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Are Healthy Obese People Healthy?

In clinical practice, it is not uncommon to meet individuals who, despite meeting the BMI criteria for obesity, appear metabolically healthy: their glucose, lipid and blood pressure levels are well within the normal range. According to the Edmonton Obesity Staging System (EOSS), we would refer to these individuals as having “Stage O” obesity.

But are these apparently metabolically healthy obese individuals really healthy in that they have a lower mortality risk than obese individuals with metabolic abnormalities?

This question was addressed by Jennifer Kuk and colleagues from York University, Toronto, Canada, in a paper just published in Diabetes Care.

Kuk and colleagues examined data from 6,011 men and women from the Third National Health and Nutrition Examination Survey (NHANES III) where metabolically abnormal was defined as having insulin resistance (IR) or two or more metabolic syndrome (MetS) criteria.

A total of 30% of obese subjects had IR, and 38.4% had two or more MetS factors, whereas only 6.0% (or 1.6% of the whole population) were free from both IR and all MetSyn factors.

Based on the mortality data over 8 years, both the metabolically healthy and metabolically abnormal obese individuals had around the same roughly 2.5 to 3-fold elevation in mortality risk compared to the metabolically normal normal-weight individuals.

The authors conclude that even in the absence of overt metabolic aberrations, excess weight is associated with increased all-cause mortality risk.

Thus, as I’ve said before, it appears that there is no such thing as “benign” obesity. Eventually excess weight will increase the risk for a wide range of health problems including cancers, osteoarthritis and obstructive sleep apnea. This is why it is critical to include the assessment of all four Ms in patients presenting with excess weight.

So how do these findings impact on weight loss recommendations in obese individuals who appear metabolically normal (EOSS 0)?

As blogged before, the first step in weight management is prevention of weight gain. As a rule, this will require substantial changes in diet and activity levels as well as mitigation of any underlying root causes of positive energy balance – this alone can be difficult enough to achieve.

With current conservative obesity treatments only a small minority of patients will achieve and maintain clinically relevant weight loss – the vast majority of weight-losers will simply yo-yo back to their excess weight. I therefore maintain that for most obese individuals weight stabilization may be a far more realistic and sustainable goal than losing weight and keeping it off.

It is also important to remember that associations (as in this paper) do not imply causality and that these new findings therefore cannot be seen as certain proof that weight loss will decrease risk or increase longevity. This question can only be resolved with appropriately designed and conducted intervention trials.

Nevertheless the data should give caution to the notion that excess weight in metabolically healthy adults is harmless.

Prevention of weight gain is likely beneficial irrespective of obesity stage and should be the primary goal of all weight management interventions.

Edmonton, Alberta


  1. Yes!! I thought so!!

    Even if labs tests don’t show it, obese people ARE at increased risk of serious problems.

    A friend of mine is into the HAES fad (Health at every size). She thinks if she eats healthy food and gets exercise, her health isn’t affected by being obese, or if she gains a bit of weight.
    I’m obese too, and I want to loose weight – sorry dr Sharma, but I lost weight a few years ago, I’ve been steady since then, but I still want to loose more weight. Apart from the health risks, being obese makes it too hard to exercise, too hard to keep up with normal weight friends just on a walk, too hard to keep up with any moderately physical work, not to mention too hard to find clothes.

    It seems to me that obese people who claim to be active actually aren’t nearly as active as they think they are. They claim they do exercise, but when you hang out with them they do far less than other people – they sit more, they walk less, they do an exercise routine then figure they’re done and sit for the rest of the day. If you hang out with not-obese people, they do an exercise routine, and that just gets them warmed up for a full day of walking & shopping & working & biking and etc. I suppose it feels to the obese people that they’re active because every move they make means lugging around a load of fat. like getting a not-obese person to wear a 80 lb backpack all the time. Just getting off the couch is a workout with an 80 lb backpack, no wonder an obese person thinks she “active” when she really isn’t. Staying the same weight is better than gaining weight, but loosing weight would mean getting out from under that 80 lb load, or at least some of it. So I’ll go for weight loss to get rid of the 80-lb backpack, as well as to avoid the health risks.

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  2. A “healthy obese person ” is an oxymoron.
    Kind of like a “healthy diabetic person”.
    Better to say “a person with an underlying health problem who is doing everything they can to be as healthy as possible despite their disease”.

    If lab tests don’t show any problems, but there is “increased all-cause mortality risk”, maybe that means the tests are missing something.
    If tests for “A,B,C & D” are ok, we can’t therefore assume everything is fine. Maybe problem “E” hasn’t been discovered yet, so there’s no test for it.

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  3. Re example of “ABCD” tests above:

    Each individual test can be at a tolerable level, but a combination of borderline results might be dangerous.

    Analogy: driving when tired, driving after 1 drink, driving in rain, driving in heavy traffic, driving in very fast traffic, driving when inexperienced or out of practice..
    Driving with one or two of these factors may be fairly safe, but the combination of all of them at once may be very dangerous even though none individually is a lethal problem.

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  4. I’m still studying HAES and trying to understand the bariatric science behind it. I’ve read many articles about the health impacts of obesity and I’ve read the skeptics. I haven’t decided one way or another where the truth is, which is why I enjoy reading Dr. Sharma’s work. He seems to reside somewhere between those who believe obesity is a death sentence and those who believe it’s not harmful.

    My step-father-in-law is an OB/GYN and my wife is obese, but skeptical of HAES and keeps me firmly grounded in the biological impact of fat and weight on the human body. I’m not scientifically minded at all, so much of what she tells me (such as the simple fact that pumping blood to every inch of a larger human body makes the heart work harder, and therefore wears it down faster) is news to me.

    I want to advocate truth, not an agenda, so before I start promoting HAES or anything along those lines, I want to know the consequences.

    Here’s how I understand it so far: obesity is the condition where you add more and more fat to your body and once you add that fat it is nearly impossible to take it off and leave it off permanently (at the most, around five years).

    (Anonymous 1: I do not dispute your success, but, likewise, you should not dispute the countless others who have repeatedly lost weight, only to regain, and then some, over and over and over again. If you have the secret to weight loss permanency, then write a book, you’ll be a millionaire. There is no shortage of money to be made telling people how to be thin. There is no end to shortcut products promising quick and permanent weight loss that are only contributing to the recidivism rate. I find your tone condescending at best. None of your fat friends spend their days “walking & shopping & working & biking and etc.”? Every single one of your fat friends (especially the ones who claim to be (tee hee hee) “active”) spends their entire day sedentary? Are you sure you don’t want to add that they stuff their faces with Twinkies or some other generalization? I’d hate to leave any stereotype out. Are there fat people who sit on their butts all day and eat? I’m sure there are. But to claim that people are fat because when they attempt weight loss through exercise it’s not “right kind” of exercise or that they’re not doing more… that’s just insulting to the core.

    Firstly, maybe you have the luxury to spend your days “walking & shopping & working & biking and etc.,” but I spend my days at work, on the train, and at home with my girls. I’m on somebody else’s clock from the time my daughter’s wake up (assuming the three-year-old hasn’t woken up multiple times in the night with night terrors) until I reach my home at 6:30 that evening.

    From 6:30 p.m. until 10 p.m., I play with my family. Apart from the 10 minute walk to and from the train, it’s the most active I am all day. While playing, are dishes to be washed, bottles to be made, baths to be given, dinner to be prepared and eaten, and any number of miscellaneous chores that pop up in the life of an average family. When our oldest finally falls goes to bed, my wife and I are exhausted and we spend time with each other, catching up and loving on each other.

    I’m fat. She’s fat. Do you want to tell us how we’re doing it wrong? Do you want to reply about how I “claim” to be active and how I “claim” to be too busy to enhance my health through “walking & shopping & working & biking and etc.”?

    And try to keep in mind that when you say, “Yes!! I thought so!!” what you are responding to is the fact that there is still uncertainty where you so absolutes. As Dr. Sharma stipulated:

    “It is also important to remember that associations (as in this paper) do not imply causality and that these new findings therefore cannot be seen as certain proof that weight loss will decrease risk or increase longevity. This question can only be resolved with appropriately designed and conducted intervention trials.”

    There is still work to be done on understanding the “mechanics” of obesity. And whether the truth is that fat, regardless of comorbidities, is deadly or benign does not give you the justification to treat fat people like little children who deserve your derision.

    We are human beings. We are not morons. We hear the evidence every day. If I hear “eat right and exercise” one more time, I’m going rip my clothes off and do fat, naked burpees until you get off my fat, sweaty back.)

    If you lose weight and regain it, then try to do so again and regain, then you are doing more metabolic damage than if you stabilized your weight and practiced HAES.

    As I (imperfectly) understand it, HAES promotes eating healthy and obeying your physical cues for satiety to change the way you eat. It also promotes being physically active in whichever way you enjoy most (the enjoyment being the reward for your effort rather than the numerical obsession). So exercise doesn’t have to mean going to Bally’s Vic Tanny every day, so much as riding your bike or swimming or playing basketball or whatever. Just move.

    By taking the emphasis off of weight loss and placing it on overall health and well-being, you are creating a lifestyle change that would not otherwise be there if you find those online advertisements for acai berry (OBEY!!!) so damned creepy or health clubs so intimidating or doctors so threatening.

    Dr. Sharma is doing his part to tackle that last third of the puzzle: replacing aggressive treatment (YOU MUST LOSE WEIGHT) with an objective assessment of the patient’s overall health, regardless of weight, through the EOSS (really, Doc, you’ve gotta get a new name or a better acronym at least… I dunno, the Royal Obesity Staging of Edmonton (ROSE), something).

    Because until there is a better understanding of the relationship between obesity and health, we should be promoting the healthiest options possible. Dieting is not the healthiest option. HAES is a proposed alternative. Let’s keep digging and get to the truth.

    By the way, Dr. Sharma, I have sent a request to your publicist for an interview. I would love to speak with you regarding EOSS and other issues if you are ever free.


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  5. If those who are deemed metabolically healthy have the same mortality as those with metabolic abnormalities-amongst the fat, then one has to question the significance of those abnormalities on health.

    Not all risk factors are equal.

    Metabolic outliers are more likely to have health issues than those in between, the sprawl of obesity goes from 30 upwards.

    We are told that healthy eating can affect the whole trajectory of your health-to the good- therefore, if it doesn’t reduce anonymous’s friend’s chances of ill health, then it’s healthiness is also up to question. IOW, her belief in healthy eating is what we are taught to believe.

    It also tends to be true that fat people do expend more energy in mere existance as well as moving around than those of a lesser weight, giving a lie to the idea that raised calorie expenditure=thin.

    If fat healthy people cannot describe themselves as healthy, then change what you call health, to reflect that, and see how many people you have left.

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  6. To Shannon: here’s my book, no $ expected !

    Dr Sharma’s is the book to buy – not mine!

    However, you asked!

    1. Regard loosing weight as a serious medical treatment, like bariatric surgery or chemo to remove a tumor – as they say, “expect some discomfort”.

    2. Continually monitor what I’ve done, and measure and evaluate the results I get. Do research. CHANGE program according to analysis. Do, measure, analyze, refine. Repeat.

    3. Daily:
    Get enough sleep.
    Weigh, record weight.
    Write (analysis: over time, how do my actions affect my weight? Also self pep talk)
    Have no “bad” food in house.
    Do have good food in house: plan, shop, prepare in advance, store.
    Prepare and clean up lunch, supper, dinner. (have daily structure)
    Take multivitamin supplement, calcium & Vit D, Arthritis supplements.
    Eat at 9am, 12noon, 3pm, 6pm, and 9pm
    Eat some protein, some carbs each time, with vegs at lunch and dinner.
    Eat about 1400 cals a day, evenly spaced out over schedule.

    4.Recognize and counteract side effects: loosing weight is hard
    Headache: Tylenol
    Tired: sleep
    Dizzy, stunned: dehydrated, drink water
    Nutrient deficiency: take supplements
    Hungry, stomach growls: wait until next scheduled time to eat. (Eat extra or early if really hungry – do not delude myself and abuse this leeway or it will show up on the scale.)
    Feeling down and sad: Recognize feeling. Get something done(small chore). Write.
    Binge: don’t get too hungry or too thirsty.

    5. Exercise. I’m terrible with this. I have a sedentary job. I need to figure out an exercise plan ( more “do, analyze, improve, do..repeat .etc) next step.

    You’re probably saying “What an idiot! That’s what ordinary people do all the time! She makes a big deal about having food, eating meals, and – how stupid is this – sleeping when she’s tired!! What a dolt!! )

    I have no medical or genetic problems, no horrendous abuse history.

    What I discovered is that I had no structure around eating – I grabbed junk whenever I felt hungry; and everything felt like hunger to me – tired, thirsty, headache, bored, sad, mad – everything had a little nagging in the pit of my stomach, so I’d feel hungry, and eat. HAES is not for me when it comes to obeying satiety clues – mine are busted, a schedule works better.

    I think enjoyable physical activity as in HAES is a great idea. I’ll work on that. It will be easier if I have less weight to carry.

    So there’s my book, and the problem is, it’s MY book, and not a solution for anyone else. Your book, should you decide to write it, will probably come to a different ending as you research, do, analyze, refine, etc. You might want to get medical expertise for a specific problem (My doctor’s total advice was..go for it) You might want to write “I’m just fine as I am, thank you”.

    You’re right, I was too hard on obese people. I was thinking of myself and the people I know well. Of those people, the normal weight people are more active, but that’s too small a sample size to draw conclusions about all obese people. I suppose you’d have to have a lorge number of people of varying weights and bmi’s and track pedometer counts or other activity measures to compare. The comparison would be between activity levels (eg distance walked) not energy expenditure (for the same activity an obese person would burn more calories, but it is the activity accomplished that is important)

    I do want to loose weight. I hate having 80 pounds of extra fat on my body. Note, I did not say I hate MYSELF. This fat is no more “ME” than a cancer tumor is the cancer patient himself. If I were trying my darndest to overcome some other medical problem, I would be complimented on my determination to succeed in spite of difficulties.

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  7. Anonymous 1,
    I may be misinterpreting your comment, but a lot of what you’re talking about sounds like an eating disorder called Orthorexia nervosa.

    You should look into it. As far as your satiety clues, if you have spent much of your life adhering to diets, then you may damage your body’s natural regulation. I read something about it recently, but can’t seem to find it.

    HAES is not for everyone, but you should talk to a nutritionist about what the best thing for your body is. You’re right, it is your book. But make sure that you’re as educated as you can be to write that book accurately.


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  8. Or of course scientist could find out a route to weight loss that actually works, merely going the route by which we think it is gained (is it?) is hugely costly and inefficient.

    Losing weight and weight loss dieting are not the one and the same thing. WLD is what causes the pain. We lose weight through the day, it is not painful, it is part of the natural rhythm of energy use.

    Weight can also be lost, often spontaneously and unexpectedly, mainly as a side effect of other changes, both positive and negative. Again, most of the time, it’s not painful, because the body’s elegance makes it a mere reversal of how we gain weight, the body allows it to happen.

    Pain in weight loss is caused by weight loss dieting, but that is only one of the many reasons why it doesn’t work.

    Basically, it is an attempt at a metabolic using part of the metabolism, the conscious part- to correct a metabolic effect-weight- that is itself corrected by the larger metabolic processes which are not under the direct control of the conscious mind.

    WLD should be seen a bit like a boomerang, the force of you throwing it, becomes the force it comes back at you.

    It ‘works’ when it very occasionally gets caught in the branches of a tree.

    When you have a force that knows exactly what it’s doing far better than you, the logical thing is to find out either how it does it and replicate it, or find a way to recruit it by linking it in some way with conscious will.

    It may not be a direct attack, like weight loss dieting.

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  9. To Shannon,

    Thanks for the link ..interesting about orthorexia nervosaI.

    I don’t think that’s me as regards the food I eat.

    The “good” food I eat isn’t specialty “health” or “organic” food, it isn’t even fancy. Toast and egg for breakfast; chili for lunch; fish, potato, vegs, for dinner. Always small portions. I cycle through several days of routine simple meals. The menu depends on what’s on sale that week.
    This is old-fashioned high school home economics! Plan, have a routine. Eat meals at mealtime!

    My old habits were completely haphazard. I ate often and I ate junk. I ate any treat that appealed to me. I ate too much of good food. I ate for enjoyment, I ate for something to do, I ate to take my mind off life’s ordinary problems, I ate “just this one” many times …blah, blah, blah … well, you get the picture. I had miserable eating habits.

    I messed up my metabolic cues by what I ate. I think my diet of overeating, eating a lot of junk food, and eating on an erratic schedule damaged my body’s regulation system even more than my occasional weight loss diets.

    My schedule and checklist approach is kind of like othorexia nervosa.

    I want to change my habits, so I’m being very deliberate about sticking to a routine.
    (I’m not totally neurotic – if I have soup at 1pm instead of chili at noon, that’s close enough, as long as I have a proper meal at lunchtime)

    I want to sort out what factors have an effect on my weight, and to do that I get obcessive about reading, researching, and writing about anything that may help. A bariatric surgery patient would have a team of nutritionists and doctors and counsellors. The medical help I got was just an ok to go ahead and loose weight, so I’m trying to consider all aspects

    now about my insomnia..3 am …at least I’m not eating…

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