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The Fat but Fit paradox: what we know and don’t know about it
  1. Francisco B Ortega1,
  2. Jonatan R Ruiz1,
  3. Idoia Labayen2,
  4. Carl J Lavie3,
  5. Steven N Blair4,5
  1. 1 PROFITH ‘PROmoting FITness and Health through physical activity’ Research Group, Department of Physical Education and Sports, Faculty of Sport Sciences, University of Granada, Granada, Spain
  2. 2 Department of Nutrition and Food Science, University of the Basque Country, Universidad del País Vasco/ Euskal Herrico Unibertsitatea (UPV/EHU), Vitoria, Spain
  3. 3 Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, Louisiana, USA
  4. 4 Department of Exercise Science, University of South Carolina, Columbia, South Carolina, USA
  5. 5 Department of Epidemiology and Biostatistics, University of South Carolina, Columbia, South Carolina, USA
  1. Correspondence to Dr Francisco B Ortega, PROFITH ‘PROmoting FITness and Health through physical activity’ Research Group, Department of Physical Education and Sports, Faculty of Sport Sciences, University of Granada, Carretera de Alfacar s/n, Granada 18071, Spain; ortegaf{at}

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What we know about it

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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  • Contributors FBO wrote the initial draft of the article, which was then discussed and refined with the other authors.

  • Funding FBO was supported by the Spanish Ministry of Economy and Competitiveness –MINECO (RYC-2011-09011). Additional support was obtained from the MINECO/FEDER (DEP2013-47540-R and DEP2016-79512-R); the University of Granada, Plan Propio de Investigación 2016, Excellence actions: Units of Excellence, Unit of Excellence on Exercise and Health (UCEES); the European Union’s Horizon 2020 research and innovation programme under grant agreement no. 667302; the SAMID III network, RETICS, funded by the PN I+D+I 2017-2021 (Spain), ISCIII- Sub-Directorate General for Research Assessment and Promotion, the European Regional Development Fund (ERDF) (Ref. RD16/0022) and the EXERNET Research Network on Exercise and Health in Special Populations (DEP2005-00046/ACTI). CJL and SNB has received unrestricted research grants from Coca-Cola Company.

  • Disclaimer The views expressed are those of the authors and do not reflect the official policy or position of the institutions they belong to.

  • Competing interests CJL has served as a consultant and speaker on fitness/obesity for the Coca-Cola and has published a book on the obesity paradox with potential royalties. SNB has served as consultant for weight loss and fitness companies and for the Coca-Cola.

  • Provenance and peer review Not commissioned; externally peer reviewed.