Relationship Between Physical Activity, BMI, and HF Risk

Study Questions:

Is there a dose-response association between lower leisure time physical activity (LTPA) and higher body mass index (BMI) and the risk of different heart failure (HF) subtypes?


Individual-level data from three cohort studies were used: The Woman’s Health Initiative in post-menopausal women, the Multi-Ethnic Study of Atherosclerosis in adult men and women aged 45-84 years, and the Cardiovascular Health Study in adults aged ≥65 years. Data were pooled and participants were stratified into guideline-recommended categories of LTPA and BMI. Associations between LTPA, BMI, and risk of overall HF, HF with preserved ejection fraction (HFpEF; EF ≥45%), and HF with reduced EF (HFrEF; EF <45%) were assessed using multivariable adjusted Cox models and restricted cubic splines.


The study included 51,451 participants with 3,180 HF events (1,252 HFpEF, 914 HFrEF, 1,014 missing EF). Mean age was 63 years; diabetes was present in 11% of those without LTPA and 7.7% in those with >1,000 metabolic equivalents of task [MET]-minute/week LTPA. A similar trend was present with hypertension status, systolic blood pressure, obesity, and BMI. In adjusted analysis, there was a dose-dependent association between higher LTPA levels, lower BMI, and overall HF risk. Among HF subtypes, LTPA in any dose range was not associated with HFrEF risk. In contrast, lower levels of LTPA (<500 MET-minute/week) were not associated with HFpEF risk, and dose-dependent associations with lower HFpEF risk were observed at higher levels. Compared with no LTPA, higher than twice the guideline-recommended minimum LTPA levels (>1,000 MET-minute/week) were associated with an 18% lower risk of HFpEF (hazard ratio, 0.81; 95% confidence interval, 0.68-0.97). The dose-response relationship for BMI with HFpEF risk was also stronger and more graded than with HFrEF risk, such that increasing BMI above the normal range (>25 kg/m2) was associated with a greater increase in risk of HFpEF than HFrEF.


The study findings demonstrate strong dose-dependent associations between LTPA levels, BMI, and risk of overall HF. Among HF subtypes, higher LTPA levels and lower BMI were more consistently and strongly associated with lower risk of HFpEF compared with HFrEF.


The authors suggest that prospective trials are needed to assess the impact of increasing physical activity and weight reduction on the incidence of the two types of HF, and to explore the mechanisms responsible for the differences in impact. Preclinical identification of persons at high risk will be necessary if we are to impact the rapidly progressive incidence of HFpEF.

Clinical Topics: Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Prevention, Acute Heart Failure, Exercise, Hypertension

Keywords: Blood Pressure, Body Mass Index, Diabetes Mellitus, Exercise, Heart Failure, Hypertension, Leisure Activities, Metabolic Equivalent, Motor Activity, Obesity, Primary Prevention, Stroke Volume, Weight Loss

< Back to Listings