‘Fat but powerful’ paradox: association of muscle power and adiposity markers with all-cause mortality in older adults from the EXERNET multicentre study
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Abstract
Objectives: To assess the influence of muscle power and adiposity on all-cause mortality risk and to evaluate the ‘fat but powerful’ (F+P) (or ‘fat but fit’) paradox in older adults. Methods: A total of 2563 older adults (65‒91 years old) from the EXERNET multicentre study were included. Adiposity (body mass index (BMI), waist circumference, body fat percentage (BF%) and fat index), allometric and relative power (sit-to-stand muscle power test) and various covariates (age, sex, hypertension, smoking status and walking and sitting times per day) were registered at baseline. All-cause mortality was recorded during a median follow-up of 8.9 years. Participants were classified into four groups: lean and powerful (L+P), F+P, lean but weak and fat and weak (F+W). Cox proportional hazard regression models and adjusted HRs were calculated. Results: According to BMI and waist circumference, all-cause mortality risk was reduced in the F+P (HR=0.55 and 0.63, p=0.044 and 0.049, respectively) and L+P (HR=0.57 and 0.58, p=0.043 and 0.025, respectively) groups. According to BF%, all-cause mortality decreased in the L+P group (HR=0.53; p=0.021), and a trend for a reduction was reported in the F+P group (HR=0.57; p=0.060). According to fat index, a survival benefit was only noted in the L+P group (HR=0.50; p=0.049). Higher levels of relative power reduced all-cause mortality risk among older people (HR=0.63 and 0.53, p=0.006 and 0.011, respectively). Conclusion: Powerful older people exhibited a reduced 9-year all-cause mortality regardless of BMI, waist circumference and BF%. Obesity according to fat index blunted the survival benefits of being powerful.
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Better mortality outcomes in persons with overweight or obesity may occur in certain race-ethnicity-sex-age strata, termed the fat but fit paradigm or obesity paradox.
“Termed by some observers as the “fat but fit” paradigm or an “obesity paradox”, better mortality outcomes in persons with overweight or obesity may occur in certain race-ethnicity-sex-age strata [47,48], and fitness level must be considered while assessing the association between body weight and medical outcomes [49].”
From Advantages and Limitations of the Body Mass Index (BMI) to Assess Adult Obesity (2024) · cites this paper as [48]
The Introduction describes lower mortality among fit people with obesity than among unfit people without obesity, calling this the ‘fat but fit’ paradox. The Conclusions report a survival benefit for powerful older adults with obesity under some adiposity measures, but not fat index. The Participants section describes an all-Caucasian sample aged 65 or older; the paper does not establish the claimed pattern across race-ethnicity-sex-age strata. (LLM, conf=0.87)
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Advantages and Limitations of the Body Mass Index (BMI) to Assess Adult Obesity
Wu, Y., Li, D., & Vermund, S. H. (2024) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph21060757 · Cited by 332 · see citing works
“…as the “fat but fit” paradigm or an “obesity paradox”, better mortality outcomes in persons with overweight or obesity may occur in certain race-ethnicity-sex-age strata [47,48], and fitness level must be considered while assessing the association between body weight and medical outcomes [49].”
Background
- Authors
- Alcazar, J., Navarrete-Villanueva, D., Mañas, A., Gómez-Cabello, A., Pedrero-Chamizo, R., Alegre, L. M., Villa, G., Gusi, N., González-Gross, M., Casajús, J. A., Vicente-Rodriguez, G., & Ara, I.
- Affiliations
- Centro de Investigación Biomédica en Red (ES)
- Universidad de León (ES)
- Corresponding author
- Ara, Ignacio
- ORCID
- Venue
- British Journal of Sports Medicine
- Publisher
- BMJ
- Published
- 2021-03-16
- Volume
- 55
- Issue
- 21
- Pages
- 1204-1211
- ISSN
- 0306-3674 (ISSN-L)
- 1473-0480
- OpenAlex
- W3136137760
- Cited by
- 43
- References
- 6
- Citations by year
- 2026: 6 · 2025: 15 · 2024: 4 · 2023: 5 · 2022: 7 · 2021: 6
- FWCI
- 3.46
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- British Journal of Sports Medicine (publishedVersion)
- medRxiv (acceptedVersion)
- PubMed (publishedVersion)
- Archivo Digital UPM (Universidad Politécnica de Madrid) (submittedVersion, cc-by-nc-nd)
- Hispana (submittedVersion, cc-by-nc-nd)
- Zaguan (University of Zaragoza Repository) (submittedVersion, cc-by-nc)
- Funders
- Ministerio de Educación y Ciencia (Red EXERNET DEP2005-00046)
- Ministerio de Economía, Industria y Competitividad, Gobierno de España (DEP2016-78309-R)
- Universidad de Zaragoza (UZ 2008-BIO-01)
- Ministerio de Sanidad, Servicios Sociales e Igualdad (147/2011)
- Consejo Superior de Deportes (09/UPB/19, 45/UPB/20)
- Ministerio de Trabajo y Asuntos Sociales-IMSERSO (104/07)
- Biomedical Research Networking Center on Frailty and Healthy Aging (CIBERFES) and FEDER funds from the European Union (CB16/10/00477)
- Centro Universitario de la Defensa de Zaragoza (UZCUD2016-BIO-01)
- Gobierno de Aragón (DGAIIU/1/20)
- Topics
- Health Sciences › Medicine › Physiology › Nutrition and Health in Aging
- Health Sciences › Medicine › Geriatrics and Gerontology › Frailty in Older Adults
- Health Sciences › Medicine › Physiology › Body Composition Measurement Techniques
- Keywords
- muscle power, adiposity, all-cause mortality, older adults, sit-to-stand test, body mass index, waist circumference, body fat percentage, fat index, relative power, obesity
- MeSH terms
- Aged, Aged, 80 and over, Female, Humans, Male, Obesity, Prospective Studies, Risk Factors, Body Mass Index, Adiposity, Muscle Strength, Waist Circumference
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