RSNA 2025: The Heartbreaking Consequence of a ‘Beer Belly’

A large new study using advanced imaging found that abdominal obesity—a.k.a., “beer belly”—is associated with more harmful heart structure changes than overall body weight alone, especially in men. Presented this week at the Radiological Society of North America (RSNA) Annual Meeting (Nov. 30-Dec. 4, Chicago), the study also suggests actions patients and doctors can take to identify potential risks and intervene earlier to protect the heart.

“Abdominal obesity, a high waist-to-hip ratio, is associated with more concerning cardiac remodeling patterns than high body mass index (BMI) alone,” said study lead author Jennifer Erley, M.D., a radiology resident at University Medical Center Hamburg-Eppendorf, Germany. “It appears to lead to a potentially pathological form of cardiac remodeling, concentric hypertrophy, where the heart muscle thickens but the overall size of the heart doesn’t increase, leading to smaller cardiac volumes. In fact, the inner chambers become smaller, so the heart holds and pumps less blood. This pattern impairs the heart’s ability to relax properly, which eventually can lead to heart failure.”

Taking into account BMI (body mass index)—a measure of general obesity calculated from weight and height—and waist-to-hip ratio (WHR), a measure of abdominal obesity, the researchers studied cardiovascular MRI images of 2,244 adults ages 46 to 78 (43% female) without known cardiovascular disease. Abdominal obesity reflects an accumulation of visceral fat, which is stored deep around internal organs and strongly linked to harmful cardiovascular effects. All of the study participants are part of the ongoing Hamburg City Health Study, a long-term population trial in Germany. 

According to BMI, 69% of males and 56% of females in the study were overweight or obese. Using WHR, 91% of the males and 64% of females met the World Health Organization (WHO) criteria for obesity. 

General obesity based on BMI was more often linked to enlarged heart chambers across all participants. Abdominal obesity was associated with thickening of the heart muscle and smaller heart chamber volumes. These changes were more prominent in men, particularly in the right ventricle, which pumps blood to the lungs. This may reflect early cardiac stress on the heart related to how abdominal fat affects breathing and lung pressure. 

The sex-specific differences suggest that male patients may be more vulnerable to the structural effects of obesity on the heart…

Obesity also was linked to subtle heart tissue changes in men, detectable only with advanced cardiac MRI, potentially signaling early heart stress before symptoms or diagnosable disease. These associations persisted even after accounting for other cardiovascular risk factors, including arterial hypertension, smoking, diabetes and cholesterol. 

“The sex-specific differences suggest that male patients may be more vulnerable to the structural effects of obesity on the heart, a finding not widely reported in earlier studies,” Dr. Erley stated. “Rather than focusing on reducing overall weight, middle-aged adults should focus on preventing abdominal fat accumulation through regular exercise, a balanced diet, and timely medical intervention, if necessary.”

The more extensive heart damage seen in men could be due to an earlier onset of more severe abdominal obesity, or the cardioprotective effect of estrogen in women, Dr. Erley noted, though more research is needed.

With a tape measure, anyone can calculate their WHR at home by dividing their waist circumference at its narrowest point by their hip circumference at its widest point. A ratio above 0.90 for men and 0.85 for women indicates abdominal obesity and is associated with increased cardiovascular disease risk, according to the WHO.

The authors also encourage clinicians to be proactive in checking and flagging abdominal obesity early on to improve health outcomes. 

“From the perspective of a radiologist, when we see this cardiac remodeling pattern, we currently think of cardiomyopathy, hypertensive heart disease, or some other form of disease, but we don’t clinically draw the line to obesity in our reports,” Dr. Erley said. “This study should alert radiologists and cardiologists to be more aware that this remodeling could be attributed independently to obesity.”

Study co-authors are Jonas H. Lund, M.D.; Isabel Molwitz, M.D.; Ersin Cavus, M.D.; Gerhard B. Adam, M.D.; Peter Bannas, M.D.; Enver G. Tahir, M.D.; and Mathias Meyer M.D.

RSNA is an association of radiologists, radiation oncologists, medical physicists and related scientists promoting excellence in patient care and health care delivery through education, research and technologic innovation. The Society is based in Oak Brook, Ill.