People with heart disease and belly fat may face an increased risk of death, even when they’re of normal weight, according to a Mayo Clinic study published in the Journal of the American College of Cardiology and reported by HealthDay News.

For the study, researchers analyzed data from five worldwide studies including various ethnic groups and involving almost 16,000 people with coronary artery disease (heart disease).

Researchers found that participants with even a little belly fat were twice as likely to die than those with fat concentrated elsewhere. The study showed that having a “beer belly” or “muffin top” posed as significant a risk of death as smoking a pack of cigarettes a day or having high blood cholesterol.

This finding showed that belly fat is a more significant death predictor than overall body mass index (height to weight ratio). And big-gut men are even more at risk.

“Visceral [belly] fat has been found to be more metabolically active,” said lead study investigator Francisco Lopez-Jimenez, MD, director of Mayo Clinic’s Cardiometabolic Program. “It produces more changes in cholesterol, blood pressure and blood sugar, [but] people who have fat mostly in other locations in the body, specifically the legs and buttocks, don’t show this increased risk.”

“What seems to be more important is how the fat is distributed on the body,” says Thais Coutinho, MD, lead study author.

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