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Better Fat Than Unfit

The 2018 JAMA special issue on obesity also includes a brief paper by Ann Blair Kennedy and colleagues reviewing the debate (which really isn’t much of a debate to anyone who knows the data) on whether it is more important to be fit than to worry about being fat (it is).

As the authors review, there is now ample data showing that cardio-respiratory fitness (CRF) is far more important for the prediction of cardiovascular mortality than the level of fatness (measured as BMI or otherwise).

In fact, once you account for differences in “fitness”, actual BMI levels almost cease to matter in terms of predicting longevity.

Unfortunately, as the authors point out, most studies linking obesity to cardiovascular outcomes (including studies on the so-called obesity “paradox”), fail to properly measure or account for cardiovascular fitness, thereby ignoring the most important confounder of this relationship.

For clinicians (and anyone concerned about their excess weight), it is helpful to remember that while achieving and maintaining a significant weight loss is a difficult (and often futile) undertaking, achieving and maintaining a reasonable degree of cardiorespiratory fitness is possible at virtually any shape or size.

Thus, as the authors point out,

“…in current US society, many people progressively gain weight and lose CRF as they age. Conceivably, maintaining CRF may be more important than preventing the development of obesity. However, for people who are overweight or have mild to moderate obesity, there are effective ways to improve CRF, including exercise and lifestyle interventions and there is general agreement that having low levels of PA is unhealthy. Increasing PA to help keep individuals from becoming unfit can be achieved if patients meet current PA guidelines of 150 minutes of moderate or 75 minutes of vigorous PA per week.”

Clearly, if your primary concern related to your patients’ excess body fat is about their cardiovascular health, you would probably be doing them a far greater service by getting them to improve their cardiorespiratory fitness rather than simply lose a few pounds (and no, exercise is not the best way to lose weight!).

On the other hand, if there are other health issues that are of primary concern (e.g. sleep apnea, osteoarthritis, fatty liver disease, etc.) or the degree of excess fat significantly affects mobility or other aspects of quality of life, then perhaps a frank discussion about available and effective “weight-loss” treatments appears warranted.

Let us not forget that it is never a good idea to simply treat numbers on the scale.

Edmonton, AB


  1. Dr. Sharma, thank you for this information. It is helpful for me to read this. I am 5 years post-RNY. I am maintaining a 200 pound weight loss but still hover between 290-300 pounds. I often feel a sense of failure and shame that I am still morbidly obese. In spite of my excess weight, I am physically active, exercising 5-6 times a week including biking, taking spin classes, elliptical machine and strength training. My resting heart rate is 64 and my blood pressure is 110/70. Most days I hit my 10K steps a day goal. I’m not sure if I would be considered a success story, but I’m living life and feel pretty healthy – something I wasn’t doing when I weighed 500 pounds and could barely get out of bed. I so appreciate your blog and all the information that you share.

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    • Oh Kim, how can your incredible achievements not be a success? But I hear you. Stopping the judgemental voices of others from getting in your head is difficult. Hearing your story inspires me. You are proof that making significant and sustained lifestyle changes is possible.

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      • Kudos to you, Kim, for your hard work and effort in staying active and maintaining your weight loss. You should feel a great sense of achievement. You have done what very few people an do.

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