The Conjurer

Sorting Out the Shell Game of Healthy Obesity

The pursuit of healthy obesity is something of a holy quest or a shell game. The game goes on with some players insisting that obesity is not real. Picking through troves of data they find exceptions to the links between a high BMI and disease risks. “Ah ha! These subjects have no health issues, just a high BMI. Obesity is nonsense.” Rounding out this game we have researchers pursuing evidence that those exceptions will follow the rule over time. Ill health will come their way.

Diabetologia published a new study last week to prove the latter point.

A Cohort of 381,363 Subjects

Ziyi Zhou and colleagues studied a large cohort of participants in the UK Biobank. Their study was prospective, with a median follow-up of 11.2 years. In their cohort, 35,103 started with a profile of metabolically healthy obesity (MHO). They had a BMI over 30, but no sign of any of six disorders linked to obesity. Another 208,625 had BMI between 18.5 and 29.9 with none of those problems (MHN). In that same weight range, another 79,259 had one or more of problems (MUN). Finally, 59,376 had both a high BMI and one or more of the obesity-linked disorders (MUO).

Clearly, they had plenty of subjects with healthy obesity at the start. But it didn’t last. Within three to five years more than a third of them developed one or more of the problems linked to obesity. Compared to the subjects without obesity or any of the conditions linked to it at baseline, the folks with “healthy obesity” were four times more likely to develop diabetes, 76 percent more likely to develop heart failure, and 22 percent more likely to die.

So healthy obesity is a risky proposition.

A Silly Debate

Frankly, the debate about healthy obesity is tiresome. All of us have health problems sooner or later. Obesity clearly causes problems, especially over time. But assessing a person’s health doesn’t boil down to a single number – like BMI. Judging health based on appearance is even more foolhardy.

So we have little patience with people who argue that BMI is a scam. Nor do we have patience with folks who argue that people with obesity are “irresponsible,” and trying to “sugarcoat” a dire threat to health.

All this energy should go toward empowering people to make their own choices and improving the access to care with a full range of options. Debates about healthy obesity are silly distractions.

Click here for the study by Zhou et al and here for further reporting. For a recent review of this subject, click here.

The Conjurer, painting by Hieronymus Bosch / Wikipedia

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June 14, 2021

4 Responses to “Sorting Out the Shell Game of Healthy Obesity”

  1. June 14, 2021 at 10:36 am, John DiTraglia said:

    BMI is a scam for individual patients.
    But that’s a different from the whole healthy obesity thing

    • June 14, 2021 at 11:39 am, Ted said:

      I agree that “scam” is an effective word for grabbing attention and BMI has limited value for individual patients. BMI is indeed often misused.

  2. June 14, 2021 at 12:10 pm, Justin said:

    I’m not a HAES practitioner, but my understanding of the argument from that perspective is that studies like this do not account for the adverse effects of weight bias and stigma. Compared with a normal-weight individual, a person with obesity will:

    1) receive worse medical care or be discouraged from seeing doctors altogether
    2) face discrimination in the workplace and their social life that negatively impacts their health
    3) be discouraged from eating healthy and exercising by negative stereotypes of people with obesity

    If a person with obesity had the same medical care, lack of discrimination, and encouragement to exercise and eat healthy as a normal weight person, their health outcomes would not be statistically different.

    Is this a fair summary of the HAES perspective? If so, what are your thoughts on this?

    • June 14, 2021 at 12:21 pm, Ted said:

      Justin, I cannot speak for the HAES perspective, but all three of the points you made are indeed accurate. Stigma and bias compound the harm of obesity, but they do not explain the baseine harm that obesity causes to health, all by itself.