Great article: “‘Fit but Fat’? the Controversy Continues”

It didn’t matter whether obese people were free from diabetes, high blood pressure or high cholesterol, a condition sometimes referred to as “metabolically healthy obesity.” As long as they were obese, they were at modestly higher risk for having a stroke, at nearly 50 percent greater risk of coronary heart disease and had nearly double the risk of developing heart failure than people who were not overweight and in similar metabolic health.

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“The bottom line is that metabolically healthy obesity doesn’t exist,” said Dr. Rishi Caleyachetty …“Obesity is not a benign condition.”

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But critics say the analysis, based on the electronic health records of 3.5 million British patients who were followed from 1995 to 2015, leaves a lot out. Doctors’ records don’t typically capture lifestyle habits, so the study fails to account for the wide-ranging effects of diet. They classify weight status by using body mass index, a formula based on height and weight that doesn’t distinguish muscle from fat. Most important, critics say, such analyses don’t take fitness level or physical activity into account.

Other studies have found a higher rate of heart failure among obese individuals, said Dr. Carl Lavie, the medical director of cardiac rehabilitation and preventive cardiology at the John Ochsner Heart and Vascular Institute in New Orleans. But when it comes to coronary heart disease outcomes, studies that take both weight and physical fitness into account have concluded that “fitness is more important than fatness,” at least for the moderately obese, he said.

“For the very large number of people who are overweight or mildly obese, I don’t think it’s doomsday if they can keep themselves out of the low fitness level,” Dr. Lavie said.

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“I do think that’s a better message than telling people, ‘You better not gain weight,’” Dr. Lavie said. “People aren’t trying to gain weight. They’re not trying to get to be obese. A better message would be to tell people that if they get themselves to be more physically active, they can improve their prognosis, despite carrying a few extra pounds. That’s a better message, and a more obtainable message.”

But Jennifer W. Bea, an assistant professor of medicine at the University of Arizona Cancer Center who was a co-author of an editorial accompanying the new study, said, “we haven’t heard the whole story yet” and questioned whether someone can be obese but “metabolically healthy.”

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That doesn’t mean that weight trumps all. Indeed, the study found that individuals who were considered to be of normal weight but who had a single risk factor such as diabetes, high blood pressure or high cholesterol were actually at greater risk for coronary heart disease than the healthy obese people.

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One of the messages of this new paper “is that metabolic health is important regardless of your weight,” Dr. Bradshaw said.