The role of central obesity as a predictor of cardiovascular disease has not been fully understood, but a recent analysis from the Jackson Heart Study has provided some answers.

During a poster session at the American Heart Association EPI Lifestyle Scientific Sessions (AHA-EPI) 2026, researchers said that prior research suggested diabetes-associated heart disease may be driven more by fat around the organs, or visceral fat, rather than hyperglycemia. They also noted systemic inflammation, reflected by levels of high-sensitivity C-reactive protein (hs-CRP), may help explain why people with more abdominal fat are at greater risk for developing heart failure.

Szu-Han Chen, medical student at the College of Medicine, National Yang Ming Chiao Tung University in Taipei, Taiwan, and the study’s first author, said the findings highlight how abdominal fat plays a key part in heart disease risk.

“Two individuals may have the same BMI — one could be physically active with higher muscle mass, while another may carry more excess fat due to a sedentary lifestyle — yet their cardiometabolic risks can be very different,” Chen said.

“In addition, prior research has described the so-called ‘obesity paradox,’ where higher BMI is sometimes associated with better cardiovascular outcomes,” he said. “Our findings help clarify this paradox by suggesting that central adiposity, rather than overall body weight, may be a more relevant predictor of heart failure risk, partly through systemic inflammation.”

Role of Inflammation

Started in 2000, the Jackson Heart Study is the country’s largest long-term study on heart disease in Black adults. For this analysis, Chen and colleagues analyzed 1998 adults in three counties in urban and rural Jackson, Mississippi, who were free of heart failure at baseline. Adiposity was measured by BMI, waist circumference, and waist-to-height ratio. 

The researchers used hs-CRP to assess systemic inflammation and Weibull accelerated failure time models to estimate adjusted hazard ratios (HRs) for incident heart failure. They also employed mediation analyses to examine the extent to which inflammation explained the association between adiposity and heart failure risk.

At a median follow-up of 6.9 years, Chen and colleagues found that elevated hs-CRP (≥ 1 mg/L) was associated with lower heart failure-free survival (log-rank P = .010). In adjusted models, waist circumference (HR, 1.31; 95% CI, 1.06-1.62) and waist-to-height ratio (HR, 1.27; 95% CI, 1.02-1.58) were independent predictors of heart failure, whereas BMI was not. 

Mediation analysis showed that hs-CRP accounted for 25.4% of the effect of waist circumference and 28.5% of the effect of waist-to-height ratio on heart failure risk, both with statistically significant indirect effects.

Ambarish Pandey, MD, MSCS, associate professor of internal medicine and medical director of the HFpEF program at UT Southwestern Medical Center in Dallas, found these data particularly striking.

“That is a meaningful proportion of risk running through a single biomarker we can actually measure and treat,” Pandey, who was involved with the study, said. “The flip side is that more than 70% remains unexplained by inflammation alone, which points to parallel pathways involving neurohormonal activation, myocardial fibrosis, and adipokine dysregulation. Inflammation is an important, measurable mediator of what is clearly a more complex story.”

‘An Important Intermediate Target’

The study concluded that those with higher levels of inflammation were more likely to develop heart failure over time. Measures of abdominal fat — waist circumference and waist-to-height ratio — were also more predictive of heart failure than BMI.

“This study gives clinicians an important intermediate target to monitor when it comes to heart failure prevention. This is particularly relevant for weight loss therapies such as GLP-1 receptor agonists, which are effective in reducing adiposity and inflammation, and may reduce heart failure risk. Improvement in inflammation burden may be an important mechanism through which these agents reduce heart failure risk,” Pandey said.

Chen and Pandey reported having no relevant financial relationships. 

Lois Anzelowitz Levine is a medical and lifestyle writer in Dallas.