A recent study discovered an association between visceral and, to a lesser extent, hepatic fat with cardiovascular risk factors and carotid atherosclerosis. This association persists even after adjusting for cardiovascular risk factors [1].
Beyond BMI
Body mass index (BMI) is a metric that compares height to total weight, including fat located under the skin (subcetaneous fat). It is easy to calculate, which is part of why it is a standard measurement of health. Some scientific studies use BMI in the assessment of health and disease risk, and they associate high BMI with many health risks, including cardiometabolic risk and various diseases [2].
However, there might be better metrics than BMI for assessing health-related risk. The researchers find that accumulation of fat around the visceral organs (visceral adipose tissue) and fat within the liver (hepatic fat) are both related to cardiometabolic risk and arteriosclerosis and can be a better reflection of those risks than BMI. Visceral fat is also linked to multiple conditions, such as type 2 diabetes mellitus (T2DM), hypertension, elevated cholesterol, increased inflammation, reduced cognitive function, and cancers [3, 4].
Large cohorts with precise data
In a recent study, the researchers set out to investigate whether visceral adipose tissue and hepatic fat are associated with carotid atherosclerosis, a condition defined as a buildup of plaques in the carotid arteries that supply blood to the brain.
They used the data from two cohorts: The Canadian Alliance for Healthy Hearts and Minds (CAHHM), which included 6,760 Canadians with a mean age of 57.1, and the UK Biobank (UKB), which included 26,547 participants with a mean age of 54.7. While the number of analyzed participants makes it a large sample size, which adds to the strength of the analysis, the cohort was mainly of European heritage, which limits the generalizability of the results to other races and ethnicities.
The datasets included information regarding health, demographics, and lifestyle. To measure carotid atherosclerosis, they used an MRI scan of the abdomen and carotid arteries (CAHHM) and an ultrasound of carotid intima-media thickness (CIMT), which is the thickness of the inner two layers of the carotid arterial wall (UKB). The authors note that the MRI assessment yields the most accurate data; it is more sensitive than an ultrasound of carotid intima-media thickness and is much better than some indirect measures, such as waist circumference or elevated liver function tests.
Positive associations
The Canadian cohort reported that visceral adipose tissue and hepatic fat fraction were associated with higher cardiovascular risk factor burden and higher odds of hypertension, diabetes mellitus, and dyslipidemia. They also noted that an increase in visceral adipose tissue volume, but not hepatic fat fraction, was associated with a higher carotid wall volume, which persisted after adjustment for cardiovascular risk factors.
The United Kingdom cohort showed a positive association between visceral adipose tissue volume and carotid-intima media thickness, as well as between hepatic fat fraction and carotid-intima media thickness, even after adjustment for cardiovascular risk factors.
The researchers also pooled the data from both studies. This analysis showed a positive association of visceral adipose tissue and hepatic fat fraction with metrics of carotid atherosclerosis, even after adjustment for cardiovascular risk factors. However, authors advise caution when interpreting those results, as the two polled studies used different measurements of carotid atherosclerosis.
Adding to the evidence
“This study shows that even after accounting for traditional cardiovascular risk factors like cholesterol and blood pressure, visceral and liver fat still contribute to artery damage,” said Russell de Souza, co-lead author of the study and a faculty member in the Mary Heersink School of Global Health and Social Medicine, and member of the Centre for Metabolism, Obesity and Diabetes Research (MODR) and at McMaster. “The findings are a wake-up call for clinicians and the public alike.”
This study adds to the growing body of evidence about visceral fat’s impact on health and cardiovascular disease risks. Previous studies on hepatic fat are less clear about its relationship to the development of cardiovascular diseases; some show the association between hepatic fat and the risk of such diseases, while others don’t [5-8].
Visceral fat is emerging as an important biomarker for cardiovascular conditions. As the authors wrote, “the International Atherosclerosis Society and International Chair on Cardiometabolic Risk Working Group on Visceral Obesity hold the position that among adiposity measures, visceral fat is the strongest predictor of adverse CV risk and is a better predictor of subclinical atherosclerosis than waist circumference” [3].
Visceral or liver “fat is metabolically active and dangerous; it’s linked to inflammation and artery damage even in people who aren’t visibly overweight. That’s why it’s so important to rethink how we assess obesity and cardiovascular risk,” said Sonia Anand, the corresponding author of the study, a vascular medicine specialist at Hamilton Health Sciences and a professor in the Department of Medicine at McMaster. “You can’t always tell by looking at someone whether they have visceral or liver fat.”
As of now, the primary way to reduce visceral and hepatic fat is through changing behavior, and in this study, the authors recommend exercising, maintaining a healthy body weight, and changing to a Mediterranean diet while avoiding food generally considered ‘unhealthy’, such as foods that are fried, heavily processed, or have dded sugar. They also suggest that time-restricted eating, very low-calorie ketogenic diets, and low-fat vegan diets may have a positive effect.
Literature
[1] de Souza, R. J., Pigeyre, M. E., Schulze, K. M., Lamri, A., Al-Khazraji, B. K., Awadalla, P., Beyene, J., Desai, D., Despres, J. P., Dummer, T. J. B., Friedrich, M. G., Hicks, J., Ho, V., LaRose, É., Lear, S. A., Lee, D. S., Leipsic, J. A., Lettre, G., Moody, A. R., Noseworthy, M. D., … Anand, S. S. (2025). Visceral adipose tissue and hepatic fat as determinants of carotid atherosclerosis. Communications medicine, 5(1), 424.
[2] Brixner, D., Ghate, S. R., McAdam-Marx, C., Ben-Joseph, R., & Said, Q. (2008). Association between cardiometabolic risk factors and body mass index based on diagnosis and treatment codes in an electronic medical record database. Journal of managed care pharmacy : JMCP, 14(8), 756–767.
[3] Neeland, I. J., Ross, R., Després, J. P., Matsuzawa, Y., Yamashita, S., Shai, I., Seidell, J., Magni, P., Santos, R. D., Arsenault, B., Cuevas, A., Hu, F. B., Griffin, B., Zambon, A., Barter, P., Fruchart, J. C., Eckel, R. H., International Atherosclerosis Society, & International Chair on Cardiometabolic Risk Working Group on Visceral Obesity (2019). Visceral and ectopic fat, atherosclerosis, and cardiometabolic disease: a position statement. The lancet. Diabetes & endocrinology, 7(9), 715–725.
[4] Anand, S. S., Friedrich, M. G., Lee, D. S., Awadalla, P., Després, J. P., Desai, D., de Souza, R. J., Dummer, T., Parraga, G., Larose, E., Lear, S. A., Teo, K. K., Poirier, P., Schulze, K. M., Szczesniak, D., Tardif, J. C., Vena, J., Zatonska, K., Yusuf, S., Smith, E. E., … Canadian Alliance of Healthy Hearts and Minds (CAHHM) and the Prospective Urban and Rural Epidemiological (PURE) Study Investigators (2022). Evaluation of Adiposity and Cognitive Function in Adults. JAMA network open, 5(2), e2146324.
[5] Al Rifai, M., Silverman, M. G., Nasir, K., Budoff, M. J., Blankstein, R., Szklo, M., Katz, R., Blumenthal, R. S., & Blaha, M. J. (2015). The association of nonalcoholic fatty liver disease, obesity, and metabolic syndrome, with systemic inflammation and subclinical atherosclerosis: the Multi-Ethnic Study of Atherosclerosis (MESA). Atherosclerosis, 239(2), 629–633.
[6] Mellinger, J. L., Pencina, K. M., Massaro, J. M., Hoffmann, U., Seshadri, S., Fox, C. S., O’Donnell, C. J., & Speliotes, E. K. (2015). Hepatic steatosis and cardiovascular disease outcomes: An analysis of the Framingham Heart Study. Journal of hepatology, 63(2), 470–476.
[7] Pisto, P., Santaniemi, M., Bloigu, R., Ukkola, O., & Kesäniemi, Y. A. (2014). Fatty liver predicts the risk for cardiovascular events in middle-aged population: a population-based cohort study. BMJ open, 4(3), e004973.
[8] Kotronen, A., & Yki-Järvinen, H. (2008). Fatty liver: a novel component of the metabolic syndrome. Arteriosclerosis, thrombosis, and vascular biology, 28(1), 27–38.
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