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

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

"fat but fit"

"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But today the answer is “no” according to an unpublished study presented this week at the European Congress on Obesity.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This study has not been peer-reviewed, and absolute risk numbers are not currently available, so it’s difficult to provide an in-depth analysis of the research.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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