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Current algorithms for assessing risk of atherosclerotic cardiovascular disease (ASCVD) and, in particular, the reliance on low-density lipoprotein (LDL) cholesterol in conditions where this measurement is discordant with apoB and LDL-particle concentrations fail to identify a sizeable part of the population at high risk for adverse cardiovascular events. This results in missed opportunities for ASCVD prevention, most notably in those with metabolic syndrome, prediabetes, and diabetes. There is substantial evidence that accumulation of ectopic fat and associated metabolic traits are markers for and pathogenic components of high-risk atherosclerosis. Conceptually, the subset of advanced lesions in high-risk atherosclerosis that triggers vascular complications is closely related to a set of coordinated high-risk traits clustering around a distinct metabolic phenotype. A key feature of this phenotype is accumulation of ectopic fat, which, coupled with age-related muscle loss, creates a milieu conducive for the development of ASCVD: atherogenic dyslipidemia, nonresolving inflammation, endothelial dysfunction, hyperinsulinemia, and impaired fibrinolysis. Sustained vascular inflammation, a hallmark of high-risk atherosclerosis, impairs plaque stabilization in this phenotype. This review describes how metabolic and inflammatory processes that are promoted in large measure by ectopic adiposity, as opposed to subcutaneous adipose tissue, relate to the pathogenesis of high-risk atherosclerosis. Clinical biomarkers indicative of these processes provide incremental information to standard risk factor algorithms and advanced lipid testing identifies atherogenic lipoprotein patterns that are below the discrimination level of standard lipid testing. This has the potential to enable improved identification of high-risk patients who are candidates for therapeutic interventions aimed at prevention of ASCVD.

Despite major efforts to reduce atherosclerotic cardiovascular disease (ASCVD) burden with conventional risk factor control, significant residual risk remains. Recent evidence on non-traditional determinants of cardiometabolic health has advanced our understanding of lifestyle-disease interactions. Chronic exposure to environmental stressors like poor diet quality, sedentarism, ambient air pollution and noise, sleep deprivation and psychosocial stress affect numerous traditional and non-traditional intermediary pathways related to ASCVD. These include body composition, cardiorespiratory fitness, muscle strength and functionality and the intestinal microbiome, which are increasingly recognized as major determinants of cardiovascular health. Evidence points to partially overlapping mechanisms, including effects on inflammatory and nutrient sensing pathways, endocrine signalling, autonomic function and autophagy. Of particular relevance is the potential of low-risk lifestyle factors to impact on plaque vulnerability through altered adipose tissue and skeletal muscle phenotype and secretome. Collectively, low-risk lifestyle factors cause a set of phenotypic adaptations shifting tissue cross-talk from a proinflammatory milieu conducive for high-risk atherosclerosis to an anti-atherogenic milieu. The ketone body ß-hydroxybutyrate, through inhibition of the NLRP-3 inflammasome, is likely to be an intermediary for many of these observed benefits. Adhering to low-risk lifestyle factors adds to the prognostic value of optimal risk factor management, and benefit occurs even when the impact on conventional risk markers is discouragingly minimal or not present. The aims of this review are (a) to discuss novel lifestyle risk factors and their underlying biochemical principles and (b) to provide new perspectives on potentially more feasible recommendations to improve long-term adherence to low-risk lifestyle factors.

IN HIS LETTER ABOUT THE ARTICLE 'THE soft science of dietary fat' (News Focus, G. Taubes, 30 Mar. 2001, p. 2536), Scott M. Grundy says that saturated fatty acids (SFA) [...]

A letter to the editor is presented in response to the article about the positive association between high intake of food red and processed meat and colorectal cancer risk, published in previous issue.

The prevalence of dementias is on the rise, increases exponentially with age and constitutes a major healthcare burden nationally and worldwide. Dementias are clinically heterogeneous and encompass numerous etiologies. Noteworthy, late onset dementias are closely related to vascular and metabolic risk factors in midlife. Cardiometabolic risk factors commonly precede the onset of cognitive decline for decades. This opens a huge window for prevention. Given the lack of established pharmacological options for treatment of most dementias, preventive strategies are of utmost importance. Several factors have been identified that have the potential to preserve a healthy metabolic phenotype and to attenuate the onset of late onset dementias. Evidence exists for low-risk lifestyle factors including a real food dietary pattern, an adequate supply with long chain omega-3 fatty acids, regular physical activity and restorative sleep, with multimodal concepts showing the greatest cumulative benefit., Competing Interests: NW, BL, MB und KL geben an, dass kein Interessenkonflikt besteht. CvS betreibt Omegametrix, ein Labor zur Fettsäureanalytik. CvS erhielt Honorare für Vorträge und Beratung von BASF/Pronova, Huntsworth Medical, DSM, Marine Ingredients und Norsan. UG erhielt Honorare für Vorträge von Oleofactum und Norsan., (© Georg Thieme Verlag KG Stuttgart · New York.)

Competing Interests: Interessenkonflikte: Nicolai Worm ist Mitglied im wissenschaftlichen Beirat der Deutschen Weinakademie und hat Vortragshonorare und Reisekosten von dieser Institution erhalten.

The health consequences of being overweight have been discussed controversially. Indeed, from a metabolic point of view, overweight and obese people are quite heterogenous. The body mass index (BMI) is not suitable to predict health oriented outcomes on an individual level without taking into account further parameters such as waist circumference, blood pressure, serum glucose, serum lipids, and physical fitness. The BMI does not distinguish between metabolically healthy and metabolically unhealthy. Of upmost importance for health consequences of obesity is body fat distribution. Two types of principally different fat distribution can be identified: abdominal and gluteofemoral fat. Waist circumference and hip circumference can be utilized to distinguish between those two types. People with accumulation of body fat in the abdominal region have a markedly higher risk of developing type-2-diabetes and cardiovascular disease. Moreover, their total mortality is increased. On the other hand, waist circumference is not sufficiently capable of indicating individual risk. Instead, the amount of visceral fat is believed to be a primary risk factor because of its metabolic characteristics (i. e. increased lipolysis, diabetogenic and atherogenic adipokine profile). Recent findings point to visceral fat being more an indicator of the parallel accumulation of fat deposits in organs placed in the abdomen. The accumulation of lipids in tissues not primary intended for fat storage is called,,ectopic fat". It can be found in muscle, liver, pancreas, and kidney. The fattening of those organs is now considered to have the key role in the pathogenesis of type-2-diabetes. The pathophysiological effects of ectopic fat and the associated metabolic derangements can solve the conflicting findings concerning health consequences of BMI--at least in part. Moreover, these findings may have therapeutic consequences. The reduction of ectopic fat as well as the modification of its metabolic effects - via dietetic, bariatric or pharmaceutic means - opens up the pathway to counteract impaired glucose tolerance early and in a causal way.