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