Energy partitioning in gluteal-femoral fat: does the metabolic fate of triglycerides affect coronary heart disease risk?

Jean Vague from the University of Marseille was the first to foresee the importance of regional adipose tissue distribution when he suggested that a “male” pattern of body fat distribution, which he referred to as android obesity, was the form of obesity more likely to be accompanied by diabetes, hypertension, and heart disease, as opposed to the typical, rather benign, “female” pattern of body fatness, which he described as gynoid obesity.1 In the early 80’s, the late Per Björntörp from the University of Gothenburg in Sweden had come across Vague’s literature, and he took advantage of the availability of anthropometric variables such as waist and hip circumferences to develop a simple index of body fat distribution, the waist to hip ratio (WHR).2–5 Having access to two prospective studies of middle-aged men and women, the Swedish team found that the proportion of abdominal fat (as crudely appreciated by the WHR) was an independent risk factor for the development of cardiovascular disease and diabetes over a follow-up period of more than a decade.2,3 Simultaneously, in the United States, Ahmed Kissebah and his group6 also generated results emphasizing the importance of regional adipose tissue distribution as an important correlate of metabolic complications that had been, in the past, associated with excess weight per se. These results published in the early 80’s have generated great interest from the scientific and medical community, and over the last 20 years a flourishing and abundant literature has been published on the topic. As for many groups around the world, the publication of Björntörp’s early results raised our interest, and we initially focused our investigations on the study of the contribution of adipose tissue distribution to the variation of plasma lipid and lipoprotein levels. Using simple skinfold measurements as indices of subcutaneous fat accumulation, we first reported in 1985 that abdominal fat accumulation was a correlate of the reduced high-density lipoprotein (HDL)cholesterol levels found in obesity, whereas leg fat accumulation was not associated with any evidence of metabolic prejudice whatsoever.7 With the development of imaging techniques such as MRI or computed tomography, it has been possible to measure with greater accuracy regional adipose tissue accumulation and, particularly, to distinguish subcutaneous abdominal fat from the fat located in the abdominal cavity which we described as intra-abdominal or visceral adipose tissue. In an issue of this journal published 14 years ago,8 we reviewed the evidence that we had published at that time which had clearly indicated that a selective deposition of visceral adipose tissue was associated with a whole cluster of metabolic abnormalities which were later defined as the features of the metabolic syndrome. Thus, in 1990, we had already described the relationship between abdominal fat mass, visceral adipose tissue accumulation, and the features of the atherogenic dyslipidemia of the metabolic syndrome, which include hypertriglyceridemia, elevated apolipoprotein B concentration, an increased proportion of small low-density lipoprotein (LDL) particles, and reduced HDL-cholesterol levels, particularly in the cardioprotective HDL2 subfraction.8