Association of BMI, fitness, and mortality in patients with diabetes: Evaluating the obesity paradox in the Henry Ford exercise Testing Project (FIT project) cohort

OBJECTIVE To determine the effect of fitness on the association between BMI and mortality among patients with diabetes. RESEARCH DESIGN AND METHODS We identified 8,528 patients with diabetes (self-report, medication use, or electronic medical record diagnosis) from the Henry Ford Exercise Testing Project (FIT Project). Patients with a BMI <18.5 kg/m² or cancer were excluded. Fitness was measured as the METs achieved during a physician-referred treadmill stress test and categorized as low (<6), moderate (6–9.9), or high (‡10). Adjusted hazard ratios for mortality were calculated using standard BMI (kilograms per meter squared) cutoffs of normal (18.5–24.9), overweight (25–29.9), and obese (‡30). Adjusted splines centered at 22.5 kg/m² were used to examine BMI as a continuous variable. RESULTS Patients had a mean age of 58 6 11 years (49% women) with 1,319 deaths over a mean follow-up of 10.0 6 4.1 years. Overall, obese patients had a 30% lower mortality hazard (P < 0.001) compared with normal-weight patients. In adjusted spline modeling, higher BMI as a continuous variable was predominantly associated with a lower mortality risk in the lowest fitness group and among patients with moderate fitness and BMI ‡30 kg/m². Compared with the lowest fitness group, patients with higher fitness had an ∼50% (6–9.9 METs) and 70% (‡10 METs) lower mortality hazard regardless of BMI (P < 0.001). CONCLUSIONS Among patients with diabetes, the obesity paradox was less pronounced for patients with the highest fitness level, and these patients also had the lowest risk of mortality.