Can you be 'fat and fit'?

In a recent article, Cosmopolitan articulates beautifully a valuable body positivity message.  It highlights the benefits of focusing on fitness & function over aesthetics, holistic health & well-being and exercise enjoyment (over exercise punishment). (I highly recommend a read)

The article has received some push back, some claiming that the promotion of obesity as healthy is irresponsible.  Particularly at the given moment due to the interaction between overweight/obesity and COVID-19 symptoms.   Tristen Justice writes in the Federalist: “This activism is a dangerous trend bearing poisonous fruit in the ongoing coronavirus pandemic, in which obesity has shown to raise people’s risk profiles to complications from COVID-19.”

But is there truly a dichotomy here, in need of the all too standard adversarial reporting model to which we are all used?  Or are Cosmo and the Federalist actually working towards the same goal in different ways?

Overweight/obesity and body positivity movements

The complex relationship between overweight/obesity and general health is well studied, the conditions undeniably linked to several health complications and co-morbidities.   In recent years a cultural push back against the broadcasting and practicalities of this reality has been seen in what have become known as ‘body positivity’ movements.

The most prominent of these movements, known as Health at Any Size (HAES), asserts that findings claiming a link between overweight/obesity and various unfavourable health outcomes are either overstated or simply untrue. Often going as far as to claim that there is no link between bodyweight and general health. The HAES movement claims to provide an alternative to the, often unsuccessful, world of conventional dieting.

The HAES movement has been praised by some for promotion of healthier attitudes towards eating behaviour by promoting health over aesthetics and its fundamental tenets have been used successfully in the treatment of some individuals with disordered eating.  

Conversely, it has received much criticism for being an unscientific (or even anti-scientific) internet movement attempting to assert itself on a scientific domain. Some critics going as far as to condemn it as simply another cultish online community - akin to anti-vaxxers or flat earthers – showing a disinterest or even disdain for any empirical evidence or research that conflicts with its dogmatic beliefs and message.  The main complaint being that HAES is promoting lifestyles that often lead to poor health and premature death.

News media and low-quality coverage

It is important to note the massive potential for misreporting and misinformation here.  The movements, initially prevalent online and on social media platforms, have moved into mainstream news media – as evidenced in the Cosmo article.

An issue arises in the fact that there is evidence that the accuracy or quality of coverage of nutritional and health issues in newspapers and magazines is generally embarrassingly poor.   For example, one study of reporting in 10 major newspapers found that that ~70% of articles failed to meet standards of evidence for claims made. (1) This led researchers to conclude that misreporting of dietary advice was widespread and may contribute to public misconceptions surrounding health.   A later study found similarly and added that poor quality information was most likely to be presented in relation to the issue of obesity. (2)

In short, if you want honest, accurate information about this topic then mainstream media sources are likely not the place to find it. 

Do you really think getting medical advice from a fashion magazine is a good idea?

Can obese individuals be metabolically healthy?

Fat and fit

One of the core principles of HAES is the notion that obese individuals can be as metabolically healthy as healthy weight individuals – often referred to culturally as ‘fat and fit.’

The HAES movement claims that fitness and bodyweight are largely unrelated factors.  This claim has some basis in the scientific literature, and it is generally accepted that exercise induced physical fitness can promote health benefit to an individual independent of reduction in weight. (3)   

One study of >25,000 adult men concluded that poor physical fitness was an independent predictor of mortality in men, regardless of body fat, after adjusting for other mortality predictors (eg. CVD, diabetes). (4) 

These results mirror another study (often cited in the HAES movement) that tested maximal fitness of ~2000 diabetic men. (5)  Mortality risk was inversely associated with physical fitness – the fitter subjects were, the lower their risk of dying.  Interestingly the association was found to be independent of BMI – suggesting that it was physical fitness, not physical ‘thinness’, that reduced mortality risk.

These studies suggest that physical fitness is not necessarily linked with body size and that, contrary to the conventional cultural belief, overweight individuals can achieve high levels of physical fitness and the accompanying physiological health benefits and reductions in mortality risk.

Conflicting Research

The above are in contrast with a much larger, more recent cohort study that assessed the physical fitness of >1.3Million Swedish men. (6) After follow up of 29 years, 44,301 deaths were noted.   It was found that those in the highest quintile of fitness experienced lowest all-cause mortality risk.  However, contrary to the above studies, the benefits of physical fitness were significantly reduced in obese individuals.  Unfit normal weight individuals (thin and unfit) were found to be at 30% lower risk of all-cause mortality then fit obese individuals (fat and fit) - strongly suggesting that obesity is more associated with mortality risk than lack of fitness. This very large sample size and long follow up time make this study particularly compelling, although it is limited to male subjects.

This study is consistent with the largest study of its kind to date on this issue. (7)  The study divided 3.5million subjects into different bodyweight categories (underweight, normal weight, overweight and obese) and classified them according to presence or absence of 3 metabolic abnormalities (diabetes, hypertension and hyperlipidaemia). 

It was found that obese individuals with no metabolic abnormalities (fat and fit) had significantly higher risk of coronary heart disease, cerebrovascular disease and heart failure than healthy weight individuals of the same (thin and fit). This study suggests that, although physical fitness is valuable for health outcomes in all weight classes, obesity is an independent risk factor for various serious illnesses – regardless of fitness level.  The massive sample size of this study and inclusion of subjects of different ages and genders makes it particularly robust.

“…the largest study of its kind to date…found that obese individuals with no metabolic abnormalities (fat and fit) had significantly higher risk of coronary heart disease, cerebrovascular disease and heart failure than healthy weight individuals of the same (thin and fit).” (7)

Fat and fit possible, but less likely

Another study (also often citied in HAES literature) divided subjects into those that were:

-  Mildly obese (BMI <34.9)

-  Moderately obese (BMI 35-39.9)

- Severely obese (BMI >40). (8)

Researchers found that even ‘severely obese’ individuals can enjoy good cardiovascular fitness and concluded that achieving CV fitness may be as valuable a goal as achieving weight loss for overall health in obese individuals.  As in the healthy weight population, there is variance in fitness levels and health outcomes in the obese population.

However, an important element of this study for this context is that only 41% of ‘mildly obese’ met the criteria for being considered fit, with the percentage dropping even lower for ‘moderately obese’ (25%) and ‘severely obese’ (11%) subjects.

This study suggests that the likelihood that an obese individual will meet criteria to be considered ‘fit’ is fairly low; with likelihood decreasing with increasing obesity levels.

The overall picture

When viewed in totality, the research suggests that some overweight/obese individuals can have similar levels of physical fitness, and resulting positive effects on general health, as healthy weight individuals.  This suggests that promotion of physical activity may be as or more beneficial than promotion of weight loss in improving the overall health of obese individuals.  

However, even in those with no metabolic abnormalities (‘fit’ people), the likelihood of suffering from various (potentially fatal) noncommunicable illnesses is increased in overweight/obese people when compared to healthy weight individuals.  Further, the risk of suffering from co-morbidities (eg. diabetes) is greatly increased in overweight/obese individuals compared to those of a healthy weight.

The literature is still unclear on whether or not metabolically healthy obese individuals (fat and fit) have greater or lesser mortality risk than metabolically unhealthy normal weight individuals (thin and unfit).  This is a gap in the research that would warrant future study.

The other end of the spectrum

Fitness models and bodybuilders are famously at their least fit, healthy and physically weakest when they superficially appear at their ‘best.’  The unsustainably low levels of body fat wreaking havoc on their endocrine and nervous systems.  The same could be said of some fashion models - forced into being unhealthily low bodyweight due to cultural expectations .  This reality is constantly pointed out by HAES advocates. (An irony that seems to escape many, clearly able to recognise that there isn’t health at every size - as long as you are talking about underweight individuals)

This is a common inconsistency, glaringly obvious within these movements. The tendency to recognise the ill health that can accompany underweight individuals, but a denial of the same realities when it comes to overweight/obese.   I agree that a cultural shift would be beneficial, moving away from idealising bodies that are objectively, medically unhealthy.  But the answer lies not in shifting the goalposts up the BMI spectrum – it lies in following the evidence.

A false dichotomy?

I have to mention I notice an unfortunate pattern in this area.  Although bolstered with motivational people, stories and quotes – I have yet to come across a body positivity article that provided any real quality evidence of its claims or was even honest about the reality of the effects of obesity in the long term. 

Although I agree with the spirit of the article, the Cosmopolitan piece is a good example of this. Comforting as it may be for many to talk about the large Instagram following of an obese individual who is a ‘superstar in the wellness industry’ -  the science is clear that, given enough time at this weight, the individual will likely suffer for it.  Will Cosmo grace their cover with this person if any of the predicted negative health outcomes come to pass? I suspect not. This is where claims of irresponsibility start to seem at least a little justified. These magazines knowing they can sell the comforting lies of today, knowing full well they will not be the ones suffering the consequences of tomorrow.

On the flip side, the aggressive dissent that body positivity movements often face seems closed to the obvious potential benefits these movements can convey.  In a culture where for so long only certain body types were propped up as beautiful and acceptable – the admiring and respecting of bodies that do not fit this narrow ideal is a welcome change. 

My only real gripe (and it is a significant one) is that this can be done without denying science.  Indeed, in my opinion, the best solution lies in a merger of the two sides of this argument.  That is to create a culture where all bodies are accepted & represented but we fully accept the reality surrounding the link between behavioural choices, bodyweight and health outcomes (even when it is not pleasing or convenient for us to do so).

Take away points

 1 – There is clear value in body positivity movements in promoting acceptance of the massive variety of healthy bodies that exist and are not traditionally highlighted as such in culture.

2 – Focusing on fitness is likely as valuable a goal as focusing solely on bodyweight in terms of overall health.

3 - Even within ‘fit’ individuals overweight/obesity are independent risk factors for various co-morbidities and premature death - this is an inconvenient, sometimes upsetting and inescapable reality.

Feed the life you want to lead,

Duncan

References:

1 - Cooper BE, Lee WE, Goldacre BM, Sanders TA. The quality of the evidence for dietary advice given in UK national newspapers. Public Underst Sci. 2012 Aug;21(6):664-73.

2 - Hainer V, Toplak H, Stich V. Fat or fit: what is more important?. Diabetes Care. 2009;32 Suppl 2(Suppl 2):S392-S397. doi:10.2337/dc09-S346

3 - Wei M, Kampert JB, Barlow CE, Nichaman MZ, Gibbons LW, Paffenbarger RS Jr, Blair SN. Relationship between low cardiorespiratory fitness and mortality in normal-weight, overweight, and obese men. JAMA. 1999 Oct 27;282(16):1547-53.

4 - Church TS, Cheng YJ, Earnest CP, Barlow CE, Gibbons LW, Priest EL, Blair SN. Exercise capacity and body composition as predictors of mortality among men with diabetes. Diabetes Care. 2004 Jan;27(1):83-8.

5 - Högström G, Nordström A, Nordström P. Aerobic fitness in late adolescence and the risk of early death: a prospective cohort study of 1.3 million Swedish men. Int J Epidemiol. 2016

Aug;45(4):1159-1168.

6 - Caleyachetty R, Thomas GN, Toulis KA, Mohammed N, Gokhale KM, Balachandran K, Nirantharakumar K. Metabolically Healthy Obese and Incident Cardiovascular Disease Events Among 3.5 Million Men and Women. J Am Coll Cardiol. 2017 Sep 19;70(12):1429- 1437.

7 - Do, K., Brown, R.E., Wharton, S. et al. Association between cardiorespiratory fitness and metabolic risk factors in a population with mild to severe obesity. BMC Obes. 2018; 5: 5.

8 - Schnurr, T.M., Jakupović, H., Carrasquilla, G.D. et al. Obesity, unfavourable lifestyle and genetic risk of type 2 diabetes: a case-cohort study. Diabetologia. 2020; 63, 1324–1332.