International Journal of Cardiology 214 (2016) 92–94

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International Journal of Cardiology

journal homepage: www.elsevier.com/locate/ijcard

Physical activity, weight status, and mortality among congestive heart

failure patients
Paul D. Loprinzi ⁎
Jackson Heart Study Vanguard Center of Oxford, Physical Activity Epidemiology Laboratory, Department of Health, Exercise Science and Recreation Management, The University of Mississippi, Uni-
versity, MS 38677, United States

a r t i c l e i n f o a b s t r a c t

Article history: Background: Although obesity contributes to increased heart failure risk, and in alignment with the “obesity par-
Received 15 March 2016 adox”, studies demonstrate that overweight/obese patients with established heart failure have better clinical out-
Accepted 20 March 2016 comes when compared to their normal weight counterparts. To address this, the purpose of this study was to
Available online 26 March 2016 evaluate the fat-but-fit paradigm among those with congestive heart failure.
Methods: Participant data from the 1999–2006 National Health and Nutrition Examination Survey were utilized,
Keywords:
with follow-up through 2011. Analyses are based on data from 573 participants who had a physician-diagnosis of
Congestive heart failure
Epidemiology
congestive heart failure. Based on self-reported physical activity status and measured body mass index, partici-
Mortality pants were categorized into 6 mutually exclusive groups: Group 1: Normal Weight and Inactive, Group 2) Over-
Survival weight and Inactive, Group 3) Obese and Inactive, Group 4) Normal Weight and Active, Group 5) Overweight and
Active and Group 6) Obese and Active.
Results: When compared to Group 1, those in Groups 2, 4, 5, and 6 had a reduced risk of all-cause mortality.
Conclusion: Physically active congestive heart failure patients, regardless of weight status, have survival benefits.
© 2016 Elsevier Ireland Ltd. All rights reserved.

1. Introduction multistage, stratified clustered probability design. Participants are

Physical inactivity and obesity contribute to increased heart failure
risk [1]. Despite this, and aligned with the “obesity paradox”, some stud-
ies demonstrate that overweight/obese patients with established heart
failure have better clinical outcomes when compared to their normal
weight counterparts [1,2]. Emerging work demonstrates that cardiore-
spiratory fitness may help to attenuate the long-term cardiovascular ad-
verse effects associated with obesity [1,3–6], often referred to as the
“Fat-but-Fit” paradigm. The purpose of this study was to apply this
“Fat-but-Fit” paradigm to patients with diagnosed congestive heart fail-
ure, with the outcome of interest being all-cause mortality.
2. Methods
interviewed in their homes and then subsequently examined in a mo-
bile examination center (MEC). Further information on NHANES meth-
odology and data collection is available on the NHANES website (http://
www.cdc.gov/nchs/nhanes.htm). Procedures were approved by the Na-
tional Center for Health Statistics review board. Consent was obtained
from all participants prior to data collection.
Participant data from the 1999–2006 National Health and Nutrition
Examination Survey were utilized. Data from participants in these cy-
cles were linked to death certificate data from the National Death
Index via a probabilistic algorithm. Person-months of follow-up were
calculated from the date of the interview until date of death or censor-
ing on December 31, 2011, whichever came first. Analyses are based
on data from 573 participants who had a physician-diagnosis of conges-
tive heart failure and complete data on the study variables.

2.1. Study design with assessment of mortality status 2.2. Assessment of congestive heart failure

The National Health and Nutrition Examination Survey is an ongoing
survey conducted by the Center for Disease Control and Prevention de-
signed to evaluate the health status of U.S. adults through a complex,
⁎ The University of Mississippi, Jackson Heart Study Vanguard Center of Oxford, Physical
Activity Epidemiology Laboratory, School of Applied Sciences, Department of Health,
Exercise Science, and Recreation Management, 229 Turner Center, University, MS 38677,
United States
E-mail address: pdloprin@olemiss.edu.
Participants who answered “yes” to the following question were
considered to have congestive heart failure: “Has a doctor or other health
professional ever told you that you had congestive heart failure?” Notably,
self-report of physician diagnosis of heart disease has demonstrated ev-
idence of validity. For example, as shown by Bergmann et al. [7], and
when compared to hospitalized confirmed diagnosis, sensitivity (true
positivity) of self-reported heart disease was 84% among American
adults.

http://dx.doi.org/10.1016/j.ijcard.2016.03.180
0167-5273/© 2016 Elsevier Ireland Ltd. All rights reserved.
 P.D. Loprinzi / International Journal of Cardiology 214 (2016) 92–94
2.3. Assessment of physical activity
As described elsewhere [8], participants were asked open-ended
questions about participation in leisure-time physical activity over the
past 30 days. Data was coded into 48 activities, including 16 sports-
related activities, 14 exercise-related activities, and 18 recreational-
related activities.
For each of the 48 activities where participants reported moderate or
vigorous-intensity for the respective activity, they were asked to report
the number of times they engaged in that activity over the past 30 days
and the average duration they engaged in that activity. For each activity,
Metabolic Equivalent of Task (MET)-min-month was calculated by mul-
tiplying the number of days, by the mean duration, by the respective
MET level (MET-min-month = days ∗ duration ∗ MET level). The MET
levels for each activity are provided elsewhere [9]. As described else-
where, this physical activity assessment has demonstrated evidence of
convergent validity by positively associating with accelerometer-
assessed physical activity [8].
Participants were categorized as active versus inactive based on the
upper quartile; those self-reporting at least 1050 MET-min-month of
moderate-to-vigorous physical activity (MVPA) (4th quartile) were
classified as active. Notably, 2000 MVPA MET-min-month is consistent
with meeting physical activity guidelines (30 min/day of MVPA), but
too few participants achieved this threshold to utilize this cut-point.
2.4. Assessment of weight status
Body mass index (BMI) at baseline was measured using standard pro-
cedures, with participants classified as normal weight (BMI b 25 kg/m2;
notably, those with a BMI b 18.5 were excluded from the analyses), over-
weight (BMI 25–29.9 kg/m2) and obese (30+ kg/m2).
2.5. Fit-but-fat groups
Based on their activity status and weight status (described
above), participants were categorized into 6 mutually exclusive
groups (N = 573):
1) Normal Weight and Inactive (Nsample = 82; Ndied = 56)
2) Overweight and Inactive (Nsample = 154; Ndied = 89)
3) Obese and Inactive (Nsample = 192; Ndied = 98)
4) Normal Weight and Active (Nsample = 35; Ndied = 13)
5) Overweight and Active (Nsample = 58; Ndied = 25)
6) Obese and Active (Nsample = 52; Ndied = 18)
2.6. Statistical analysis
All statistical analyses were computed in Stata (v. 12) and accounted
for the complex survey design employed in NHANES by utilizing sample
weights, primary sampling units and strata via the Taylor series (linear-
ization) method. A weighted multivariable Cox proportional hazards
model was used to examine the association between the fat-but-fit
groups and all-cause mortality among those with congestive heart fail-
ure. For the 6 fat-but-fit groups, Group 1 (Normal Weight and Inactive)
served as the referent group in a Cox proportional hazards model. Co-
variates in this Cox proportional hazard model included: age, gender,
race-ethnicity and comorbid illness, with comorbid illness indicating
the summed number of physician-diagnosed morbidities including ar-
thritis, coronary artery disease, stroke, heart attack, emphysema, chron-
ic bronchitis, hypertension and diabetes.
3. Results
Among the 573 congestive heart failure patients (Mage = 65.3 years;
54.9% men; 76.6% non-Hispanic white), 299 died over the follow-up pe-
riod, with the duration of the unweighted median follow-up period
93
being 75 months (IQR: 42–104). For the entire sample, 41,825 person-
months occurred with an incidence rate of 7.14 deaths per 1000
person-months. The Cox proportional hazard results (proportional haz-
ards assumption not violated [P = 0.54]), after adjusting for age, gender,
race-ethnicity, and comorbid illness are as follows:
1) Normal Weight and Inactive (Referent)
2) Overweight and Inactive (HRadjusted = 0.62; 95% CI: 0.0.41–0.93;
P = 0.02)
3) Obese and Inactive (HRadjusted = 0.71; 95% CI: 0.44–1.13; P = 0.15)
4) Normal Weight and Active (HRadjusted = 0.38; 95% CI: 0.17–0.82;
P = 0.01)
5) Overweight and Active (HR adjusted = 0.48; 95% CI: 0.24–0.93;
P = 0.03)
6) Obese and Active (HRadjusted = 0.47; 95% CI: 0.22–0.99; P = 0.04)
After adding duration of congestive heart failure as a covariate,
results were unchanged:
1) Normal Weight and Inactive (Referent)
2) Overweight and Inactive (HRadjusted = 0.62; 95% CI: 0.42–0.91;
P = 0.01)
3) Obese and Inactive (HRadjusted = 0.70; 95% CI: 0.44–1.11; P = 0.13)
4) Normal Weight and Active (HRadjusted = 0.30; 95% CI: 0.14–0.64;
P = 0.003)
5) Overweight and Active (HR adjusted = 0.50; 95% CI: 0.26–0.93;
P = 0.03)
6) Obese and Active (HRadjusted = 0.46; 95% CI: 0.21–0.98; P = 0.04)
4. Discussion
The purpose of this study was to evaluate the fat-but-fit paradigm
among patients with congestive heart failure. These results suggest
that overweight inactive heart failure patients had a reduced all-cause
mortality risk when compared to normal weight inactive heart failure
patients. This is consistent with the pre-obesity paradox [10]. Addition-
ally, Groups 4–6 all had a reduced mortality risk. These 3 groups were
those who were ‘active’ and either normal weight, overweight, or
obese. Taken together, these findings suggest that ‘active’ congestive
heart failure patients, regardless of weight status, may have survival
benefits. The greatest survival benefits (62–70% reduced all-cause mor-
tality risk [HR = 0.38 or HR = 0.30]) occurred among congestive heart
failure patients who were normal weight and active. Ultimately, these
findings underscore the importance of promoting physical activity to
congestive heart failure patients, across all weight statuses. Future con-
firmatory work on this topic is needed, which should overcome the lim-
itations of this study, including the subjective assessment of physical
activity and the non-objective confirmation of congestive heart failure
status.
Conflict of interest
No conflicts of interest are disclosed.
Acknowledgments
No funding was used to prepare this manuscript.
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