The current standard measure of cardiorespiratory fitness introduces confounding by body mass: the DR's EXTRA study

Int J Obes (Lond). 2012 Aug;36(8):1135-40. doi: 10.1038/ijo.2011.212. Epub 2011 Nov 22.


Objective: Cardiorespiratory fitness is currently estimated by dividing maximal oxygen consumption (VO(2max)) by body weight (per-weight standard). However, the statistically correct way to neutralize the effect of weight on VO(2max) in a given population is adjustment for body weight by regression techniques (adjusted standard). Our objective is to quantify the bias introduced by the per-weight standard in a population distributed across different categories of body mass.

Design: This is a cross-sectional study.

Subjects and methods: Baseline measures from participants of the Dose-Responses to Exercise Training Study (DR's EXTRA), 635 men (body mass index (BMI): 19-47 kg m⁻²) and 638 women (BMI: 16-49 kg m⁻²) aged 57-78 years who performed oral glucose tolerance tests and maximal exercise stress tests with direct measurement of VO(2max). We compare the increase in VO(2max) implied by the per-weight standard with the real increase of VO(2max) per kg body weight. A linear logistic regression model estimates odds for abnormal glucose metabolism (either impaired fasting glycemia or impaired glucose tolerance or Type 2 diabetes) of the least-fit versus most-fit quartile according to both per-weight standard and adjusted standard.

Results: The per-weight standard implies an increase of VO(2max) with 20.9 ml min⁻¹ in women and 26.4 ml min⁻¹ in men per additional kg body weight. The true increase per kg is only 7.0 ml min⁻¹ (95% confidence interval: 5.3-8.8) and 8.0 ml min⁻¹ (95% confidence interval: 5.3-10.7), respectively. Risk for abnormal glucose metabolism in the least-fit quartile of the population is overestimated by 52% if the per-weight standard is used.

Conclusions: In comparisons across different categories of body mass, the per-weight standard systematically underestimates cardiorespiratory fitness in obese subjects. Use of the per-weight standard markedly inflates associations between poor fitness and co-morbidities of obesity.

Publication types

  • Research Support, Non-U.S. Gov't
  • Technical Report

MeSH terms

  • Aged
  • Aging / physiology
  • Body Mass Index
  • Body Weight*
  • Cross-Sectional Studies
  • Exercise Test
  • Exercise Tolerance* / physiology
  • Female
  • Glucose Tolerance Test
  • Humans
  • Male
  • Middle Aged
  • Obesity / metabolism
  • Obesity / physiopathology*
  • Oxygen Consumption*
  • Reproducibility of Results