Association of Physical Activity With All‐Cause and <scp>CVD</scp> Mortality Across Metabolic and Obesity Phenotypes

ABSTRACT Aims To examine the independent and joint associations of metabolic status, obesity, and physical activity with all‐cause and cardiovascular disease (CVD) mortality across metabolic–obesity phenotypes. Materials and Methods We analysed 442 666 adults from the Korean National Health Insurance Service health screening cohort (2009–2012). Metabolic status was defined using modified NCEP‐ATP III criteria (elevated triglycerides, low HDL‐C, elevated blood pressure or antihypertensive use, and elevated fasting glucose or antidiabetic use); ≥ 2 abnormalities indicated metabolically unhealthy. Obesity was defined as BMI ≥ 25 kg/m 2 (WHO Asia‐Pacific), yielding four phenotypes: metabolically healthy lean (MHL), metabolically unhealthy lean (MUHL), metabolically healthy obesity (MHO), and metabolically unhealthy obesity (MUHO). Physical activity was assessed by self‐report and categorised by total MET‐min/week (0, 1–499, 500–999, 1000–1499, ≥ 1500). Multivariable Cox proportional hazards models estimated hazard ratios (HRs) for all‐cause and CVD mortality. Results In the primary multivariable model (Model 2a), compared with MHL, MUHL had the highest all‐cause mortality (HR 1.23, 95% CI 1.19–1.26), whereas MUHO was not significantly associated with all‐cause mortality (HR 0.97, 95% CI 0.94–1.01), and MHO showed lower risk (HR 0.85, 95% CI 0.81–0.89). Higher physical activity was consistently associated with lower all‐cause and CVD mortality in a dose–response manner, and joint analyses showed progressively lower mortality across all metabolic–obesity phenotypes with increasing activity levels. Conclusions Metabolic–obesity phenotypes were associated with differential mortality risk, and higher physical activity was associated with lower all‐cause and CVD mortality across phenotypes.