Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Review Article
  • Published:

Healthy obese versus unhealthy lean: the obesity paradox

Nature Reviews Endocrinology volume 11, pages 55–62 (2015)Cite this article

Subjects

Key Points

  • The prevalence of obesity has increased in most of the world over the past few decades

  • Patients with obesity have more cardiovascular and metabolic risk factors than people of normal weight and have an increased risk of developing cardiovascular diseases

  • Data suggest that metabolically healthy obesity, especially when combined with a high level of fitness, is associated with at most a minimal increase in overall risk of cardiovascular diseases and mortality

  • In patients with established cardiovascular diseases and other chronic conditions (kidney disease, severe arthritis), those with overweight and class I obesity have a better prognosis than lean patients—the 'obesity paradox'

  • Fitness is more important than fatness for long-term prognosis; in the obesity paradox, fitness markedly alters the relationship between adiposity and long-term health outcomes

  • Despite accumulating evidence on the obesity paradox, the available data still support purposeful weight loss for long-term health, particularly when combined with increased physical activity, muscular strength and fitness

Abstract

Overweight and obesity have reached epidemic proportions in the USA and most of the rest of the world. Particularly concerning is the very high prevalence of class III obesity (BMI ≥40 kg/m2), which has reached ∼3% in the USA. In the past few years, controversy has surrounded the idea that some individuals with obesity can be considered healthy with regards to their metabolic and cardiorespiratory fitness, which has been termed the 'obesity paradox'. These controversies are reviewed in detail here, including discussion of the very favourable prognosis in patients with obesity who have no notable metabolic abnormalities and who have preserved fitness. The article also discusses the suggestion that greater emphasis should be placed on improving fitness rather than weight loss per se in the primary and secondary prevention of cardiovascular diseases, at least in patients with overweight and class I obesity (BMI 30–35 kg/m2).

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Figure 1: Physical activity related to occupation from 1960 to 2010.
Figure 2: Change in mean weight in the USA.
Figure 3: Energy expenditure related to physical activity (mean kilocalories per week) in mothers in the USA, 1965–2010.
Figure 4: The joint effects of different measures of obesity and cardiorespiratory fitness on all-cause mortality.
Figure 5: Kaplan–Meier survival analyses according to BMI in a study of 2,066 patients with systolic heart failure.

Similar content being viewed by others

References

  1. Lavie, C. J., Milani, R. V. & Ventura, H. O. Obesity and cardiovascular disease: risk factor, paradox, and impact of weight loss. J. Am. Coll. Cardiol. 53, 1925–1932 (2009).

    Article  PubMed  Google Scholar 

  2. Sturm, R. Increases in clinically severe obesity in the United States, 1986–2000. Arch. Intern. Med. 163, 2146–2148 (2003).

    Article  PubMed  Google Scholar 

  3. Sturm, R. Increases in morbid obesity in the USA: 2000–05. Public Health 121, 492–496 (2007).

    Article  PubMed  CAS  Google Scholar 

  4. Masters, R. K. et al. The impact of obesity on US mortality levels: the importance of age and cohort factors in population estimates. Am. J. Public Health 103, 1895–1901 (2013).

    Article  PubMed  PubMed Central  Google Scholar 

  5. Flegal, K. M., Kit, B. K., Orpana, H. & Graubard, B. L. Association of all-cause mortality with overweight and obesity using standard body mass index categories: a systematic review and meta-analysis. JAMA 309, 71–82 (2013).

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  6. Kramer, C. K., Zinman, B. & Retnakaran, R. Are metabolically healthy overweight and obesity benign conditions? A systematic review and meta-analysis. Ann. Intern. Med. 159, 758–769 (2013).

    Article  PubMed  Google Scholar 

  7. Lavie, C. J., McAuley, P. A., Church, T. S., Milani, R. V. & Blair, S. N. Obesity and cardiovascular diseases: implications regarding fitness, fatness and severity in the obesity paradox. J. Am. Coll. Cardiol. 63, 1345–1354 (2014).

    Article  PubMed  Google Scholar 

  8. Lavie, C. J. et al. Impact of obesity and the obesity paradox on prevalence and prognosis in heart failure. JACC Heart Fail. 1, 93–102 (2013).

    Article  PubMed  Google Scholar 

  9. Bastien, M., Poirier, P., Lemieux, I. & Després, J. P. Overview of epidemiology and contribution of obesity to cardiovascular disease. Prog. Cardiovasc. Dis. 56, 369–381 (2014).

    Article  PubMed  Google Scholar 

  10. Alpert, M. A., Omran, J., Mehra, A. & Ardhanari, S. Impact of obesity and weight loss on cardiac performance and morphology in adults. Prog. Cardiovasc. Dis. 56, 391–400 (2014).

    Article  PubMed  Google Scholar 

  11. Westerterp, K. R. & Plasqui, G. Physically active lifestyle does not decrease the risk of fattening. PLoS ONE 4, e4745 (2009).

    Article  PubMed  PubMed Central  Google Scholar 

  12. Swinburn, B., Sacks, G. & Ravussin, E. Increased food energy supply is more than sufficient to explain the US epidemic of obesity. Am. J. Clin. Nutr. 90, 1453–1456 (2009).

    Article  CAS  PubMed  Google Scholar 

  13. Katan, M. B. & Ludwig, D. S. Extra calories cause weight gain—but how much? JAMA 303, 65–66 (2010).

    Article  CAS  PubMed  Google Scholar 

  14. Church, T. S. et al. Trends over 5 decades in US occupation-related physical activity and their associations with obesity. PLoS ONE 6, e19657 (2011).

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  15. Archer, E. R. et al. 45-Year trends in women's use of time and household management energy expenditure. PLoS ONE 8, e56620 (2013).

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  16. Archer, E. et al. Maternal inactivity: 45-year trends in mothers' use of time. Mayo Clin. Proc. 88, 1368–1377 (2013).

    Article  PubMed  Google Scholar 

  17. Lavie, C. J., Milani, R. V. & Ventura, H. O. Disparate effects of metabolically healthy obesity in coronary heart disease and heart failure. J. Am. Coll. Cardiol. 63, 1079–1081 (2014).

    Article  PubMed  Google Scholar 

  18. Manson, J. E., Stampfer, M. J., Hennekens, C. H. & Willett, W. C. Body weight and longevity. A reassessment. JAMA 257, 353–358 (1987).

    Article  CAS  PubMed  Google Scholar 

  19. Mørkedal, B., Vatten, L. J., Romundstad, P. R., Laugsand, L. E. & Janszky, I. Risk of myocardial infarction and heart failure among metabolically healthy but obese individual. The HUNT Study Norway. J. Am. Coll. Cardiol. 63, 1071–1078 (2014).

    Article  PubMed  Google Scholar 

  20. Ortega, F. B. et al. The intriguing metabolically healthy but obese phenotype: cardiovascular prognosis and role of fitness. Eur. Heart J. 34, 389–397 (2013).

    Article  PubMed  Google Scholar 

  21. Hamer, M. & Stamatakis, E. Metabolically healthy obesity and risk of all-cause and cardiovascular disease mortality. J. Clin. Endocrinol. Metab. 97, 2482–2488 (2012).

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  22. Ogorodnikova, A. D. et al. Incident cardiovascular disease events in metabolically benign obese individuals. Obesity 20, 651–659 (2012).

    Article  PubMed  Google Scholar 

  23. Calori, G. et al. Prevalence, metabolic features, and prognosis of metabolically healthy obese Italian individuals: the Cremona Study. Diabetes Care 34, 210–215 (2011).

    Article  PubMed  Google Scholar 

  24. Voulgari, C. et al. Increased heart failure risk in normal-weight people with metabolic syndrome compared with metabolically healthy obese individuals. J. Am. Coll. Cardiol. 58, 1343–1350 (2011).

    Article  CAS  PubMed  Google Scholar 

  25. Fan, J., Song, Y., Chen, Y., Hui, R. & Zhang, W. Combined effect of obesity and cardio-metabolic abnormality on the risk of cardiovascular disease: a meta-analysis of prospective cohort studies. Int. J. Cardiol. 168, 4761–4768 (2013).

    Article  PubMed  Google Scholar 

  26. Romero-Corral, A. et al. Association of bodyweight with total mortality and with cardiovascular events in coronary artery disease: a systematic review of cohort studies. Lancet 368, 666–678 (2006).

    Article  PubMed  Google Scholar 

  27. Oreopoulos, A. et al. Body mass index and mortality in heart failure: a meta-analysis. Am. Heart J. 156, 13–22 (2008).

    Article  PubMed  Google Scholar 

  28. Park, J. et al. Obesity paradox in end-stage kidney disease patients. Prog. Cardiovasc. Dis. 56, 415–425 (2014).

    Article  PubMed  Google Scholar 

  29. Chittal, P., Babu, A. S. & Lavie, C. J. Obesity paradox: does fat alter outcomes in chronic obstructive pulmonary disease? COPD http://dx.doi.org/10.3109/15412555.2014.915934.

  30. Jahangir, E., De Schutter, A. & Lavie, C. J. Low weight and overweightness in older adults: risk and clinical management. Prog. Cardiovasc. Dis. 57, 127–133 (2014).

    Article  PubMed  Google Scholar 

  31. Lavie, C. J., Osman, A. F., Milani, R. V. & Mehra, M. R. Body composition and prognosis in chronic systolic heart failure: the obesity paradox. Am. J. Cardiol. 91, 891–894 (2003).

    Article  PubMed  Google Scholar 

  32. Lavie, C. J., Milani, R. V., Artham, S. M., Patel, D. A. & Ventura, H. O. The obesity paradox, weight loss, and coronary disease. Am. J. Med. 122, 1106–1114 (2009).

    Article  CAS  PubMed  Google Scholar 

  33. Lavie, C. J., De Schutter, A., Patel, D., Artham, S. M. & Milani, R. V. Body composition and coronary heart disease mortality: an obesity or a lean paradox? Mayo Clin. Proc. 86, 857–864 (2011).

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  34. Lavie, C. J. et al. Body composition and survival in stable coronary heart disease: impact of lean mass index and body fat in the “obesity paradox”. J. Am. Coll. Cardiol. 60, 1374–1380 (2012).

    Article  PubMed  Google Scholar 

  35. Coutinho, T. et al. Central obesity and survival in subjects with coronary artery disease: a systematic review of the literature and collaborative analysis with individual subject data. J. Am. Coll. Cardiol. 57, 1877–1886 (2011).

    Article  PubMed  Google Scholar 

  36. Coutinho, T. et al. Combining body mass index with measures of central obesity in the assessment of mortality in subjects with coronary disease: role of “normal weight central obesity”. J. Am. Coll. Cardiol. 61, 553–560 (2013).

    Article  PubMed  Google Scholar 

  37. Clark, A. L., Chyu, J. & Horwich, T. B. The obesity paradox in men versus women with systolic heart failure. Am. J. Cardiol. 110, 77–82 (2012).

    Article  PubMed  PubMed Central  Google Scholar 

  38. McAuley, P. A. et al. The obesity paradox, cardiorespiratory fitness, and coronary heart disease. Mayo Clin. Proc. 87, 443–451 (2012).

    Article  PubMed  PubMed Central  Google Scholar 

  39. Kaminsky, L. A. et al. The importance of cardiorespiratory fitness in the United States: the need for a national registry: a policy statement from the American Heart Association. Circulation 127, 652–662 (2013).

    Article  PubMed  Google Scholar 

  40. Kodama, S. et al. Cardiorespiratory fitness as a quantitative predictor of all-cause mortality and cardiovascular events in healthy men and women: a meta-analysis. JAMA 301, 2024–2035 (2009).

    Article  CAS  PubMed  Google Scholar 

  41. Gupta, S. et al. Cardiorespiratory fitness and classification of risk of cardiovascular disease mortality. Circulation 123, 1377–1383 (2011).

    Article  PubMed  PubMed Central  Google Scholar 

  42. Artero, E. G. et al. A prospective study of muscular strength and all-cause mortality in men with hypertension. J. Am. Coll. Cardiol. 57, 1831–1837 (2011).

    Article  PubMed  PubMed Central  Google Scholar 

  43. Lyerly, G. W. et al. The association between cardiorespiratory fitness and risk of all-cause mortality among women with impaired fasting glucose or undiagnosed diabetes mellitus. Mayo Clinic Proc. 84, 780–786 (2009).

    Article  Google Scholar 

  44. Blair, S. N. et al. Influences of cardiorespiratory fitness and other precursors on cardiovascular disease and all-cause mortality in men and women. JAMA 276, 205–210 (1996).

    Article  CAS  PubMed  Google Scholar 

  45. Church, T. S., LaMonte, M. J., Barlow, C. E. & Blair, S. N. Cardiorespiratory fitness and body mass index as predictors of cardiovascular disease mortality among men with diabetes. Arch. Intern. Med. 165, 2114–2120 (2005).

    Article  CAS  PubMed  Google Scholar 

  46. Barry, V. W. et al. Fitness vs fatness on all-cause mortality: a meta-analysis. Prog. Cardiovasc. Dis. 56, 382–391 (2014).

    Article  PubMed  Google Scholar 

  47. Lee, D. C. et al. Long-term effects of changes in cardiorespiratory fitness and body mass index on all-cause and cardiovascular disease mortality in men: the Aerobics Center Longitudinal Study. Circulation 124, 2483–2490 (2011).

    Article  PubMed  PubMed Central  Google Scholar 

  48. Lee, D. C. et al. Changes in fitness and fatness on the development of cardiovascular disease risk factors: hypertension, metabolic syndrome, and hypercholesterolemia. J. Am. Coll. Cardiol. 59, 665–672 (2012).

    Article  PubMed  PubMed Central  Google Scholar 

  49. Lavie, C. J. et al. Impact of cardiorespiratory fitness on the obesity paradox in patients with heart failure. Mayo Clin. Proc. 88, 251–258 (2013).

    Article  PubMed  Google Scholar 

  50. De Schutter, A., Lavie, C. J., Patel, D. A. & Milani, R. V. Obesity paradox and the heart: which indicator of obesity best describes this complex relationship? Curr. Opin. Clin. Nutr. Metab. Care 16, 517–524 (2013).

    Article  PubMed  Google Scholar 

  51. Lavie, C. J., De Schutter, A., Patel, D. A. & Milani, R. V. Does fitness completely explain the obesity paradox? Am. Heart J. 166, 1–3 (2013).

    Article  PubMed  Google Scholar 

  52. McAuley, P. A. & Beavers, K. M. Contribution of cardiorespiratory fitness to the obesity paradox. Prog. Cardiovasc. Dis. 56, 434–440 (2014).

    Article  PubMed  Google Scholar 

  53. Artero, E. G. et al. Effects of muscular strength on cardiovascular risk factors and prognosis. J. Cardiopulm. Rehabil. Prev. 32, 351–358 (2012).

    Article  PubMed  PubMed Central  Google Scholar 

  54. Dullo, A. G. & Jacquet, J. The control of partitioning between protein and fat during human starvation: its internal determinants and biological significance. Br. J. Nutr. 82, 339–356 (1999).

    Article  Google Scholar 

  55. Zavin, A. et al. Adiposity facilitates increased strength capacity in heart failure patients with reduced ejection fraction. Int. J. Cardiol. 167, 2468–2471 (2013).

    Article  PubMed  Google Scholar 

  56. Lavie, C. J. et al. Obesity paradox, cachexia, frailty, and heart failure. Heart Fail. Clin. 10, 319–326 (2014).

    Article  PubMed  Google Scholar 

  57. Allison, D. B. et al. Weight loss increases and fat loss decreases all-cause mortality rates: results from two independent cohort studies. Int. J. Obes. Relat. Metab. Disord. 23, 603–611 (1999).

    Article  CAS  PubMed  Google Scholar 

  58. Fulster, S. et al. Muscle wasting in patients with chronic heart failure: results from the studies investigating co-morbidities aggravating heart failure (SICA-HF). Eur. Heart J. 34, 512–519 (2013).

    Article  PubMed  Google Scholar 

  59. Pocock, S. J. et al. Weight loss and mortality risk in patients with chronic heart failure in the candesartan in heart failure: assessment of reduction in mortality and morbidity (CHARM) programme. Eur. Heart J. 29, 2641–2650 (2008).

    Article  PubMed  Google Scholar 

  60. Anker, S. D. et al. Prognostic importance of weight loss in chronic heart failure and the effect of treatment with angiotensin-converting-enzyme inhibitors: an observational study. Lancet 361, 1077–1083 (2003).

    CAS  PubMed  Google Scholar 

  61. Aktas, M. K. et al. The effect of weight loss on clinical outcomes in patients implanted with a cardiac resynchronization therapy device: A MADIT-CRT sub-study. J. Card. Fail. 20, 183–189 (2014).

    Article  PubMed  Google Scholar 

  62. Lavie, C. J. & Ventura, H. O. Clinical implications of weight loss in heart failure. J. Card. Fail. 20, 190–192 (2014).

    Article  PubMed  Google Scholar 

  63. Tuomilehto, J. et al. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N. Engl. J. Med. 344, 1343–1350 (2001).

    Article  CAS  PubMed  Google Scholar 

  64. Knowler, W. C. et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N. Engl. J. Med. 346, 393–403 (2002).

    Article  CAS  PubMed  Google Scholar 

  65. Ades, P. A. & Savage, P. D. Potential benefits of weight loss in coronary heart disease. Prog. Cardiovasc. Dis. 56, 448–456 (2014).

    Article  PubMed  Google Scholar 

  66. Eilat-Adar, S., Eldar, M. & Goldbourt, U. Association of intentional changes in body weight with coronary heart disease event rates in overweight subjects who have an additional coronary risk factor. Am. J. Epidemiol. 161, 352–358 (2005).

    Article  PubMed  Google Scholar 

  67. Sierra-Johnson, J. et al. Prognostic importance of weight loss in patients with coronary heart disease regardless of initial body mass index. Eur. J. Cardiovasc. Prev. Rehabil. 15, 336–340 (2008).

    Article  PubMed  Google Scholar 

  68. De Schutter, A., Lavie, C. J. & Milani, R. V. The impact of obesity on risk factors and prevalence of coronary heart disease: the obesity paradox. Prog. Cardiovasc. Dis. 56, 401–408 (2014).

    Article  PubMed  Google Scholar 

  69. Clark, A. L., Fonarow, G. C. & Horwich, T. B. Obesity and obesity paradox in heart failure. Prog. Cardiovasc. Dis. 56, 409–414 (2014).

    Article  PubMed  Google Scholar 

  70. Wing, R. R. et al. Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. N. Engl. J. Med. 369, 145–154 (2013).

    Article  CAS  PubMed  Google Scholar 

  71. Swift, D. L., Johannsen, N. M., Lavie, C. J., Earnest, C. P. & Church, T. S. The role of exercise and physical activity in weight loss and maintenance. Prog. Cardiovasc. Dis. 56, 441–447 (2014).

    Article  PubMed  Google Scholar 

  72. Keteyian, S. J. et al. Relation between volume of exercise and clinical outcomes in patients with heart failure. J. Am. Coll. Cardiol. 60, 1899–1905 (2012).

    Article  PubMed  PubMed Central  Google Scholar 

  73. Lavie, C. J., Berra, K. & Arena, R. Formal cardiac rehabilitation and exercise training programs in heart failure: evidence for substantial clinical benefits. J. Cardiopulm. Rehabil. Prev. 33, 209–211 (2013).

    Article  PubMed  Google Scholar 

  74. Kushner, R. F. Weight loss strategies for treatment of obesity. Prog. Cardiovasc. Dis. 56, 465–472 (2014).

    Article  PubMed  Google Scholar 

  75. Johanssen, N. et al. Categorical analysis of the impact of aerobic and resistance exercise training, alone and in combination, on cardiorespiratory fitness levels in patients with type 2 diabetes: results from the HART-D study. Diabetes Care 36, 3305–3312 (2013).

    Article  Google Scholar 

  76. Sénéchal, M. et al. Changes in body fat distribution and fitness are associated with changes in hemoglobin A1c after 9 months of exercise training: results from the HART-D study. Diabetes Care 36, 2843–2849 (2013).

    Article  PubMed  PubMed Central  Google Scholar 

  77. Vuori, I. M., Lavie, C. J. & Blair, S. N. Physical activity promotion in the health care system. Mayo Clin. Proc. 88, 1446–1461 (2013).

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School, University of Queensland School of Medicine, 1514 Jefferson Highway, New Orleans, 70121-2483, LA, USA

    Carl J. Lavie, Alban De Schutter & Richard V. Milani

Authors
  1. Carl J. Lavie
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Alban De Schutter
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Richard V. Milani
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

C.J.L., A.D.S. and R.V.M. researched data for the article, contributed to discussion of the content and reviewed and/or edited the manuscript before submission. C.J.L. wrote the article.

Corresponding author

Correspondence to Carl J. Lavie.

Ethics declarations

Competing interests

C.J.L. has served as a consultant and speaker for The Coca-Cola Company (on fitness and obesity and not on their products) and has published a book on the obesity paradox with potential royalties. A.D.S. and R.V.M. declare no competing interests.

PowerPoint slides

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Lavie, C., De Schutter, A. & Milani, R. Healthy obese versus unhealthy lean: the obesity paradox. Nat Rev Endocrinol 11, 55–62 (2015). https://doi.org/10.1038/nrendo.2014.165

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/nrendo.2014.165

This article is cited by

Search

Advanced search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing