“Fat but fit”? Studies confuse, while advocates & journalists do little to clarify

Michael Joyce produces multimedia at HealthNewsReview.org and tweets as @mlmjoyce

"fat but fit"Can you be fat but fit?

Over the years the answer to that question has been:  yes, no, and depends. What it really depends on is what study you read.

The answer was “yes” in this 2012 study in which lead author, Francisco Ortega concluded:

“”It is well known that obesity is linked to a large number of chronic disease such as cardiovascular problems and cancer. However, there appears to be a sub-set of obese people who seem to be protected from obesity-related metabolic complications.”

The study was heralded with headlines like this one from CNN which claimed, “You can be fat AND fit, researchers say.”

But today the answer is “no” according to an unpublished study presented this week at the European Congress on Obesity.

That led to this vitriolic headline in The Telegraph: “‘Fat but fit’ is a myth and big is not beautiful – so stop making excuses for obesity.”

Researchers from the University of Birmingham, UK reviewed the records of 3.5 million people (1975-2014) without evidence of cardiovascular disease (at the start of the study) and divided them into people with and without obesity based on body mass index (BMI) measurements. The study found that, compared to people without obesity, individuals with obesity (BMI >30) who were deemed “metabolically healthy” (i.e. normal blood pressure, cholesterol and no type 2 diabetes) had higher risk of coronary artery disease, heart failure, stroke, and peripheral vascular disease (compromised blood flow to the arms and legs).

The findings prompted lead author, Rishi Caleyachetty to conclude:

“The priority of health professionals should be to promote and facilitate weight loss among obese persons, regardless of the presence or absence of metabolic abnormalities. At the population level, so-called ‘metabolically healthy obesity’ is not a harmless condition and perhaps it is better not to use this term to describe an obese person, regardless of how many metabolic complications they have.”

This study has not been peer-reviewed, and absolute risk numbers are not currently available, so it’s difficult to provide an in-depth analysis of the research. However, we can say it’s an observational study — not a clinical trial — so attributing the cardiovascular outcomes to obesity alone is not possible. Furthermore, BMI is an imperfect measure of obesity but is, according to the authors, the most practical measure available in reviewing such a large data base.

But evaluating these preliminary results is not my goal here. My point is this:

We are a riding a roller-coaster of conflicting observational studies that can only show association, not causation … that haven’t consistently or reliably defined obesity …. and that typically use surrogate markers (things like blood pressure and cholesterol) to define a concept none of us can agree upon (and probably never will): so-called “fitness.”

An agenda for every study & a study for every agenda

The end result is that advocates will often selectively highlight results that align best with their agendas and news organizations will gladly hype either end of the spectrum knowing full well that any story that features both obesity and fitness will be clickbait nirvana. Left dangling in the middle are readers who are usually offered little to no context with which to make informed choices.

An example of this is a recent news release review we published regarding an allegedly “non-surgical”  weight loss treatment. A regular reader — who raises some important points — took issue with how we handled the story:

“I wish that you would challenge the weight industrial complex with this same critical lens you apply elsewhere. …your reviews always start with the usual unsubstantiated fearmongering, like this, ‘obesity increases an individual’s risk for heart disease, stroke, diabetes and other health problems. On top of those health risks, obesity also has an adverse effect on an individual’s quality of life.’ Use the same lens you use elsewhere: just because there’s association doesn’t mean there’s causation. And just because ‘everyone says it’ doesn’t mean it’s true. Challenge these ideas. When you let go of your assumptions, it is well established that there is much that can explain increased disease incidence that had little to do with weight itself. Weight stigma plays a much larger role in the diseases associated with weight than high weight itself, and this article just contributes to that.” [see full comment at link above]

The writer of this comment, Dr. Linda Bacon, is an author, academic, and proponent of a registered trademark labeled “Health at Every Size.” It is dedicated to “celebrating body diversity” and feels the “war on obesity” has led to significant “collateral damage” in the form of eating disorders, stigmatization, and poor health.

I would suspect a group with this focus might not agree with obesity being portrayed as a chronic disease. Furthermore, they might call more attention to research that supports the notion that you can be “fat and fit.”

Novo nordisk ad for their “weight management” injectable drug. Novo nordisk is the major sponsor of this week’s European Congress on Obesity

On the other end of the spectrum are pharmaceutical companies heavily invested in medicines and treatments directly or indirectly related to obesity as a medical condition or “disease.” They represent the largest funders of this week’s congress on obesity. For them, the prospect of “metabolically healthy obese” would likely translate into billions of dollars in lost income. They’d likely prefer “fat and unfit”  because it opens a vast market that is estimated to grow to over $15 billion by 2024.

What role can journalists play?

In short, more context and less hyped-up declarations based on inadequate evidence. How can you write about obesity and fitness without mentioning how researchers define those terms? Is it even possible for the study being reported on to link the two? Finally, what’s wrong with admitting uncertainty and nuance? Both obesity and fitness exist along a spectrum. So taking this week’s Birmingham data and translating it into an unequivocal “fat but fit is a myth” is not helping this debate — or the reader — one bit.

It’s easy to come away from the “fat but fit” versus “fat is unfit” debate with your head — and emotions — spinning. Is there some “truth” to be found?  I turned to Yoni Freedhoff MD, one of our regular contributors on issues related to nutrition and health. Dr. Freedhoff works in family medicine at the University of Ottawa, and is director of their Bariatric Medical Institute – a weight management clinic.

“That exercise and an active lifestyle are beneficial to health are about as established as facts as any in medicine. And consistency in exercise provides more benefits than pretty much any medication any doctor could ever prescribe for the primary and secondary prevention of a myriad of chronic non-communicable diseases. Another clear fact? That obesity — especially at its extremes — confers risk.”

I wish we saw more quotes like this in stories addressing obesity and fitness. This is useful information. This is not a hyped-up declaration designed to manipulate emotions or further an agenda. It’s pragmatic advice based on evidence. We need more of that.

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Comments (14)

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Laurie Klipfel

May 19, 2017 at 12:25 pm

Regardless of whether you believe you can be “fat but fit” or you believe “fat is unfit,” we should be making the same recommendation for healthcare. There is absolutely no doubt that healthy behavior is good for ALL people regardless of size with or without weight loss. If you focus on weight loss, those that do not need to lose weight will not be encouraged to follow healthy behavior. Weight loss without healthy behavior is well documented to cause more harm than good. So even if you continue to think that weight loss should be the focus, you should be encouraging healthy behavior. We all know and there is absolutely no argument that you can not judge how much healthy behavior someone is doing based on weight alone. There are many skinny people who do very unhealthy behavior and many who are large who do very healthy behavior. No matter what weight you are and no matter what health you inherited, healthy behavior can improve health. We have absolutely no evidence to support benefits of weight loss long term, but have a lot of evidence to show benefits of healthy behavior with or without weight loss. Studies that show benefit with weight loss short term do not separate the benefit between weight loss and the benefit of the healthy behavior that caused the weight loss. The problem is that healthy behavior does not always lead to weight loss and even when it does lead to weight loss, it is less than 5-7% even in our large studies. When the focus is on weight loss, people get frustrated with and quit the healthy behavior thinking that it is not successful. When they understand the benefit of healthy behavior with a side effect of small amount of weight loss, they are more likely to continue the healthy behavior with or without weight loss. Even if there is weight loss, it usually turns out to be weight cycling which is very detrimental to health. A weight focus also leads to a lot of stigma and discrimination that have been well documented to make health worse.

So even if you do not believe someone can be fit and fat, encouraging healthy behavior for ALL people should be the recommendation from healthcare providers, not weight loss itself.

David Spero RN

May 19, 2017 at 1:13 pm

Great article! Thanks for sharing Dr. Linda Bacon’s comment that social reaction to weight causes more health problems than weight itself. For me, the glaring fallacy in many studies that promote weight loss is that the conclusion “Weight causes harm” is just assumed, despite much evidence that the effect of fatness varies with context. Extra weight can be protective (the “obesity paradox.”) In this Birmingham study, though the data are impressive, the conclusion – that heavy patients should be strongly encouraged to lose weight – is completely unsupported. No interventions exist that accomplish weight loss in more than a tenth of the population, so why should doctors tell people to do it? Is it to sell more weight loss drugs and surgeries?
I wrote about this ten years ago in my book Diabetes: Sugar-Coated Crisis, but much more evidence has come in since. Focus on weight loss is counterproductive for most patients.

Deb Burgard, PhD, FAED

May 19, 2017 at 2:33 pm

People seem to think that if fat people are not as healthy, they should try to lose weight. This is fundamentally flawed reasoning.

There is a higher risk for higher weight people of some events – and this is a correlation. There are many other factors impacting the health of higher weight people than just fat cells, and those factors actually cause ill health. We need to ask, when we find that higher-weight people’s health is not as robust, why do we not see this as a possible health disparity that is linked to weight stigma, less access to competent, bias-free (or any) healthcare, iatrogenic effects of weight cycling, and greater exposure to racism, violence, poverty, and all the other social determinants of health factors. Very few studies effectively control for the sdh or even SES.

The methodological problem with studies finding less robust health in higher weight people is is that they conclude that if you are a higher weight person, you should try to suppress your weight to that of always-been-thinner people. The assumption is that you will have the risk profile of those people. These data are always SILENT on this hypothesis, because you would have to follow higher weight people who try to lose weight (and keep it off for x years) and higher weight people who do not try to lose weight. But that doesn’t stop them from telling people to try to lose weight, EVEN THOUGH we have data that the majority of people will weight cycle and that itself might be a cause of some of the health problems that are more likely at higher weights.

We need to ask, why is it necessary for fat people to demonstrate an arbitrary level of health for the argument to be legitimate that we should be treated with respect and medical interventions that are proven to be helpful and not harmful?
Poodle Science! https://www.youtube.com/watch?v=H89QQfXtc-k

Deb Burgard, PhD, FAED

May 19, 2017 at 2:46 pm

One additional thought: In the article above you position the people who are traditional weight-loss vested interests at one end of a spectrum and people identified with Health at Every Size at the other as if there is some sort of middle ground that is not self-interested or vulnerable to confirmation bias. That itself is a problem in journalism where our limitations in access to the full knowledge of an issue makes us impose a kind of equivalency to the defenders of the status quo and the people critiquing it. You would not be getting closer to the truth if you imagined it as existing somewhere in the middle between people who believed the earth was flat and people who believed the earth is round. There is no way around the need for critical thinking skills, even for the people making arguments that you can place somewhere between two other positions. Sometimes those arguments are nuanced and careful; sometimes they are the incomplete efforts of people who have one foot in one paradigm and one foot in the other, which does not make them more correct.

Linda Bacon

May 19, 2017 at 2:54 pm

Important comments already posted so I’ll just focus on a smaller point. You are concerned that people may selectively highlight results that best align with their agenda (a valid and important consideration), and so you dismiss a social justice advocate (me) in favor of the director of a weight management clinic? I hope you see the irony here. Bariatric medicine is probably one of the highest paid medical specialties, and there’s no shortage of research challenging the efficacy of weight management goals. I don’t mean to call Freedhoff as an individual into question or suggest that he isn’t reputable, merely to suggest that you reconsider your litmus test. Your technique is not providing helpful challenge to the status quo.

    Kevin Lomangino

    May 21, 2017 at 9:18 am


    Thanks for your comments. I’ll let Michael respond more fully, but I’d like to address two things that struck me in your response and that of others commenting on this post:

    First, I don’t see anywhere that you were “dismissed.” You were quoted at considerable length and with a lead-in that said you “raise some important points.” That’s hardly a dismissal.

    Second, it’s Michael’s opinion, but I would guess that the reason Dr. Freedhoff’s comments carried more weight with him is that they reinforce the theme of the post, which is that the evidence is inadequate to draw sweeping conclusions in the “fat but fit” debate. Michael asked, “What’s wrong with admitting uncertainty and nuance? Both obesity and fitness exist along a spectrum.” Dr. Freedhoff conveyed the nuance that Michael was looking for and didn’t selectively argue for one end of the spectrum or the other.

    Kevin Lomangino
    Managing Editor

Meret Boxler

May 19, 2017 at 3:51 pm

It is high time that the “war on obesity”-rhetoric and the amount of weight-stigmatization in our society are having the very opposite effect: People are afraid and ashamed, they either obsess over food and exercise or they resign altogether. We have to recognize that there are many “fat” and healthy people out there, just as much as there are “thin” and unhealthy people out there. I personally look very “healthy”, but am, in fact, recovering from compulsive exercise and restrictive eating; habits that I adopted because I was so afraid of becoming fat. We have to do better with this!

Linda Bacon, PhD

May 19, 2017 at 4:18 pm

By the way, I wrote some guidelines for journalists covering weight concerns. You can find them here: http://tinyurl.com/mpxomjf. I also have provided some other odds and ends educational articles for journalists here: https://lindabacon.org/_resources/resources-for-journalists/.

Yoni Freedhoff

May 19, 2017 at 4:31 pm

For what it’s worth Linda, I earn significantly less money than the average family physician in Ontario. Perhaps you’re confusing me with a surgeon?

That said, I’m not complaining about my income, I left traditional family medicine because I love my job.

Ani Janzen

May 20, 2017 at 4:58 pm

I have to agree with Dr. Bacon. You dismiss her expertise and call out her bias but don’t do the same for Dr. Freedhoff, who also has bias.

Thank you, however, for covering this story with more nuance than I typically see in reporting in obesity research. I hope we as a society can continue to work towards examining the context and helping people understand the complexities of this kind of research.

rob oliver

May 22, 2017 at 6:59 am

People trying to dismiss or minimize clearly established sequella of obesity somehow manage to compartmentalize decades of outcomes data from bariatric surgery. When you can show reversal or resolution of multiple medical conditions with massive weight loss, you can pretty reasonably conclude causation rather then correlation of obesity with them in the first place. Trying to soft pedal this correlation and causation issue is noble, but overly downplays the body of evidence as a whole supporting that relationship.

The idea of “fat but fit” was always an implausible premise to people who treat the medical (htn, cholesterol, diabetes, sleep apnea, CAD) and physical (pain, OA, skin conditions, venous pathology) that result from obesity.

Michael Joyce

May 22, 2017 at 9:20 am

Thank you all for this discussion. It not only speaks to the emotional landscape of this topic, but also helps illuminate some of the “uncertainty and nuance” that is so often neglected in media coverage of this topic.

My motivation in writing this piece, and choosing the sources I did, was the public that walks past my office window each day. What must it be like for them to navigate conflicting headlines? To make sense of passionate professionals giving them seemingly opposite advice? Simply judging from the small number of comments here — and the lack of consensus on what “obesity” and “fitness” are or are not — you can see why readers might become confused.

That is why I wanted to introduce the notion of uncertainty into a topic so often presented to the public with vested certainty. I feel many of us would benefit from questioning that.

Juan Gérvas

May 22, 2017 at 9:34 am

Obesity is neither a medical problem, nor a disease. Obesity is a social problem, is a problem of inequity, is a problem of city design, is a problem of poverty. If you like to decrease “the obesity epidemy”, decrease social inequity, improve formal education, improve public transportation and parks, decrease the use of private transportation, decrease the price of Mediterranean food, increase time for cooking, decrease poverty.
As an example:
Social determinants vs. lifestyle in type 2 diabetes mellitus in Andalusia
(Spain): difficulty in making ends meet or obesity?
To assess the relationship between difficulty in making ends meet and obesity and type 2 diabetes mellitus in Andalusia.
We performed a cross-sectional survey based on the Andalusian Health Survey-2003. Measures of the prevalence and odds ratios (OR) of type 2 diabetes mellitus were calculated according to lifestyle variables, besity and type 2 diabetes mellitus according to self-perceived difficulties in making ends meet.
The age-adjusted OR of type 2 diabetes mellitus in obese individuals with respect to those with normal weight was 2.52 (95%CI: 1.63–3.88) in women and 2.13 (95%CI: 1.28–3.54) in men. A sedentary
lifestyle was not related to a significant risk of type 2 diabetes mellitus in either sex. For women with greater difficulties in making ends meet compared with women with less difficulty, the risk of being obese,
adjusted by age and physical exercise, was 3.03 (95%CI: 1.96–4.66), and the risk of having type 2 diabetes mellitus, adjusted by age, physical exercise and body mass index, was 2.55 (95%CI: 1.28–5.10). In men, none of the estimated OR was statistically significant.
For women, difficulties in making ends meet reflect a socio-economic context that contributes to a greater risk of obesity and type 2 diabetes mellitus. The gender and social inequalities identified could
help to broaden the current framework of risks for type 2 diabetes mellitus, which is excessively focused on individual behaviors. Self-perceived difficulties in making ends meet could be useful as a poverty indicator in the study of inequalities in health.
Un saludo juan gérvas MD, PhD @JuanGrvas

Glen Duncan

May 26, 2017 at 3:45 pm

There is a more fundamental issue here, and it has to do with what “fat but fit” means. This phrase can be traced back to Blair’s work with the Aerobics Center Longitudinal Study (ACLS). Specifically, Blair and colleagues demonstrated a host of health benefits (e.g., decreased all-cause and CVD specific mortality, decreased incidence of type 2 diabetes) in individuals who were categorized as obese by BMI standards (>= 30 kg/m2) but were in the highest tertile of cardiorespiratory fitness (CRF). Hence, “fit” in this context is specifically defined by treadmill assessment of CRF. The headline of the Ortega study — You can be fat but fit — is consistent with decades worth of data from Blair and colleagues’ analyses of ACLS data and from other cohorts reporting associations between high CRF and health outcomes independent of BMI, because they actually measured the appropriate predictor (CRF) in their study. On the other hand, the headline from The Telegraph (Fat but fit is a myth) is not consistent with the body of “fat but fit” literature because they did not measure “fitness” (specifically CRF), but rather a host of metabolic risk factors. So, more simply, you can’t really talk about “fat but fit” when you don’t measure CRF, and if you do, then you are not really talking about the “fat but fit” concept at all.