Abdominal fat predicts heart disease risk better than BMI
acc.org
acc.org
"Resistant starch intake facilitates weight loss in humans by reshaping the gut microbiota"
https://pmc.ncbi.nlm.nih.gov/articles/PMC10963277/
Edit: Ah, HN submission 2 years ago: https://news.ycombinator.com/item?id=39592367
this is a great study if you are an overweight/obese adult without overt metabolic disease, willing and able to consume 90 g/d of starch supplement within a controlled diet, and living in Shanghai with similar baseline fiber intakes endemic to that population. it is extremely not generalizeable to you or even me though I fit more of those characteristics than I care to admit
stay skeptical of small studies like this, friend
But there's already a general advise on this: eat more fiber.
https://med.stanford.edu/news/all-news/2017/08/hunter-gather...
We're a great ape, our body evolved to process a lot of fiber from fruits and starches. It's the modern fiber-deficient diet that's really weird.
90g/day of fiber is similar to the Hadza tribe diet, where they can consume 100-150g of fiber per day.
fiber is great and under-consumed (especially soluble) and is very well-studied on modern populations [0]. we don't really need to make mechanistic reasonings about evolutionary adaptations that occurred hundreds of thousands of years ago or rely on studies of a small, homogenized population whose lived realities are far from yours and mine
plus, following the the hierarchy of evidence, mechanistic guesses are considered extremely low quality, only ranking above things like mouse studies [1]
[0] https://www.uptodate.com/contents/healthy-diet-in-adults#H61... [1] https://en.wikipedia.org/wiki/Hierarchy_of_evidence
https://nutritionsource.hsph.harvard.edu/carbohydrates/fiber...
> Resistant starch – Soluble fermentable fiber found in legumes, unripe bananas, cooked and cooled pasta, and potatoes that acts as a prebiotic. Adds bulk to stools but has minimal laxative effect. May help to normalize blood sugar and cholesterol levels.
For stronger studies, these guys have you covered: https://www.ncbi.nlm.nih.gov/books/NBK559033/
This includes a part of the "resistant starch", which is poorly digested by humans, so a big part of it reaches the large intestine.
So yes, the "resistant" starch counts as "fiber", but not all of it, because some part of it is hydrolyzed into glucose, which is absorbed.
looking into RS's in general, it seems like there is a special carve-out after a lot of industry lobbying for very specific forms of RS's to be classified as fibers and only if they have physiological effects similar to the classic definition of fiber: https://www.fda.gov/media/113663/download
for practical reasons, I suppose I'm just not understanding why you don't eat more 'classical' fibers. psyllium husk, for eg, which is cheap and effective and has been utilized as a digestive aid in Chinese traditional medicine for centuries (one of the few to survive rigorous empirical evaluation, naturally)
Also savannah human diet is chock full of fiber too: baobab pulp, grass seeds, tuber plants, etc
You just have to look to the belly of a healthy, non-obese human and compare it with the bellies of the apes. The bellies of the apes are much bigger, despite not having the fat of humans, because they have much longer intestines, which are packed in there, which are required for the fermentation of the large amount of fiber included in their diets.
The intestines of humans are not so reduced as those of the obligate carnivores, but they are still much shorter than of most apes or monkeys.
Our health is still dependent on eating a decent amount of "fiber", but the amount we need is not comparable with what an ape needs.
My point is just modern diet is severely lacking in fiber, when our gut evolved to process them.
It's not a surprise this evolutionary mismatch will cause so many problems in our body.
While they're not essential in short-term survival, they're essential for long-term health:
https://www.ncbi.nlm.nih.gov/books/NBK559033/
We have enough peer-reviewed studies on this.
We’ve already known fruits and vegetables are healthy. Fiber is the reason why eating an orange is good, but drinking a glass of orange juice is about equivalent to a bottle of coke. That’s not an exaggeration, by the way, it’s about the same sugar content.
If you want to eat the recommended 35g of fiber a day, you won’t be able to reach it with just supplements. You need to be eating fruits and vegetables at every meal. For my entire life, everyone has been saying to eat fruits and vegetables at every meal in large quantities.
But the fiber does not survive. The fiber alone is what makes the sugar intake okay - fiber slows and prevents blood sugar spikes, which, over time, is what causes insulin resistance and then diabetes. Drinking orange juice is diabetes fodder. Again, it’s basically soda. Eating oranges doesn’t have that effect because of the fiber.
Also, another note on vitamins: for most vitamins, once you get enough, the rest is wasted. It’s not like eating more vitamin C gives you more and more benefits. No, your body has an amount it needs, which is quite low. Past that, you pass it in urine. The amount you need you reach every day with no effort.
And, additional vitamins still have to be metabolized in the liver and go through the kidneys. Too much vitamin intake is damaging, many doctors can tell you stories of acute liver failure as a result of excessive vitamin intake. It’s basically impossible to do that via food. But when you see those vitamin supplements that are like “2000% daily value” - yeah, don’t take those. You’re not getting any benefit.
The US had for a long time a much too low recommendation of around 0.8 g of protein per kilogram of body weight per day.
That has been discredited by various studies. It is an amount that is sufficient to keep you alive, but it is not sufficient to keep you in good health until an old age.
It is not known with any certainty which is the optimum amount of protein intake. On certain lab animals protein restriction lengthens life, but for now there is no evidence that this also works for humans. Too much protein is known with certainty to be harmful for humans.
I believe that it is likely that the optimum protein intake is somewhere between 1.2 and 1.5 grams of protein per day and per kilogram of body weight, for a person with no overweight. For an overweight person, the protein needs do not increase proportionally to the total mass, i.e. the extra fat does not need much protein.
I wonder whether the so low protein recommendation of USA was actually intended for average Americans, which are likely to be overweight, in which case that number might provide an adequate protein intake.
sample size is 37, number of authors 29
https://prebioticassociation.org/resistant-starch-research-u...
Several of those are reviews themselves.
But obviously, most people are a lot more interested in finding a magic food which does this rather than a proven calorie deficit, which is highly effective.
Purely behavioral lifestyle interventions have the lowest long term success rates of all available treatments for obesity. It's especially unreliable if you have weight loss targets higher than 15%.
They are of course still widely recommended due to numerous benefits other than weight loss, but "highly effective" is just wrong in the context of obesity treatments.
I seem to remember a meta analysis a decade ago or so finding that the particulars (high protein, atkins, paleo, whatever) didn't really matter so much as the the willingness and commitment to the change.
What? Surely changing one's behaviour - particularly the parts of behaviour that caused the obesity in the first place - is a sure way to stop being obese.
Behavioural changes work, the issue is that most people don't actually change their behaviour.
It's funny how proposing an healthy diet is unrealistic and watching fatties eat themselves to death is the new normal, complete value inversion and looser mentality
It's just that you should probably suggest other treatments in addition to the lifestyle changes that have relatively low long term efficacy.
Of course, that assumes your goal is to actually help the fatties instead of judging them.
I don't believe that's possible. They have to choose a healthier lifestyle by themselves.
It's not that people are fat because no one told them to eat healthy and exercise sometimes. They're fat because they have ignored that advice for a long time.
They aren't missing information about diet and exercise, they're missing diet and exercise.
I wonder what changed in between? Maybe our food and our relation to it? Who knows right?
You believe incorrectly.
> They're fat because they have ignored that advice for a long time.
Ah yes, the medical equivalent of "works on my machine".
You've now shifted from "how effective is this treatment" to "whose fault is it when the treatment doesn't work".
You will be able to help the fatties when you shift back into asking the question that matters.
But you are right with the fact that at the end, it mostly doesn't work. But those who stick with regime, it works 100% and positive changes in life, quality, happiness etc are massive.
The real solution - treat underlying mental issues. They are always there with obese people, they are massive (no pun intended), and they manifest as obesity, among plethora of other mental issues.
perhaps you can elaborate on how systemic death spirals are funny?
Running a marathon a month is a sure way to improve your health. However, less than 1% of people would be willing to do that. So it’s not an effective solution.
It’s an effective solution if we just ignore life, sure. But solutions are rooted in pragmatism.
If you opt for it, then yes of course, abstinence-only sex education is a sure way to stop ten pregnancy.
Similarly, if you opt to change your lifestyle and start living healthier, and follow through, it will work.
If someone tries to force you, of course it will fail (in both of these cases). There is no way to stop someone else from being fat. We can only change ourselves.
Being fit and maintaining the normal weight is not the same thing as reaching a BMI of 50 kg/m² then losing it. I've seen fitness influencers take up that challenge only to find that "changing oneself" is significantly harder than it used to be when they were fit.
If you change your lifestyle temporarily, the effects are temporary.
If you change your lifestyle permanently, the effects are permanent.
For the love of god or any other deity I can't grasp this, its trivial for me to muster a tiny fraction of discipline and simply change direction from now on. But people out there are vastly different than me, thats pretty obvious, ie many people detest sports or even sweating. Addictions, and over-eating is an addiction (or some form of stress-coping mechanism) have a way to grasp core of one's existence and not let go.
My wife sees such overweight folks with not-so-much-time-remaining-on-earth as GP regularly. As she says - they basically over-ate themselves into mental disorder (or started with it and their body over time aligned with behavior). To actually fix this, that mental disorder needs to be tackled, no gastric operations or wegovy injections provide permanent solution. But they sure make pharma companies richer and give this warm fuzzy feeling of achieving actually something visible, even if temporary.
Not quite.
If the lifestyle deteriorates, then weight regain is expected. However, people might regain only a fraction of the weight lost. It is possible for some of the weight loss to be permanent.
Also, even temporary changes in lifestyle can produce benefits that outlast the intervention, like lower risk of disease such as diabetes. Exercise is notable for providing numerous benefits that persist even if weight is completely unmodified.
> If you change your lifestyle permanently, the effects are permanent.
No. It improves your odds of success, but does not guarantee it.
Body adapts significantly over time when subjected to weight loss. There are compensatory physiological adaptations that favor weight regain, such as changes in energy expenditure and appetite. Even with sustained effort, maintaining the initial weight loss may become progressively more difficult because of those changes. This shows up in research as results like mean weight loss of ~9% at year 1 and ~5% at year 8.
It's the same thing for the mental issues epidemic... you can't build a completely hostile environment to human life and well being and then say "welp, I guess we need drugs to make you feel normal now", now they'll sell us the drug and the cure, and you'll be clapping and thanking them for saving you, truly amazing.
Henry VIII might have a word for you on that one, as would many other of history’s aristocrats. The only thing that’s really changed is the cost of food that used to be reserved for kings.
When I lived, in my childhood, in communistic Bulgaria/Czechoslovakia, nobody was starving. Yes, we did not have bananas and Argentinian steaks, but there was enough basic food, including the protein-rich one (eggs, cheese, even meat, although the best cuts were 'under the counter'). Still, few people were really obese; those were obviously sick.
Nowadays, there is plenty of junk food. The food is not really cheap (especially with the recent inflation), even the junk one. Still, being obese is (almost) the new normal. You can see that everywhere.
Yes, people spend more time indoors - but even in the old times people tended to spend a lot of time behind TV.
My hypothesis is that the junk food just does not have enough real nutrients, just mostly empty calories. So the body signals 'I need more nutrients', to which the typical response is 'here you have more empty calories'.
The quality and type of food also completely changed, you can't ignore that.
5% of supermarket aisles are food, the rest are treats and comfort food you should have less than once a week at best
The markets responding by promoting extremely cheap calories from industrial sugar sources rather than cane cut by hand by (relative to a machine or petrochemical processes extremely costly) slave labour is really just a natural consequence of capitalism feeding capitalists.
It’s not the food killing people, it’s the people selling the food that are killing people.
You’re right we didn’t evolve since the 80s. But our food has certainly changed. It’s not like some God from above put laziness in peoples brains just now. No… people were always lazy.
It’s just that you could be accidentally skinny before. You can’t be accidentally skinny now, it has to be intentional.
Many jobs used to involve physical labour, huge number of us now are desk jockeys. Decades of prioritising motorists and increasingly large vehicles over active transport mean walking, cycling are a fraction of what they used to be [0].
[0] e.g. https://ajph.aphapublications.org/doi/pdf/10.2105/AJPH.2010.... , https://la.streetsblog.org/2023/04/17/exactly-how-much-less-...
What really changed is the foodscape. And quite thoroughly so. Even basic agricultural products like wheat, corn or fruit are different from the variants 50+ years ago, there was a concerted effort to make them bigger, pesticide-resistant, more sweet, more energy-dense...
I remember the apples of the 1980s. Nowhere near as sweet as today, some were thoroughly sour. And these are considered the healthy choice now.
"The only solution is behavioural, everything else is cope."
This is like, your opinion, man. An opinion that can make you feel smug, but that is no victory. In practice, GLP-1s are doing what a generation of preachers like you could not - making people more thin and healthier.
In a sense, it is you who is coping hard and defending a "solution" which provably never worked on a population scale.
Alright, then let's continue making food worse and worse over the years, let's keep building a system that is less and less viable for humans. When we'll all be on GLP-1, + depression + ADHD drugs to just cope with days to day life maybe we'll finally wake up and ask ourselves how we ended in such a shit show.
If you really did something material to improve our food choice and food quality, I salute you. But this is rare enough for me to doubt it. Most people are content with wagging their fingers on strangers.
I've lost weight through forcing myself into a calorie deficit, and it works really well, but it's not particularly fun.
Sure but food doesn't have to equate to consume large quantities of junk food for it to be pleasurable.
We can learn to have a healthy meal with a reasonable portion that is as satisfying.
For the "eat to get slimmer" claim, I think we're at the point where "extraordinary claims require extraordinary proof."
What do you mean by "these foods"? Just buy unprocessed food and 99% of the problems disappear. There is no fake, no people trying to sell you these out of malicious intent. Just buy local food people had access to in 1900 and you'll cure all your problems.
It definitely is not "you can just go on a calorie deficit", that is how jo-jo effect works.
For average person that has children, full time job, and whole range of adult responsibilities it is hard. Not impossible but hard, this is why people are looking fo easier solutions.
I've lost weight and kept it off by making sure I don't have sweets and other types of food that I know I'll down in ten minutes. But if I don't have any on hand, I won't eat any.
Ditto for normal food: if I increase the portion of filling, low-calorie foods (think salads and other greens), with a lot of protein, I know I won't have cravings later in the day and feel full longer. But if I buy fatty sausage, with a hefty helping of salty cheese, I'll eat until I explode.
If when I'm hungry I have a choice between "a quick bite" of something very palatable, calorie-rich but nutritionally poor, and a "good" meal, I know I'll make the wrong choice. But if my only choice is the good meal, I'll eat that and stay on track.
This also has a positive feedback effect: after a while, not only did I stop craving various junk foods, but they actually don't register as food anymore when I see them in ads or similar. Which, of course, makes it easier to stick to the "diet". Now, when I'm hungry, I crave "actual" food. The other day I couldn't have lunch on time, and all I could think of was a fat bowl of lettuce with some roasted chicken breast and yogurt. Walking in front of the local McDonald's peddling their latest mystery burger didn't do anything to me.
Short term "diets" are nonsense. The solution is permanent lifestyle changes.
A good dietician is worth a few consults if you don’t have the will power to just fast. And as a bonus you don’t lose muscle mass as well because they’ll focus on keeping protein up.
Fasting is like using a nuke where a bullet would do.
How will a dietician measure your maintenance calories? How will they continuously update your macros and calories when your maintenance calorie change week to week?
I am making a claim here: most dietician will not be able to track your maintenance calories better than MacroCodex's algorithm.
Many dieticians simply rely on BMR/TDEE static formulas, and the limitation of this approach is that it cannot reliably track a user's actual maintenance calories well through the span of their dieting journey.
But changing lifestyle is virtually impossible for parents who also work, and have a bunch of issues here and there. Remaining the current lifestyle without dropping to a worse one is difficult enough.
Also this pic says it all, if everyone is so loved and beautiful why is everyone hopping on the ozempic train...?
How are you defining highly effective? In the sense that a body will definitely lose weight when starved? Or in the sense that counting calories is broadly effective as a weight loss strategy?
The former is painfully obvious and entirely unhelpful, and the latter is provably false.
Anyway what's cute about this is that this isn't novel phenomenon. There are lots of parallels to this in other fields where often effective solutions do exist, but at a system level don't seem to work.
Telling people to diet doesn't fix population level obesity. Telling people about personal financial management doesn't stop people from accruing too much high interest debt. Telling teenagers to stop idolizing instagram influences doesn't fix body anxiety issues. Telling people to stop smoking/drinking doesn't fix addictions. 3-2-1 data backups absolutely work but people lose files all the time.
"general population doesn't have the discipline for it" — only that this feels somewhat condescending.
Let's agree that counting macros or going for calorie deficit is hard if it is not someones job. General population has other jobs, family, social life, other hobbies they enjoy more than fitness. It is not "just eat less" it is "spend considerable amount of time thinking about and planning your eating".
If you turn things into individual discipline problems then surprise you get population level issues. As you pointed out people have other things to focus willpower on thats not this.
The fault, as it often does, lies in marketing. Turns out heavily marketed, hyper palatable food, designed to be minimally satiating so you maximally over eat is great for profits and terrible for obesity.
Nonsense. It doesn't take any more time. Just buy unprocessed, basic food, fruit and veg. When you open your cupboard, cook something tasty from what you have.
When you go to the supermarket, just don't walk into the aisles with snacks. Don't buy anything laden with sugar and fat.
Get into the habit of drinking black coffee instead of Starbucks' calorific drinks; it takes less than a week for your taste buds to adjust.
It's not rocket science. Just most people don't want to admit that every excess 100 calories they eat adds 11 grams of fat to their middle. Which adds up week by week, year by year.
Because for me it sounds like you might have awful lot of time to figure out your life.
In my previous and current post I am writing about an average person. I am pretty well off myself — what I was writing about I am far from dropping advice "just do X" on less fortunate. Because what is easy: "writing someone should do XYZ".
I have the problem that I absolutely abhor most fruit and veg and would rather not eat anything (which you can do for a couple of days at most). It's hard to get full on onions and sundried tomatoes.
But even with this kind of food, if I figure "sure, lemme have a sugary ice-cream", two hours later I'll be looking around the fridge and cupboards for some "quick bite".
Just don't buy this crap. I find it's much, much easier to have none at all than to hope to be "reasonable" and only eat a bit.
If your maintenance calories are 2700kcal and you eat 300kcal less than that, is eating 2400kcal starving for you?
Most people cannot tell a difference if they eat 100-150kcal less in a day.
>Or in the sense that counting calories is broadly effective as a weight loss strategy?
Yes, it is, and the reason people fail with it is not because calorie counting doesn't work, but because people's maintenance calorie estimates are often poor.
Deficit = maintenance calories (TDEE) - calorie intake
In this, even if your calorie tracking is on point, a deficit requires you to have a decent estimate of maintenance calories.
To throw a monkey wrench into all this, your maintenance calories often shift downward as you progress in your "diet" journey.
It's already factored in our algorihtm: https://macrocodex.app/knowledge/macrocodex/smart-calorie-bu...
I would have thought that it would mostly be because they can't resist that extra snack.
Or 'optimistically' underestimate the calories in the not pre-packaged food.
Serious question: Is there a significant variability in how the food calories are absorbed? Maybe different combinations are not absorbed equally efficiently (like with water/oil-based vitamins)
This is a pretty good inadvertent explanation for why a lot of people come into this discussion waving around morality arguments, lack of discipline, etc.
The average person gains a couple pounds a year. Adds up. How many calories do you think that is, amortized throughout the year? I'll help you with the math. It's 19. The average person eats 19 calories per day beyond maintenance.
It's not "weak willed slob cannot resist that extra snack."
I feel like discussions like this attract a number of people who've never actually been overweight and then lost the weight and tried to keep it off longer than a year. So much bro science, so much condescension, so much smug analysis that anybody who cannot resist their own body's hunger indefinitely are just weak.
A bit more complicated than that, CICO is not the answer. It's an observation, not a strategy.
I had been to doctors, gotten colonoscopies and endoscopies and other tests, elimination diets, etc.
One week of this powder mixed with water and my ever present mild diarrhea is basically gone. It's as close to a miracle cure as I can imagine.
However, I haven't lost a single pound or lost a single inch from my waistline.
I have, however, gained muscle, because I can now work out more because I'm not constantly fatigued and my body can recover much faster so I'm lifting weights quite steadily.
I'm so enthusiastic about this that I sound like a bot or a shill but it is what it is.
It doesn't work as a bulking agent like psyllium husk did. I can vary the dose and take it with or without food on a full or an empty stomach and it still works making me think that it might be related to changes in microbiota. I apologize for too much info but I must add that the solidness and color and smell of my feces changed completely and that my digestive system has slowed digestion.
Baer, David J., et al. "Dietary fiber decreases the metabolizable energy content and nutrient digestibility of mixed diets fed to humans." The Journal of nutrition 127.4 (1997): 579-586.
Somehow American Heart Association and its European counterpart are in denial, and still pushing dinasour screening mechanism with very low accuracy for heart disease risk prediction.
The standard risk model for CVD based on PREVENT (US) and SCORE-2 (Europe) like parameters are very poor as reported in the recently published paper on the their accuracy performance by the Swedish team [1]. As all CVD risk stratification with cardiologist review (expert-in-the-loop), the most important accuracy metric is sensivity/recall (avoiding false negative that will escape review) of PREVENT and SCORE-2, 26% and 48%, respectively.
The paper alternative proposal increased the sensitivity to 58% by performing clustering instead of conventional regression models as practiced in the PREVENT and SCORE-2.
These type of models including the latest proposal performed very poorly as indicated by their otherwise excellent and intuitive display of graphical abstract results [1].
[1] Risk stratification for cardiovascular disease: a comparative analysis of cluster analysis and traditional prediction models:
https://academic.oup.com/eurjpc/advance-article/doi/10.1093/...
There are many related research work with excellent results, patent, etc by biomedical researchers around the world that I'd care to mention, including yours truly. Biomedical researchers even has yearly global competition organized so called CINC that used ECG as one of the main input for heart disease risk prediction since it's readily available [1].
In particular check out work by Prof. Friedman on ECG [2]. Somehow his excellent work is mostly being ignored by AHA and their counterparts because apparently these standard risk prediction models in US and Europe are not including it as part of their parameters.
[1] Computing in cardiology (CINC):
[2] The Electrocardiogram at 100 Years: History and Future:
https://www.ahajournals.org/doi/pdf/10.1161/CIRCULATIONAHA.1...
https://www.mayoclinic.org/tests-procedures/heart-scan/about...
https://www.mayoclinic.org/tests-procedures/ct-coronary-angi...
My dad’s doctor said he should get one, Medicare denied it, but he paid out of pocket to get one anyway. He found out he was 95% blocked pretty much everywhere and had a quadruple bypass. It likely added many years to his life and avoided a heart attack.
If you’re under a certain age (I want to say somewhere in your 50s), there isn’t any guidance for what normal is. If you’re in your 20s or 30s, I wouldn’t run out and get one. But if you’re in your 40s with a family history, or up into your 50s and beyond, it’s worth thinking about. I’ve also heard you’re only supposed to get them every 2-3 years, it’s not a yearly thing, due to the radiation.
(I am not a doctor)
He says, without symptoms, never get a stent. Never get a bypass unless you have chest pains, shortness of breath, or other symptoms.
Lot of people have plugged up heart arteries. If it does not impact them, don't mess with them.
My story: 61 years old. excessive fatigue. echo cardiogram, no-exercise showed no issues. CT scan looked like a christmas tree. Heart Catheterization was unable to get into the vessels for stenting. Triple CABG a few days later.
The CT scan was easy, cheap (my insurance covered it), and fast. And it put me on path to get my heart fixed.
The main advantage of ECG compared to echo is that it's represent the functionality of the heart and overall CVD rather than structure like echo.
CT scan is not for screening and risk prediction, it's normally recommended after discovery of CVD related symptoms.
Having said that even CT cannot detect some of CVDs since it mainly cover the vascular part of the CVD not cardio engine (heart).
ECG is the only one technique that cover comprehensive CVDs screening and it's non-invasive.
The time to take action is long before you have a CAC score. e.g. Start tracking ApoB regularly, see if you have genetic LPa exposure, and avoid the foods that increase your exposure while ignoring the grifters telling you it's a nonissue.
GP was talking about screening though, not diagnosis. Coronary angiography are specialized, expensive and require intravenous constrast. Doctors aren't going to order them for everyone who shows up for a routine consult.
Emphasis on non-invasive diagnostic screening as invasive testing like angiogram need to be operated by specialist and can take months to be arranged, and only done after incidents e.g heart attack.
ECG is excellent for generic top level CVD anomaly conditions for examples arrhythmia and ischemia.
ECG is the only one technique that cover comprehensive CVDs screening and it's purely non-invasive (no injection necessary). If someone has blocked arteries or even genetically malform heart like Hypertrophic Cardiomyopathy (HCM) it will show in the ECG traces, that can be cross checked with other relevant CVD diagnostic techniques. The main problem is that the screening GP and even the cardiologist has trouble performing the correct interpretation. This is where advanced signal processing and analytics, ML, AI, etc can really help, but somehow the heart fraternity like AHA is very much still in denial on this matter.
Please check the short overview article from Prof. Friedman on ECG based CVD detection in my other comment, ironically commemorating on the 100 years of AHA.
(Edit: This is intended to be sarcastic. I agree 100% with the comment)
(Edit 2: Added the smiley face)
A lot, probably. You could sell people on the idea that it should be a part of your yearly health screening.
"And if you really care about your health you should do them every 3 months to catch problems early!"
or some such.
When I moved to Houston just after law school, I found a doctor and made an appointment to get a routine physical exam; I hadn't had one since getting out of the Navy three years earlier.
Doctor: So what brings you here?
Me: A triennial physical exam.
Doctor (incredulously): You get a physical exam three times a year?
Me: No ....
An ECG if it was just part of the normal yearly panel of things that get looked at I don't think ppl will stop doing it just because it doesn't find something right away
I do not consider the average HN commenter to be average.
You could say that it’s almost as if their model has a home-field advantage. Because of that fact alone, you can’t really conclude anything about the comparative performance of their models versus the existing ones from this paper.
Getting an ECG, EKG, TTE, CAC, carotid duplex US, lipid panel, CMP, TSH, 25-OH Vit D, B12 + folate were what my cardio recommended before appointment #2 on hypertension. Both of us are data guys.
Those are the same thing, did you mean to type something else?
BMI is easily misunderstood by people who know just enough to see that it’s imperfect, but not enough to understand why it’s still a valuable screening tool.
I’ve been in the “overweight” BMI range with low body fat before. It’s not too hard to get there if you’re lifting weights and paying attention to your diet consistently for years, but it takes a lot of work to get there. It doesn’t happen accidentally except for people who win some genetic lottery to build a lot of muscle and keep body fat low without trying.
Getting all the way to the obese BMI range while having healthy body fat is only happening for people with an extreme dedication to body building and diet (and let’s be honest, a lot of the people in this category are manipulating hormones too).
Yet whenever BMI comes up some people try to dismiss it as too flawed based on these possible edge cases. The edge cases for BMI exist, but that doesn’t mean it’s not useful. It’s a good general purpose screening tool with numbers that are available. If someone has more precise measurements available, those should be used instead. BMI is a really good first pass screener to determine if a closer look should happen.
In other words, for my height, I have a very long torso and very short legs. I think it should be relatively obvious that an inch of leg weighs significantly less than an inch of torso, so at a given level of body fat percentage, I'm going to weigh quite a bit more than someone my same height with more typical proportions, and thus my BMI reads me as more overweight than it otherwise would.
My point is not that BMI is bad or useless or anything else. My point is that it was designed as a population statistic and that it can be fraught when one tries to apply it to any individual with no nuance. A high BMI should cause one to consider and examine your health and weight. But it should not over-ride specific details about your physiology that point in the other direction.
It still functions well as a measure of load on your circulatory system, joints, you name it.
Your body is working harder than a typical 6'2" person, even if you have a great waist-to-hip ratio.
(But you'd still be better off with a smaller WTH ratio!)
I was also in the "overweight" category at one point while being low body fat. It was never a problem for anything, anywhere. I wasn't going to doctors who looked only at the BMI sheet and then told me to lose weight, because everyone could see that I was not overweight.
And I agree that it's never caused me problems, but that's because I and, as you suggest, doctors who look at the number, have understood that it's not that big of a problem in my case. That's what I mean by not looking at the BMI number naively and ignoring other physiological states.
I don't think anything you said conflicts with anything I said, and it sounds like we mostly agree.
Anything to pretend they aren't too heavy.
People tend to think in absolutes. Even perfectly rational people fall logically foul to not considering outliers.
Did you do that as a natural lifter? It’s hard for me to imagine most guys being able to get into the “overweight” range at < 15% body fat without some assistance.
The vast majority of natural lifters will never get enough muscle to really seriously throw it off.
For someone not working out or working a job that builds muscle, getting into the overweight category probably does mean they should take a look at their body weight.
I am only 6' and only an intermediate lifter. I'm overweight, but BMI makes me look obese. It really only takes a normal person a year or so to get to three plates on squat with no supplements other than chicken broccoli and rice if they don't skip workouts. Assuming no injuries. That level of strength easily distorts bmi wildly if you are even a little taller than average.
And sumo wrestlers.
The line seems to be drawn at (effortful) activity level more than anything else. And BMI doesn't say anything about that.
I think the vexation comes from the focus on an attribute that is not directly mutable, per one's agency, because that's easier to sell things related to. Versus action that you have a lot more direct control over (social or physical circumstances notwithstanding).
(from https://en.wikipedia.org/w/index.php?title=Sumo&oldid=136533...), so I'm not sure this is a counterexample.
There's an enormous amount of wear-and-tear on their bodies, but the current cohort of wrestlers have access to much better knowledge about what's happening to them during their careers and afterwards, when compared to previous ones. During their prime years, they're objectively more metabolically healthy than the general population. Once retired, they're probably better able to manage their weight than earlier generations, and know to manage incidental issues like sleep apnea and alcohol consumption. I also wonder about the effects the tight-knit stables have on them, since we know positive and abundant social connection early in adulthood has ramifications later on.
>so I'm not sure this is a counterexample.
Yeah, don't just cite Wikipedia blindly. Some of the effects described seem strong, but there are caveats.
Many active gym people have pretty high BMIs but fairly low fat (because muscle is dense), and unsurprisingly have better outcomes than the average person (if you ignore the share that uses/overuses anabolic steroids and co)
I think this is greatly exhaggerated.
Yeah you can put on as much muscle as Arnold and have a FFMI of about 27 then maybe have a BMI of 34 if you have 20% body fat.
But a very gifted natty might cap out at maybe 24 with a BMI of 30 at 20% bodyfat. But let's be realistic. This is not "many active gym people". This is the guy winning the local strongman meet.
Yes a couple of years training for most people can add a couple of points to BMI but I think people exaggerate how much this is. Go look at a 20lb brisket at costco - you don't see people with that much extra muscle all that often.
At 6 feet / 183 cm that it takes 184 lbs / 83 kg to be overweight. From what I could find, for regular gymgoers the typical weight for people around 6feet is 180-190lbs, which put many people around the overweight threshold. I am myself at 24.9, and while not skinny I am definitely in the skinnier half of the people at my local gym.
Yeah really well muscled guy being BMI 27 is probably ok but by 30 it's not natural muscles that are making the scales go up.
And obviously genetics matter, but it look at master level soccer players: athttps://pmc.ncbi.nlm.nih.gov/articles/PMC6239137/
I’ve been in the overweight BMI category with low body fat by being active at the gym and focusing on diet. It takes some work to get there.
If I check the calculators for the obese BMI range, there was no way I could get there without either gaining a lot of fat on top of the muscle. The amount of muscle required to have an obese BMI with healthy amount of fat is absurd.
E.g. 20% bodyfat at 250lbs is still a lot of fat.
Of course it's difficult to ever get very high on absolute fat if at 15% or below.
Additional muscle is positive for health, but only up to some reasonable threshold. There is no health benefit to having very high levels of muscle, and in fact it may be negative for your health at extreme levels. E.g. many bodybuilders have trouble breathing, sleep apnea etc.
Both people in the example have 60lbs of fat. 1lb of muscle doesn't cancel out the negative health effect of 1lb of fat
From what I have heard from doctors, there is a clear sequence:
intra-organ fat (really bad) > visceral fat (quite bad) > subcutaneous fat (relatively harmless).
The nasty detail is that some people gain relatively more visceral fat than others. These three fats are correlated, but the correlation isn't the same in every human. Some have better metabolism and don't store as much fat inside as others do.
It’s not the fat that kills. It’s oxidated lipids that kill.
1. https://www.cdc.gov/nchs/data/series/sr_03/sr03-046-508.pdf
https://medlineplus.gov/ency/article/003998.htm
"People typically lose almost one-half inch (about 1 centimeter) every 10 years after age 40. Height loss is even more rapid after age 70. You may lose a total of 1 to 3 inches (2.5 to 7.5 centimeters) in height as you age."
So people DO in fact tend to lose about 2 inches at age 80 versus their younger selves.
As for 2, men in the US are getting shorter because of immigration which adds many confounders.
I often wonder far from the median I am in this regard. I was under the impression that it was pretty accurate for assessing populations, but fell apart very quickly at the individual level. How many "normal"/otherwise healthy people do fall outside BMI's numbers?
BMI has known biases in gender, age, and race. It misclassified Asians, women, elderly w sarcopenia, and people with high body fat to lean tissue ratio.
The people most obsessed with "BMI isn't accurate" are overweight people making excuses for themselves.
I like to think of this as four quadrants around two axes. Low fat/low muscle is simply skinny. High fat/high muscle is the "big guy/gal" look that I associate with laborers. Low fat/high muscle is an athletic look; unhealthy in extremes (bodybuilding) but generally desirable. High fat/low muscle is skinny fat, which I associate with sedentary knowledge workers.
[0] And that, at least somewhat, tracks visual perceptions. Nobody looks at me with a shirt on and believes I need to lose weight, because 10-15lb isn't _that_ much extra on a tall frame. If I were 40-50lb overfat then that would be painfully obvious regardless.
My actual methodology is pretty crude though -- when I was 15lbs lighter I had borderline visible abs and other visual indicators of being around the 15-20% body fat mark, and aside from gaining weight I don't have any reason to believe I've had any notable muscular atrophy since then, so I'm estimating the actual excess fat in that ballpark. It's be easy for numbers to be off 10lb or more, but even then it'd still indicate the overfat surplus being much less than the overweight surplus.
A better methodology uses calipers and various skin measurements to estimate true body fat percentage.
But my target is to waffle around 20% or so on average.
"Overweight" can mean the same thing for weight, but it also refers to those with a BMI specifically between 25 and 30, and those with BMIs greater than 30 are classified as "obese".
It's specifically a high level of visceral body fat.
Genetics determines which parts of the body gain fat first as you gain fat overall, and some people have the unfortunate genetics to gain it first viscerally and some people have the fortune to gain it there last (and everything in between).
This means that you can have different people with the same body fat percentage but drastically different disease risks.
But yes this was also known already.
That's why it's been recommended to take a waist measurement alongside BMI to get a much more informative screening tool. Waist-to-height ratios are another alternative.
It is what is called “skinny fat“.
It's just a particular type of abdominal fat so obviously the more abdominal fat that you can see it means you also have more of the type that can't see as well... It's not that complicated
But I'm not sure why you think you can have a lot of visceral fat without any obvious abdominal fat
Seems decent to me.
BMI
Waist circumference (WC)
Waist to hip ratio (WHR)
Subsequent risk of nine cardiovascular/mortality outcomes in >260,000 people followed for ~20 years
To make it even more useful they should have included DEXA scan bodyfat%.
Also, BMI becomes somewhat biased at height extremes because body mass doesn't scale exactly with height². Humans aren't geometrically scaled copies of one another and empirical scaling exponents are often somewhere between 2 and 3. Conventional BMI tends to read relatively high in very tall people and relatively low in very short people. But changing the exponent would only fix one relatively small limitation of BMI
For better height adjusted replacement for BMI itself, one option is Trefethen’s BMI
WHR and WC is positively correlated to bodyfat% but this may get distorted for strongmen or sumo wrestler who tend to have much higher than average lean mass, may also have higher WC and WHR but difference maybe waist to shoulder ratio, they tend to have much bigger and powerful shoulders.
what's interesting is, for sumo wrestlers specifically, WC still correlates strongly with BF% one study reported r ≈ 0.86
There is a category in fitness called "skinny fat" where you are at low bodyweight (so low BMI) but your fat mass is relatively higher when compared to lean mass, so higher bodyfat%
Many skinny fat people refuse to believe they carry higher bodyfat% because they think they've low bodyweight so they can't possibly carry higher fat, which is wrong.
If you are interested in knowing more about bodyfat, this may help you: https://aretecodex.pages.dev/knowledge/measure/bodyfat
How does one determine if one has an excess of visceral fat?
https://health.ucdavis.edu/sports-medicine/resources/dxa-inf...
You want to make sure you measure under similar conditions, like in the morning after relieving yourself (for example).
If it's too high, losing a ~0.5-1 lbs per week while strength and endurance training with progressive overload will get it down sustainably.
https://www.barbellmedicine.com/blog/visceral-fat-waist-vs-w...
But it's a cheap and effective one.
If you've lost 5 inches from your waist as measured from your bellybutton, it's unlikely you've lost zero visceral body fat.
This was all explained in the link I shared.
Cutting saturated fat to under 15g per day and increasing intake of viscose fibre (e.g. beans) will reduce your LDL particle count in a few weeks, which reduces your CVD hazard ratio. You can measure your LDL and look up the papers yourself. Statins will reduce it a lot too (potentially with side effects). Replace solid fats like butter with liquid fats like olive oil.
Literally any amount of regular exercise, including walking, will decrease CVD HR. The more the better (up until quite a large amount e.g. professional athlete). The more your heart is steadily pumping during exercise the better. Every bit helps reduce CVD risk. Movement is medicine.
For the love of God do not smoke. Literally one of the surest ways to die a horrible death. Stopping smoking reduces CVD risk by a large amount.
Do not give yourself diabetes by eating vast amounts of sugar. If you are doing this, stop. Not having diabetes decreases CVD risk.
Other factors you probably can't change so focus on these.
Doctors, if I got anything wrong please correct me.
Not eating vast quantities of sugar is good advice, but it's not the direct cause of T2 diabetes. The best evidence suggests that T2 diabetes is caused by the accumulation of fat in the liver and pancreas. See the twin cycle hypothesis. To prevent diabetes, one needs to maintain a weight low enough where the body isn't storing fat in the liver and pancreas (everyone has their own individual threshold for this). If you're pre-diabetic, lose enough weight and most people will regain insulin sensitivity.
https://en.wikipedia.org/wiki/De_novo_synthesis#Fatty-acid_(...
https://link.springer.com/article/10.1007/s00018-018-2860-6
https://pmc.ncbi.nlm.nih.gov/articles/PMC6213738/
https://drive.google.com/file/d/13sQiOt1tVKDYe8h3bSOL_sazalL...
https://link.springer.com/article/10.1007/s13668-026-00740-w
This can help sustain a high level of exercise (the more the better). Certainly don't if you're sedentary, but the sugar during exercise is really helpful for getting in 10+ hours/week of exercise.
https://link.springer.com/article/10.1007/s13668-026-00740-w
(When I say sugar, I mean things like gummies, gels, and sugar-sweetened beverages. If sedentary people habitually eat these, it does increase their T2D risk.)
overall, it sounds like some of the concerns about sugar metabolism aren't necessarily buffered because you metabolize it faster or exercise more, but the evidence isn't really there to know anything much.
0. https://www.cell.com/cell-metabolism/fulltext/S1550-4131(17)...
> habitually drinking... sugar-sweetened-beverages
Yes, terrible idea, avoid!
Any idiot with a bathroom scale and a measuring tape can do it. And by adulthood, height doesn't change significantly and you probably know it, so you may not even need that measuring tape. Other metrics need specialized equipment, error prone or complex procedures, etc... I don't even know how to make a waist measurement. Where exactly? How relaxed should the subject be? How long after eating?...
That's the value of BMI: simple repeatable. Not the best but enough to get and idea and make statistics.
But height does change in adulthood [0]. On average people living past 40 gradually lose height. At age 80, it's likely height loss will be >=2 inches. This loss is reflected in higher BMI even when body fat content hasn't changed. Average BMI increase isn't large, but think about a person losing 4 or 5 inches of height while maintaining body fat unchanged.
Self-reported height is generally greater than measured height. Adding 1/2 to 1 inch is common (per experience measuring height). "Height inflation" has modest effect on BMI but problematic in research and workup for medical procedures. In the latter cases, measuring height is necessary.
[0] https://www.uhhospitals.org/blog/articles/2024/10/why-do-peo...
If I'm reading that right, it sounds like obesity (and therefore BMI) is still a better predictor for all-cause mortality. Perhaps waist circumference is better at predicting cardiovascular risk but BMI is still useful.
Thirty years after we learned that abdominal fat distribution matters, large-scale longitudinal evidence shows that waist measurements meaningfully reclassify cardiovascular risk beyond BMI alone.
For example, I’m 45yo/178cm/93kg and am obese by BMI measurement. However, my body fat is 20% (Dexa), VO2 of 50 (lab) & have the aerobic fitness to run a half marathon after work and not care.
I’m not surprised that you need other metrics like hip/waist ratio, measured body fat, visceral fat, etc to better understand the composition of someone’s body and how it might relate to health outcomes like heart disease.
I've stopped worrying about weight (or BMI) and focus solely on waist circumference as a proxy for visceral fat.
They need to figure out a way to reliably Measure OXLDL.
(previously at https://news.ycombinator.com/item?id=45857053)
BMI was never meant to be used as a diagnostic measure. BMI is just a rough filter for large data sets, and entirely dependent on the average height and habits of that population.
Anyone taller than about 6'3" could tell you the recommended weight according to their BMI has always been absurdly low. If it's a printed chart on the wall, they might not even be on it.
The "ideal weight" of a person is proportional to height to an exponent somewhere between 2 and 3. Simple physics would say 3 but because tall people are not just scaled up copies of small people, it is closer to 2 in practice, maybe around 2.3, but we say 2 because it is easier to calculate.
The downside is that BMI overestimates the "ideal weight" for short people and underestimate it for tall people. But BMI is not great at capturing exceptions anyways, so there is little interest in "fixing" this.
Using your 6 3" male as an example, they are significantly more likely to be clinically obese (using waist circumference, body fat % etc) at a weight lower than BMI cut-off of 240 lbs.
It's really good at catching people who are obese who are overweight.
No. I'm saying that since height is genetic, being too tall or too short for BMI happens in clusters. There are also specific activities that select for tallness or shortness (basketball, horse racing, pilots, etc.) concentrating attention on the topic even further.
It's not a fringe problem when you have whole groups of people against an idea. I'm just telling you why BMI has never been taken seriously by a lot more people than those directly affected.
This is an insight worth having far beyond just BMI. Most rough stats are rejected by the public for exactly the same reasons. The problem with BMI isn't its existence, but its abuse and marketing. People abuse stats all the time and this is a really glaringly obvious one that needed to be taken down decades ago.
https://en.wikipedia.org/wiki/Waist%E2%80%93hip_ratio (hip to waist)
just got statin at 44 :(
i am not fat and workout ( although diet can use some improvment)
And these aren't merely hypothetical bodybuilder edge cases. A systematic review found BMI had only ~50% sensitivity for detecting obesity when compared with body-fat reference methods—i.e. it missed roughly half the people classified as obese by adiposity.
More importantly, the 2025 Lancet Commission on clinical obesity explicitly recommended that BMI be used only as a population-level risk surrogate or screening tool, not as an individual measure of health. For individual assessment they recommend actually confirming excess adiposity with waist measurements or direct body-fat measurement.
Which is basically what this study is demonstrating again: where the fat is contains substantially more useful cardiovascular information than the number you get from dividing someone's mass by the square of their height.