Central Adiposity May Predict Cardiovascular Risk Better Than BMI Alone, Major Study Finds

Central Fat May Reveal Heart Risk That BMI Misses

A major study published in the Journal of the American College of Cardiology (JACC) suggests that doctors may need to look beyond body mass index (BMI) when assessing a person’s risk of heart disease and other cardiovascular conditions.

Researchers from the Cross-Cohort Collaboration (CCC) Obesity Working Group found that two simple measurements — waist circumference (WC) and waist-to-hip ratio (WHR) — can provide important information about cardiovascular risk that BMI categories alone may fail to capture.

The study, published on 11 August 2026, analysed health data from 259,388 adults who did not have coronary heart disease (CHD) at the beginning of the research.

After a median follow-up period of approximately 20 years, researchers found substantial differences between people’s BMI classifications and the amount of fat stored around their waist.

The findings suggest that where body fat is stored may be just as important as how much a person weighs when assessing long-term cardiovascular health.

What Is Central Adiposity?

Central adiposity refers to the accumulation of excess fat around the abdomen and waist.

Unlike BMI, which estimates body size based on height and weight, waist measurements provide information about fat distribution.

Two measurements were particularly important in this study:

Waist circumference (WC): Measures the size of the waist and provides an indication of abdominal fat.
Waist-to-hip ratio (WHR): Compares waist measurement with hip measurement to assess how body fat is distributed.

This distinction matters because two people can have the same BMI while having very different levels of abdominal fat.

Fat concentrated around the abdomen is often considered more metabolically active and has been associated with several health problems, including cardiovascular disease.

A Large Study With Nearly 260,000 Participants

The researchers pooled information from 15 prospective cohorts supported by the US National Institutes of Health (NIH) and National Heart, Lung, and Blood Institute (NHLBI).

Key study details

Participants: 259,388 adults
Baseline condition: No coronary heart disease
Data source: 15 prospective NIH/NHLBI CCC cohorts
Median follow-up: 20 years
Main measurements: BMI, waist circumference and waist-to-hip ratio
Clinical outcomes: Nine cardiovascular and mortality outcomes

The researchers examined whether central adiposity was associated with a range of serious cardiovascular events and causes of death.

The Nine Health Outcomes Examined

The analysis looked at:

Fatal and non-fatal myocardial infarction (heart attack)
Fatal and non-fatal stroke
Heart failure
Atrial fibrillation
Total coronary heart disease
Total cardiovascular disease
Coronary heart disease mortality
Cardiovascular mortality
All-cause mortality

The long follow-up period allowed researchers to examine how body-fat distribution was associated with cardiovascular outcomes over decades.

BMI Does Not Always Tell the Full Story

One of the most striking findings was the discordance between BMI categories and central adiposity.

Some people classified as having normal weight according to BMI still had elevated levels of abdominal fat.

At the same time, some people classified as having obesity had relatively low waist measurements.

Among participants classified as normal weight:

5% had elevated waist circumference
18% had elevated waist-to-hip ratio

Among participants classified as having obesity:

9% had low waist circumference
45% had low waist-to-hip ratio

These figures highlight why BMI alone may not provide a complete picture of cardiovascular risk.

Higher Waist Measurements Were Linked to Greater Cardiovascular Risk

The study found that elevated waist circumference and waist-to-hip ratio were generally associated with a 15% to 50% higher risk of most of the nine clinical outcomes among people in normal-weight and overweight BMI categories.

This is particularly important because someone can fall within a BMI range that appears relatively reassuring while still carrying a substantial amount of abdominal fat.

In other words, a person’s BMI may look healthy on paper, but their waist measurement could reveal an additional cardiovascular risk signal.

Abdominal Fat Was Particularly Important Among People With Obesity

Researchers also found that central adiposity accounted for a substantial proportion of cardiovascular events among participants with obesity.

According to the analysis, central adiposity was associated with approximately 13% to 49% of cardiovascular events in this group.

Elevated waist circumference was particularly notable for several outcomes.

Among participants with obesity, elevated waist circumference was associated with:

46% of atrial fibrillation events
49% of heart failure events
36% of coronary heart disease deaths

These findings do not mean that abdominal fat directly caused every individual event. Rather, they indicate the substantial contribution of elevated central adiposity to cardiovascular outcomes within the study population.

What Happens When Someone Has Obesity but a Lower Waist Measurement?

The study also produced an interesting finding among people classified as having obesity by BMI.

Participants with obesity but low waist circumference generally had cardiovascular risk profiles similar to normal-weight participants with low waist circumference.

There was one notable difference: their risk of all-cause mortality was significantly lower.

By contrast, participants with obesity who also had high waist circumference or high waist-to-hip ratio experienced substantially higher event rates.

This further supports the argument that body-fat distribution can add valuable information to BMI-based assessment.

Experts Say BMI Alone May Misclassify Cardiovascular Risk

Michael J. Blaha, MD, MPH, senior author of the study and director of clinical research at the Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, highlighted the importance of the findings.

The researchers observed that some people considered to have normal weight according to BMI nevertheless had elevated central adiposity and high waist-to-hip ratios.

According to the study team, these individuals showed higher risks across most of the cardiovascular outcomes examined.

Lead author Zeina Dardari, PhD, MS, also warned that relying exclusively on BMI could lead to cardiovascular risk being misclassified across a broad range of outcomes.

The researchers encouraged clinicians to consider central fat distribution across the entire BMI spectrum, particularly when assessing cardiovascular risk for primary prevention.

Editorial: It May Be Time to Look Beyond BMI

An accompanying editorial by Kershaw Patel, MD, and Neela Thangada, MD, argues that BMI-based assessment does not comprehensively capture cardiovascular risk.

The editorial emphasises that central adiposity measurements can refine cardiovascular risk estimates across different BMI categories.

This represents an important shift in the way obesity and cardiovascular health may be considered.

BMI remains a useful and simple population-level measurement, but it does not distinguish between:

Muscle and fat
Visceral and subcutaneous fat
Different patterns of body-fat distribution
People with the same BMI but different metabolic risk profiles

Adding waist circumference and waist-to-hip ratio may therefore give clinicians a broader understanding of an individual’s cardiovascular risk.

Why Waist Circumference Matters for Heart Health

The findings reinforce an increasingly important concept in obesity research: fat distribution matters.

Abdominal fat can be associated with metabolic disturbances and cardiovascular problems, meaning that two people with identical body weights may not necessarily have identical health risks.

A BMI calculation might therefore be only the starting point rather than the complete assessment.

JACC’s Editor-in-Chief Calls for a Broader Approach

Harlan M. Krumholz, MD, SM, MACC, Editor-in-Chief of JACC, said the study provides strong evidence that cardiovascular assessment should not focus exclusively on BMI.

The large-scale analysis, involving hundreds of thousands of participants, demonstrates that waist circumference and waist-to-hip ratio provide important information about cardiovascular risk — including among people whose BMI falls within the normal range.

The broader message is simple: where fat is stored matters.

What the Findings Could Mean for Doctors and Patients

The study does not suggest that BMI should simply be abandoned.

Instead, it supports a more comprehensive approach to cardiovascular risk assessment.

Healthcare professionals may consider combining:

BMI
Waist circumference
Waist-to-hip ratio
Blood pressure
Cholesterol levels
Blood glucose and diabetes risk
Smoking status
Physical activity
Family history
Age and other established cardiovascular risk factors

Looking at several measures together can provide a more complete picture than relying on one number.

Important Takeaways From the Study

1. BMI is useful, but it has limitations

BMI can classify people according to weight relative to height, but it cannot show where fat is located.

2. Waist measurements provide additional information

Waist circumference and waist-to-hip ratio can identify increased central adiposity that BMI may overlook.

3. Normal BMI does not always mean low cardiovascular risk

Some people with normal BMI still had elevated waist measurements and experienced higher risks of cardiovascular outcomes.

4. Abdominal fat was strongly linked with several cardiovascular outcomes

Higher central adiposity was associated with increased risks of heart attack, stroke, heart failure, atrial fibrillation, coronary heart disease and mortality outcomes.

5. People with obesity can have different risk profiles

Participants with obesity and lower central adiposity generally had lower cardiovascular risk than those with obesity and high waist measurements.

What Patients Should Know

The findings should not be interpreted as meaning that everyone should become focused on their waist measurement or attempt to lose weight without professional advice.

Instead, the study highlights the importance of looking at overall cardiovascular health rather than relying on BMI alone.

If you are concerned about your cardiovascular risk, a healthcare professional can assess your weight, waist measurement, blood pressure, cholesterol, blood glucose and other relevant risk factors together.

Importantly, waist circumference and waist-to-hip ratio are risk-assessment tools, not standalone diagnoses.

A New Perspective on Obesity and Cardiovascular Health

The research forms part of a broader JACC special issue focusing on obesity and cardiovascular disease.

Its central message is increasingly clear: the location of body fat matters.

For decades, BMI has played a major role in defining overweight and obesity. While it remains convenient and useful, the new findings suggest that cardiovascular risk assessment could be improved by also considering measures of central adiposity.

The study’s enormous sample size and long follow-up period strengthen the evidence that waist circumference and waist-to-hip ratio can provide meaningful information beyond BMI.

Bottom Line

A healthy-looking BMI does not necessarily tell the whole story about heart health.

The large JACC analysis found that waist circumference and waist-to-hip ratio can identify additional cardiovascular risk across the BMI spectrum. Higher central adiposity was associated with increased risks of heart disease, stroke, heart failure, atrial fibrillation and mortality.

For clinicians, the message is to consider where body fat is distributed, not simply how much a person weighs.

For patients, the findings reinforce the importance of taking a broader view of cardiovascular health — one that includes body composition and fat distribution alongside traditional risk factors.

Sources and References

Journal of the American College of Cardiology (JACC): Cross-Cohort Collaboration Obesity Working Group study on central adiposity and cardiovascular outcomes.
JACC Editorial: Commentary by Kershaw Patel, MD, and Neela Thangada, MD, on BMI and cardiovascular risk assessment.
JACC Special Issue on Obesity: Research and expert perspectives examining the relationship between obesity and cardiovascular disease.
Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease: Research leadership and cardiovascular prevention expertise referenced in the study.

Original research: JACC study on Central Adiposity as a Predictor of Cardiovascular Outcomes

Editorial commentary: JACC accompanying editorial on obesity and cardiovascular risk

JACC obesity special issue: Journal of the American College of Cardiology – Obesity Special Issue

Medical note: This article is an informational summary of published research and is not a substitute for individual medical advice or a cardiovascular risk assessment by a qualified healthcare professional.

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