Abstract
BackgroundContested evidence suggests that obesity confers no risk to health in people who have a healthy lifestyle, particularly if there are no metabolic complications of obesity. The aim was to examine the association between adherence to lifestyle recommendations and the absence of metabolic complications on the incident or fatal cardiovascular disease and all-cause mortality across different categories of body mass index (BMI).MethodsThis contemporary prospective cohort study included 339,902 adults without cardiovascular disease at baseline, recruited between 2006 and 2010 from the UK Biobank and followed until 2018–2020. The main exposures were four healthy lifestyle behaviours: never smoker, alcohol intake ≤ 112g/ week, 150 min moderate physical activity or 75 min vigorous activity/week, ≥ 5 servings of fruit or vegetables/day, and we assessed these overall and across the BMI groups. Metabolic complications of excess adiposity were hypertension, diabetes and hyperlipidaemia, and we examined whether obesity was associated with increased risk in the absence of these complications. The outcomes were all-cause mortality, death from, and incident cardiovascular disease (CVD).ResultsIndividuals who met four lifestyle recommendations but had excess weight had higher all-cause mortality; for BMI 30–34.9 kg/m2, the hazard ratio (HR) was 1.42 (95% confidence interval 1.20 to 1.68), and for BMI ≥ 35 kg/m2, HR was 2.17 (95% CI 1.71 to 2.76). The risk was lower, but still increased for people with no metabolic complications; for all-cause mortality, BMI 30–34.9 kg/m2 had an HR of 1.09 (95% CI 0.99 to 1.21), and BMI ≥ 35 kg/m2 had an HR of 1.44 (95% CI 1.19 to 1.74) for all-cause mortality. Similar patterns were found for incident and fatal CVD.ConclusionsMeeting healthy lifestyle recommendations, or the absence of metabolic complications of obesity offsets some, but not all, of the risk of subsequent CVD, and premature mortality in people with overweight or obesity. Offering support to achieve and maintain a healthy weight and to adopt healthy behaviours are likely to be important components in effective preventative healthcare.
Highlights
Contested evidence suggests that obesity confers no risk to health in people who have a healthy lifestyle, if there are no metabolic complications of obesity
Using a large contemporary UK cohort, we aimed to examine the association between adherence to four key lifestyle recommendations on allcause mortality and fatal and total cardiovascular disease (CVD) risk overall and across body mass index (BMI) groups
Amongst the people meeting all four healthy lifestyle behaviours who were overweight, the hazard ratio (HR) was 1.11 (95% confidence interval (CI) 0.99 to 1.24); for people with obesity, it was 1.42; and those with severe obesity, it was 2.17
Summary
Contested evidence suggests that obesity confers no risk to health in people who have a healthy lifestyle, if there are no metabolic complications of obesity. Largely in the United States (US) health professional populations, have suggested that by adopting healthy behaviours, individuals with obesity could reduce their cardiovascular and all-cause mortality risk to equal to that of people with a BMI in the healthy range [6, 7]. This has led to the hypothesis that some people have a “fat but fit” phenotype, which posits that excess weight only confers additional risk if accompanied by low cardiorespiratory fitness [7]. Understanding whether this is sufficient to overcome the adverse health implications associated with excess weight is essential to inform future obesity strategies
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