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Special Communication

Response to Letter to the Editor

Lavie, Carl J. MD; Kachur, Sergey MD; O'Keefe, Evan MD; Elagizi, Andrew MD; Carbone, Salvatore PhD

Author Information
Current Sports Medicine Reports: February 2020 - Volume 19 - Issue 2 - p 96-97
doi: 10.1249/JSR.0000000000000686
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Dear Editor-in-Chief:

We appreciate the interest from Drs. Stovitz and Shrier in our recent invited article in Current Sports Medicine Reports (CSMR). Although they state that we are causing “confusion” with our article, we suspect that most experts in obesity and cardiovascular diseases (CVD) are no longer “confused,” and the confusion is rather isolated to a few not familiar with the obesity paradox and those who do not yet fully comprehend it.

Certainly, many of the leading journals in CVD (1–4) and general medicine (5–8) have published major articles on the obesity paradox, including original research (1,2,5–7), meta-analyses (7), and major state-of-the-art review articles (4,8), including those that my colleagues and I have been invited to write (4,8). Stovitz and Shrier write about “collider bias,” which we also have listed as a possible explanation for the obesity paradox. However, the articles on collider bias are not generally published in the very top journals, especially in CVD, as are many of our articles, and we listed this as a possibility to satisfy the review process. Certainly, “collider bias” is not considered by most experts to be a leading cause of the obesity paradox.

They mention that we cited 13 of our articles, but if they look up, they will see that one of us (C.J.L.) is ranked first worldwide on both the topics of obesity and fitness, and that C.J.L. also has 799 articles currently on PubMed, so 13 represents a very small percentage of his articles, including those invited by top journals.

They also mention weight reduction, which we also believe in and promote to our patients and in our articles, especially to prevent obesity in the first place and its progression into more severe forms (4). However, with the exception of bariatric surgery in severe obesity, there is very little information that weight loss reduces major clinical events, especially in CVD, although it may lead to improvements in symptoms and blood pressure, as well as other CVD risk factors. One of the articles they cite by Quinn Pack (their reference 3) actually showed that weight loss was associated with an increase in clinical events, and there was only a reduction in events noted in the studies where the weight loss was “presumed” to be purposeful. Certainly, weight loss studies that assess major clinical events are needed in CVD (4).

In defense of Drs. Stovitz and Shrier, we also were “confused” about the obesity paradox. More than two decades ago, one of us (C.J.L.) when sitting with CVD patients in the office postmyocardial infarction and/or with heart failure, one with a body mass index (BMI) of 23 and the other 32, the one with the ideal BMI would have been predicted to have the best prognosis. Now more than two decades later, numerous studies and meta-analyses, although not all, suggest that we would have been “dead wrong.” Although patients with ideal BMI may develop less CVD in the first place, once CVD becomes manifest, those with ideal BMI, unless their fitness level is high, generally have a worse prognosis than do patients with higher BMI, who also have a low level of fitness.

Stovitz and Shrier misunderstand our intention in reporting the obesity paradox, suggesting that we believe that “more fat is better for people with obesity and CVD.” The importance of reporting the obesity paradox in the scientific literature is to better inform both medical professionals and the public regarding healthy body composition. For example, the “fat but fit” and “normal weight obese” phenomena are excellent examples to highlight this point, both of which are related to the obesity paradox and have been discussed in our publications. The “fat but fit” phenomenon, in which individuals with the highest levels of fitness often have the lowest mortality rate, regardless of BMI, is a tremendously important concept as it challenges the common view of a normal BMI being “healthy.” This inappropriate notion is shared by many members of the public and health care providers alike. Further, the normal weight obese phenomenon describes patients with normal BMI and high adiposity which leads to metabolic disturbances that increase the risk for CVD and worsens prognosis, again challenging the common notion that maintaining a normal BMI is considered “healthy.” We are surprised that these concepts are difficult to grasp by some of our colleagues in the medical field. To think that the obesity paradox is a way of promoting obesity is completely false and dismisses these other important concepts (so important that the American Heart Association has advocated for fitness to be used as a vital sign, which has already been adopted by large institutions, such as Kaiser Permanente).

Therefore, rather than focusing on weight in secondary prevention, we believe that the “weight” of evidence currently suggests that fitness is more important than fatness (8) and that efforts to increase aerobic and muscular fitness should be emphasized in the secondary prevention of CVD. Obviously, preventing obesity in the first place, as well as maintaining fitness throughout the lifespan, would be ideal (4).

Carl J. Lavie, MD
Ochsner Medical Center
New Orleans, LA.
[email protected]
Sergey Kachur, MD
Evan O'Keefe, MD
Andrew Elagizi, MD
Ochsner Medical Center
New Orleans, LA
Salvatore Carbone, PhD
Department of Kinesiology & Health Sciences
College of Humanities & Sciences
Virginia Commonwealth University Richmond, VA
VCU Pauley Heart Center, Division of Cardiology
Department of Internal Medicine,
Virginia Commonwealth University
Richmond, VA

The authors declare no conflict of interest and do not have any financial disclosures.


1. Lavie CJ, De Schutter A, Patel DA, et al. Body composition and survival in stable coronary heart disease: impact of lean mass index and body fat in the “obesity paradox”. J. Am. Coll. Cardiol. 2012; 60:1374–80.
2. Moholdt T, Lavie CJ, Nauman J. Sustained physical activity, not weight loss, associated with improved survival in coronary heart disease. J. Am. Coll. Cardiol. 2018; 71:1094–101.
3. Ortega FB, Lavie CJ, Blair SN. Obesity and cardiovascular disease. Cir Res. 2016; 118:1752–70.
4. Lavie CJ, Laddu D, Arena R, et al. Healthy weight and obesity prevention: JACC health promotion series. J. Am. Coll. Cardiol. 2018; 72:1506–31.
5. Lavie CJ, Cahalin LP, Chase P, et al. Impact of cardiorespiratory fitness on the obesity paradox in patients with heart failure. Mayo Clin. Proc. 2013; 88:251–8.
6. Moholdt T, Lavie CJ, Nauman J. Interaction of physical activity and body mass index on mortality in coronary heart disease: data from the Nord-Trøndelag Health Study. Am. J. Med. 2017; 130:949–57.
7. Romero-Corral A, Montori VM, Somers VK, et al. Association of bodyweight with total mortality and with cardiovascular events in coronary artery disease: a systematic review of cohort studies. Lancet. 2006; 368:666–78.
8. Kennedy AB, Lavie CJ, Blair SN. Fitness or fatness: which is more important? JAMA. 2018; 319:231–2.
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