The article discusses the evolving understanding of body fat distribution and its impact on cardiovascular disease (CVD) risk. It highlights the progress made in identifying both non-modifiable and modifiable risk factors for CVD, such as smoking, hypertension, and high cholesterol levels, which have significantly reduced coronary heart disease mortality over the past 50 years. However, the rise in obesity and type 2 diabetes due to poor nutrition and a sedentary lifestyle has introduced new CVD risk factors. The focus has shifted from BMI to regional body fat distribution, particularly visceral adipose tissue, which is more strongly correlated with metabolic complications and cardiovascular outcomes than BMI alone. The article reviews the historical context, from early observations by Jean Vague to modern imaging techniques that allow for precise measurement of visceral adiposity. It emphasizes the importance of waist circumference and triglyceride levels as markers of visceral adiposity and their predictive value for metabolic and clinical outcomes. The article also explores the mechanisms linking excess visceral adiposity to cardiometabolic risk, including the "portal free fatty acid" hypothesis and the role of hormones and neuroendocrine factors. It discusses the significance of liver fat content and epicardial-pericardial adipose tissue as key ectopic fat depots contributing to CVD risk. Finally, it suggests that assessing and managing high-risk obesity should go beyond weight loss, focusing on improving cardiorespiratory fitness and reducing waist circumference and triglyceride levels.The article discusses the evolving understanding of body fat distribution and its impact on cardiovascular disease (CVD) risk. It highlights the progress made in identifying both non-modifiable and modifiable risk factors for CVD, such as smoking, hypertension, and high cholesterol levels, which have significantly reduced coronary heart disease mortality over the past 50 years. However, the rise in obesity and type 2 diabetes due to poor nutrition and a sedentary lifestyle has introduced new CVD risk factors. The focus has shifted from BMI to regional body fat distribution, particularly visceral adipose tissue, which is more strongly correlated with metabolic complications and cardiovascular outcomes than BMI alone. The article reviews the historical context, from early observations by Jean Vague to modern imaging techniques that allow for precise measurement of visceral adiposity. It emphasizes the importance of waist circumference and triglyceride levels as markers of visceral adiposity and their predictive value for metabolic and clinical outcomes. The article also explores the mechanisms linking excess visceral adiposity to cardiometabolic risk, including the "portal free fatty acid" hypothesis and the role of hormones and neuroendocrine factors. It discusses the significance of liver fat content and epicardial-pericardial adipose tissue as key ectopic fat depots contributing to CVD risk. Finally, it suggests that assessing and managing high-risk obesity should go beyond weight loss, focusing on improving cardiorespiratory fitness and reducing waist circumference and triglyceride levels.