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Fitness, Obesity, and Health Care Costs

Association between cardiorespiratory fitness, obesity, and health care costs: The Veterans Exercise Testing Study



Obesity is a chronic disease, a risk factor for other chronic conditions and for early mortality, and is associated with higher health care utilization. Annual spending among obese individuals is at least 30% higher vs. that for normal-weight peers. In contrast, higher cardiorespiratory fitness (CRF) is related to many health benefits. We sought to examine the association between CRF and health care costs across the spectrum of body mass index (BMI).


Data from 3,924 men (58.1 ± 11.1 years, 29.2 ± 5.3 kg.m−2) who completed a maximal exercise test for clinical reasons and to estimate CRF were recorded prospectively at the time of testing. Cost data (USD) from each subject during a 6-year period after the exercise test were merged with the exercise database and compared according to BMI and estimated CRF (CRFe). Subjects were categorized as normal-weight (BMI < 25.0 kg.m−2), overweight (BMI 25.0–29.9 kg.m−2), and obese (BMI ≥ 30.0 kg.m−2). We also formed four CRFe categories based on age-stratified quartiles of metabolic equivalents (METs) achieved: least-fit (5.1 ± 1.5 METs; n = 1,044), moderately-fit (7.6 ± 1.5 METs; n = 938), fit (9.4 ± 1.5 METs; n = 988), and highly-fit (12.4 ± 2.2 METs; n = 954).


Average annual costs per person adjusted for age and presence of cardiovascular disease were $37,018, $40,572, and $45,683 for normal-weight, overweight, and obese subjects, respectively (p < 0.01). For each 1-MET incremental increase in CRFe, annual cost savings per person were $3,272, $4,252, and $6,103 for normal-weight, overweight, and obese subjects, respectively. Stratified by CRFe categories, annual costs for normal-weight, overweight, and obese subjects in the highest CRFe quartile were $28,028, $31,669, and $32,807 lower, respectively, compared to subjects in the lowest CRFe quartile (p < 0.01).


Higher CRFe is associated with lower health care costs. Cost savings were particularly evident in obese subjects, suggesting that the economic burden of obesity may be reduced through interventions that target improvements in CRF.

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  1. World and Health Organization (WHO). Fact sheet on obesity and overweight. Accessed 10 Jan 2018.

  2. Nguyen NT, Magno CP, Lane KT, Hinojosa MW, Lane JS. Association of hypertension, diabetes, dyslipidemia, and metabolic syndrome with obesity: findings from the National Health and Nutrition Examination Survey, 1999 to 2004. J Am Coll Surg. 2008;207:928–34.

    Article  Google Scholar 

  3. Hall JE, do Carmo JM, da Silva AA, Wang Z, Hall ME. Obesity-induced hypertension: interaction of neurohumoral and renal mechanisms. Circ Res. 2015;116:991–1006.

    CAS  Article  Google Scholar 

  4. Arnold M, Leitzmann M, Freisling H, Bray F, Romieu I, Renehan A, et al. Obesity and cancer: an update of the global impact. Cancer Epidemiol. 2016;41:8–15.

    Article  Google Scholar 

  5. Flegal KM, Kit BK, Orpana H, Graubard BI. Association of all-cause mortality with overweight and obesity using standard body mass index categories: a systematic review and meta-analysis. JAMA. 2013;309:71–82.

    CAS  Article  Google Scholar 

  6. Pantalone KM, Hobbs TM, Chagin KM, Kong SX, Wells BJ, Kattan MW, et al. Prevalence and recognition of obesity and its associated comorbidities: cross-sectional analysis of electronic health record data from a large US integrated health system. BMJ Open. 2017;7:e017583.

    Article  Google Scholar 

  7. Dee A, Kearns K, O’Neill C, Sharp L, Staines A, O’Dwyer V, et al. The direct and indirect costs of both overweight and obesity: a systematic review. BMC Res Notes. 2014;7:242.

    Article  Google Scholar 

  8. Breland JY, Phibbs CS, Hoggatt KJ, Washington DL, Lee J, Haskell S, et al. The obesity epidemic in the Veterans Health Administration: prevalence among key populations of women and men veterans. J Gen Intern Med. 2017;32(Suppl 1):11–17.

    Article  Google Scholar 

  9. Finkelstein EA, Trogdon JG, Cohen JW, Dietz W. Annual medical spending attributable to obesity: payer-and service-specific estimates. Health Aff (Millwood). 2009;28:w822–831.

    Article  Google Scholar 

  10. Biener AI, Decker SL, Agency for Healthcare Research and Quality. Medical care use and expenditures associated with adult obesity in the United States. JAMA. 2018;319:218.

  11. Wang YC, McPherson K, Marsh T, Gortmaker SL, Brown M. Health and economic burden of the projected obesity trends in the USA and the UK. Lancet. 2011;378:815–25.

    Article  Google Scholar 

  12. Harber MP, Kaminsky LA, Arena R, Blair SN, Franklin BA, Myers J, et al. Impact of cardiorespiratory fitness on all-cause and disease-specific mortality: advances since 2009. Prog Cardiovasc Dis. 2017;60:11–20.

    Article  Google Scholar 

  13. Lear SA, Hu W, Rangarajan S, Gasevic D, Leong D, Iqbal R, et al. The effect of physical activity on mortality and cardiovascular disease in 130 000 people from 17 high-income, middle-income, and low-income countries: the PURE study. Lancet. 2017;390:2643–54.

    Article  Google Scholar 

  14. Ross R, Blair SN, Arena R, Church TS, Després JP, Franklin BA, et al. Importance of assessing cardiorespiratory fitness in clinical practice: a case for fitness as a clinical vital sign: a scientific statement from the American Heart Association. Circulation. 2016;134:e653–99.

    Article  Google Scholar 

  15. Mitchell TL, Gibbons LW, Devers SM, Earnest CP. Effects of cardiorespiratory fitness on healthcare utilization. Med Sci Sports Exerc. 2004;36:2088–92.

    Article  Google Scholar 

  16. Peeters GMEE, Gardine PA, Dobson AJ, Brown WJ. Associations between physical activity, medical costs and hospitalisations in older Australian women: results from the Australian Longitudinal Study on Women´s Health. J Sci Med Sport 2017;21:604–8.

  17. Kennedy AB, Lavie CJ, Blair SN. Fitness or fatness: which is more important? JAMA. 2018;319:231–2.

    Article  Google Scholar 

  18. Kokkinos P, Myers J. Exercise and physical activity: clinical outcomes and applications. Circulation. 2010;122:1637–48.

    Article  Google Scholar 

  19. Bray GA, Frühbeck G, Ryan DH, Wilding JP. Management of obesity. Lancet. 2016;387:1947–56.

    Article  Google Scholar 

  20. Barry VW, Baruth M, Beets MW, Durstine JL, Liu J, Blair SN. Fitness vs. fatness on all-cause mortality: a meta-analysis. Prog Cardiovasc Dis. 2014;56:382–90.

    Article  Google Scholar 

  21. Lee DC, Sui X, Artero EG, Lee IM, Church TS, McAuley PA, et al. Long-term effects of changes in cardiorespiratory fitness and body mass index on all-cause and cardiovascular disease mortality in men: the Aerobics Center Longitudinal Study. Circulation. 2011;124:2483–90.

    Article  Google Scholar 

  22. Shue P, Froelicher VF. EXTRA: an expert system for exercise test reporting. J Non-Invasive. 1998;II-4:21–27.

    Google Scholar 

  23. Myers J, Buchanan N, Walsh D, et al. Comparison of the ramp versus standard exercise protocols. J Am Coll Cardiol. 1991;17:1334–42.

    CAS  Article  Google Scholar 

  24. Glass S, Dwyer GB. ACSM’s metabolic equations handbook. Philadelphia: Lippincott, Williams & Wilkins; 2007.

  25. Kokkinos P, Myers J, Franklin B, Narayan P, Lavie CJ, Faselis C. Cardiorespiratory fitness and health outcomes: a call to standardize fitness categories. Mayo Clin Proc. 2018;93:333–6.

    Article  Google Scholar 

  26. U.S. Department of Veterans Affairs. Health Economics Resource Center (HERC). Accessed 15 Aug 2018.

  27. Anis AH, Zhang W, Bansback N, Guh DP, Amarsi Z, Birmingham CL. Obesity and overweight in Canada: an updated cost-of-illness study. Obes Rev. 2010;11:31–40.

    CAS  Article  Google Scholar 

  28. Buchmueller TC, Johar M. Obesity and health expenditures: evidence from Australia. Econ Hum Biol. 2015;17:42–58.

    Article  Google Scholar 

  29. McAuley PA, Kokkinos PF, Oliveira RB, Emerson BT, Myers JN. Obesity paradox and cardiorespiratory fitness in 12,417 male veterans aged 40 to 70 years. Mayo Clin Proc. 2010;85:115–21.

    Article  Google Scholar 

  30. Myers J, Doom R, King R, Fonda H, Chan K, Kokkinos P, et al. Association between cardiorespiratory fitness and health care costs: The Veterans Exercise Testing Study. Mayo Clin Proc. 2018;93:48–55.

    Article  Google Scholar 

  31. Wang F, McDonald T, Reffitt B, Edington DW. BMI, physical activity, and health care utilization/costs among Medicare retirees. Obes Res. 2005;13:1450–7.

    Article  Google Scholar 

  32. Carlson SA, Fulton JE, Pratt M, Yang Z, Adams EK. Inadequate physical activity and health care expenditures in the United States. Prog Cardiovasc Dis. 2015;57:315–23.

    Article  Google Scholar 

  33. Prince SA, Adamo KB, Hamel ME, et al. A comparison of direct versus self-report measures for assessing physical activity in adults: a systematic review. Int J Behav Nutr Phys Act. 2008;5:56.

    Article  Google Scholar 

  34. Warner ET, Wolin KY, Duncan DT, Heil DP, Askew S, Bennett GG. Differential accuracy of physical activity self-report by body mass index. Am J Health Behav. 2012;36:168–78.

    Article  Google Scholar 

  35. Weiss JP, Froelicher VF, Myers JN, Heidenreich PA. Health-care costs and exercise capacity. Chest. 2004;126:608–13.

    Article  Google Scholar 

  36. Bachmann JM, DeFina LF, Franzini L, Gao A, Leonard DS, Cooper KH, et al. Cardiorespiratory fitness in middle age and health care costs in later life. J Am Coll Cardiol. 2015;66:1876–85.

    Article  Google Scholar 

  37. Kodama S, Saito K, Tanaka S, Maki M, Yachi Y, Asumi M, et al. Cardiorespiratory fitness as a quantitative predictor of all-cause mortality and cardiovascular events in healthy men and women: a meta-analysis. JAMA. 2009;301:2024–35.

    CAS  Article  Google Scholar 

  38. Kaminsky LA, Arena R, Myers J. Reference standards for cardiorespiratory fitness measured with cardiopulmonary exercise testing: data from the Fitness Registry and the Importance of Exercise National Database. Mayo Clin Proc. 2015;90:1515–23.

    Article  Google Scholar 

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Christina Grüne de Souza e Silva was supported by Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)/Programa de Doutorado Sanduíche−88881.136006/2016–01

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Correspondence to Christina Grüne de Souza de Silva.

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de Souza de Silva, C., Kokkinos, P., Doom, R. et al. Association between cardiorespiratory fitness, obesity, and health care costs: The Veterans Exercise Testing Study. Int J Obes 43, 2225–2232 (2019).

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