A few weeks ago I posted the story of a fat yoga teacher on my Facebook page.
After people grasp the fact that yes, I’m fat, and yes, I’m their yoga teacher, they usually go about setting up their mat and getting ready for class.
Sometimes, though, people first want to have a conversation with me. This usually goes something like:
Them (eyeing me suspiciously): “How many calories will I burn in this class?”
Me: “I couldn’t say. This is a fairly gentle class, and each person’s body is different.”
Them (looking me up & down): “But will I burn calories?”
Me: “Yes, of course. We all burn calories all the time.”
Them (all but saying, “Clearly, I won’t be burning enough calories!”): “Okay, because I really want to burn a LOT of calories. I don’t want more curves.”
Me: “Well, this is a great opportunity to see if this class is a good fit for you. Glad you’re here.”
So after I posted the story, I then asked the fat and fit people who are following my page whether they’ve had any similar experiences. Comments started. Even though I’m exercising, I’d seriously not want to compete with any of these women!
“I’ve worked in industrial baking jobs and people are shocked at the weight I could lift such as an industrial mixing bowl full of dough. I just tell people I’m super buff I just hide my muscles in a protective layer of fat. Haha”
“Love this! I am a very active fat woman and I am currently training to swim in a team triathalon. I am also a field researcher and can spend 8 hours swimming at times. Not every fat person is lazy or inactive. And I know plenty of skinny people who wouldnt stand a chance of keeping up with me!”
“Yeah, I know that look. I am obese according to my BMI, yet I clean houses for a living and work in my garden. Many houses, large houses. I see that look when I show up for the first time, it’s the “How will you possibly do this job looking like you do?” When I leave the look is more like “How did you get all that done in less time than it takes me, and so thoroughly?” Hah!
The fat bias propaganda has folks believing that because we are fat we are lazy, sloppy, and quite obviously suffering from a moral deficit making us incapable of work. LOL, I’ll go up against a skinny girl any day of the week when it comes to working out.”
Yes people are surprised to see fat and fit individuals. We’re conditioned to believe that fat automatically equals unhealthy and unfit. Some of us even believe that fat people are lazy. But that’s not the case at all.
There fat people who are healthy. There are fat people who are unhealthy.
There are fat people who are fit, and fat people who are unfit.
There are thin people who are unhealthy, and thin people who are healthy.
There are thin people who are lazy, just like there are fat people who are lazy.
Being fat doesn’t really mean anything other showing that you’re bigger. That’s it. It’s descriptive.
If fat=unhealthy, does blonde=dumb?
Just like being a blonde means you have blond hair. It doesn’t mean you are lazy. And it doesn’t mean you’re dumb! (Ha, blond people, esp. women, are discriminated against as well). I hope having blond highlights doesn’t make people automatically assume I’m dumb!
Hey, I’m a Stanford Engineering grad. The biggest dilemma of my life was choosing what grad school offer I should accept – Stanford’s or MIT’s. Hold on before you jump into conclusions!
Yet jumping into conclusions about people’s health is almost even accepted when it comes to fat people. Concern trolling, a type of fat-shaming, is prevalent – it happens when people who seem concerned about other (fat) people’s health and give them “friendly” advice to maintain “healthy weight.” So if you don’t have a “healthy weight,” then you’re automatically unhealthy!
So let’s put our glasses on, pull our sleeves up, and see if what we believe about obesity and its relationship to health is actually true.
Is obesity really that bad? And is it any different for fat and fit people?
Since heart disease is the Nr. #1 killer in the USA, since it’s about 90% preventable, and since obesity is one of the major risk factors, I’m gonna focus on the link between obesity and heart disease and how fitness changes the picture.
What you already knew: Obesity increases heart disease risk
According to the World Health Organization obesity is the fifth leading global risk factor for mortality. Obesity adversely affects hypertension, diabetes melletus, metabolic syndrome, atherosclerosis and CHD events.
Again according to WHO raised BMI increases the risk of cardiovascular disease (mainly heart disease and stroke). The risk for CVD increases with an increase in BMI.
The Obesity Paradox: So you’re fat and suffer from coronary artery disease. Are you sure you need to lose weight?
Now here’s where it gets interesting. Obesity (at least mild obesity) seems to have a protective effective on people who’re already suffering from cardiovascular disease.
Uretsky et al. studied 22,576 hypertensive patients with coronary artery disease. During two-year follow-up, they discovered that all-cause mortality was 30% lower in overweight and obese patients, despite less effective blood pressure control in these patients compared with the normal weight group. Fat people were less likely to either die or experience a non-fatal heart attack or stroke.
In a population with hypertension and coronary artery disease, overweight and obese patients had a decreased risk of primary outcome compared with patients of normal weight, which was driven primarily by a decreased risk of all-cause mortality.
(To clarify: Coronary Heart Disease (CHD) is the buildup of plaque in our arteries. It’s the result of Coronary Artery Disease (CAD) which builds up plaque in our arteries until the blood flow to the heart muscle becomes limited.)
And that’s just one of the studies that demonstrate the obesity paradox. Apparently, fat people who already suffer from heart-related conditions get a better prognosis than their normal-weight counterparts.
Here’s another example: Fonarow et al. analyzed BMI and in-hospital mortality for 108,927 decompensated Heart Failure patients higher BMI was associated with lower mortality. In fact:
For every 5-U [=5 units] increase in BMI, the odds of risk-adjusted mortality was 10% lower.
So the fatter you are, the better the “protection” you get!
So does this mean that being morbidly obese is ok?
Not so fast speed-racer. Some studies have found that it’s the overweight people who get protection, while super-obese people don’t get any protection at all. In a meta-analysis assessing all cause mortality, Flegal et al. found that:
Underweight and obesity, particularly higher levels of obesity, were associated with increased mortality relative to the normal weight category.
In other words, people whose BMIs were in the overweight range (between 25 and 29.9) showed the lowest mortality rates.
Now the Obesity Paradox is pretty weird right? Even though it has been found in multiple studies, we still can’t explain it.
Some people have explained the Paradox by blaming the inability of BMI to distinguish between fat mass and muscle mass. However, Lavie at all. showed the Obesity Paradox has persisted even in studies who don’t only rely on BMI and have also measured body fat.
Now I’m not talking about the Obesity Paradox to claim that “being obese is good, so don’t worry.” I’m only talking about the obesity paradox to demonstrate that there’s still a lot to know about the causes of cardiovascular mortality.
What if the problem is NOT obesity but lack of fitness?
Yes obesity has been linked to cardiovascular disease. But what if obesity is not the problem?
Traditional risk factors for all-cause and cardiovascular disease mortality include hypertension, diabetes, smoking, or obesity. Cardiorespiratory fitness (CRF) is often overlooked, or not measured at all.
So here’s what many studies are missing. Obesity comes for a reason, mainly consuming more calories than what is needed. And one factor responsible for this surplus is lack of physical activity and living a sedentary lifestyle.
What we know is that fitness has been shown to have a big effect on mortality. According to Lee et al., the protective effect of CRF on mortality is independent of age, ethnicity, adiposity, smoking status, alcohol intake, and health conditions.
In the Aerobics Center Longitudinal Study (ACLS), compared with the least fit men and women, the most fit men and women had 43% and 53% lower risk for all-cause mortality, and 47% and 70% lower risk of CVD mortality, respectively.
And it gets better. If you’re fat and think you need to lose weight…
Kodama et al. explained that a 1-MET higher level of CRF is comparable to a 7-cm, 5-mmHg decrement in waist circumference and systolic blood pressure respectively.
MET is a way to measure fitness level. So getting a bit fitter is equivalent to losing 7 cm from your waist! That’s almost 3 inches!
So what happens when you’re both fit and fat?
Barry et al. in a meta-analysis of fitness and fatness on all-cause mortality conclude:
Compared to normal weight-fit individuals, unfit individuals had twice the risk of mortality regardless of BMI. Overweight and obese-fit individuals had similar mortality risks as normal weight-fit individuals. Furthermore, the obesity paradox may not influence fit individuals. Researchers, clinicians, and public health officials should focus on physical activity and fitness-based interventions rather than weight-loss driven approaches to reduce mortality risk.
I don’t know what to highlight the most from this conclusion. The fact that fat and fit individuals had similar mortality to normal weight and fit individuals? Or the fact that the researchers suggest to focus on fitness rather than weight?
Ortega et al. set out to discover why some obese people are healthy. Seriously! They investigated the role of fitness:
When adjusting for fitness and other confounders, metabolically healthy but obese individuals had lower risk (30–50%, estimated by hazard ratios) of all-cause mortality, non-fatal and fatal cardiovascular disease, and cancer mortality than their metabolically unhealthy obese peers; while no significant differences were observed between metabolically healthy but obese and metabolically healthy normal-fat participants.
The authors concluded that “the metabolically healthy but obese phenotype is a benign condition.” In other words, if you’re fit, who cares if you’re fat?
Lee et al. report:
We have found that a moderate to high level of CRF eliminates the higher risk of mortality associated with obesity (Lee et al., 1999). We observed similar findings among older adults aged 60 years or older (Sui et al., 2007). In these ACLS studies, obese individuals who were fit had comparable mortality risk to normal-weight individuals who were unfit. These findings were consistent when using percentage body fat or waist circumference instead of BMI. Recently, the Veterans Exercise Testing Study in men aged 40–70 years also found that overweight and obese men had higher risk of all-cause mortality only if they had a low fitness level (McAuley et al., 2010).
However, in other studies fitness reduced the risks posed by obesity but did not completely eliminate them. At this point, we’re not sure if fitness completely reverses the effects of obesity or not. So we can’t claim that obesity is not a problem.
What we are sure about though is that fitness plays a major role on health and mortality risk. According to Lee et al:
CRF improves insulin sensitivity, blood lipid and lipoprotein profile, body composition, inflammation, and blood pressure and the autonomic nervous system. Insulin resistance is a major determinant of CVD, especially in overweight or obese individuals
BMI good enough but not perfect. Belly fat matters too.
So if fitness is to blame then why were we so focused on weight loss? A possible explanation is that many obesity-related studies first didn’t measure fitness, and second didn’t take into account waist circumference (WC) or body fat percentage. It is generally accepted that waist circumference (WC) is positively associated with increased morbidity and mortality from Type 2 diabetes and cardiovascular disease (CVD) independent of body mass index (BMI).
And guess what? If you’re fit you’re gonna have less belly fat than if you’re unfit, no matter your BMI! According to Wong et al:
For a given BMI, men in the HIGH CRF group had significantly lower WC (P < 0.001), total abdominal (P < 0.001), visceral AT (adipose tissue) (P < 0.001), and abdominal subcutaneous AT (P < 0.001) compared with men in the LOW CRF group.
Fat and fit men had less belly fat than fat and unfit people. Obviously since muscle weighs more than fat, people with the same BMI but different fitness level will have different body composition, with the person who exercises having less fat and more muscle compared to the person who doesn’t exercise.
How this changes everything for fat and fit people (and pretty much everyone else too)
Is obesity linked to cardiovascular disease? Yes it is. Is it bad? Yes it is. But maybe obesity is ok, and it just happens that obese people with increased risks were also unfit. Maybe fitness was the problem from the start, and this wasn’t caught early because it was not studied.
But maybe obesity does have an effect, regardless of fitness. We don’t know the extent of this effect. Lack of fitness may or may not play a bigger role than obesity. Seriously, what if lack of fitness is 2x as severe as having extra pounds? Or what if the effect of obesity is minuscule compared to the effect of being unfit?
These are answers that we’ll have to investigate in future research.
That said, if lack of fitness rather than obesity is to blame for heart disease then this changes everything, at least for cardiovascular conditions.
Fat people who suffer from heart-related conditions will be told to start exercising, not to lose weight.
Thin people who suffer from heart-related conditions will be told to start exercising
Both fat and thin people who are healthy but don’t exercise will be told to start exercising, just like doctors tell smokers who don’t have yet health issues to stop smoking.
If you’re fat and fit you’ll be able to concern troll all your fat or thin but unfit friends. Just kidding!
So what is your status? Fit or unfit? If you’re fat and fit, have you also experienced fat-bias or surprise from people who don’t expect that you’re exercising? Leave a comment below.
Oh, and not yet following my page? Like Fitness Reloaded on Facebook for daily commentary and debunking of the most common health fads!
References
Flegal et al. “Excess Deaths Associated With Underweight, Overweight, and Obesity.” The Journal of the American Medical Association, 2005;293(15):1861-1867
Uretsky at al. “Obesity Paradox in Patients with Hypertension and Coronary Artery Disease.” The American Journal of Medicine, October 2007, 863-870
Fonarow et al. “An obesity paradox in acute heart failure: Analysis of body mass index and inhospital mortality for 108 927 patients in the Acute Decompensated Heart Failure National Registry.” American Heart Journal, January 2007, Pages 74–81
Lavie et al. “The obesity paradox, weight loss, and coronary disease.” American Journal of Medicine, 2009
Lee et al. “Mortality trends in the general population: the importance of cardiorespiratory fitness, Journal of Psychopharmacology.” 2010 Nov; 24(4_supplement): 27–35.
Kodama et al., “Cardiorespiratory fitness as a quantitative predictor of all-cause mortality and cardiovascular events in healthy men and women: a meta-analysis.” The Journal of the American Medical Association, 2009 May 20;301(19):2024-35.
Wong et al. “Cardiorespiratory Fitness is Associated With Lower Abdominal Fat Independent of Body Mass Index.” Medicine and Science in Sport and Exercise, 2004;36(2)
Barry et al. “Fitness vs. Fatness on All-Cause Mortality: A Meta-Analysis.” Progress in Cardiovascular Diseases, Volume 56, Issue 4, January–February 2014, Pages 382–390
Ortega et al. “The intriguing metabolically healthy but obese phenotype: cardiovascular prognosis and role of fitness.” European Heart Journal, 2012