title: Body mass, fitness and survival in veteran patients: another obesity paradox?
abstract: OBJECTIVE
  The paradox of obesity in patients with heart failure (HF) also has been observed in non-HF veteran patients. Veterans had to have met military fitness requirements at the time of their enlistment. Therefore, we assessed the relation of body mass index (BMI) to mortality in a clinical cohort of non-HF veterans, adjusting for fitness.
  
  
  METHODS
  After excluding HF patients (n=580), the study population comprised 6876 consecutive patients (mean age 58 [+/-11] years) referred for exercise testing. Patients were classified by BMI category: normal weight (BMI 18.5-24.9 kg/m2), overweight (BMI 25.0-29.9 kg/m2), or obese (BMI > or =30.0 kg/m2). The association between BMI, fitness, other clinical variables, and all-cause mortality was assessed by Cox proportional hazards analysis.
  
  
  RESULTS
  During a mean (+/-SD) follow-up of 7.5+/-4.5 years, a total of 1571 (23%) patients died. In a multivariate analysis including clinical, risk factor, and exercise test data, higher BMI was associated with better survival. Expressing the data by BMI category, obese patients were 22% less likely to die (relative risk [RR]=0.78, 95% confidence interval [CI], 0.69-0.90, P<.001) than patients of normal weight. After further adjustment for cardiorespiratory fitness (CRF), this relationship strengthened such that mortality risk for the obese category was 35% lower (RR=0.65, 95% CI, 0.57-0.76, P<.001), versus the normal weight category.
  
  
  CONCLUSIONS
  As has been observed in HF patients, obesity was associated with a substantially lower mortality risk in a clinical population of non-HF veterans. Higher CRF and obesity in later life may account for an obesity paradox in this population.
authors.affiliation: Cardiology Division, VA Palo Alto Health Care System/Stanford University, Palo Alto, Calif 94304, USA.
authors.forename: Paul
authors.initials: P
authors.lastname: McAuley
authors.forename: Jonathan
authors.initials: J
authors.lastname: Myers
authors.forename: Joshua
authors.initials: J
authors.lastname: Abella
authors.forename: Victor
authors.initials: V
authors.lastname: Froelicher
mesh_terms: D000368:Aged; D000375:Aging; D015992:Body Mass Index; D002318:Cardiovascular Diseases / Q000401:mortality; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009765:Obesity / Q000401:mortality*; D010809:Physical Fitness / Q000502:physiology*; D012307:Risk Factors; D012727:Sex Characteristics; D014728:Veterans