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At-Risk is Not The Same as Unhealthy

sharma-obesity-cardiometabolic-risk1Clearly, this week’s posts on the two articles suggesting that there is no such thing as “healthy obesity” have hit a nerve.

I do not wish to repeat my previous criticisms of these two articles, which you can read here and here.

But I do wish to take the opportunity to set the record straight, that I do indeed take obesity seriously!

I am certainly well aware of the many health problems, emotional pain and physical limitations that are commonly associated with excess weight.

After all, I work in a clinic that provides all forms of behavioural, medical and surgical treatments for obesity and can certainly attest to the substantial health benefits of successful obesity management.

I am also well aware that with increasing BMI levels, it becomes harder and harder to find obese people who one would consider to be perfectly healthy.

As we showed in our analyses of NHANES data, EOSS Stage 0 individuals make up only 15% of individuals in the BMI 25 to 30 range, decreasing to 8% of individuals in the BMI 30 to 35 range and dropping to less than 5% in those with a BMI greater than 35.

Although we regularly see individuals with EOSS Stage 0 even at BMI levels well beyond 40, these are indeed rare individuals – the vast majority of our patients present with EOSS Stage 2 or higher.

Thus, my “advocacy” for the existence of “healthy obesity” has nothing to do a lack of recognition or even underestimation of the considerable health risks and problems related to excess weight.

Rather, my insistence on not immediately assuming that everyone with a higher BMI is in immediate need of medical attention, is motivated by our ability to look at individual risk rather than having to simply rely on statistical probabilities.

Fortunately, we have a rather good understanding of the key underlying risk factors that mediate cardiometabolic risk (high blood pressure, dysglycemia and dyslipidemia), which, together with smoking, account for virtually 90% of all cardiovascular risk. There is nothing mysterious about these risk factors and all can (and should) be easily measured in clinical practice.

Thus, whether an obese person is actually at increased cardiometabolic risk or not does not have to be a guessing game – a few simple physical and laboratory tests will quickly provide a clear answer (whereas stepping on the scale will not!).

This is the whole point of the argument. Why should we jump to the conclusion that anyone with a higher BMI is unhealthy based on BMI alone, when it is so simple to determine actual risk?

A common counterargument is that, because the vast majority of people with higher BMI’s are at increased risk, it may be easier to simply tell everyone to lose weight.

But that is exactly where the problem lies. Losing weight is anything but easy and may in fact cause harm (if the methods employed are unhealthy and/or weight recidivism adversely affects emotional and physical health).

Based on our calculations in the US-NHANES data set, recommending that anyone with a BMI greater than 25 loses weight would include almost 10 million individuals in the US, who we would consider EOSS Stage 0, i.e. perfectly healthy.

Readers will hopefully agree that 10 million is not a trivial number by any standard – these are the people who stand to be harmed by blanket recommendations that label all overweight and obese people as unhealthy – the risk/benefit ration for these individuals may well be on the side of risk rather than benefit.

At a minimum, these 10 million people deserve the courtesy of health professionals actually measuring their actual risk before making pronouncement as to their prognosis.

I strongly feel that in our public health messaging (and clinical practice guidelines) – both sides can stand alongside each other.

Yes, excess weight can increase the risk of cardiometabolic risk factors (and other health problems) – simple tests in your doctor’s office can help determine these risks.

On the other hand, not everyone carrying a few extra pounds is at immediate risk of developing diabetes or heart attacks (or stands to benefit from obsessing about their weight) –  again, simple tests in your doctor’s office can help identify those at low risk.

To me the real question of interest is not whether or not “healthy obese” people exist – they do!

The interesting question is what these individuals can teach us about the sociopsychobiology of obesity. What behavioural or biological factors keep these individuals healthy? Perhaps there are learnings here that can help “unhealthy obese” individuals live healthier lives.

New Delhi, India


  1. I have to ask you about one thing that stuck in my craw from the editorial. Towards the end, they said “Metabolically healthy overweight persons are at risk for gaining more weight and becoming obese.” Why is it assumed that everyone who is overweight is automatically at-risk and needs intervention? Wouldn’t it be just as logical to make the blanket statement that everyone under BMI 25 was at-risk of becoming overweight?

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  2. This is an important debate and discussion to have because of the weight loss implications of relying solely on BMI.

    I understand the importance of evaluating individual risk and in so doing an “overweight” individual (as classified by the BMI ranges) might be entirely healthy. However what is the long-term risk of living with that excess weight? Especially if the individual displays central adiposity, are they are at increased risk for dyslipidemia/dysglycemia/hypertension over time? Has anyone followed individuals with an EOSS Stage 0 for long enough to see what happens to them?

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  3. Shaping the medical care given to the individual needs of the patient herself or himself is the gold standard.

    Having a situation in which a few logical tests that are good inclusions in most peoples’ annual exams, anyway, can allow the physician to achieve this along with a bit of personal behavioral modification on the physician’s part is something for physicians to appreciate.

    One of my friends is healthy obese. Knowing he is healthy actually spurs him to exercise. He loves that he is healthy while also being happy at and about his weight. I have walked miles at a fast pace with him, have seen him lift heavy equipment, bolts up stairs, and otherwise be more active physically and socially than many with lower BMIs. Luckily, his physician shapes his care to his needs at any given time. As a result he does not neglect medical testing and care, stays active, and tries to optimize his health for his weight, the same thing involved patients do at any weight when stats place them in a category where they may be at increased risk at some point for any type of medical problem. Being respected as an individual helps him be an involved patient.

    Patients — at least many of them — are not so naive that they do not know when they are being put into a box, whether it is a box that underestimates or overestimates a risk compared to their actual health. They live in their bodies and they see their test results. A physician can test, hand the patient a page and say, “Here are the typical risk figures for your BMI figure with the mean being the average and the mode being the most typical, and here is where you fit into that as an individual for these health measurements. Then based on that the physician can discuss options, approaches, and how the physician and staff can help or refer when they are needed or wanted, but just saying, “Lose weight.” does not work for most.

    Having a clear medical reason to lose weight based on individual needs can be a great impetus. Someone else I know successfully lost and kept off 60 pounds and became more active, now being categorized as thin and athletic, when his final option for avoiding prostate surgery was seeing if loss of the pressure from abdominal adipose tissue would allow reasonable function. It did. He had a clear goal, was warned that it would be difficult and that he was aiming to be in the minority, but also was encouraged as being someone who stood a chance of success, then a friend acted as trainer and cheering section, a tracking program allowed him to make slow and steady progress, and rewards at home were mostly reshaped to being non-food ones. His physician shaped his needs to him as an individual, was honest while being encouraging, and gave useful advice on how to approach that goal, plus he had the desire to avoid the surgery. That is how it should be.

    What you are saying, Dr. Sharma, is that there is no good reason for physicians and nurses as well as other health professionals to not aim for the gold standard and to try to get their staff to do likewise (and many women in their prime can honestly say that sadly sometimes it is the nurses at gynecologists offices who can be the worst for just saying, “Lose x pounds.”). In some medical offices, as the gateway professionals, some nurses need refresher courses on listening and conversing.

    Your reasons are excellent ones. Shaping the care to the needs of the specific patient as an individual at a given point in time is more respectful, more likely to have the patient not neglecting medical care, better designed to avoid problems that could arise from a need being tackled in a dangerous way, and more likely to have some level of success.

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  4. The next question to ask is- at what level of risk/bmi does weight intervention improve outcome and decrease risk? Consider a person with BMI 26 and mild LDL elevation and no other risk factors– which intervention improves risk better- weight reduction or treatment of the hyperlipidemia?

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    • Good question – my guess is treatment of hyperlipidemia, as LDL Cholesterol generally appears less responsive to weight loss than high triglycerides or low HDL.

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  5. During my long experience of working w obese and overweight people this was obvious as I saw lots of people with more fat but less comorbidities and reverse is true where some have less fat mass but it’s internal and lab analysis reveal high cholesterol and triglycerides these usually have genetic tendencies and for them less is more
    I do believe that people are different w different tendencies stressful lifestyles exercise patterns each individual has to be studied and therapy routine custom made for his or her specificity
    Afterall lots of people spend their life time being obese w no notion whatsoever to do anything about of course that s not to be encouraged but it does exist
    Still obesity as we all realize has to be taken seriously and efficiently taking into consideration all individual factors that matters to the person suffering

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  6. Not every “risk factor” is due to obesity, either. Many of us have autoimmune diseases that are the underlying cause of things like high blood pressure and fatigue. Do you test for autoimmune diseases, as we “zebras” go undiagnosed for decades?

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  7. ksol says, above

    “Wouldn’t it be just as logical to make the blanket statement that everyone under BMI 25 was at-risk of becoming overweight? ”

    Well, i’d say yes!!
    Given an obesogenic culture and the general ballooning of the population, i’d say even if you’re BMI 25 you better beware of obesity!!

    (btw, I’m saying this with a smile, I’m not seriously advocating weight paranoia!!)

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  8. I suppose I walked right into that one, Anonymous. (also said with a smile)

    But my feeling is that we DO have too much weight paranoia, thanks to this attitude that we always have to beware, beware, beware that we might become obese when some studies show that your best bet for health is simply to exercise and eat healthy even if it doesn’t result in weight loss.

    Intentional weight loss is an intervention that can have adverse consequences. Some people develop eating disorders. More people gain additional weight than succeed in dieting down to an “acceptable” weight. I believe we are whitewashing those consequences and intervening when the risks truly outweigh (so to speak) the benefits. Doctors often engage in watchful waiting when someone has a condition that could get worse, but is not worth the side effects of treating just yet.

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  9. Yes, weight paranoia is bad.

    But I have several friends who are healthy weights. When I remarked once how “lucky” they were not to have to watch their weight, they said “We DO watch our weight!! ”

    Most said : “I eat well, but I also weigh regularly and as soon as there are 3 or 4 extra pounds I eat a little bit less than usual until I’m back at my best weight.”

    (Except for one lean athletic type who said :”I have to struggle to keep weight ON!” Go figure!)

    I would agree that often …”Intentional weight loss is an intervention that can have adverse consequences. ”

    However, it’s a myth that weight stability “just happens” for everybody who maintains a good weight. I think intentionally monitoring weight and making changes to loose small gains is sensible. That’s much better than letting small gains add up to big gains and big problems.

    If eating healthy and exercising don’t keep your weight steady (ie if you’re not perfect!), I think think that that is one instance when intentional weight loss (of small amounts, by gentle means) isn’t paranoid, it’s realistic and effective.

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  10. It’s also important to realize that the current definition of “overweight” is relatively new in the past 15 years or so and extremely restrictive. In reality, if you see a man with a BMI of 25.1, you are quite unlikely to think of him as too fat. My spouse has a BMI of almost exactly 25 and I buy him slim fit shirts and he can even wear skinny jeans like a teenager, although he wears slim cuts instead which are more age-appropriate. Yet he is technically overweight. An awful lot of ‘overweight’ men are in a BMI range that didn’t even used to be called overweight.

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