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This article originally posted and appeared in  Issue 451CardiovascularObesity

It’s Here, A New Disease For The 21st Century: “PreObesity”

The risk of heart failure goes up 11% for every one-point increase in body-mass index (BMI)


The risk of new heart failure went up by about 11% for every one-point increase in body-mass index (BMI) over a follow-up of about 20 years in an analyses from the venerable Physician's Health Study (PHS) that also looked at HF risk according to the baseline BMI category in the trial's male participants [1].


"Obese" participants had almost three times the risk of those considered "lean," but even those who were "overweight," with a BMI of 25 to <30 kg/m2, had a significant jump in risk, of about 50%. The increases were independent of other potential HF risk factors, including clinical diabetes and coronary disease.

The study, also suggested that the risk of heart failure could be cut significantly by regular "vigorous physical exercise," which it defined modestly as exercising until "breaking a sweat" and which was protective even if performed only a few times a month.

"This finding may imply that any vigorous physical activity is an indicator of healthier lifestyle in men at risk of developing HF," the authors, led by Dr Satish Kenchaiah (Brigham and Women's Hospital, Boston, MA), cautiously note in their report, scheduled for the journal's January 6, 2009 issue.

"Additional research is warranted to ascertain whether intentional weight reduction to optimal levels in overweight and obese individuals, together with improved physical activity, would lessen the probability of HF." The current study, along with other research, including data from the Framingham Heart Study [2], they write, suggests that men and women who are overweight without necessarily being obese can have a significant heart-failure risk and that "perhaps a BMI <25 kg/m2 represents an optimal goal for the primary prevention of HF."

The analysis encompassed 21 094 participants of the PHS who had complete relevant baseline data and were initially free of heart failure. They had been separately randomized to low-dose aspirin or placebo and to beta-carotene supplements or placebo.

Hazard ratio* (95% CI) for heart failure by BMI (as both continuous and categorical variables) and by exercise level

BMI and exercise variable

HR (95% CI)

BMI, as continuous variable


HR per BMI-unit increment

1.11 (1.09–1.13)

BMI categories


Lean (<25 kg/m2)

1.00 (reference)

Overweight (25–29.9 kg/m2)

1.49 (1.32–1.69)

Obese (>30 kg/m2)

2.80 (2.24–3.50)

p for trend


Frequency of vigorous exercise



1.00 (reference)

1–3 times/mo

0.78 (0.63–0.97)

1–4 times/wk

0.86 (0.73–1.01)

5–7 times/wk

0.73 (0.59–0.90)

p for trend


*Adjusted for age, smoking, alcohol consumption, MI family history, aspirin and beta-carotene assignment, vigorous exercise level and BMI (as appropriate to analysis), and history of hypertension, diabetes, and hypercholesterolemia
Other findings included:

  • With increasing frequency of vigorous exercise came steeper reductions in risk.
  • Persons categorized as "lean and active" had the lowest observed risk of heart failure, while those who were "obese and inactive" had the greatest risk--almost four times the risk of the former group.
  • The positive association between BMI and HF risk was more pronounced in younger compared with older patients and in nondiabetics compared with diabetics.

Launched in 1982 [3] and with an original enrollment of >22 000 male physicians, the PHS has generated hundreds of papers, famously finding in the 1980s that daily low-dose aspirin could lower the risk of a first MI [4] and in the 1990s that beta-carotene supplements had no effect either way on the risks of either cancer or cardiovascular disease [5].
Circulation, Dec 22, 2008

  • Kenchaiah S, Sesso HD, Gaziano JM. Body mass index and vigorous physical activity and the risk of heart failure among men. Circulation 2009; DOI:10.1161/CIRCULATIONAHA.108.807289. Available at: Abstract
  • Kenchaiah S, Evans JC, Levy D, et al. Obesity and the risk of heart failure. N Eng Med 2002; 347:305–313. Abstract
  • Physicians' Health Study
  • Belanger C, Buring JE, Cook N, et al. Final report on the aspirin component of the ongoing Physicians' Health Study. N Engl J Med 1989; 321:129-135. Abstract

Hennekens CH, Buring JE, Manson JE, et al. Lack of effect of long-term supplementation with beta-carotene on the incidence of malignant neoplasms and cardiovascular disease. N Eng J Med 1996; 334:1145-1149. Abstract



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This article originally posted 13 January, 2009 and appeared in  Issue 451CardiovascularObesity

Past five issues: Issue 796 | Diabetes Clinical Mastery Series Issue 255 | Issue 795 | SGLT-2 Inhibitors Special Edition August 2015 | Diabetes Clinical Mastery Series Issue 254 |

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