Abstract
High body mass index (BMI) and low cardiorespiratory fitness (CRF) are important modifiable risk factors for heart failure (HF). While the individual contributions of CRF and BMI toward risk for HF are well established, the interrelationship between BMI and CRF in modifying long-term HF risk is more complex and not well understood. In this review, we discuss and summarize the available evidence-base on individual and joint contributions of obesity and low CRF toward HF risk, including the potential mechanisms through which these lifestyle risk factors may lead to HF. We also discuss the role of interventions aimed at intentional loss of weight or CRF improvement as potential HF preventive strategies. Finally, the article also highlights the modifying effects of CRF on survival in relation to the obesity paradox in patients with established HF.
This is a preview of subscription content, access via your institution.


Abbreviations
- BMI:
-
Body mass index
- CCLS:
-
Cooper Center for Longitudinal Study
- CHD:
-
Coronary heart disease
- CRF:
-
Cardiorespiratory fitness
- CV:
-
Cardiovascular
- CVD:
-
Cardiovascular disease
- DM:
-
Diabetes mellitus
- HF:
-
Heart failure
- HTN:
-
Hypertension
- LV:
-
Left ventricle or ventricular
- LVH:
-
Left ventricular hypertrophy
- MET:
-
Metabolic equivalent
- MetS:
-
Metabolic syndrome
- PA:
-
Physical activity
References
Chen J, Normand SL, Wang Y, Krumholz HM. National and regional trends in heart failure hospitalization and mortality rates for Medicare beneficiaries, 1998–2008. JAMA. 2011;306:1669–78.
Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, Blaha MJ, et al. Executive summary: heart disease and stroke statistics—2014 update: a report from the american heart association. Circulation. 2014;129:399–410.
Dhingra A, Garg A, Kaur S, Chopra S, Batra JS, Pandey A, et al. Epidemiology of heart failure with preserved ejection fraction. Current Heart Fail Rep. 2014;11:354–65.
Archer E, Shook RP, Thomas DM, Church TS, Katzmarzyk PT, Hebert JR, et al. 45-Year trends in women's use of time and household management energy expenditure. PLoS ONE. 2013;8:e56620.
Church TS, Thomas DM, Tudor-Locke C, Katzmarzyk PT, Earnest CP, Rodarte RQ, et al. Trends over 5 decades in U.S. occupation-related physical activity and their associations with obesity. PLoS ONE. 2011;6:e19657.
Lavie CJ, Alpert MA, Arena R, Mehra MR, Milani RV, Ventura HO. Impact of obesity and the obesity paradox on prevalence and prognosis in heart failure. JACC Heart Fail. 2013;1:93–102.
Lavie CJ, Milani RV, Ventura HO. Obesity and cardiovascular disease: risk factor, paradox, and impact of weight loss. J Am Coll Cardiol. 2009;53:1925–32.
Flegal KM, Carroll MD, Ogden CL, Johnson CL. Prevalence and trends in obesity among US adults, 1999–2000. JAMA. 2002;288:1723–7.
Poirier P, Giles TD, Bray GA, Hong Y, Stern JS, Pi-Sunyer FX, et al. Obesity committee of the council on nutrition PA and metabolism. Obesity and cardiovascular disease: pathophysiology, evaluation, and effect of weight loss: an update of the 1997 american heart association scientific statement on obesity and heart disease from the obesity committee of the council on nutrition, physical activity, and metabolism. Circulation. 2006;113:898–918.
Sturm R. Increases in clinically severe obesity in the United States, 1986–2000. Arch Intern Med. 2003;163:2146–8.
Berry JD, Pandey A, Gao A, Leonard D, Farzaneh-Far R, Ayers C, et al. Physical fitness and risk for heart failure and coronary artery disease. Circ Heart Fail. 2013;6:627–34.
Kenchaiah S, Sesso HD, Gaziano JM. Body mass index and vigorous physical activity and the risk of heart failure among men. Circulation. 2009;119:44–52.
Pandey A, Patel M, Gao A, Willis BL, Das SR, Leonard D, et al. Changes in mid-life fitness predicts heart failure risk at a later age independent of interval development of cardiac and noncardiac risk factors: the cooper center longitudinal study. Am Heart J. 2015;169:290–7. e1.
Pandey AGS, Khunger M, Kumbhani D, Mayo H, De Lemos J, Berry J. Dose response relationship between physical activity and risk of heart failure: a meta-analysis. Circulation. 2015; EPI Lifestyle Conference supplement:MP02.
Rahman I, Bellavia A, Wolk A. Relationship between physical activity and heart failure risk in women. Circ Heart Fail. 2014;7:877–81.
Wang Y, Tuomilehto J, Jousilahti P, Antikainen R, Mahonen M, Katzmarzyk PT, et al. Occupational, commuting, and leisure-time physical activity in relation to heart failure among finnish men and women. J Am Coll Cardiol. 2010;56:1140–8.
Khan H, Kunutsor S, Rauramaa R, Savonen K, Kalogeropoulos AP, Georgiopoulou VV, et al. Cardiorespiratory fitness and risk of heart failure: a population-based follow-up study. Eur J Heart Fail. 2014;16:180–8.
Kraigher-Krainer E, Lyass A, Massaro JM, Lee DS, Ho JE, Levy D, et al. Association of physical activity and heart failure with preserved vs. Reduced ejection fraction in the elderly: the Framingham heart study. Eur J Heart Fail. 2013;15:742–6.
Pandey A, Darden D, Berry JD. Low fitness in midlife: a novel therapeutic target for heart failure with preserved ejection fraction prevention. Prog Cardiovasc Dis. 2015.
Lam CS, Lyass A, Kraigher-Krainer E, Massaro JM, Lee DS, Ho JE, et al. Cardiac dysfunction and noncardiac dysfunction as precursors of heart failure with reduced and preserved ejection fraction in the community. Circulation. 2011;124:24–30.
Arbab-Zadeh A, Dijk E, Prasad A, Fu Q, Torres P, Zhang R, et al. Effect of aging and physical activity on left ventricular compliance. Circulation. 2004;110:1799–805.
Brinker SK, Pandey A, Ayers CR, Barlow CE, DeFina LF, Willis BL, et al. Association of cardiorespiratory fitness with left ventricular remodeling and diastolic function: the cooper center longitudinal study. JACC Heart Fail. 2014;2:238–46.
Savage DD, Levy D, Dannenberg AL, Garrison RJ, Castelli WP. Association of echocardiographic left ventricular mass with body size, blood pressure and physical activity (the Framingham study). Am J Cardiol. 1990;65:371–6.
Wang TJ, Evans JC, Benjamin EJ, Levy D, LeRoy EC, Vasan RS. Natural history of asymptomatic left ventricular systolic dysfunction in the community. Circulation. 2003;108:977–82.
Kosmala W, Jellis CL, Marwick TH. Exercise limitation associated with asymptomatic left ventricular impairment: analogy with stage B heart failure. J Am Coll Cardiol. 2015;65:257–66.
Bhella PS, Hastings JL, Fujimoto N, Shibata S, Carrick-Ranson G, Palmer MD, et al. Impact of lifelong exercise “dose” on left ventricular compliance and distensibility. J Am Coll Cardiol. 2014;64:1257–66.
Hu G, Jousilahti P, Antikainen R, Katzmarzyk PT, Tuomilehto J. Joint effects of physical activity, body mass index, waist circumference, and waist-to-hip ratio on the risk of heart failure. Circulation. 2010;121:237–44.
Voulgari C, Tentolouris N, Dilaveris P, Tousoulis D, Katsilambros N, Stefanadis C. Increased heart failure risk in normal-weight people with metabolic syndrome compared with metabolically healthy obese individuals. J Am Coll Cardiol. 2011;58:1343–50.
Ingelsson E, Sundstrom J, Arnlov J, Zethelius B, Lind L. Insulin resistance and risk of congestive heart failure. JAMA. 2005;294:334–41.
Bahrami H, Bluemke DA, Kronmal R, Bertoni AG, Lloyd-Jones DM, Shahar E, et al. Novel metabolic risk factors for incident heart failure and their relationship with obesity: the MESA (multi-ethnic study of atherosclerosis) study. J Am Coll Cardiol. 2008;51:1775–83.
Morkedal B, Vatten LJ, Romundstad PR, Laugsand LE, Janszky I. Risk of myocardial infarction and heart failure among metabolically healthy but obese individuals: HUNT (nord-trondelag health study), Norway. J Am Coll Cardiol. 2014;63:1071–8.
Alpert MA. Obesity cardiomyopathy: pathophysiology and evolution of the clinical syndrome. Am J Med Sci. 2001;321:225–36.
Alpert MA, Terry BE, Kelly DL. Effect of weight loss on cardiac chamber size, wall thickness and left ventricular function in morbid obesity. Am J Cardiol. 1985;55:783–6.
Turkbey EB, McClelland RL, Kronmal RA, Burke GL, Bild DE, Tracy RP, et al. The impact of obesity on the left ventricle: the multi-ethnic study of atherosclerosis (MESA). J Am Coll Cardiol Img. 2010;3:266–74.
Russo C, Jin Z, Homma S, Rundek T, Elkind MS, Sacco RL, et al. Effect of obesity and overweight on left ventricular diastolic function: a community-based study in an elderly cohort. J Am Coll Cardiol. 2011;57:1368–74.
Kishi S, Armstrong AC, Gidding SS, Colangelo LA, Venkatesh BA, Jacobs Jr DR, et al. Association of obesity in early adulthood and middle age with incipient left ventricular dysfunction and structural remodeling: the CARDIA study (coronary artery risk development in young adults). JACC Heart Fail. 2014;2:500–8.
Mentz RJ, Kelly JP, von Lueder TG, Voors AA, Lam CS, Cowie MR, et al. Noncardiac comorbidities in heart failure with reduced versus preserved ejection fraction. J Am Coll Cardiol. 2014;64:2281–93.
Paulus WJ, Tschope C. A novel paradigm for heart failure with preserved ejection fraction: comorbidities drive myocardial dysfunction and remodeling through coronary microvascular endothelial inflammation. J Am Coll Cardiol. 2013;62:263–71.
Wessel TR, Arant CB, Olson MB, Johnson BD, Reis SE, Sharaf BL, et al. Relationship of physical fitness vs body mass index with coronary artery disease and cardiovascular events in women. JAMA. 2004;292:1179–87.
Barry VW, Baruth M, Beets MW, Durstine JL, Liu J, Blair SN. Fitness vs. fatness on all-cause mortality: a meta-analysis. Prog Cardiovasc Dis. 2014;56:382–90.
Lee DC, Sui X, Artero EG, Lee IM, Church TS, McAuley PA, 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. 2011;124:2483–90.
Lee DC, Sui X, Church TS, Lavie CJ, Jackson AS, Blair SN. Changes in fitness and fatness on the development of cardiovascular disease risk factors hypertension, metabolic syndrome, and hypercholesterolemia. J Am Coll Cardiol. 2012;59:665–72.
Cornwell WNI, Pandey A, Wilis B, Leonard D, Gao A, Defina L, et al. Combined association of midlife obesity and fitness with long-term risk of heart failure—the cooper center longitudinal study. Circulation. 2013;128.
Wing RR, Reboussin D, Lewis CE, Look ARG. Intensive lifestyle intervention in type 2 diabetes. N Engl J Med. 2013;369:2358–9.
Pandey A, Parashar A, Kumbhani DJ, Agarwal S, Garg J, Kitzman D, et al. Exercise training in patients with heart failure and preserved ejection fraction: meta-analysis of randomized control trials. Circ Heart Fail. 2015;8:33–40.
Swift DL, Johannsen NM, Lavie CJ, Earnest CP, Church TS. The role of exercise and physical activity in weight loss and maintenance. Prog Cardiovasc Dis. 2014;56:441–7.
Pandey A, Swift DL, McGuire DK, Ayers CR, Neeland IJ, Blair SN, et al. Metabolic effects of exercise training among fitness nonresponsive patients with type 2 diabetes mellitus: the HART-D study. Diabetes Care. 2015.
Alpert MA, Omran J, Mehra A, Ardhanari S. Impact of obesity and weight loss on cardiac performance and morphology in adults. Prog Cardiovasc Dis. 2014;56:391–400.
Haufe S, Utz W, Engeli S, Kast P, Bohnke J, Pofahl M, et al. Left ventricular mass and function with reduced-fat or reduced-carbohydrate hypocaloric diets in overweight and obese subjects. Hypertension. 2012;59:70–5.
Lavie CJ, Alpert MA, Ventura HO. Risks and benefits of weight loss in heart failure. Heart Fail Clin. 2015;11:125–31.
Hollekim-Strand SM, Bjorgaas MR, Albrektsen G, Tjonna AE, Wisloff U, Ingul CB. High-intensity interval exercise effectively improves cardiac function in patients with type 2 diabetes mellitus and diastolic dysfunction: a randomized controlled trial. J Am Coll Cardiol. 2014;64:1758–60.
Clark AL, Fonarow GC, Horwich TB. Obesity and the obesity paradox in heart failure. Prog Cardiovasc Dis. 2014;56:409–14.
Shah R, Gayat E, Januzzi Jr JL, Sato N, Cohen-Solal A, di Somma S, et al. Body mass index and mortality in acutely decompensated heart failure across the world: a global obesity paradox. J Am Coll Cardiol. 2014;63:778–85.
Fonarow GC, Srikanthan P, Costanzo MR, Cintron GB, Lopatin M, Committee ASA and Investigators. An obesity paradox in acute heart failure: analysis of body mass index and inhospital mortality for 108,927 patients in the Acute Decompensated Heart Failure National Registry. Am Heart J. 2007;153:74–81.
Sharma A, Lavie CJ, Borer JS, Vallakati A, Goel S, Lopez-Jimenez F, et al. Meta-analysis of the relation of body mass index to all-cause and cardiovascular mortality and hospitalization in patients with chronic heart failure. Am J Cardiol. 2015;115:1428–34.
Khalid U, Ather S, Bavishi C, Chan W, Loehr LR, Wruck LM, et al. Pre-morbid body mass index and mortality after incident heart failure: the ARIC study. J Am Coll Cardiol. 2014;64:2743–9.
Lavie CJ, De Schutter A, Patel D, Artham SM, Milani RV. Body composition and coronary heart disease mortality—an obesity or a lean paradox? Mayo Clin Proc. 2011;86:857–64.
Lavie CJ, De Schutter A, Patel DA, Romero-Corral A, Artham SM, Milani RV. 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. 2012;60:1374–80.
Lavie CJ, McAuley PA, Church TS, Milani RV, Blair SN. Obesity and cardiovascular diseases: implications regarding fitness, fatness, and severity in the obesity paradox. J Am Coll Cardiol. 2014;63:1345–54.
Anker SD, Negassa A, Coats AJ, Afzal R, Poole-Wilson PA, Cohn JN, 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. 2003;361:1077–83.
Kalantar-Zadeh K, Block G, Horwich T, Fonarow GC. Reverse epidemiology of conventional cardiovascular risk factors in patients with chronic heart failure. J Am Coll Cardiol. 2004;43:1439–44.
Mohamed-Ali V, Goodrick S, Bulmer K, Holly JM, Yudkin JS, Coppack SW. Production of soluble tumor necrosis factor receptors by human subcutaneous adipose tissue in vivo. Am J Physiol. 1999;277:E971–5.
Mehra MR, Uber PA, Park MH, Scott RL, Ventura HO, Harris BC, et al. Obesity and suppressed B-type natriuretic peptide levels in heart failure. J Am Coll Cardiol. 2004;43:1590–5.
Clark AL, Fonarow GC, Horwich TB. Impact of cardiorespiratory fitness on the obesity paradox in patients with systolic heart failure. Am J Cardiol. 2015;115:209–13.
De Schutter A, Lavie CJ, Patel DA, Milani RV. Obesity paradox and the heart: which indicator of obesity best describes this complex relationship? Curr Opin Clin Nutr Metab Care. 2013;16:517–24.
Lavie CJ, Cahalin LP, Chase P, Myers J, Bensimhon D, Peberdy MA, et al. Impact of cardiorespiratory fitness on the obesity paradox in patients with heart failure. Mayo Clin Proc. 2013;88:251–8.
Lavie CJ, De Schutter A, Milani RV. Healthy obese versus unhealthy lean: the obesity paradox. Nat Rev Endocrinol. 2015;11:55–62.
McAuley PA, Artero EG, Sui X, Lee DC, Church TS, Lavie CJ, et al. The obesity paradox, cardiorespiratory fitness, and coronary heart disease. Mayo Clin Proc. 2012;87:443–51.
Davies EJ, Moxham T, Rees K, Singh S, Coats AJ, Ebrahim S, et al. Exercise training for systolic heart failure: Cochrane systematic review and meta-analysis. Eur J Heart Fail. 2010;12:706–15.
Lavie CJ, De Schutter A, Patel DA, Milani RV. Does fitness completely explain the obesity paradox? Am Heart J. 2013;166:1–3.
Compliance with Ethics Guidelines
Conflict of Interest
Ambarish Pandey: None
Jarett D. Berry: None
Carl J. Lavie has received personal fees outside of the submitted work.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Author information
Authors and Affiliations
Corresponding author
Additional information
This article is part of the Topical Collection on Epidemiology of Heart Failure
Rights and permissions
About this article
Cite this article
Pandey, A., Berry, J.D. & Lavie, C.J. Cardiometabolic Disease Leading to Heart Failure: Better Fat and Fit Than Lean and Lazy. Curr Heart Fail Rep 12, 302–308 (2015). https://doi.org/10.1007/s11897-015-0265-5
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11897-015-0265-5
Keywords
- Obesity
- Heart failure
- Cardiorespiratory fitness
- Physical activity
- Exercise