Cardiorespiratory fitness, body mass index and mortality: a systematic review and meta-analysis

Abstract

Objective: The purpose of this review was to assess the joint relationship of cardiorespiratory fitness (CRF) and Body Mass Index (BMI) on both cardiovascular disease (CVD) and all-cause mortality risk.

Design: A systematic review and meta-analysis was conducted. Pooled HR and 95% CI were calculated using a three-level restricted maximum likelihood estimation random-effects model with robust variance estimation. The reference group was normal weight-fit and was compared with normal weight-unfit, overweight-unfit and fit, and obese-unfit and fit.

Data sources: Electronic databases (PubMed/MEDLINE, Web of Science and SportDiscus) were searched following registration on PROSPERO.

Eligibility criteria: Articles meeting the following criteria were included: (1) published between January 1980 and February 2023, (2) prospective cohort study, (3) CRF assessed using a maximal or VO₂peak exercise test, (4) BMI reported and directly measured, (5) joint impact of CRF and BMI on all-cause mortality or CVD mortality were analysed, and (6) the reference group was normal weight, fit individuals.

Results: 20 articles were included in the analysis resulting in a total of 398 716 observations. Compared with the reference group, overweight-fit (CVD HR (95% CI): 1.50 (0.82-2.76), all-cause HR: 0.96 (0.61-1.50)) and obese-fit (CVD: 1.62 (0.87-3.01), all-cause: 1.11 (0.88-1.40)) did not have a statistically different risk of mortality. Normal weight-unfit (CVD: 2.04 (1.32-3.14), all-cause: 1.92 (1.43-2.57)), overweight-unfit (CVD: 2.58 (1.48-4.52), all-cause: 1.82 (1.47-2.24)) and obese-unfit (CVD: 3.35 (1.17-9.61), all-cause: 2.04 (1.54-2.71)) demonstrated 2-3-fold greater mortality risks.

Conclusions: CRF is a strong predictor of CVD and all-cause mortality and attenuates risks associated with overweight and obesity. These data have implications for public health and risk mitigation strategies.

Keywords: Cardiovascular Diseases; Exercise; Health promotion; Risk factor; VO2peak.

Figure 1. PRISMA diagram of study selection. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Figure 2. Forest plots for all-cause mortality. (A.) Overweight-fit. (B.) Obese-fit. (C.) Normal weight-unfit. (D.) Overweight-unfit. (E.) Obese-unfit. (US) Stevens et al, 2004, USA-based cohort; (R) Stevens et al, 2004, Russian-based cohort.

Figure 3. Forest plots for cardiovascular mortality. (A.) Overweight-fit. (B.) Obese-fit. (C.) Normal weight-unfit. (D.) Overweight-unfit. (E.) Obese-unfit. (US) Stevens et al, 2004, USA-based cohort; (R) Stevens et al, 2004, Russian-based cohort.