Role of Physical Activity and Fitness in the Characterization and Prognosis of the Metabolically Healthy Obesity Phenotype: A Systematic Review and Meta-analysis

doi:10.1016/j.pcad.2018.07.008

Progress in Cardiovascular Diseases

Volume 61, Issue 2, July–August 2018, Pages 190-205

https://doi.org/10.1016/j.pcad.2018.07.008 Get rights and content

Abstract

The aims of the present article are to systematically review and meta-analyze the existing evidence on: 1) differences in physical activity (PA), sedentary behavior (SB), cardiorespiratory fitness (CRF) and muscular strength (MST) between metabolically healthy obesity (MHO) and metabolically unhealthy obesity (MUO); and 2) the prognosis of all-cause mortality and cardiovascular disease (CVD) mortality/morbidity in MHO individuals, compared with the best scenario possible, i.e., metabolically healthy normal-weight (MHNW), after adjusting for PA, SB, CRF or MST. Our systematic review identified 67 cross-sectional studies to address aim 1, and 11 longitudinal studies to address aim 2. The major findings and conclusions from the current meta-analysis are: 1) MHO individuals are more active, spend less time in SB, and have a higher level of CRF (yet no differences in MST) than MUO individuals, suggesting that their healthier metabolic profile could be at least partially due to these healthier lifestyle factors and attributes. 2) The meta-analysis of cohort studies which accounted for PA (N = 10 unique cohorts, 100% scored as high-quality) support the notion that MHO individuals have a 24–33% higher risk of all-cause mortality and CVD mortality/morbidity compared to MHNW individuals. This risk was borderline significant/non-significant, independent of the length of the follow-up and lower than that reported in previous meta-analyses in this topic including all type of studies, which could be indicating a modest reduction in the risk estimates as a consequence of accounting for PA. 3) Only one study has examined the role of CRF in the prognosis of MHO individuals. This study suggests that the differences in the risk of all-cause mortality and CVD mortality/morbidity between MHO and MHNW are largely explained by differences in CRF between these two phenotypes.

Section snippets

Protocol and registration

The present systematic review and meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement.⁴³ The study protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO reference number: CRD42018093955).

Data sources and search strategies

The search was conducted for studies published from inception to March 21, 2018 in two major electronic databases: PubMed and Web of Science. The keywords used in search strategy were related

Literature search

In total, 70 unique studies were included in the systematic review; 67 of them were included for the systematic review for aim 1. Among them, 55 studies51., 52., 53., 54., 55., 56., 57., 58., 59., 60., 61., 62., 63., 64., 65., 66., 67., 68., 69., 70., 71., 72., 73., 74., 75., 76., 77., 78., 79., 80., 81., 82., 83., 84., 85., 86., 87., 88., 89., 90., 91., 92., 93., 94., 95., 96., 97., 98., 99., 100., 101., 102., 103., 104., 105. were focused on the differences between MHO and MUO in PA (N = 53)

Main findings

In the present systematic review and meta-analysis, we focused on two relevant topics related to the MHO phenotype, its characterization (aim 1) and prognosis (aim 2). The studies included in this review were mostly (80–100%) scored as high-quality studies indicating a low risk of bias in the findings obtained. We found 67 studies examining differences between MHO and MUO in PA, SB, CRF and MST. Our meta-analysis showed that MHO individuals have significantly higher levels of PA and CRF and

Conclusions

Our systematic review and meta-analysis provides novel insights in the characterization and prognosis of the MHO phenotype. First, the meta-analysis on cross-sectional studies supports that MHO individuals are more active, spent less time in SB, and have a higher level of CRF (yet no differences in MST) than MUO individuals, suggesting that their healthier metabolic profile could be, at least partially, due to these healthier lifestyle factors and attributes. Second, the findings from the

Funding

Current research activities of Dr. Ortega and Dr. Ruiz are supported by the Spanish Ministry of Economy and Competitiveness – MINECO/FEDER (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 -

Statement of Conflict of Interest

The authors declare no conflict of interest related to this work. Prof. Blair has served as consultants for weight loss and fitness companies and for The Coca-Cola Company, which has also provided them unrestricted research grants.

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^☆: Statement of Conflict of Interest: see page 203.

¹: Co-first authors.

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Role of Physical Activity and Fitness in the Characterization and Prognosis of the Metabolically Healthy Obesity Phenotype: A Systematic Review and Meta-analysis☆

Abstract

Section snippets

Protocol and registration

Data sources and search strategies

Literature search

Main findings

Conclusions

Funding

Statement of Conflict of Interest

Lancet

Metabolism

Lancet

Lancet

J Am Coll Cardiol

Prog Cardiovasc Dis

Lancet

Mayo Clin Proc

Metabolism

Prog Cardiovasc Dis

Lancet Diabetes Endocrinol

J Am Coll Cardiol

J Am Coll Cardiol

Int J Cardiol

PLoS One

J Clin Epidemiol

Rev Esp Cardiol (Engl Ed)

Am J Clin Nutr

J Adolesc Health

Nutr Metab Cardiovasc Dis

Nutr Metab Cardiovasc Dis

Am J Cardiol

Prev Med

Prim Care Diabetes

J Diabetes Res

Womens Health Issues

Am J Cardiol

Am J Prev Med

Heart Lung Circ

Trends in adult body-mass index in 200 countries from 1975 to 2014: a pooled analysis of 1698 population-based measurement studies with 19.2 million participants

Lancet

Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016: a pooled analysis of 2416 population-based measurement studies in 128.9 million children, adolescents, and adults

Lancet

Epidemiology of obesity and diabetes and their cardiovascular complications

Circ Res

What are the physical characteristics associated with a normal metabolic profile despite a high level of obesity in postmenopausal women?

J Clin Endocrinol Metab

The prevalence, metabolic risk and effects of lifestyle intervention for metabolically healthy obesity: a systematic review and meta-analysis: a PRISMA-compliant article

Medicine (Baltimore)

Obesity and cardiovascular disease

Circ Res

Physical activity, all-cause mortality, and longevity of college alumni

N Engl J Med

Physical activity as an index of heart attack risk in college alumni

Am J Epidemiol

Physical fitness and all-cause mortality. A prospective study of healthy men and women

JAMA

Cardiorespiratory fitness as a quantitative predictor of all-cause mortality and cardiovascular events in healthy men and women: a meta-analysis

JAMA

Association between muscular strength and mortality in men: prospective cohort study

BMJ

Muscular strength in male adolescents and premature death: cohort study of one million participants

BMJ

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

Muscular strength in adolescence and later disability: a population based cohort study of one million men

Br J Sports Med

Muscular strength as a predictor of all-cause mortality in an apparently healthy population: a systematic review and meta-analysis of data from approximately 2 million men and women

Arch Phys Med Rehabil

Fitness and fatness as health markers through the lifespan: an overview of current knowledge

Prog Prev Med

Characterizing the profile of obese patients who are metabolically healthy

Int J Obes (Lond)

The intriguing metabolically healthy but obese phenotype: cardiovascular prognosis and role of fitness

Eur Heart J

Fitness or fatness: which is more important?

JAMA

Obesity is rarely healthy

Lancet Diabetes Endocrinol

Beyond BMI: the “metabolically healthy obese” phenotype & its association with clinical/subclinical cardiovascular disease and all-cause mortality — a systematic review