviewed : January 16, 2025; Accepted: January 16, 2025

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

The worldwide prevalence of obesity is a key factor involved in the epidemic proportions reached by chronic societal diseases. A revolution in the study of obesity has been the development of imaging techniques for the measurement of its regional distribution. These imaging studies have consistently reported that individuals with an excess of visceral adipose tissue (VAT) were those characterized by the highest cardiometabolic risk. Excess VAT has also been found to be accompanied by ectopic fat deposition. It is proposed that subcutaneous versus visceral obesity can be considered as two extremes of a continuum of adiposity phenotypes with cardiometabolic risk ranging from low to high. The heterogeneity of obesity phenotypes represents a clinical challenge to the evaluation of cardiometabolic risk associated with a given body mass index (BMI). Simple tools can be used to better appreciate its heterogeneity. Measuring waist circumference is a relevant step to characterize fat distribution. Another important modulator of cardiometabolic risk is cardiorespiratory fitness. Individuals with a high level of cardiorespiratory fitness are characterized by a lower accumulation of VAT compared to those with poor fitness. Diet quality and level of physical activity are also key behaviors that substantially modulate cardiometabolic risk. It is proposed that it is no longer acceptable to assess the health risk of obesity using the BMI alone. In the context of personalized medicine, precision lifestyle medicine should be applied to the field of obesity, which should rather be referred to as ‘obesities.’

Keywords: Health behavior, Obesity, Population health, Visceral obesity

Developed economies such as South Korea and Canada enjoy fairly high life expectancies. The recent track record of South Korea in this regard is commendable. Indeed, despite the coronavirus disease 2019 (COVID-19) crisis, this country has been able to slightly increase its life expectancy, now being ranked 3rd worldwide, a remarkable achievement compared to other countries (e.g., USA) where life expectancy has decreased during that challenging period.1

Irrespective of their longevity rankings, developed economies are facing the challenge of controlling costly health services and medical procedures that are too often used late in the health trajectory of our population, while our living and socio-economic environments too often force us to adopt lifestyle habits not compatible with human health.

This issue had already been recognized by a group of experts of the American Heart Association (AHA) who proposed, in 2010, to shift the focus from the management of cardiovascular disease (CVD) to the promotion of cardiovascular health.2 The implications of this paradigm shift are not trivial as this approach recognized the absolute necessity of reducing the burden of disease management on our healthcare system by trying to avoid the development of altered CVD risk factors in the first place, an ambitious objective defined as primordial prevention.2

In their effort to emphasize cardiovascular health, this AHA committee had to agree on criteria to define it. On the basis of an abundant literature, the experts identified three well-established biological risk factors (normal blood pressure, cholesterol, and glucose levels) and four behaviors (normal body mass index [BMI] as a crude marker of energy balance, enough physical activity, not smoking, and a healthy dietary pattern defined with simple dietary markers). When they explored the association between these features of the so-called ‘Life’s Simple 7,’ three key findings emerged: (1) There was a powerful discrimination of CVD risk observed as a function of increasing components of ideal cardiovascular health. In other words, the very few persons at ideal CVD risk were at very low risk of CVD events.3,4 (2) The prevalence of individuals meeting the seven criteria of ideal cardiovascular health was very low (below 1%).5-8 (3) Behaviors were essentially as powerful predictors of cardiovascular events as biological risk factors.5 Indeed, even among the subgroup of individuals with normal blood pressure, cholesterol, and glucose levels, not meeting the criteria for optimal behaviors was associated with a substantial increase in CVD risk.5 Results from several cohort studies that have performed similar analyses are clear: in order to optimally reduce the risk of CVD, behaviors matter.5,9

Recently, the AHA has added another behavior to define ideal cardiovascular health (sleep) and proposed to consider the BMI as a biological risk factor rather than a behavior but the concept remained the same: behaviors are as important to assess and manage as biological risk factors to prevent CVD.10 Unfortunately, surveys conducted in the medical community in Canada and in the USA have revealed that only a minority of physicians address the issue of diet and physical activity when dealing with a group of patients (those living with type 2 diabetes mellitus) in need of support to favour lifestyle changes.11,12 These results clearly indicate the need for health practitioners and their patients to base their jointly decided management approaches on all components of ideal cardiovascular health rather than limiting themselves to traditional biological CVD risk factors. Unfortunately, healthcare systems have not adapted their services to optimally assess and target behaviors relevant to cardiovascular health.

The same knowledge translation deficit could be raised regarding how obesity is diagnosed in clinical practice.13,14 Indeed, despite overwhelming evidence derived from sophisticated imaging techniques that the BMI is too crude of an anthropometric variable to discriminate the CVD risk associated with obesity,15,16 our communication activities about this condition too often involve excess weight, weight loss, and achieving a healthy weight.17,18

When proper imaging techniques are used such as computed tomography or magnetic resonance imaging, it is possible to detect and precisely assess the amount of fat located in various regions of the body. Reviewing the now abundant literature on this topic is way beyond the scope of this short review. However, it is now very well documented that individuals with a preferential accumulation of subcutaneous adipose tissue (particularly at the lower part of the body in hips and thighs) are at lower risk of CVD and type 2 diabetes mellitus than persons with a selective accumulation of adipose tissue in their abdominal cavity,19-22 a condition that has been referred to as visceral obesity.15,23,24 Thus, as even an individual presumed to have a normal BMI may nevertheless have a high accumulation of visceral adipose tissue, there is a need to rely on other metrics than the BMI to assess a patient’s health risk.

Furthermore, excess visceral adiposity can also be accompanied by increased accumulation of fat in normally lean tissues such as the liver, the heart, the kidney, the pancreas, and the skeletal muscle, a condition that has been described as ectopic fat deposition.25-27 Although persons with excess visceral adiposity tend to have more ectopic fat, there is considerable variation among individuals. For instance, less than 50% of individuals with visceral obesity have evidence of increased liver fat accumulation, whereas it appears that some people with excess visceral adiposity are relatively protected against excessive accumulation of liver fat.28,29 Reasons for these discordant phenotypes are not clear. With the proliferation of large cardiometabolic imaging studies, it is expected that some light will be shed on health conditions that have been traditionally related to obesity per se. This will become a very fertile area of investigation in the coming years. In summary, in this day and age, it is no longer acceptable to assess health risk of obesity on the basis of the BMI and we should refer to obesity phenotypes rather than to a single, homogeneous entity (Fig. 1).13,14

With the concept of ideal cardiovascular health and the importance of behaviors in the prevention of CVD, we have been interested in developing approaches where the heterogeneity of obesity and behaviors could be assessed in health care. On the basis of our previous work on the topic, we have proposed the use of four ‘lifestyle vital signs’: (1) waist circumference (as an index of abdominal adiposity); (2) cardiorespiratory fitness (CRF; as a physiological marker of the ability to perform physical activity); (3) overall diet quality; and (4) level of physical activity.30,31

Waist circumference

Three decades ago, we proposed the use of the waist circumference as a simple index of abdominal adiposity.32 Many studies have now confirmed that within every BMI category, an increase in waist circumference is predictive of an increased morbidity/mortality risk,16,33-38 the largest cohort having reported this phenomenon being from South Korea with more than 23 million adults studied.39

Cardiorespiratory fitness

CRF is the capacity to perform continuous vigorous physical activity/exercise and can be assessed by several simple field tests.40,41 Seminal studies published by Blair and colleagues42-45 and then confirmed by a very large body of literature have all shown that a low level of CRF (often defined by being in the lowest quintile of CRF for sex and age) is a powerful, if not the best, predictor of an increased risk of CVD and of other clinical outcomes.40,41

Overall diet quality

People do not eat macronutrients, they eat foods. Some experts in the field of clinical nutrition and nutritional epidemiology have raised the issue that we may have been too technical in our effort to educate the population about the features of healthy eating and that it may be easier for patients to understand food-based recommendations.46-50 Many cohort studies that have quantified overall dietary patterns on the basis of food-based questionnaires have shown their ability to contribute to the discrimination of health risk.51-55

Physical activity level

As for CRF, level of physical activity either reported by participants or directly measured by portable devices has been consistently associated with a reduced risk of developing a plethora of clinical outcomes.56-59 It is now very well established that a physically active lifestyle is cardioprotective, even in the absence of weight loss.60,61

Of course, measuring the above ‘lifestyle vital signs’ in clinical practice would minimally require human and financial resources and we have not been able to integrate these important markers into our publicly funded healthcare services.

We have therefore collaborated to develop a privately funded workplace health promotion program that would be offered to companies aiming at improving the lifestyle habits and the health of their employees. The health promotion program has been offered via a mobile cardiometabolic/cardiorespiratory health unit that would operate at worksites. The unit allows a complete health evaluation, has an in-house laboratory to perform the blood assays on-site and has a trailer with treadmills so that all the relevant metrics of ideal cardiovascular health plus our four ‘lifestyle vital signs’ are measured. All workers receive a complete and confidential health evaluation report with a major focus on their ‘lifestyle vital signs’ and their data are then anonymized for research purposes. Several papers have been published on this cohort of workers that has been growing in size since the introduction of this private program.30,31,51,62-64 A full review of the results that we have published with the use of this mobile cardiometabolic/cardiorespiratory health unit is beyond the scope of this short paper and the reader is referred to several articles for more details.30,31,51,62-64 However, some key findings should be highlighted.

From weight to waist: changing the conversation

Because of the evidence now available on the topic, weight loss was not a primary goal of this workplace health promotion program. Rather, in the discussion of their confidential health reports, our health professionals would explain the importance of regularly monitoring the waistline as an index of the amount of body fat more closely related to health than weight. Participants would be told that reducing their waistline by just a few centimeters would have a major impact on their health.37,65,66

CRF: the key vital sign

Apart from knowing that being fit is good for heart health, the vast majority of workers were unaware that a low level of CRF is more dangerous to their health than raised blood pressure, cholesterol, or glucose levels.40,41 For those with low CRF levels, discussions with our staff on simple approaches to increase their CRF would be entertained, making it a target for the next visit at the end of the program.

Overall diet quality

The food-based diet quality questionnaire that we used is based on 25 questions and generates a score that theoretically can range from 0 to 100.67 A score below 60 is considered as defining poor diet quality, between 60 and 75 is considered as good, whereas a score of 75 and above is excellent. Albeit about 50% of male workers had a diet of overall poor quality, only 10% had an excellent overall diet quality score.68 Women did better than men, with 30% of them having a low diet quality score and 21.5% having an excellent score.68 Because the score is based on foods, it did allow our staff to have personalized discussions with workers about food items that they should eat less and about those that they should eat more to increase the overall quality of their diet. This approach is easier to understand and follow by participants than a technical discussion about caloric restriction and macronutrient composition of the diet. Several large cohort studies have shown the value of this food-based substitution approach.54,69-71

Physical activity level

As regular moderate-to-vigorous physical activity is the modality that should be used to increase CRF,72 considerable emphasis is placed on physical activity modalities when participants receive their confidential report, particular attention being given to workers reporting not being active enough in their leisure time.

Several of our published analyses on our workplace cohort have clearly indicated the value of measuring and targeting the four ‘lifestyle vital signs’ described above (Fig. 2). For instance, when our workers were stratified on the basis of their physical activity and overall diet quality levels, we indeed reported that workers with good scores for both variables had the lowest prevalence of visceral obesity (estimated by the hypertriglyceridemic waist phenotype).68 Furthermore, when classified on the basis of both their CRF and diet quality score, the discrimination was even better across the groups.68 While CRF was a powerful discriminator of the presence/absence of hypertriglyceridemic waist, overall diet quality was also related, a finding confirming the notion that both physical activity/CRF and diet quality are important for the prevention of visceral obesity.

We have also developed a lifestyle risk score by classifying our workers into quartiles for each of our four variables: (1) waist circumference: highest quartile (4 risk points) to lowest quartile (1 risk point); (2) CRF: lowest quartile (4 risk points) to highest quartile (1 risk point); (3) overall diet quality score: lowest quartile (4 risk points) to highest quartile (1 risk point); and (4) physical activity level: lowest quartile (4 risk points) to highest quartile (1 risk point). The lifestyle risk score therefore ranged from 4 (low risk) to 16 (high risk). Without getting into the details of our findings, we reported that this lifestyle risk score was strongly related to the blood lipid profile, to glycosylated hemoglobin levels, and to blood pressure.31 Again, this is robust evidence that these ‘lifestyle vital signs’ are the driving force behind the altered biological risk factors and that they should be assessed and targeted in the public healthcare system.

Considering that the energy expenditure related to work has considerably declined over the last 50 years,73 we were also interested in examining more closely the contribution of leisure versus occupational physical activity in our cohort. When we specifically focussed on hypertriglyceridemic waist (as a surrogate marker of the presence of visceral obesity) and CRF as outcomes, we found that our workers who were sedentary at work but who reported being physically active during their leisure time were characterized by a low prevalence of visceral obesity and by a high level of CRF.64 This finding really emphasizes the importance of promoting regular physical activity during our leisure time to combat the deleterious effects of our sedentary occupations. Studies that have used accelerometry-derived measurements of physical activity have confirmed that about 30 to 40 minutes of moderate-to-vigorous physical activity per day can considerably, if not abolish, the risk associated with prolonged sitting time.74

As we have not been able to test the value of measuring and targeting ‘lifestyle vital signs’ in our publicly funded healthcare system, we have used our workplace program to examine the response to a 3-month lifestyle modification program. Details of the intervention have already been published.30,51,62 Table 1 provides a summary of our key findings. Even with an intervention not aiming at weight loss, on average participants lost approximately 2 kg (2.7% of their initial body weight) but more importantly reduced their waist circumference by 4 cm, a change that is predictive of considerable cardiometabolic benefits as described in Table 1. Several features of cardiometabolic risk were improved showing the value of targeting the driving force behind cardiometabolic risk: features of our lifestyle which can be measured with simple field tools.

From precision lifestyle medicine to precision population health: filling the gap!

Although we feel that there is now sufficient evidence to recommend that features of our lifestyle should be included among the markers to be considered by precision medicine approaches,75 even the best precision lifestyle medicine approach will not deal with the features of our socio-economic model that are also important determinants of our unhealthy behaviors. We also need to carefully monitor features of our living environments promoting cardiometabolic health versus disease.76 To achieve this ambitious goal, we will need to fill the gap between clinical/individual approaches and populations health. A simple but devastating example of this situation is the difference in life expectancy of patients living with type 2 diabetes mellitus depending upon their socio-economic status.77 Despite the fact that in Canada, we have (at least in theory) access to universal health care, the health trajectory of patients with low socio-economic status is markedly different from those who can afford to buy fruits and vegetables and pay for additional support/resources to improve their lifestyle.78 To do so, inclusive learning ecosystems should be developed where proximity health services and public health experts work in close coordination. Health democracy should be promoted and this will be achieved with a bottom-up citizen-centered approach.

The work of the authors discussed in this review paper has been and is currently supported by the Canadian Institutes of Health Research (CIHR) (Foundation grant: FDN-16778) and by the Fondation de l’Institut universitaire de cardiologie et de pneumologie de Québec. The workplace health promotion program discussed in the present review paper is the result of a consortium between the Grand Défi Entreprise Inc. and the Institut universitaire de cardiologie et de pneumologie de Québec – Université Laval. The Grand Défi Entreprise was not involved in any way in the study design, the conduction of the present study and did not participate in data analysis/interpretation or the writing of the present paper. Dominic J. Chartrand is a recipient of the Frederick Banting & Charles Best Canada Graduate Scholarships-Doctoral Award from the CIHR and of a doctoral training award from the Fonds de recherche du Québec – Santé (FRQS). Jean-Pierre Després is co-holder of the Chaire de recherche en santé durable funded by the FRQS.

Study concept and design: JPD and NA; acquisition of data: DJC, AMD, IL, and NA; analysis and interpretation of data: JPD, DJC, AMD, IL, and NA; drafting of the manuscript: JPD; critical revision of the manuscript: JPD, DJC, AMD, IL, and NA; statistical analysis: DJC, AMD, and IL; obtained funding: JPD and NA; administrative, technical, or material support: NA; and study supervision: JPD and NA.

Fig. 1. Obesity phenotypes and health risk. Although the body mass index (BMI) is related to clinical outcomes at the population level, it is a black box at the individual level because of the heterogeneity of overweight/obesity phenotypes. Adding waist circumference allows a better discrimination of health risk, particularly when accompanied by measurements of biological and behavioral risk factors.
Fig. 2. Proposed expanded model for the optimal prevention/management of cardiovascular disease (CVD). In addition to non-modifiable risk factors such as age, sex, and family history of premature CVD, (A) illustrates CVD risk factors considered in clinical practice. (B) Attention is given to ‘lifestyle vital signs’ that are proposed to modulate CVD risk beyond the contribution of traditional risk factors. *Lifestyle vital signs; †Triglycerides (TG): although circulating TG are not generally considered as a lipid target compared to low-density lipoprotein cholesterol, the combination of elevated waist circumference and increased TG levels is suggestive of the presence of a high-risk visceral obesity phenotype which contributes to further increase cardiometabolic risk beyond the contribution of traditional biological risk factors. BMI, body mass index; CRF, cardiorespiratory fitness.

Key findings of the 3-month workplace health promotion program30,51,62

2 kg decrease in body weight
4 cm decrease in waist circumference
6 mmHg decrease in systolic blood pressure and 4 mmHg decrease in diastolic blood pressure
Absolute decrease of 0.7% in HbA1c levels*
Improved overall lipid profile
Increased level of physical activity
Improved diet quality
60% decrease in smokers (from 13.2% to 5.3%)
Improved cardiorespiratory fitness
2.5-year decrease in vascular age

*In the subgroup of workers treated for type 2 diabetes mellitus.

HbA1c, glycosylated hemoglobin.

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