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Ming Wei, MD, MPH; James B. Kampert, PhD; Carolyn E. Barlow, MS; Milton Z. Nichaman, MD, ScD; Larry W. Gibbons, MD, MPH; Ralph S. Paffenbarger, Jr, MD, DrPH; Steven N. Blair, PED

JAMA. 1999;282:1547-1553.

Context  Recent guidelines for treatment of overweight and obesity include recommendations for risk stratification by disease conditions and cardiovascular disease (CVD) risk factors, but the role of physical inactivity is not prominent in these recommendations.

Objective  To quantify the influence of low cardiorespiratory fitness, an objective marker of physical inactivity, on CVD and all-cause mortality in normal-weight, overweight, and obese men and compare low fitness with other mortality predictors.

Design  Prospective observational data from the Aerobics Center Longitudinal Study.

Setting  Preventive medicine clinic in Dallas, Tex.

Participants  A total of 25,714 adult men (average age, 43.8 years [SD, 10.1 years]) who received a medical examination during 1970 to 1993, with mortality follow-up to December 31, 1994.

Main Outcome Measures  Cardiovascular disease and all-cause mortality based on mortality predictors (baseline CVD, type 2 diabetes mellitus, high serum cholesterol level, hypertension, current cigarette smoking, and low cardiorespiratory fitness) stratified by body mass index.

Results  During the study period, there were 1025 deaths (439 due to CVD) during 258,781 man-years of follow-up. Overweight and obese men with baseline CVD or CVD risk factors were at higher risk for all-cause and CVD mortality compared with normal-weight men without these predictors. Using normal-weight men without CVD as the referent, the strongest predictor of CVD death in obese men was baseline CVD (age- and examination year-adjusted relative risk [RR], 14.0; 95% confidence interval [CI], 9.4-20.8); RRs for obese men with diabetes mellitus, high cholesterol, hypertension, smoking, and low fitness were similar and ranged from 4.4 (95% CI, 2.7-7.1) for smoking to 5.0 (95% CI, 3.6-7.0) for low fitness. Relative risks for all-cause mortality in obese men ranged from 2.3 (95% CI, 1.7-2.9) for men with hypertension to 4.7 (95% CI, 3.6-6.1) for those with CVD at baseline. Relative risk for all-cause mortality in obese men with low fitness was 3.1 (95% CI, 2.5-3.8) and in obese men with diabetes mellitus 3.1 (95% CI, 2.3-4.2) and as slightly higher than the RRs for obese men who smoked or had high cholesterol levels. Low fitness was an independent predictor of mortality in all body mass index groups after adjustment for other mortality predictors. Approximately 50% (n = 1674)of obese men had low fitness, which led to a population-attributable risk of 39% for CVD mortality and 44% for all-cause mortality. Baseline CVD had population attributable risks of 51% and 27% for CVD and all-cause mortality, respectively.

Conclusions  In this analysis, low cardiorespiratory fitness was a strong and independent predictor of CVD and all-cause mortality and of comparable importance with that of diabetes mellitus and other CVD risk factors.

Author Affiliations: The Cooper Institute for Aerobics Research (Drs Wei, Kampert, and Blair and Ms Barlow), and Cooper Clinic (Dr Gibbons), Dallas, Tex; Westat Inc, Rockville, Md (Dr Nichaman); and Department of Health Research and Policy, Stanford University School of Medicine, Stanford, Calif (Dr Paffenbarger).

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