Can you be Obese and Healthy?

The word “obesity” gets thrown around quite a bit these days. Not only is it closely related to the word “epidemic”, but is absolutely considered in a negative light. From general concern over health to fat shaming, obese individuals have been told that their physical condition is nothing short of terrible. However, is obesity the death trap people make it out to be? While obesity itself is not the moniker of good health, is it possible that a person who is obese could be healthy? Or even yet, be healthier than a skinnier person? It seems that the research indicates some interesting conclusions in this area. As usual, let’s get this show on the road and find out the truth about the subject. LETS GO!

How do we define Obesity?
I’ve always been a big supporter of having some understanding of how we define concepts before getting into the meat of a subject. In this case, it is imperative that we understand the definition of the term “obese”. When the Center of Disease Control mentions that 78.6 million people (roughly 34%) in the United States are considered obese, what do they mean by that [1]?

According to the National Library of Medicine, obesity is defined as “having too much body fat” [2]. While this may seem self-explanatory to most, the CDC offers a more quantitative look at the definition stating that a person with a Body Mass Index (BMI) of 30 or more is considered obese [1]. Now, while BMI has gotten quite a bit of heat for its lack of detail and coverage of some important variables, when referring to extremes as supposedly detailed in obesity, one can assume that, for most, BMI is accurate enough a measure to be strongly correlated to obesity related diseases [1]. For the purpose of this article, even with a skew in body composition, this definition of obesity will suffice. However, even with this definition, we need one more such definition to really get started.

 

How do we define Health?
That’s right, we use words so carelessly that we fail to really realize there are a multitude of various definitions for a single word and expressing which definition we are referring to would help immensely in looking at the reality of the data presented shortly. So, how shall we define health? Well, this may not be all encompassing, but let us take the guidelines defined by the American College of Sports Medicine’s (ACSM) definition by focusing on these factors as risk factors for health issues characterized by cardiovascular disease (CVD) and metabolic syndrome [4]:

1. Age
  - Men: Over 45, Women: Over 55

2. Family History/Genetics
  - Heart problems in 1st degree relative of male before 55 and female before 65

3. Amount of Physical Activity
  - Need to do moderate exercise, 3 times a week, for 30 minutes

4. Obesity
  - Over 30 BMI, and/or 102 cm (40 in.) waist (men), 88 cm (35 in.) waist (women)

5. Lipid Profile
  - Total Cholesterol: Over 200 mg/dL
  - LDL: Over 130 mg/dL
- HDL: Less than 40 mg/dL

6. Blood Glucose
  - Fasting glucose: Over 100 - 126 mg/dL
 

Now, there are shortcomings to this definition as this definition does not cover every aspect of health (such as bone density, lung function, ease of living, etc.), but it does cover some of the most important physiological shortcomings we suffer from in the United States. Specifically, cardiovascular disease (the number one killer in the United States) and diabetes (top ten killer in the United States and a large prevalence in the obese) are huge risk factors in obesity and reducing even these two would lead to a massive improvement in longevity [3][5].


Can a person be Obese and Healthy?
And here we are; the question of the article. Without further ado, let us look at some of this research and break things down.

This topic is not as clear cut as many people try and make it. Most people see someone who is obese and immediately assume that they are unhealthy, and while in some (or most) cases this may be true as we have a litany of research indicating that obesity is strongly linked to metabolic syndrome (increased blood pressure, diabetes, high cholesterol, etc.) this does not necessarily mean that obese individuals cannot be healthy if they take certain measures, even if those measures do not push them out of their obesity [6][7][8]. So, what tool can be used to promote health?

Exercise.

Granted, one might think that exercise is absolutely a way for people to lose weight and therefor makes this article a moot point, because those who exercise will fall out of the “obese range” eventually. This is not the case, however. In several clinical studies, it was shown that exercise, while beneficial (which we will delve into in a bit), did not lead to significant weight loss, even after months of high adherence levels and several exercise prescriptions [9][10]. One study did show changes in body weight, but from difficult, high amounts of exercise (20 miles running per week at 65-80% VO2) and those weight changes were little [11]. So, exercise will, in all likelihood, not lead to a decrease in obesity. However, it does do something else for us – let’s take a look.

It has been shown that although exercise may not decrease weight by any significant amount, if any; leaving people obese, it does, however, have a dose-dependent response on health. In this study, weight barely changed, yet cholesterol markers (concentration and type) were all significantly improved, to ACSM recommended levels in some instances, more so dependent on duration of exercise than intensity [11].

So, exercise helps with cholesterol, but it also seems to help with insulin sensitivity (related to diabetes) if performed at higher intensity (70% VO2)[12]. A more precise study mentions that even moderate intensity exercise has an impact on insulin sensitivity [13]. Between these two studies, in obese individuals that saw small to no changes in body weight, there was still a positive effect seen in insulin resistance. Not only that, but those that did see some weight change, it was not seen as the cause of the betterment of insulin response.

Studies show that a person can remain obese yet improve one’s health dramatically in terms of cardiovascular risk, fighting diabetic numbers by increasing insulin sensitivity, as well as dramatically decrease mortality rate simply by exercising [14]. Looking back at the ACSM stratification, age will always be a factor, yet most of the studies incorporated in this article were done on ages 40-65 (within the “risk” category, for the most part) and significant improvements were still seen. Family history is an enemy that can be battled, but is just luck of the draw – either way, improvement is improvement. Physical activity is the key to living a far healthier life, even in the face of lack of nutritional intervention. Obesity, while still possible to be much healthier even in the face of the struggle to live with obesity, being obese, in its own right brings about a massive amount of issues – in almost no way is being obese a healthy factor, even if we’ve seen that obesity is not exclusive to health. In regards to lipid profile, it has been shown that lipid markers can significantly improve depending on the appropriate exercise intervention, and the same is true of insulin sensitivity (diabetes management and prevention). However, one last nagging question hangs in the back of the mind.


 

Can a person who is obese be healthier than a person who is not obese?
For us to understand this accurately, we need to understand a concept called “relative risk”. Relative risk is the proportional risk increase of one group with a particular condition to groups without the condition. Fascinatingly, two large scale studies looked at the relative risk within groups (obese fit vs obese unfit, over weight fit vs overweight unfit, normal weight fit vs normal unfit, etc.) as well as the relative risk between groups (obese fit vs normal unfit, for example). The Aerobic Center Longitudinal Study found that the relative risk comparison of obese fit people to normal weight unfit people is lower for risk of mortality in favor of the obese fit [15].

You read that correctly, fit obese people are considered healthier than unfit normal people.

Now, before this gets pegged as a sensationalist article (my worst fear), it should be mentioned that the Aerobic study was done on, almost exclusively, a white population, so this conclusion may not extend to other populations. On another note, a more diverse study, conducted by the Lipid Research Clinic, looking at mortality (from all causes) looking at between groups showed that those fit and overweight were almost as healthy as those unfit and normal weight [16]. So, while the extravagant title of “you can be obese and healthier than non-obese” may not apply here, the idea that a person is obese yet as healthy as their normal weight buddies is not so farfetched.
Finally, looking at the Nurse’s Health Study, we see that in overall mortality, again, fit obese individuals were just as safe as those who were unfit normal weight individuals [17]. However, if we narrow in on CVD risk, while CVD risk diminished significantly (almost half) between fit obese and unfit obese, the risk was still lower among unfit normal weight individuals. So, this would tell us that, most likely, being obese has irreversible, insurmountable negative side effects. However, this study has flaws in its self-report of exercise and failure to define and measure “physical activity” as anything beyond 3.5 hours a week. As we have seen earlier in this article, most of the benefit derived from exercise comes from high volume, and in some cases, high intensity exercise. We also know that exercise is a dose-response relationship. Knowing these bits of information, we can safely assume that performing exercise for longer than 3.5 hours and at, possibly, a higher intensity (>70% VO2) might lead to more benefit than expressed in this study, even if self-report data was to be believed. This is further evidenced by a study conducted by an Harvard Alumni Health Survey that evaluated and concluded, via self-report, that those who were fit and normal weight had the lowest incidence of mortality and unfit obese had the highest incidence of mortality (no shock there), but again that unfit normal weight and fit obese individuals had no significant difference in mortality [18].

It should be mentioned that many of these conclusions become clearer in the face of measuring waist circumference as waist circumference, in normal weight, overweight, or obese populations is a strong predictor of metabolic syndrome considering it tends to be prominent in android obesity, so it does matter where adipose tissue (fat) is deposited [20]. With this in mind, it is possible for BMI to be largely unaffected, yet visceral adiposity (fat that tends to surround the organs and create a “gut” in excess) to decrease, leading to better health markers in those that are fit [19].

Finally, in an overview analysis of most of these studies published by the American Diabetes Association, it was mentioned, poignantly,

“Moreover, a number of studies suggest that physical activity may counterbalance the hazardous health effects of increased adiposity. This suggests that that improvement of CRF in an obese patient might improve his or her health perspective even if the patient remains obese.” [14]

Let us put this all in a nice, short, concise, rational perspective package.

 

SUMMARY

Based on the main markers assessed by the ACSM for health (which, admittedly, do not cover everything) it seems quite possible for someone to be obese and healthy. This does not occur due to pure chance, however. Individuals need to do high volume aerobic exercise for most benefit, and high intensity (>70% VO2) for added benefits. Finally, while some evidence shows fit, obese individuals as being in superior health to those who are unfit, normal weight, it is more likely that a more moderate stance is an acceptable conclusion: being fit and obese will lead to great improvement in health markers up to comparable levels with unfit and normal weight individuals. Is an unfit, normal weight individual healthy? That is up for debate, and maybe we will read about it in a future Omni Focus Fitness article.
 

Writer: Nicolas Verhoeven

Quick word of thanks to Professor McCammon of the Kinesiology Department at East Carolina University for providing resources and lecture on the subject.

                                                                                                            Citations

 

[1] Obesity and Overweight for Professionals: Adult: Defining - DNPAO - CDC. (n.d.). Retrieved from http://www.cdc.gov/obesity/adult/defining.html

[2] Obesity: MedlinePlus. (n.d.). Retrieved from https://www.nlm.nih.gov/medlineplus/obesity.html

[3] WHO | Obesity and overweight. (n.d.). Retrieved from http://www.who.int/mediacentre/factsheets/fs311/en/


[4] ACSM Risk Stratification Screening Questionnaire. (n.d.). Retrieved from http://www.exerciseismedicine.org/assets/page_documents/Appendix%20D%20-%20ACSM%20Risk%20Stratification%20Q.pdf

[5] FastStats - Leading Causes of Death. (n.d.). Retrieved from http://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm

[6] Zimmet, P., Alberti, G., & Shaw, J. (0). A new IDF worldwide definition A new IDF worldwide definition of the metabolic syndrome: of the metabolic syndrome: the rationale and the results.The Lancet. Retrieved from http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(05)67402-8/fulltext

[7] What Is Metabolic Syndrome? - NHLBI, NIH. (n.d.). Retrieved from http://www.nhlbi.nih.gov/health/health-topics/topics/ms

[8] Obesity and Metabolic syndrome. (n.d.). Retrieved from http://www.womenshealth.gov/heart-truth/pdf/obesity_metabolic.pdf

[9] Church, T. S., Earnest, C. P., Skinner, J. S., & Blair, S. N. (2007). Effects of Different Doses of Physical Activity on Cardiorespiratory Fitness Among Sedentary, Overweight or Obese Postmenopausal Women With Elevated Blood Pressure: A Randomized Controlled Trial. Jama-journal of The American Medical Association. doi:10.1001/jama.297.19.2081

[10] CHURCH, T. S., EARNEST, C. P., THOMPSON, A. M., PRIEST, E. L., RODARTE, R. Q., SAUNDERS, T., . . . BLAIR, S. N. (2010). Exercise without Weight Loss Does Not Reduce C-Reactive Protein: The INFLAME Study. Medicine and Science in Sports and Exercise. http://www.ncbi.nlm.nih.gov/pubmed/19952828

[11] Kraus, W. E., Houmard, J. A., Duscha, B. D., Knetzger, K. J., Wharton, M. B., McCartney, J. S., . . . Slentz, C. A. (2002). Effects of the Amount and Intensity of Exercise on Plasma Lipoproteins. New England Journal of Medicine. http://www.nejm.org/doi/full/10.1056/NEJMoa020194

[12] Kang, J., Robertson, R. J., Hagberg, J. M., Kelley, D. E., Goss, F. L., DaSilva, S. G., . . . Utter, A. C. (1996). Effect of exercise intensity on glucose and insulin metabolism in obese individuals and obese NIDDM patients. Diabetes Care. http://care.diabetesjournals.org/content/19/4/341?ijkey=e8f1bb3f7db9d055495e22fe0864784a7b512248&keytype2=tf_ipsecsha

[13] Houmard, J. A. (2003). Effect of the volume and intensity of exercise training on insulin sensitivity. Journal of Applied Physiology. http://jap.physiology.org/content/96/1/101.long#T3

[14] Hainer, V., Toplak, H., & Stich, V. (2009). Fat or Fit: What Is More Important? Diabetes Care. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2811477/

[15] CD, L. (1998). US weight guidelines: is it also important to consider cardiorespiratory fitness?International Journal of Obesity Related Disorders. http://www.ncbi.nlm.nih.gov/pubmed/9778090/

[16] Stevens, J., Evenson, K. R., Thomas, O., Cai, J., & Thomas, R. (2004). Associations of fitness and fatness with mortality in Russian and American men in the lipids research clinics study.International Journal of Obesity. http://www.ncbi.nlm.nih.gov/pubmed/12397001/

[17] Stevens, J., Evenson, K. R., Thomas, O., Cai, J., & Thomas, R. (2004). Associations of fitness and fatness with mortality in Russian and American men in the lipids research clinics study.International Journal of Obesity. http://www.ncbi.nlm.nih.gov/pubmed/15616204/

[18] Lee, I., & Paffenbarger, R. S. (0). Physical Activity and Stroke Incidence The Harvard Alumni Health Study. International Journal of Obesity. http://www.ncbi.nlm.nih.gov/pubmed/10670554/

[19] Kay, S. J., & Singh, M. A. (2006). The influence of physical activity on abdominal fat: a systematic review of the literature. Obesity Reviews. http://www.ncbi.nlm.nih.gov/pubmed/16629874/

[20] Waist Size Matters | Obesity Prevention Source | Harvard T.H. Chan School of Public Health. (n.d.). Retrieved from http://www.hsph.harvard.edu/obesity-prevention-source/obesity-definition/abdominal-obesity/

Illustrations:

A) http://examinedexistence.com/wp-content/uploads/2013/10/obesity.jpg


B) https://trexrunner.files.wordpress.com/2012/11/p1000383-e1354065384960.jpg

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