Obesity Paradox and Cardiorespiratory Fitness in 12,417 Male Veterans Aged 40 to 70 Years

Department of Human Performance and Sport Sciences, Winston-Salem State University, 601 S Martin Luther King Jr Dr, Anderson C 24-E, Winston-Salem, NC 27110, USA.
Mayo Clinic Proceedings (Impact Factor: 6.26). 02/2010; 85(2):115-21. DOI: 10.4065/mcp.2009.0562
Source: PubMed


To evaluate the influence of cardiorespiratory fitness (fitness) on the obesity paradox in middle-aged men with known or suspected coronary artery disease.
This study consists of 12,417 men aged 40 to 70 years (44% African American) who were referred for exercise testing at the Veterans Affairs Medical Centers in Washington, DC, or Palo Alto, CA (between January 1, 1983, and June 30, 2007). Fitness was quantified as metabolic equivalents achieved during a maximal exercise test and was categorized for analysis as low, moderate, and high (defined as <5, 5-10, and >10 metabolic equivalents, respectively). Adiposity was defined by body mass index (BMI) according to standard clinical guidelines. Separate and combined associations of fitness and adiposity with all-cause mortality were assessed by Cox proportional hazards analyses.
We recorded 2801 deaths during a mean+/-SD follow-up of 7.7+/-5.3 years. Multivariate hazard ratios (95% confidence interval) for all-cause mortality, with normal weight (BMI, 18.5-24.9 kg/m2) used as the reference group, were 1.9 (1.5-2.3), 0.7 (0.7-0.8), 0.7 (0.6-0.7), and 1.0 (0.8-1.1) for BMIs of less than 18.5, 25.0 to 29.9, 30.0 to 34.9, and 35.0 or more kg/m2, respectively. Compared with highly fit normal-weight men, underweight men with low fitness had the highest (4.5 [3.1-6.6]) and highly fit overweight men the lowest (0.4 [0.3-0.6]) mortality risk of any subgroup. Overweight and obese men with moderate fitness had mortality rates similar to those of the highly fit normal-weight reference group.
Fitness altered the obesity paradox. Overweight and obese men had increased longevity only if they registered high fitness.

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    • "This may be especially so if the comparator individuals are thin because of severe illnesses (e.g., chronic heart or lung disease, cancer), or because the thinner individuals smoke cigarettes, which would not only reduce body weight, but would also increase CVD risk [71, 72]. Men who are overweight or obese may have reduced mortality only if they are physically fit [73, 74]. Patients with chronic heart failure seem to have no mortality benefit if they have type 2 diabetes mellitus [75]. "
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    • "This implies that obese persons are considered slothful if they are sedentary, while normal weight persons are not associated with slothfulness even when they are inactive. This is problematic given the 'fitness and fatness' relationship demonstrated by McAuley et al. (2010) and Lyerly et al. (2009). Thus, finding ways to counter such stereotypes and to modify bias towards normal weight yet sedentary persons, in addition to bias towards obese yet active persons, is necessary. "
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    • "Smoking cessation and physical activity are key aspects of secondary prevention programs (Clark et al., 2005; Smith et al., 2011), although it is unclear if better uptake and adherence to lifestyle advice might partly explain the obesity paradox in CVD patients. Several papers, for example, show that an obesity paradox does not persist in coronary patients with high levels of physical fitness (Goel et al., 2011; McAuley et al., 2010). The aim of this study was to examine the role of self-rated health, behavioral and objectively assessed risk factors, in order to further explore mechanisms that might influence the association between BMI and mortality in a community sample with established CVD. "
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