Healthy obese versus unhealthy lean: the obesity paradox

Key Points

  • The prevalence of obesity has increased in most of the world over the past few decades

  • Patients with obesity have more cardiovascular and metabolic risk factors than people of normal weight and have an increased risk of developing cardiovascular diseases

  • Data suggest that metabolically healthy obesity, especially when combined with a high level of fitness, is associated with at most a minimal increase in overall risk of cardiovascular diseases and mortality

  • In patients with established cardiovascular diseases and other chronic conditions (kidney disease, severe arthritis), those with overweight and class I obesity have a better prognosis than lean patients—the 'obesity paradox'

  • Fitness is more important than fatness for long-term prognosis; in the obesity paradox, fitness markedly alters the relationship between adiposity and long-term health outcomes

  • Despite accumulating evidence on the obesity paradox, the available data still support purposeful weight loss for long-term health, particularly when combined with increased physical activity, muscular strength and fitness


Overweight and obesity have reached epidemic proportions in the USA and most of the rest of the world. Particularly concerning is the very high prevalence of class III obesity (BMI ≥40 kg/m2), which has reached 3% in the USA. In the past few years, controversy has surrounded the idea that some individuals with obesity can be considered healthy with regards to their metabolic and cardiorespiratory fitness, which has been termed the 'obesity paradox'. These controversies are reviewed in detail here, including discussion of the very favourable prognosis in patients with obesity who have no notable metabolic abnormalities and who have preserved fitness. The article also discusses the suggestion that greater emphasis should be placed on improving fitness rather than weight loss per se in the primary and secondary prevention of cardiovascular diseases, at least in patients with overweight and class I obesity (BMI 30–35 kg/m2).

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Figure 1: Physical activity related to occupation from 1960 to 2010.
Figure 2: Change in mean weight in the USA.
Figure 3: Energy expenditure related to physical activity (mean kilocalories per week) in mothers in the USA, 1965–2010.
Figure 4: The joint effects of different measures of obesity and cardiorespiratory fitness on all-cause mortality.
Figure 5: Kaplan–Meier survival analyses according to BMI in a study of 2,066 patients with systolic heart failure.


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C.J.L., A.D.S. and R.V.M. researched data for the article, contributed to discussion of the content and reviewed and/or edited the manuscript before submission. C.J.L. wrote the article.

Correspondence to Carl J. Lavie.

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Competing interests

C.J.L. has served as a consultant and speaker for The Coca-Cola Company (on fitness and obesity and not on their products) and has published a book on the obesity paradox with potential royalties. A.D.S. and R.V.M. declare no competing interests.

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Lavie, C., De Schutter, A. & Milani, R. Healthy obese versus unhealthy lean: the obesity paradox. Nat Rev Endocrinol 11, 55–62 (2015).

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