Recently Lori, a client of mine, called me angry, upset and discouraged. She had just returned from her yearly physical, which she had been eagerly anticipating. Though she hadn't reached her weight-loss goal, Lori had made many lifestyle changes to promote good health. She had begun exercising on a regular basis, made some subtle shifts in her dietary habits that made her feel better, and had even begun a weekly yoga/meditation class to manage stress.
The results of the physical demonstrated her efforts had been paying off. Her blood pressure was in the normal level for the first time in years, her blood sugars had dropped, and her cholesterol profile had greatly improved. However, once the exam was complete and she was sitting with her physician in his office, rather than commenting on the improvements, he stated, "Lori, I was really hoping you would have dropped a lot more weight since our last visit. If you don't get serious about taking off the extra pounds, your risk of early disease will continue. Have you tried dieting?"
There is an overwhelming presumption in our country that if an individual is overweight they are also unhealthy. Research clearly supports that being overweight is a major health risk factor, contributing to an increase in cardiovascular disease, diabetes, stroke, and many types of cancer. So can we assume that if you are hauling around extra pounds that classify you as overweight or obese, it will destine you to a future filled with illness and disease?
An intense debate has emerged in the last few years amongst obesity researchers, asking the question, "Can people be overweight but still be healthy?" Is the number on the scale the only thing that counts, or should we take other factors into consideration? Scientists are now dueling over the relative importance of "fatness vs. fitness" when it comes to determining the health of an overweight individual.
A small but vocal group of researchers have been challenging conventional wisdom. They argue that not only is it possible to be both fat and fit, but fitness is actually a more significant measure of health than body weight. The first major fatness versus fitness study was conducted by researchers at the Cooper Institute, a nonprofit fitness organization in Dallas. In a study of 22,000 men ages 30–83, the researchers measured subjects' body composition (the proportion of fat to muscle) and put them through treadmill tests. They concluded if you are fit, being overweight doesn't increase mortality risk.
Steven N. Blair, who heads the Cooper Institute, defends the role of fitness as a major determinant of health regardless of one's weight. "We've studied this from many perspectives in women and in men and we get the same answer: It's not the obesity—it's the fitness," Blair said. "Fitness can substantially reduce, if not eliminate, the high risk of being obese."
Results of studies done by Mary Fran Sowers and Judith Wylie, obesity researchers at the University of Michigan, showed that thin, unfit people can develop heart-related problems that fat but fit people often do not. Kelly Brownell, Director of the Yale Center for Eating and Weight Disorders, concluded in a 2003 study that heavy people that are fit have a lower risk of heart disease than thin people who are unfit.
However, others are concerned that sending this message will be misunderstood, giving overweight and obese individuals the message that weight doesn't matter; an excuse to accept the extra pounds as unimportant and not to be worried about diet as long as they exercise.
"Being overweight has a clear association with important health problems, and even modest weight loss has important health benefits," said Walter Willett, an expert on nutrition and health at the Harvard School of Public Health. "To tell people it doesn't matter is really misleading. It does make a difference. It makes a huge difference."
The Nurses' Health Study, which since 1976, has been looking at the lifestyle habits and mortality rates of approximately 238,000 nurses, found that being a little active and a little fat wasn't such a bad combination. But physical activity didn't completely eliminate the risks that were associated with being overweight or obese. In fact, when the nurses were grouped by how active they were, the heavier nurses were more likely to have died than the lighter ones at every activity level.
Despite the differences in these studies, they all suggest that physical activity will offset some of the effects of excess weight, if it's just a few extra pounds. No one is debating that there is a marked difference in disease rates in the obese vs. the overweight. When assessing overall health risk, we need to look at many factors, not just the number on the scale.
There are many ways to assess overall health and mortality risk, and it's time to look at all these factors together before putting a stamp of "healthy" or "unhealthy" on anyone. The most common measure used to determine if a person's weight puts them at a health risk is the BMI, which is a measurement of the ratio of weight to height. Healthy individuals fall within a BMI range of 18.5-24.9; overweight between 25-29.9; and obese above 30. However, the problem with the BMI is that it does not take into account body composition. Since muscle is more dense than fat is, a person with a high percentage of lean muscle mass may end up in the overweight category, despite being lean and fit.
Although the BMI has value, it should be looked at along with other factors. Among healthy weight individuals, people with larger waists and pot bellies have a greater incidence of increased blood pressure and increased cholesterol. Women with a waist circumference over 35, and men over 40, have an increased risk of obesity related diseases.
Metabolic syndrome, which is a disorder of growing proportion in this country, is marked with a greater risk for coronary artery disease and diabetes. According to the Mayo Clinic, it is diagnosed when an individual has at least three of the following symptoms:
CRP test, a simple blood test that measures C-reactive protein, is also a strong indicator of heart disease risk. And of course, a health profile would be incomplete without looking at other risk factors such as cigarette smoking and family history.
With all of this information, what does it mean for individuals like Lori who overweight, but active, and not displaying many of the measurements of increased health risk? Should the emphasis be on taking the pounds off, improving fitness, or both?
The healthcare industry may be missing the mark and doing a disservice to our overweight clients and patients with the typical approach of focusing so heavily on nutritional changes. We've looked at exercise as a modality to help take the extra pounds off, but the main emphasis has been on diet. If the goal is to improve the overall health profile of the individual, could we do this by looking at fitness first?
There is no debate that taking off excess pounds improves health. It is a well known documented fact that losing as little as 5% of overall body weight results in significant improvement in the markers that determine health. And it is true that manipulating dietary intake results in faster weight loss than exercise alone. We certainly know that the best approach is dietary changes and exercise together. But this total overhaul of lifestyle can be overwhelming and extremely difficult for people to adopt. It takes patience, perseverance, support and education. Not everyone is ready to embark on all of these changes at once.
For most, the first attack on excess pounds is "going on a diet." Unfortunately, this usually brings up feelings of deprivation, boredom, and a serious lack of confidence in permanent success. "Dieters" often focus on everything they no longer can eat. Too many end up feeling badly about themselves when they have lapses in willpower and are unable to completely eliminate "bad foods." Rather than dieting, a lifestyle approach that includes dietary changes is essential.
Similarly, if the main reason exercise is encouraged is to help with weight loss, you may be sorely disappointed. But when you view exercise as a means to improve health and well-being, rather than something you have to do in order to lose weight, you can measure success from a different parameter. Once adopted, exercise often leads to marked improvements in emotional outlook, physical strength, and self-esteem—no matter what your size. Ironically, when an individual embarks on an exercise program, they often report feeling more in control of their dietary habits. They suddenly want to eat healthier to fuel the new active lifestyle.
So apart from any weight-loss goals you've set for yourself, it's important to exercise regularly. However, it's salient to realize exercise isn't going to magically erase all the health risks of being heavy--especially if you're doing a minimal amount of exercise. Inconsistent physical activity isn't enough to keep you healthy at any size. Neither will doing just the minimum requirments (or less). Regular exercise that includes cardiovascular (aerobic), flexibility and strength components and adds up to at least 150 minutes per week is essential. To find out just how fit you are, try these four fitness tests you can do at home to assess your current fitness level. Weight has no factor on these results, but if your fitness scores are poor or below average, that would be an indication that you need to step it up in the exercise department if you hope to offset the risks associated with being overweight.
Rather than going on a diet, eat for good health and energy. By de-emphasizing the number on the scale, and looking at all the measures of health risk, you'll feel empowered to be proactive about their health. Ironically, when this healthy lifestyle pattern becomes habitual, excess pounds often disappear as a result.
So what was my advice to Lori? Continue to exercise, eat for good health and vitality, pay attention to all the health parameters—not just the number on the scale—and lastly, find a new, more compassionate and knowledgeable physician!
Is It Okay to be Fat if You're Fit?, The Harvard Medical School Family Health Guide.
Do You Know the Health Risks of Being Overweight?, Weight-control Information Network.
Myth: You Can't Be Overweight and Healthy, An Epidemic of Obesity Myths.
Metabolic Syndrome, Mayo Clinic.
This article has been reviewed and approved by SparkPeople's nutrition expert, Becky Hand, M.S., Licensed and Registered Dietitian, and SparkPeople's fitness expert, Nicole Nichols, B.S., Certified Personal Trainer.