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Abdominal Visceral and Subcutaneous Adipose Tissue Compartments: Association With Metabolic Risk Factors in the Framingham Heart Study
Abstract
Background— Visceral adipose tissue (VAT) compartments may confer increased metabolic risk. The incremental utility of measuring both visceral and subcutaneous abdominal adipose tissue (SAT) in association with metabolic risk factors and underlying heritability has not been well described in a population-based setting. Methods and Results— Participants (n=3001) were drawn from the Framingham Heart Study (48% women; mean age, 50 years), were free of clinical cardiovascular disease, and underwent multidetector computed tomography assessment of SAT and VAT volumes between 2002 and 2005. Metabolic risk factors were examined in relation to increments of SAT and VAT after multivariable adjustment. Heritability was calculated using variance-components analysis. Among both women and men, SAT and VAT were significantly associated with blood pressure, fasting plasma glucose, triglycerides, and high-density lipoprotein cholesterol and with increased odds of hypertension, impaired fasting glucose, diabetes mellitus, and metabolic syndrome ( P range <0.01). In women, relations between VAT and risk factors were consistently stronger than in men. However, VAT was more strongly correlated with most metabolic risk factors than was SAT. For example, among women and men, both SAT and VAT were associated with increased odds of metabolic syndrome. In women, the odds ratio (OR) of metabolic syndrome per 1–standard deviation increase in VAT (OR, 4.7) was stronger than that for SAT (OR, 3.0; P for difference between SAT and VAT <0.0001); similar differences were noted for men (OR for VAT, 4.2; OR for SAT, 2.5). Furthermore, VAT but not SAT contributed significantly to risk factor variation after adjustment for body mass index and waist circumference ( P ≤0.01). Among overweight and obese individuals, the prevalence of hypertension, impaired fasting glucose, and metabolic syndrome increased linearly and significantly across increasing VAT quartiles. Heritability values for SAT and VAT were 57% and 36%, respectively. Conclusions— Although both SAT and VAT are correlated with metabolic risk factors, VAT remains more strongly associated with an adverse metabolic risk profile even after accounting for standard anthropometric indexes. Our findings are consistent with the hypothesized role of visceral fat as a unique, pathogenic fat depot. Measurement of VAT may provide a more complete understanding of metabolic risk associated with variation in fat distribution.
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“Body fat has better predictive validity on the development of the metabolic syndrome192 and cardiovascular disease risk193 than BMI.”
From Sarcopenic obesity in older adults: aetiology, epidemiology and treatment strategies (2018) · cites this paper as [192]
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“Moreover, ectopic fat depots, such as epicardial and perivascular fat, might exert local pathogenic effects on heart and blood vessels.[7][8][9]”
From Semaglutide and cardiovascular outcomes by baseline and changes in adiposity measurements: a prespecified analysis of the SELECT trial (2025) · cites this paper as [7]
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“In addition to the association between triglyceride levels and BMI, the Framingham Heart Study 155 reported strong associations of triglyceride levels with both subcutaneous abdominal adipose tissue and visceral adipose tissue in men and women (mean age 50 years).”
From Triglycerides and Cardiovascular Disease: A Scientific Statement From the American Heart Association (2011) · cites this paper as [155]
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“Thus, although it is clear that excess adiposity is associated with elevated triglyceride levels, visceral adiposity is a greater contributor than subcutaneous adipose tissue.155,156”
From Triglycerides and Cardiovascular Disease: A Scientific Statement From the American Heart Association (2011) · cites this paper as [155]
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“pose tissue (VAT) is metabolically active and has been found to correlate with obesity-related diseases (9).”
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“Recently, visceral obesity has been identified as an important factor in the development of metabolic disorders.(12) Several studies have reported that visceral obesity is correspondence: Mi hee Kong Department of Family Medicine, Jeju national University hospital, 15, aran 13-gil, Jeju-si, Jeju-do, 63241, republic of…”
Visceral adipose tissue in patients with COVID-19: risk stratification for severity
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“VAT is linked to metabolic syndrome, cardiovascular impairment, and increased susceptibility to infection and sepsis [15].”
BackgroundFeng, Y., Yang, X., Li, Y., Wu, Y., Han, M., Qie, R., Huang, S., Wu, X., Zhang, Y., Liu, D., et al. (2021) · Nutrition · doi:10.1016/j.nut.2021.111443 · Cited by 55
A Prospective Study of Abdominal Obesity and Coronary Artery Calcium Progression in Older Adults
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Inflammatory biomarker pentraxin 3 (PTX3) in relation to obesity, body fat depots and weight loss
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“Moreover, VAT depots are recognized to be more strongly associated with cardiometabolic disorders compared to SAT depots (37-40) and our study shows that visceral, but not subcutaneous adipose tissue, is associated with PTX3 serum levels.”
BackgroundLongitudinal Body Composition Changes Due to Dialysis
Pellicano, R., Strauss, B. J., Polkinghorne, K. R., & Kerr, P. G. (2011) · Clinical Journal of the American Society of Nephrology · doi:10.2215/cjn.06790810 · Cited by 55
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“The main component of the metabolic syndrome - visceral adipose tissue – seems to be strongly associated with cardio-metabolic risk factors, due to its metabolic activity (15).”
BackgroundRelations of Liver Fat With Prevalent and Incident Atrial Fibrillation in the Framingham Heart Study
Long, M. T., Yin, X., Larson, M. G., Ellinor, P. T., Lubitz, S. A., McManus, D. D., Magnani, J. W., Stærk, L., Ko, D., Helm, R. H., et al. (2017) · Journal of the American Heart Association · doi:10.1161/jaha.116.005227 · Cited by 55
“MDCT Protocol and Measurement of Liver Fat The MDCT substudy has been described in detail previously.(27) Briefly, participants underwent abdominal imaging (LightSpeed Ultra; General Electric, Milwaukee, WI) in the supine position with 25 contiguous 5-mm slices (120 kVp, 400 mA; gantry rotation time, 500 ms; table fee…”
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Allometric relationship between changes of visceral fat and total fat mass
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“individual, contributing to the development of certain diseases associated with the increase in fat accumulation [40,49].”
BackgroundVisceral fat mass: is it the link between uric acid and diabetes risk?
Seyedsadjadi, N., Berg, J., BILGIN, A. A. B., & Grant, R. (2017) · Lipids in Health and Disease · doi:10.1186/s12944-017-0532-4 · Cited by 54
“VAT may have differential metabolic risks compared to SAT [35].”
Adipose-derived stromal/stem cells from different adipose depots in obesity development
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21st Century Advances in Multimodality Imaging of Obesity for Care of the Cardiovascular Patient
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MethodInfluentialExercise, Physical Activity, and Cardiometabolic Health
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“Visceral WAT is strongly associated with increased cardiometabolic risk.(70,71) In contrast, scWAT may confer beneficial effects on insulin and glucose homeostasis and lipid metabolism.”
BackgroundAbdominal Visceral Adipose Tissue and All-Cause Mortality: A Systematic Review
Saad, R. K., Ghezzawi, M., Horanieh, R., Khamis, A. M., Saunders, K. H., Batsis, J. A., & Chakhtoura, M. (2022) · Frontiers in Endocrinology · doi:10.3389/fendo.2022.922931 · Cited by 56
“org 10 dyslipidemia (37, 38), and hypertension (39–41), in both younger and older individuals; risk that seemed independent of insulin resistance, BMI, and waist circumference (35, 39, 41).”
BackgroundVisceral adiposity and risk of coronary heart disease in relatively lean Chinese adults
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Multiple Adipose Depots Increase Cardiovascular Risk via Local and Systemic Effects
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Fat distribution in men of different waist girth, fitness level and exercise habit
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“In obesity, different fat depots are associated with differential metabolic risk (17).”
BackgroundCho, N. H., Oh, T. J., Kim, K. M., Choi, S. H., Lee, J. H., Park, K. S., Jang, H. C., Kim, J. Y., Lee, H. K., & Lim, S. K. (2015) · Scientific Reports · doi:10.1038/srep18565 · Cited by 53
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“Abdominal adipose tissue including subcutaneous (SAT) and visceral adipose tissue (VAT) has been widely recognized as a pathogenic phenotype.(2,5,6) In addition, recent studies suggested that qualitative aspects of adipose tissue, such as adipocyte size,(7) macrophage infiltration,(8) angiogenesis,(9) hypoxia,(10) and…”
BackgroundSelf-citationFujiyoshi, A., Miura, K., Kadowaki, S., Azuma, K., Tanaka, S., Hisamatsu, T., Arima, H., Kadota, A., Miyagawa, N., Takashima, N., et al. (2016) · Preventive Medicine Reports · doi:10.1016/j.pmedr.2016.06.013 · Cited by 48
“, 1990) and the same or similar ranges of attenuation have been adopted to estimate VAT/SAT in population studies (DeNino et al., 2001; Ding et al., 2008; Fox et al., 2007; Wheeler et al., 2005).”
BackgroundImpact of the cardiovascular system-associated adipose tissue on atherosclerotic pathology
Chistiakov, D. A., Grechko, A. V., Myasoedova, V. A., Melnichenko, A. А., & Orekhov, A. N. (2017) · Atherosclerosis · doi:10.1016/j.atherosclerosis.2017.06.017 · Cited by 54
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“(9) In the FHS, VAT volume and SAT volume are both correlated with metabolic risk factors; however, VAT is more strongly associated with an adverse metabolic risk profile.(26) Future studies aimed at the prevention and treatment of NAFLD should consider interventions aimed at improving visceral adiposity.”
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“According to previous studies, there were significant differences in the relationship of total body fat and hypertension between men and women.(33,34) Therefore, Cox regressions were stratified by sex, with hypertension as the end event and the time interval between baseline and hypertension diagnosis as the time vari…”
MethodAdipose tissue and the physiologic underpinnings of metabolic disease
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What Is “Metabolically Healthy Obesity”?: From Epidemiology to Pathophysiological Insights
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ERα upregulates Phd3 to ameliorate HIF-1 induced fibrosis and inflammation in adipose tissue
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“For example, women generally possess a higher total body fat percentage than men, but men tend to accrue a higher percentage of visceral adipose tissue (VAT) [23], which increases the risk of MetS and cardiovascular disease [24,25].”
Cellulite: Advances in treatment: Facts and controversies
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The Framingham Heart Study — 67 years of discovery in metabolic disease
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“Also, it is of note that studies investigating the association of childhood and adulthood obesity suggest that body fat and its distribution in the body are more important determinants of risk for cardiometabolic consequences including hypertension, rather than simply body weight status and level of obesity [10].”
BackgroundPeppler, W. T., Townsend, L. K., Knuth, C. M., Foster, M. T., & Wright, D. C. (2017) · American Journal of Physiology-Endocrinology and Metabolism · doi:10.1152/ajpendo.00226.2017 · Cited by 52
Imaging of body composition in children
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“Indeed, visceral adipose tissue (VAT) has been proven to have an important metabolic activity, secreting inflammatory markers into the portal circulation, with an increased effect on cardiometabolic risk (5).”
BackgroundElzinga, S. E., Savelieff, M. G., O’Brien, P. D., Mendelson, F. E., Hayes, J. M., & Feldman, E. L. (2021) · Disease Models & Mechanisms · doi:10.1242/dmm.048909 · Cited by 48
“…from a lean to an obese profile, which is characterized by VAT expansion, is linked to adverse metabolic health in both sexes, including IR (de Mutsert et al., 2018, Campos et al., 2019), dyslipidemia (Fox et al., 2007), and altered adipokine levels (Campos et al., 2019, Unamuno et al., 2018).”
BackgroundLee, M. H., Zea, R. D., Garrett, J. W., Graffy, P. M., Summers, R. M., & Pickhardt, P. J. (2022) · Radiology · doi:10.1148/radiol.220574 · Cited by 57
Ackermann, D., Jones, J. L., Barona, J., Calle, M. C., Kim, J. E., LaPia, B. J., Volek, J. S., McIntosh, M. S., Kalynych, C. J., Najm, W. I., et al. (2011) · Nutrition Research · doi:10.1016/j.nutres.2011.02.004 · Cited by 51
Application of alternative anthropometric measurements to predict metabolic syndrome
Sağun, G., Oğuz, A., Karagoz, E., Filizer, A. T., Tamer, G. I., & Mesçi, B. (2014) · Clinics · doi:10.6061/clinics/2014(05)09 · Cited by 51
Fat Distribution and Glucose Intolerance Among Greenland Inuit
Jørgensen, M. E., Borch‐Johnsen, K., Stolk, R. P., & Bjerregaard, P. (2013) · Diabetes Care · doi:10.2337/dc12-2703 · Cited by 51
“The Framingham Heart Study examined cross-sectionally the association between abdominal fat distribution determined by CT and various metabolic risk factors (7,8).”
BackgroundBrune, J. E., Kern, M., Kunath, A., Flehmig, G., Schön, M. R., Lohmann, T., Dreßler, M., Dietrich, A., Faßhauer, M., Kovacs, P. L., et al. (2015) · Obesity · doi:10.1002/oby.21317 · Cited by 51
Dalle, H., Garcia, M., Antoine, B., Boehm, V., Do, T. T. H., Buyse, M., Ledent, T., Lamazière, A., Magnan, C., Postic, C., et al. (2018) · Diabetes · doi:10.2337/db17-1577 · Cited by 51
“However high doses of GCs can lead to adverse effects, including hyperglycemia, dyslipidemia, insulin resistance, and lipodystrophy (2), which is characterized by an enlargement of visceral adipose tissue (VAT) at the expense of subcutaneous adipose tissue (SCAT).”
BackgroundChlorophyll Derivatives from Marine Cyanobacteria with Lipid-Reducing Activities
Freitas, S., Silva, N. G., Sousa, M. L., Ribeiro, T., Rosa, F., Leão, P. N., Vasconcelos, V. M., Reis, M. A., & Urbatzka, R. (2019) · Marine Drugs · doi:10.3390/md17040229 · Cited by 54
Han, Y., Tang, X., Han, M., Yang, J., Cardoso, M. A., Zhou, J., & Simó, R. (2021) · Ageing Research Reviews · doi:10.1016/j.arr.2021.101445 · Cited by 54
Metabolic Score for Visceral Fat: a novel predictor for the risk of type 2 diabetes mellitus
Feng, Y., Yang, X., Yang, L., Wu, Y., Han, M., Qie, R., Huang, S., Wu, X., Zhang, Y., Zhang, J.-L., et al. (2021) · British Journal Of Nutrition · doi:10.1017/s0007114521004116 · Cited by 50
“An increase in fat mass is considered to be an important risk factor for the incidence of T2DM worldwide(17–20), especially VAT mass which has been shown to be more harmful than fat stored elsewhere in the body(1,21,22).”
BackgroundWang, X., Wu, N., Sun, C., Jin, D., & Lu, H. (2023) · Diabetology & Metabolic Syndrome · doi:10.1186/s13098-023-01085-y · Cited by 54
“Considering the associations between the accumulation of adipose tissue (VAT, SAT and ectopic fat) and NAFLD with an increased risk of cardiometabolic disorders [6, 37, 42].”
BackgroundEngin, A. (2024) · Advances in experimental medicine and biology · doi:10.1007/978-3-031-63657-8_1 · Cited by 59
Association of lung function measurements and visceral fat in men with metabolic syndrome
Thijs, W., Dehnavi, R. A., Hiemstra, P. S., Roos, A., Melissant, C. F., Janssen, K., Tamsma, J. T., & Rabe, K. F. (2013) · Respiratory Medicine · doi:10.1016/j.rmed.2013.10.003 · Cited by 50
Schöttl, T., Kappler, L., Braun, K., Fromme, T., & Klingenspor, M. (2014) · Endocrinology · doi:10.1210/en.2014-1689 · Cited by 50
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“disease is mediated through the negative effect of excess visceral adiposity on risk factors such as blood pressure, blood lipids, insulin resistance, plasma glucose, and inflammatory markers.(10) Accurate screening of obesity in adults with CP is an important step toward identifying those with an increased risk of ca…”
BackgroundPrediction of Type 2 Diabetes Using Alternate Anthropometric Measures in a Multi-Ethnic Cohort
MacKay, M. F., Haffner, S. M., Wagenknecht, L. E., D'Agostino, R. B., & Hanley, A. J. (2009) · Diabetes Care · doi:10.2337/dc08-1663 · Cited by 50
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Dickson, L. M., Gandhi, S., Layden, B. T., Cohen, R., & Wicksteed, B. L. (2016) · American Journal of Physiology-Regulatory, Integrative and Comparative Physiology · doi:10.1152/ajpregu.00114.2016 · Cited by 51
VanWagner, L. B., Terry, J. G., Chow, L. S., Alman, A. C., Kang, H., Ingram, K. H., Shay, C. M., Lewis, C. E., Bryan, R. N., Launer, L. J., et al. (2017) · Obesity · doi:10.1002/oby.21767 · Cited by 50
“Different fat compartments carry differential metabolic risks (35), and there is evidence that abdominal obesity and visceral fat are more correlated with vascular risk than global body mass (36).”
Residential Proximity to Major Roadways, Fine Particulate Matter, and Hepatic Steatosis
Li, W., DORANS, K. S., Wilker, E. H., Rice, M. B., Long, M. T., Schwartz, J. D., Coull, B. A., Koutrakis, P., Gold, D. R., Fox, C. S., et al. (2017) · American Journal of Epidemiology · doi:10.1093/aje/kwx127 · Cited by 50
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German, M. N., Lutz, M. K., Pickhardt, P. J., Bruce, R. J., & Said, A. (2019) · Journal of Clinical Gastroenterology · doi:10.1097/mcg.0000000000001260 · Cited by 51
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“In fact, visceral adipose tissue (VAT) accumulation of central obesity, other than subcutaneous adipose tissue (SAT) accumulation of peripheral obesity, contributes to the high risk of metabolic diseases[3], including dyslipidemia, atherosclerosis, hypertension and diabetes[4].”
BackgroundLugones‐Sánchez, C., Sánchez-Calavera, M. A., Repiso-Gento, I., Adalia, E. G., Ramírez‐Manent, J. I., Agudo‐Conde, C., Rodríguez‐Sánchez, E., Gómez-Marcos, M. Á., Recio-Rodriguez, J. I., García‐Ortiz, L., et al. (2020) · JMIR mhealth and uhealth · doi:10.2196/21771 · Cited by 55
“In addition, BIA is the most cost-effective method of measuring body composition [26], making it a good alternative for its estimation.”
MethodIs Adipose Tissue Inflammation the Culprit of Obesity‐Associated Comorbidities?
Turner, L., Wanasinghe, A. I., Brunori, P., & Santosa, S. (2025) · Obesity Reviews · doi:10.1111/obr.13956 · Cited by 61
“Of all AT depots, the accumulation of VAT may be the greatest risk factor for the onset and progression of CVD [159, 160].”
Effect of alcohol on adipose tissue: a review on ethanol mediated adipose tissue injury
Kema, V. H., Mojerla, N. R., Khan, I., & Mandal, P. (2015) · Adipocyte · doi:10.1080/21623945.2015.1017170 · Cited by 50
Cho, N. H., Kim, K. M., Choi, S. H., Park, K. S., Jang, H. C., Kim, S. S., Sattar, N. A., & Lim, S. K. (2015) · Diabetes Care · doi:10.2337/dc14-1931 · Cited by 49
“ing expensive imaging techniques would be required to better inform on the associations between regional adiposity and metabolic disorders (34).”
BackgroundBody Fat Distribution, Adipocyte Size, and Metabolic Characteristics of Nondiabetic Adults
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“Furthermore, a one standard deviation increase in PLOSONE | DOI:10.1371/journal.pone.0123062 April 7, 2015 9 / 13 VAT before adjustment for waist circumference is associated with an increase in fasting glucose in the FHS [7] of ~ 4.0 mg/dl = 0.2 mmol/l that is almost identical to that found in our study (Fig 4).”
BackgroundInfluentialWildman, R. P., Janssen, İ., Khan, U. I., Thurston, R. C., Barinas‐Mitchell, E., Khoudary, S. R. E., Everson‐Rose, S. A., Kazlauskaite, R., Matthews, K. A., & Sutton-Tyrrell, K. (2011) · American Journal of Clinical Nutrition · doi:10.3945/ajcn.110.007153 · Cited by 49
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“Previous studies have highlighted the association between abdominal visceral fat and cardiometabolic risks [9–11], abdominal subcutaneous fat and metabolic syndromes [10, 12, 13], epicardial adipose tissue (EAT) adiposity and CAD risks [14–16], and regional-specific EAT * Correspondence: wu.”
BackgroundMetabolic Health Status and the Obesity Paradox in Older Adults
Cheng, F. W., Gao, X., Mitchell, D. C., Wood, C., Rolston, D. D. K., Still, C. D., & Jensen, G. L. (2016) · Journal of Nutrition in Gerontology and Geriatrics · doi:10.1080/21551197.2016.1199004 · Cited by 50
Association Between Posterior Left Atrial Adipose Tissue Mass and Atrial Fibrillation
van Rosendael, A. R., Dimitriu‐Leen, A. C., van Rosendael, P. J., Leung, M., Smit, J. M., Saraste, A., Knuuti, J. M., van der Geest, R. J., van der Arend, B. W. H., van Zwet, E. W., et al. (2017) · Circulation Arrhythmia and Electrophysiology · doi:10.1161/circep.116.004614 · Cited by 49
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Body composition and cardiometabolic health: the need for novel concepts
Bosy‐Westphal, A., Braun, W., Geisler, C., Norman, K., & Müller, M. J. (2018) · European Journal of Clinical Nutrition · doi:10.1038/s41430-018-0158-2 · Cited by 53
“mediated glucose uptake [13] or metabolic risk factors [14]”
Background
Metadata
- Authors
- Fox, C. S., Massaro, J. M., Hoffmann, U., Pou, K. M., Maurovich-Horvat, P., Liu, C.-Y., Vasan, R. S., Murabito, J. M., Meigs, J. B., Cupples, L. A., D’Agostino, R. B., & O’Donnell, C. J.
- Affiliations
- Boston University (US)
- From the National Heart, Lung and Blood Institute’s Framingham Heart Study (C.S.F., C.J.O.), Framingham, Mass; Division of Endocrinology, Metabolism, and Diabetes, Department of Medicine (C.S.F., K.M.P.), Brigham and Women’s Hospital and Harvard Medical School, Boston, Mass; Boston University, Department of Mathematics (J.M.M.; R.B.D.) and School of Public Health, Division of Biostatistics (C.-Y.L., L.A.C.), Boston, Mass; Radiology Department (U.H.) and Department of Medicine (J.B.M., C.J.O.),...
- ORCID
- Venue
- Circulation
- Published
- 2007-07-03
- Volume
- 116
- Issue
- 1
- Pages
- 39-48
- ISSN
- 0009-7322 (ISSN-L)
- 1524-4539
- OpenAlex
- W1989400130
- Cited by
- 2,882
- References
- 78
- Citations by year
- 2026: 102 · 2025: 163 · 2024: 172 · 2023: 164 · 2022: 190 · 2021: 196 · 2020: 162 · 2019: 161 · 2018: 161 · 2017: 157 · 2016: 182 · 2015: 182 · 2014: 184 · 2013: 151 · 2012: 124
- FWCI
- 68.66
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Circulation (publishedVersion)
- PubMed (publishedVersion)
- Funders
- National Institutes of Health (n01hc25195-41-0-1)
- National Heart, Lung, and Blood Institute (N01‐HC25195, K24HL004334)
- National Institute of Diabetes and Digestive and Kidney Diseases (T32DK007529)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Disease and Adiposity
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes, Cardiovascular Risks, and Lipoproteins
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Adipokines, Inflammation, and Metabolic Diseases
- Keywords
- visceral adipose tissue, subcutaneous adipose tissue, metabolic risk factors, metabolic syndrome, sex differences, hypertension, impaired fasting glucose, diabetes mellitus, body fat distribution, obesity, body mass index, waist circumference
- MeSH terms
- Adult, Calcium, Cardiovascular Diseases, Coronary Disease, Diabetes Mellitus, Female, Humans, Hypercholesterolemia, Hyperglycemia, Hypertension, Male, Middle Aged, Obesity, Organ Size, Risk, Sex Factors, United States, Hypertriglyceridemia, Cohort Studies, Comorbidity, Body Mass Index, Glucose Intolerance, Metabolic Syndrome, Tomography, Spiral Computed, Intra-Abdominal Fat, Overweight, Subcutaneous Fat, Abdominal
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