ASEAN Heart Journal

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Original Article

ASEAN Heart Journal

December 2014, 22:19

First online: 19 December 2014

Original Article

Elevated cardiovascular risk factors in a young, asymptomatic and physically active population within a normal body mass index

Lee GK,1 Sim HW,1 Tan Y1 , Ma T,2 Liew KH,2 Tan EC,2 Lee LC, 3 Sum CF,4 Ong HY4
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  • About this Article


Obesity is associated with significant morbidity and mortality. The body mass index (BMI) is a simple and inexpensive technique to quantify obesity. In a low-risk population, we aim to determine the association of BMI with cardiovascular risk factors (CVRFs) including undiagnosed diabetes.

We studied 3026 subjects referred for routine health screening. Patients with pre-existing diabetes mellitus and/or vascular disease were excluded. Each subject had anthropometric measurements and CVRF parameters (blood pressure, fasting lipids and fasting glucose) taken.​

The mean age was 38.9 ± 5.4 years, 89.9% male. Chinese persons comprised 58.6% of our cohort, Malays 34.0% and Indians 7.4%. The majority (84.5%) of subjects were low-risk (10-year risk <10%) for cardiac events using the FRS algorithm. The mean BMI was 25.2kg/m2. A positive correlation was seen between BMI and prevalence of CVRFs (p<0.001 for all). Serum lipid levels worsen significantly beyond a BMI of 20.0kg/m2, while blood pressure worsens significantly beyond a BMI of 22.0kg/m2. A positive relationship between BMI and the prevalence of impaired fasting glucose and frank diabetes was noted for BMIs ≥20.0kg/m2 (p<0.001); no subject below 20.0kg/m2 had frank diabetes.

A significant proportion of our subjects with a normal (Asian) BMI of <23.0kg/m2 had elevated CVRFs on routine screening. The step-wise rise and additive nature of these CVRFs and her consistent correlation with a rising BMI of >20.0kg/ m2 suggest that traditional cardiovascular risk factors can be reduced to very low levels by weight reduction alone.

body mass index - Asian - diabetes mellitus - hypertension - hyperlipidemia

Open Access: This article is distributed under the terms of the Creative Commons Attribution License which permits any use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited.

Supplementary Material



1. Haslam DW, James WP. Obesity. Lancet. Oct 1 2005;366(9492):1197–1209.

2. Ezzati M, Lopez AD, Rodgers A, Vander Hoorn S, Murray CJ. Selected major risk factors and global and regional burden of disease. Lancet. Nov 2 2002;360(9343):1347–1360.

3. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA. Mar 10 2004;291(10):1238–1245.

4. Obesity: preventing and managing the global epidemic. Report of a WHO consultation. World Health Organ Tech Rep Ser. 2000;894:i–xii, 1–253.

5. Razak F, Anand SS, Shannon H, et al. Defining obesity cut points in a multiethnic population. Circulation. Apr 24 2007;115(16):2111–2118.

6. Wilson PW, D’Agostino RB, Sullivan L, Parise H, Kannel WB. Overweight and obesity as determinants of cardiovascular risk: the Framingham experience. Arch Intern Med. Sep 9 2002;162(16):1867–1872.

7.Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet. Jan 10 2004;363(9403):157–163.

8.Forouhi NG, Jenkinson G, Thomas EL, et al. Relation of triglyceride stores in skeletal muscle cells to central obesity and insulin sensitivity in European and South Asian men. Diabetologia. Aug 1999;42(8):932–935.

9. Jafar TH, Chaturvedi N, Pappas G. Prevalence of overweight and obesity and their association with hypertension and diabetes mellitus in an Indo-Asian population. CMAJ. Oct 24 2006;175(9):1071–1077.

10. Lear SA, Toma M, Birmingham CL, Frohlich JJ. Modification of the relationship between simple anthropometric indices and risk factors by ethnic background. Metabolism. Oct 2003;52(10):1295–1301.

11. Lovegrove JA, Brady LM, Lesauvage SV, Lovegrove SS, Minihane AM, Williams CM. Lack of association between central adiposity and lipaemia in UK Sikh men. Int J Obes RelatMetab Disord. Nov 2003;27(11):1373–1382.


12. Unwin N, Harland J, White M, et al. Body mass index, waist circumference, waist-hip ratio, and glucose intolerance in Chinese and Europid adults in Newcastle, UK. J Epidemiol Community Health. Apr 1997;51(2):160–166.

13. Chang CJ, Wu CH, Chang CS, et al. Low body mass index but high percent body fat in Taiwanese subjects: implications of obesity cutoffs. Int J Obes Relat Metab Disord. Feb 2003;27(2):253–259.


14. Chowdhury B, Lantz H, Sjostrom L. Computed tomography-determined body composition in relation to cardiovascular risk factors in Indian and matched Swedish males. Metabolism. May 1996;45(5):634–644.

15. Deurenberg-Yap M, Chew SK, Deurenberg P. Elevated body fat percentage and cardiovascular risks at low body mass index levels among Singaporean Chinese, Malays and Indians. Obes Rev. Aug 2002;3(3):209–215.

16. Deurenberg-Yap M, Chew SK, Lin VF, Tan BY, van Staveren WA, Deurenberg P. Relationships between indices of obesity and its co-morbidities in multi-ethnic Singapore. Int J Obes Relat Metab Disord. Oct 2001;25(10): 15541562.


17. Odegaard AO, Koh WP, Vazquez G, et al. BMI and diabetes risk in Singaporean Chinese. Diabetes Care. Jun 2009;32(6):1104–1106.

18. Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). JAMA. May 16 2001;285(19):2486–2497.

19. Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. May 21 2003;289(19):2560–2572.

20. Genuth S, Alberti KG, Bennett P, et al. Follow-up report on the diagnosis of diabetes mellitus. Diabetes Care. Nov 2003;26(11):3160–3167.

21. Wilson PW, D’Agostino RB, Levy D, Belanger AM, Silbershatz H, Kannel WB. Prediction of coronary heart disease using risk factor categories. Circulation. May 12 1998;97(18):1837–1847.

22. Zarich S, Luciano C, Hulford J, Abdullah A. Prevalence of metabolic syndrome in young patients with acute MI: does the Framingham Risk Score underestimate cardiovascular risk in this population? Diab Vasc Dis Res. Sep 2006;3(2):103–107.

23. Lee GK, Lee LC, Liu CW, et al. Framingham risk score inadequately predicts cardiac risk in young patients presenting with a first myocardial infarction. Ann Acad Med Singapore. Mar 2010;39(3):163–167.

24. Hu FB, Wang B, Chen C, et al. Body mass index and cardiovascular risk factors in a rural Chinese population. Am J Epidemiol. Jan 1 2000;151(1):88–97.

25. Tirosh A, Shai I, Afek A, et al. Adolescent BMI trajectory and risk of diabetes versus coronary disease. N Engl J Med. Apr 7 2011;364(14):1315–1325.

26. Jee SH, Sull JW, Park J, et al. Body-mass index and mortality in Korean men and women. N Engl J Med. Aug 24 2006;355(8):779–787.

27. Gu D, He J, Duan X, et al. Body weight and mortality among men and women in China. JAMA. Feb 15 2006;295(7):776–783.

28. Yuan JM, Ross RK, Gao YT, Yu MC. Body weight and mortality: a prospective evaluation in a cohort of middleaged men in Shanghai, China. Int J Epidemiol. Oct 1998;27(5):824–832.



29. Zhou BF. Effect of body mass index on all-cause mortality and incidence of cardiovascular diseases––report for metaanalysis of prospective studies open optimal cut-off points of body mass index in Chinese adults. Biomed Environ Sci. Sep 2002;15(3):245–252.

30. Zheng W, McLerran DF, Rolland B, et al. Association between body-mass index and risk of death in more than 1 million Asians. N Engl J Med. Feb 24 2011;364(8):719–729.

31. Human Development Report 2001. New York, NY: Oxford University Press; 2001.

32. Yun KE, Park HS, Song YM, Cho SI. Increases in body mass index over a 7-year period and risk of causespecific mortality in Korean men. Int J Epidemiol. Apr 2010;39(2):520–528.


33. Odegaard AO, Pereira MA, Koh WP, et al. BMI, all-cause and cause-specific mortality in Chinese Singaporean men and women: the Singapore Chinese health study. PLoS One. 2010;5(11):e14000.

PubMedCentral      PubMed       CrossRef


34. Hubert HB, Feinleib M, McNamara PM, Castelli WP. Obesity as an independent risk factor for cardiovascular disease: a 26-year follow-up of participants in the Framingham Heart Study. Circulation. May 1983;67(5):968–977.


35. Sowers JR. Obesity as a cardiovascular risk factor. Am J Med. Dec 8 2003;115 Suppl 8A:37S–41S.

36. Van Gaal LF, Mertens IL, De Block CE. Mechanisms linking obesity with cardiovascular disease. Nature. Dec 14 2006;444(7121):875–880.

About this Article

Elevated cardiovascular risk factors in a young, asymptomatic and physically active population within a normal body mass index

Open Access
Available under Open Access

Journal >> 22:1

Online Date
21 November 2019


Online ISSN

ASEAN Federation of Cardiology

Additional Links Cardiology

body mass index
diabetes mellitus

Author Affiliations
1. Department of Medicine, National University Health System, Singapore, Singapore
2. Health for Life Program, Khoo Teck Puat Hospital, Singapore, Singapore
3. Gleneagles Hospital Penang, Penang, Malaysia
4. Departments of Medicine and Cardiology, Khoo Teck Puat Hospital, 768828, 90 Yishun Central, Singapore, Singapore

Correspondence to: