Title : When BMI misleads: Integrating body composition, biomarkers, and personalized interventions for cardiometabolic healthspan in aging Asian and European cohorts
Abstract:
Background: Body Mass Index (BMI) remains the cornerstone of cardiometabolic risk stratification. However, growing evidence suggests that BMI inadequately reflects adiposity, metabolic health, and vascular aging across diverse populations. In particular, Asian populations demonstrate disproportionately higher cardiometabolic risk at lower BMI thresholds compared with Europeans, raising concerns regarding the validity of current risk models.
Objectives: To examine ethnic differences in cardiometabolic aging between Asian and European populations, and to evaluate the limitations of BMI-centric frameworks in predicting cardiovascular risk and guiding therapeutic strategies.
Methods: This narrative review synthesizes data from epidemiological cohorts, imaging-based adiposity studies, and cardiometabolic biomarker analyses across Asian and European populations. Key domains include body fat distribution, insulin resistance, vascular stiffness, and clinical outcomes such as type 2 diabetes, heart failure with preserved ejection fraction, and atherosclerotic cardiovascular disease.
Results: Asian populations exhibit greater visceral adiposity and ectopic fat deposition at lower BMI, contributing to earlier onset of insulin resistance and endothelial dysfunction. These changes are accompanied by accelerated vascular aging, with higher prevalence of arterial stiffness and microvascular disease. Consequently, cardiometabolic conditions—including type 2 diabetes and HFpEF—often manifest at younger ages and lower BMI compared with European counterparts. Current BMI-based thresholds fail to capture this risk, leading to under-recognition and delayed intervention.
Conclusions: BMI alone is an insufficient surrogate for cardiometabolic risk across populations. Ethnicity-specific differences in fat distribution and metabolic vulnerability necessitate a shift toward more nuanced risk assessment incorporating waist measures, imaging, and biomarkers of biological aging. Revisiting guideline thresholds and adopting population-informed strategies may enable earlier intervention and improve long-term cardiovascular outcomes in high-risk groups.
