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The Fat but Fit paradox: what we know and don’t know about it
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In the late 1980s, one of us (SNB) published a study that demonstrated that individuals with a low (below first quintile=20th percentile) cardiorespiratory fitness level had a higher risk of mortality 8 years later, when compared with those who were at least moderately fit.1 Since then, many longitudinal studies have consistently confirmed this notion in men and women, as well as in healthy and diseased individuals, for all-cause mortality, as well as for cardiovascular disease (CVD) mortality.2 Obesity is related to multiple physical and mental comorbidities and it is an incontrovertible risk factor for all-cause and CVD mortality.3 It has been suggested, however, that being fit might attenuate some of the adverse consequences of obesity, independently of some key potential confounders. In this context, in the late 1990s, some studies provided first evidence for what was later known as the Fat but Fit paradox (see review by Ortega et al .3). These studies demonstrated that all-cause and CVD mortality risk in obese individuals, as defined by body mass index (BMI), body fat percentage or waist circumference, who are fit (ie, cardiorespiratory fitness level above the age-specific and sex-specific 20th percentile) is not significantly different from their normal-weight and fit counterparts (ie, the theoretically healthiest group possible) (figure 1). Figure 1 Illustration of the Fat but Fit paradox in relation with cardiovascular disease (CVD) mortality and all-cause mortality in …
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“which can, at medium to high fitness levels, attenuate the adverse consequences of obesity on health, irrespective of body mass index (BMI). 5 , 6 , 7”
From What exercise prescription is optimal to improve body composition and cardiorespiratory fitness in adults living with obesity? A network meta‐analysis (2021) · cites this paper as [5]
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“On the other hand, muscular strength has also been shown to be related to cardiovascular diseases in young adults [12,20,21], and it has been associated with a greater risk of metabolic syndrome [19,37].”
BackgroundResultSehn, A. P., Brand, C., Silveira, J. F. D. C., Andersen, L. B., Gaya, A. R., Todendi, P. F., Valim, A. R. D. M., & Reuter, C. P. (2022) · BMC Cardiovascular Disorders · doi:10.1186/s12872-022-02537-5 · Cited by 12
“Also, we hypothesized that CRF could exert a protective role in this context, once there is evidence supporting that better fitness levels seem to attenuate deleterious outcomes to cardiometabolic health associated with higher adiposity [29], and even attenuate the potential development of excess weight amongst those…”
BackgroundBrand, C., Dias, A. F., Fochesatto, C. F., García‐Hermoso, A., Mota, J. A. P. S., Gaya, A. C. A., & Gaya, A. R. (2018) · Motriz Revista de Educação Física · doi:10.1590/s1980-6574201800040015 · Cited by 11
Amaro‐Gahete, F. J., Jurado‐Fasoli, L., Ruiz, J. R., & Castillo, M. J. (2020) · Nutrients · doi:10.3390/nu12041186 · Cited by 11
“9) or overweight–obese (BMI ≥ 25) and (ii) as metabolically healthy or metabolically unhealthy phenotype [34].”
BackgroundSelf-citationGrao‐Cruces, A., Racero-García, A., Sánchez‐Oliva, D., Luengo, D. B., Nuviala, A. N., & García‐Calvo, T. (2020) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph17134821 · Cited by 12
“We found that this vulnerability lies in their poor PF level, thus, students who are fit, even if they are overweight, would not have that problem, which is in line with the Fat but Fit paradox [43].”
ResultSmartphone App (2kmFIT-App) for Measuring Cardiorespiratory Fitness: Validity and Reliability Study
Muntaner‐Mas, A., Martínez-Nicolás, A., Quesada, A., Cadenas‐Sánchez, C., & Ortega, F. B. (2020) · JMIR mhealth and uhealth · doi:10.2196/14864 · Cited by 11
“There is strong evidence suggesting that higher levels of CRF are associated with a healthier metabolic profile [2-4], and that CRF is a powerful predictor of morbidity and mortality [1,5,6] Given the well-known relevance of CRF to general health status, its assessment has been strongly recommended in the recent Ameri…”
BackgroundSelf-citationBody composition phenotypes and bone health in young adults: A cluster analysis
Torres-Costoso, A. I., Martínez‐Vizcaíno, V., Baptista, F., Reina‐Gutiérrez, S., de Arenas‐Arroyo, S. N., Hernández-Castillejo, L. E., & Garrido‐Miguel, M. (2023) · Clinical Nutrition · doi:10.1016/j.clnu.2023.05.006 · Cited by 10
Gerardo Weisstaub, N., Bravo, M. A. G., García‐Hermoso, A., Salazar, G., & López‐Gil, J. F. (2022) · Translational Pediatrics · doi:10.21037/tp-22-25 · Cited by 10
“In young population, evidence with regards to this paradox is not consistent (25-28).”
Gorny, A. W., Low, M. C., Sayampanathan, A. A., Shiraz, F., & Müller‐Riemenschneider, F. (2021) · BMC Public Health · doi:10.1186/s12889-021-10373-z · Cited by 11
“Interventions which have treated activity or fitness as the primary outcome and relegated weight loss to a secondary outcome have gained traction in recent years [55].”
BackgroundPlaza‐Florido, A., Altmäe, S., Esteban, F. J., Löf, M., Radom‐Aizik, S., & Ortega, F. B. (2021) · Scandinavian Journal of Medicine and Science in Sports · doi:10.1111/sms.14028 · Cited by 10
Self-citationMartínez‐Vizcaíno, V., Álvarez‐Bueno, C., Sánchez‐López, M., Jiménez‐López, E., Soriano‐Cano, A., Ortega, F. B., Cavero‐Redondo, I., & Garrido‐Miguel, M. (2020) · The Journal of Pediatrics · doi:10.1016/j.jpeds.2020.12.062 · Cited by 11
Self-citationDavis, M. E., Blake, C. M., & O’Donoghue, G. (2024) · Obesity Science & Practice · doi:10.1002/osp4.749 · Cited by 14
Kjær, I. G. H., Anderssen, S. A., & Torstveit, M. K. (2018) · Preventive Medicine Reports · doi:10.1016/j.pmedr.2018.06.011 · Cited by 9
Navarro‐Lomas, G., Plaza‐Florido, A., De‐la‐O, A., Castillo, M. J., & Amaro‐Gahete, F. J. (2023) · American Journal of Human Biology · doi:10.1002/ajhb.23945 · Cited by 9
“These results highlight the fact that fitness and fatness are not always directly associated (Ortega et al., 2018; Sloan et al., 2016).”
BackgroundCadenas‐Sánchez, C., Esteban‐Cornejo, I., Migueles, J. H., Labayen, I., Verdejo‐Román, J., Mora-González, J., Henriksson, P., Maldonado, J. A., Gómez-Vida, J. M., Hillman, C. H., et al. (2020) · Journal of Clinical Medicine · doi:10.3390/jcm9041059 · Cited by 9
“Previous studies have tested the ‘fat but fit’ paradox, showing that higher levels of fitness attenuate the negative consequences of excess body mass on cardiovascular disease risk [2,41].”
BackgroundSelf-citationNormative Values for Muscular Fitness for Chinese Children and Adolescents Aged 7–18 Years
Sun, Y., Yin, X., Li, Y., Bi, C., Li, M., Yang, X., Zhang, T., & Zhang, F. (2020) · Sustainability · doi:10.3390/su12156078 · Cited by 10
“One study showed that individuals below the 20th percentile had a higher health risk, and this is often used as a threshold to define healthy and unhealthy [35]; however, a Swedish cohort study showed significantly higher rates of all-cause mortality, cardiovascular disease mortality, and suicide mortality in populati…”
BackgroundValenzuela, P. L., Pinto‐Escalona, T., Lucı́a, A., & Martínez‐de‐Quel, Ó. (2021) · Pediatric Obesity · doi:10.1111/ijpo.12850 · Cited by 9
“There is evidence that an optimal cardiorespiratory fitness (CRF) attenuates some of the adverse consequences of obesity, at least at the cardiovascular level—the so-called ‘fat but fit’ paradox.(6) CRF can also influence academic achievement,(7) with a high CRF attenuating the detrimental effects of obesity on academ…”
BackgroundBody Mass Index, Obesity, and Mortality– Part I
Mestre, L. M., Lartey, S. T., Ejima, K., Mehta, T. S., Keith, S. W., Maki, K. C., & Allison, D. B. (2023) · Nutrition Today · doi:10.1097/nt.0000000000000609 · Cited by 9
Tracking of cardiometabolic risk in a Brazilian schoolchildren cohort: a 3-year longitudinal study
Silveira, J. F. D. C., Reuter, C. P., Welser, L., Pfeiffer, K. A., Andersen, L. B., Pohl, H. H., & Lima, R. A. (2021) · The Journal of Sports Medicine and Physical Fitness · doi:10.23736/s0022-4707.20.11479-8 · Cited by 9
Gafni, T., Weinstein, G., Leonard, D. S., Barlow, C. E., DeFina, L. F., Gabriel, K. P., Berry, J. D., & Shuval, K. (2023) · BMJ Open · doi:10.1136/bmjopen-2023-075571 · Cited by 9
Sparks, J. R., Wang, X., Lavie, C. J., & Sui, X. (2024) · Reviews in Cardiovascular Medicine · doi:10.31083/j.rcm2508291 · Cited by 9
“Over the past 20+ years, the “fat but fit” concept has supported the obesity paradox through the lens of PA engagement and CRF improvement [81].”
BackgroundSelf-citationUS Army Accession and Retention Standards: Impact on Obesity and Medical Readiness
Potter, A. W., & Friedl, K. E. (2024) · Military Medicine · doi:10.1093/milmed/usae554 · Cited by 9
“28 Even the observed associations between high (or low) BMI or high %BF with increased musculoskeletal injury during initial entry training may only be a surrogate for the The Marine Corps has adopted body fat standards that are linked to a sliding scale of physical performance testing, where…”
Brand, C., Sehn, A. P., Fochesatto, C. F., Villa‐González, E., Gaya, A. R., Renner, J. D. P., Ojeda-Aravena, A., & Reuter, C. P. (2023) · Biology of Sport · doi:10.5114/biolsport.2024.129473 · Cited by 8
Mora-González, J., Esteban‐Cornejo, I., Migueles, J. H., Rodríguez‐Ayllón, M., Molina‐García, P., Cadenas‐Sánchez, C., Solis‐Urra, P., Plaza‐Florido, A., Kramer, A. F., Erickson, K. I., et al. (2020) · Developmental Science · doi:10.1111/desc.13048 · Cited by 9
Self-citationTodendi, P. F., Brand, C., Silveira, J. F. D. C., Burns, R. D., Martínez, J. A., Fiegenbaum, M., Gaya, A. R., Renner, J. D. P., Reuter, C. P., & Valim, A. R. D. M. (2021) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph18189797 · Cited by 8
“Other findings also demonstrate that healthier CRF levels seems to attenuate the adverse outcomes of excess adiposity on overall health [25].”
BackgroundGrunseit, A. C., Bohn-Goldbaum, E. E., Crane, M. A., Milat, A., Cashmore, A. W., Fonua, R., Gow, A., Havrlant, R., Reid, K., Hennessey, K., et al. (2019) · Australian and New Zealand Journal of Public Health · doi:10.1111/1753-6405.12914 · Cited by 8
Jones, J., Reneau, P. D., & dos Santos, J. M. (2021) · Medical Hypotheses · doi:10.1016/j.mehy.2021.110542 · Cited by 7
Sehn, A. P., Brand, C., Welser, L., Gaya, A. R., Agostinis‐Sobrinho, C., Cristi‐Montero, C., de Mello, E. D., & Reuter, C. P. (2021) · BMC Pediatrics · doi:10.1186/s12887-021-02696-y · Cited by 7
“Still, it is suggested that regardless of body weight, it is important to achieve appropriate CRF levels [44, 52, 53].”
Background“Fat but Fit” Paradox and Cardiometabolic Risk in Children: The Role of Physical Activity
Pozuelo‐Carrascosa, D. P., Martínez‐Vizcaíno, V., Torres-Costoso, A. I., Martínez, M. S., Rodríguez‐Gutiérrez, E., & Garrido‐Miguel, M. (2022) · Childhood Obesity · doi:10.1089/chi.2022.0073 · Cited by 7
“13– 15 Furthermore, individuals with obesity and moderate-to-high CRF levels did not show a significantly higher risk of cardiovascular disease mortality than the theoretically healthiest group possible (normal-weight and fit).”
Balducci, S., Haxhi, J., Vitale, M., Mattia, L., Sacchetti, M., Orlando, G., Cardelli, P., Iacobini, C., Bollanti, L., Conti, F., et al. (2023) · Diabetes/Metabolism Research and Reviews · doi:10.1002/dmrr.3671 · Cited by 7
Gerber, M., Cody, R., Beck, J., Brand, S., Donath, L., Eckert, A., Hatzinger, M., Imboden, C., Kreppke, J.-N., Lang, U. E., et al. (2023) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2023.1193004 · Cited by 8
Leite, N., Tadiotto, M. C., de Moraes-Junior, F. B., de Menezes-Junior, F. J., Corazza, P. R. P., da Silva, L. R., Lopes, W. A., de Matos, O., Radominski, R. B., & Coelho-e-Silva, M. J. (2024) · Scientific Reports · doi:10.1038/s41598-024-61805-w · Cited by 9
Acosta‐Manzano, P., Acosta, F. M., Flor‐Alemany, M., Gavilán‐Carrera, B., Delgado‐Fernández, M., Baena‐García, L., Segura‐Jiménez, V., & Aparicio, V. A. (2022) · International Journal of Sport Nutrition and Exercise Metabolism · doi:10.1123/ijsnem.2021-0274 · Cited by 6
da Costa, B. G. G., da Costa, R. M., de Mello, G. T., Bandeira, A. D. S., Chaput, J., & da Silva, K. S. (2023) · Quality of Life Research · doi:10.1007/s11136-023-03379-0 · Cited by 6
Monacis, D., Pascali, G., & Colella, D. (2024) · Pedagogy of Physical Culture and Sports · doi:10.15561/26649837.2024.0304 · Cited by 9
“According to Ortega et al. being normal weight or not being obese is not enough for manteinig health, and adequate physical fitness levels are unavoidable to gain and achieve health [42].”
The “Fat but Fit” Paradigm from a Children's Health-Related Quality of Life Perspective
Martínez‐Vizcaíno, V., Garrido‐Miguel, M., Redondo‐Tébar, A., Notario‐Pacheco, B., Rodríguez‐Martin, B., & Sánchez‐López, M. (2021) · Childhood Obesity · doi:10.1089/chi.2021.0041 · Cited by 6
Metadata
- Authors
- Ortega, F. B., Ruiz, J. R., Labayen, I., Lavie, C. J., & Blair, S. N.
- Affiliations
- Universidad de Granada (ES)
- University of the Basque Country (ES)
- The University of Queensland (AU)
- University of South Carolina (US)
- Corresponding author
- Ortega, Francisco B
- Venue
- British Journal of Sports Medicine
- Publisher
- BMJ
- Published
- 2017-06-05
- Volume
- 52
- Issue
- 3
- Pages
- 151-153
- ISSN
- 0306-3674 (ISSN-L)
- 1473-0480
- OpenAlex
- W2622199341
- Cited by
- 179
- References
- 11
- Citations by year
- 2026: 10 · 2025: 15 · 2024: 12 · 2023: 31 · 2022: 26 · 2021: 23 · 2020: 28 · 2019: 11 · 2018: 19 · 2017: 3
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- British Journal of Sports Medicine (publishedVersion)
- PubMed (publishedVersion)
- Institutional Repository of the University of Granada (University of Granada) (submittedVersion, cc-by-nd)
- HighWire Press Open Archive (submittedVersion)
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Physical Activity and Health
- Health Sciences › Medicine › Physiology (medical) › Cardiovascular and exercise physiology
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Obesity, Physical Activity, Diet
- Keywords
- cardiorespiratory fitness, obesity, all-cause mortality, cardiovascular mortality, body mass index, body fat percentage, waist circumference
- MeSH terms
- Cardiorespiratory Fitness, Cardiovascular Diseases, Health Status, Humans, Mortality, Obesity, Meta-Analysis as Topic, Exercise, Overweight
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