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.......................................................................................... 4.2.2 Obesity A person with a body mass index (BMI) >30 kg/m2 or (preferentially) a waist circumference >94 cm for males and >80 cm for females (both for European Caucasians) is considered obese.120,121

European guidelines for obese individuals recommend that a minimum of 150 min/week of moderate-intensity endurance exercise training should be combined with three weekly sessions of resistance exercise.121 Such intervention leads to a reduction in intra-abdominal fat mass, increments in muscle and bone mass, attenuation in the weight loss-induced decline of resting energy expenditure, reduction in BP and chronic inflammation, and improvement in glucose tolerance, insulin sensitivity, lipid profile, and physical fitness.121,122 There is also a positive influence on the long-term maintenance of weight reduction, general well-being and self-esteem, and reduction in anxiety and depression.121 The impact of exercise intervention alone on fat mass is modest.123 According to a series of large randomized controlled trials a high endurance-type exercise volume, >225 min/week, is required to maximize fat mass loss in obese individuals.124 A pre-participation CV assessment is warranted in obese individuals who intend to engage in high-intensity exercise (Figure 4), due to associated comorbidities such as type 2 diabetes, hypertension, dyslipidaemia, and CV and respiratory diseases.121 Obese individuals with a normal CV assessment should not have any restrictions on exercise. There is evidence from healthy, nonobese and non-athletic individuals that running, and abrupt increases in training volume, contribute to musculoskeletal injuries.125127 Therefore, it may be reasonable to consider that obese individuals should limit high-volume weight-bearing exercises on a hard surface (i.e. <2 h/day) until a considerable

Recommendations for cardiovascular evaluation and regular exercise in healthy individuals aged >35 years

Recommendations Classa Levelb

Among individuals with low to moderate CVD risk, the participation in all recreational sports should be considered without further CV evaluation. IIa C Cardiac screening with family history, symptoms, physical examination, and 12-lead resting ECG should be considered for competitive athletes. IIa C Clinical evaluation, including maximal exercise testing, should be considered for prognostic purposes in sedentary people and individuals with high or very high CV risk who intend to engage in intensive exercise programmes or competitive sports. IIa C In selected individuals without known CAD who have very high CVD risk (e.g. SCORE>10%, strong family history, or familial hypercholesterolaemia) and want to engage in high- or very high-intensity exercise, risk assessment with a functional imaging test, coronary CCTA, or carotid or femoral artery ultrasound imaging may be considered. IIb B

CCTA = coronary computed tomography angiography; CV = cardiovascular; CVD = cardiovascular disease; SCORE = Systematic Coronary Risk Evaluation. aClass of recommendation. bLevel of evidence.

©ESC 2020

Figure 4 Proposed algorithm for cardiovascular assessment in asymptomatic individuals aged >35-years-old with risk factors for cardiovascular disease and possible subclinical chronic coronary syndrome before engaging in sports. *Consider functional test or CCTA if exercise stress test is equivocal or the ECG is uninterpretable. aSee text for examples of functional imaging. bSingle-photon emission computed tomography: area of ischaemia >_10% of the left ventricular myocardium; stress echocardiography: >_3 of 16 segments with stress-induced hypokinesia or akinesia; stress cardiovascular magnetic resonance: >_2 of 16 segments with stress perfusion defects or >_3 dobutamine-induced dysfunctional segments; coronary computed tomography angiography (CCTA): three-vessel disease with proximal stenoses; left main disease; proximal left anterior descending disease.110 CVD = cardiovascular disease; ECG = electrocardiogram; SCORE = Systematic Coronary Risk Evaluation. Downloaded from academic.oup.com/eurheartj/article/42/1/17/5898937 by guest on 07 October 2026