Loading
Cardiovascular Disease and Adiposity / Diabetes, Cardiovascular Risks, and Lipoproteins · Journal article
Journal of Istanbul Faculty of Medicine / İstanbul Tıp Fakültesi Dergisi · August 14, 2026
Raises a question worth testing. It does not answer one.
This is a critical letter that challenges the interpretation of an obesity paradox finding in diabetic coronary artery disease, arguing that body mass index alone is insufficient and that reverse causation, sarcopenia, and visceral adiposity distribution may better explain observed differences in angiographic disease complexity. The author proposes that prospective multicenter studies incorporating body composition and metabolic markers are needed to clarify the phenomenon.
Journal article. Patients with coexisting diabetes mellitus and coronary artery disease.
Obese diabetic patients had significantly lower SYNTAX scores than non-obese counterparts in the cited study Visceral adiposity is more strongly associated with chronic inflammation, insulin resistance, endothelial dysfunction, and adverse cardiovascular outcomes than BMI itself Lower BMI in non-obese individuals may reflect sarcopenia, occult malignancy, or advanced chronic disease rather than genuine protective effect
Visceral adiposity is more strongly associated with chronic inflammation, insulin resistance, endothelial dysfunction, and adverse cardiovascular outcomes than BMI itself
Clinicians should recognize that BMI-based classifications of obesity may not capture cardiometabolic risk adequately in diabetic patients with coronary disease, and that lower BMI may indicate frailty or underlying disease rather than protective status. Further research incorporating body composition and metabolic markers is required before drawing clinical conclusions from the obesity paradox.
This is a critical letter raising methodological concerns about an observational study's interpretation of the obesity paradox, proposing alternative explanations rather than presenting new empirical evidence.
Quoted from the source exactly as published.
Clinicians should recognize that BMI-based classifications of obesity may not capture cardiometabolic risk adequately in diabetic patients with coronary disease, and that lower BMI may indicate frailty or underlying disease rather than protective status. Further research incorporating body composition and metabolic markers is required before drawing clinical conclusions from the obesity paradox.
Graded across the dimensions that decide whether you should act, each from what the source actually supports. There is no single score, and where a dimension was not assessed it says so.
Dear Editor,I have read with great interest the recently published article entitled "The Obesity Paradox in the Coexistence of Diabetes and Coronary Artery Disease" by Aydoğan et al. (1). The authors demonstrated that obese individuals with diabetes mellitus had significantly lower SYNTAX scores than their non-obese counterparts, suggesting an inverse association between obesity, as defined by body mass index, and angiographic coronary disease complexity (1). Although obesity is widely recognized as a major risk factor for diabetes mellitus and atherosclerotic cardiovascular disease, numerous observational studies over the past two decades have paradoxically reported more favorable clinical outcomes among overweight or obese patients after the development of cardiovascular disease (2). Nevertheless, the underlying mechanisms responsible for this paradox remain incompletely understood. In this context, we believe that several issues deserve further consideration.Body mass index (BMI) is a limited anthropometric measure that does not adequately reflect body fat distribution or body composition. In particular, visceral adiposity has been shown to be more strongly associated with chronic inflammation, insulin resistance, endothelial dysfunction, and adverse cardiovascular outcomes than BMI itself. Therefore, incorporating additional parameters such as waist circumference, waist-to-height ratio, body fat percentage, or imaging-based assessment of visceral adipose tissue may provide a more accurate evaluation of cardiometabolic risk (3).Furthermore, reverse causation and residual confounding may substantially contribute to the observed obesity paradox. A lower BMI may reflect sarcopenia, occult malignancy, chronic inflammatory disorders, or advanced chronic diseases rather than indicating a genuinely protective effect of obesity. Consequently, the greater angiographic disease complexity observed in non-obese individuals may partly reflect differences in frailty, muscle mass, comorbidity burden, or underlying disease severity (4). Although the authors acknowledged the study’s methodological limitations, including its retrospective design and small sample size, future prospective multicenter studies incorporating nutritional status, skeletal muscle mass, and markers of metabolic health may provide a more comprehensive understanding of this phenomenon.
Taken from the source record, never inferred. Follow any of these and new work involving them reaches your briefing.