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The Obesity Paradox:
When Thinner Means Sicker and Heavier Means Healthier
Dr Carl Lavie
For anyone who is worried about their weight, it has been a discouraging few weeks. Inch by inch and pound by pound, we have been told, we are losing the battle of the bulge and facing all kinds of health problems. First there was a 188-country study by William Flew of the University of Washington, which said that British people are among the fattest in western Europe with nearly 70 per cent of adult men and women termed overweight and clinically obese. Then it was suggested that fat people should be marched off to slimming clubs in order to save the NHS millions of pounds in treating obesity-related conditions. And to pile on the misery, a Harley Street clinic offering fat-freezing treatments claimed that more than half of British women hate their bodies so much that they’d rather stay at home than go on holiday.
All of this makes Dr Carl Lavie's new book The Obesity Paradox: When Thinner Means Sicker and Heavier Means Healthier very interesting. We have been duped, he says, into thinking that excess body fat is bad no matter what and that it must be burnt away at all costs. Fatness is misunderstood and wrongly portrayed because it can protect us in many ways and help us live longer. Many people who struggle with their weight might be closer to the model of ideal health than they think. 'If you have some excess weight on you, its not doomsday,' says the American-born expert on obesity and the heart. 'You can still be healthy carrying 20, 30, 40 or even 50 pounds, particularly if you maintain a certain level of fitness.'
As a society, Dr Lavie claims, we demonise fat to our own detriment. Excess fat can certainly wreak havoc with our metabolism, cause dangerous health conditions such as diabetes and heart disease and increase our risk of dying young. 'But much in the way that a glass of wine a day has been proven to have health benefits and four or five glasses puts our health at risk, body fat in the right amount can be exactly what we need to live long and enjoy a high quality of life,' he says. 'I want to make it clear that I'm not promoting obesity and I'm certainly not suggesting that anyone should try to gain weight and start stuffing themselves with doughnuts - but fat is not always the devil.”
In his book, the cardiologist outlines the obesity paradox that he came across more than a decade ago while treating patients for heart failure. People who were overweight or obese were living longer than thinner people with the same heart problems. 'It didn't make sense,' he recalls. 'If obesity is bad for heart health how can it be beneficial in surviving heart disease?'
He thought he and his team had made a mistake but they checked their findings and found what Dr Lavie calls 'the same big, fat conundrum'. The individuals with certain chronic diseases who lived the longest were the fattest. The research, he says, caused scepticism when it was published, with one reviewer at a major medical journal suggesting that there was a fatal flaw in the data. Since then hundreds of other scientific papers have been published confirming the same fascinating incongruity.
He cites a study by the epidemiologist Katherine Flegal, who analysed data from 97 studies covering 2.9 million people and 270,000 deaths. She found that people at either end of the weight spectrum - those who were underweight or morbidly obese - have the biggest risk of death.
Using BMI, or body mass index, classifications, the measure of body fat based on weight and height, the best survival rate was in the 25-30 BMI range, which is classified as overweight, with a 6 per cent lower mortality rate than the normal BMI group of 18-25. The mildly obese, who have a BMI of 30 to 35, had a 5 per cent lower mortality rate than the normal-weight BMI.
'In the overweight and mildly obese there's very little data to prove that dropping extra pounds will help you live longer,' Dr Lavie adds. 'Thin people who are low in muscle mass and cardio fitness are the ones who do worse than almost anyone else.'
The benefits of the obesity paradox also extend to patients with other chronic conditions such as arthritis, kidney disease, diabetes, some cancers and HIV, it has been found.
As we get older, therefore, having some fat is a survival advantage and there appears to be evolutionary grounds for being a little chubby. Although doctors do not know all the reasons for the obesity paradox, Dr Lavie says, it has been suggested that overweight people, who have greater reserves of metabolic energy in their fat cells, may have more energy to fight chronic diseases. A thin person may have less of a cushion to fall back on.
Where fat is stored on the body is crucial, adds the author. Abdominal fat is associated with greater risks for diseases while fat stored on bottoms, hips, thighs or upper arms does not carry the same risk factors, he says. 'The worst fat is visceral fat that accumulates around the organs and is associated with more adverse health consequences,' he says.
While BMIs are a benchmark for classifying weight categories, they should not be used strictly to define who is healthy or not healthy, he believes. 'BMIs are a crude way of determining one's risk for obesity-related illnesses and disorders but they're not a crystal ball,' Dr Lavie says. 'They can't predict who will die prematurely and who will live long and thrive. The fitter you are, the less your weight or BMI matters.'
Millions of people who are categorised as being overweight or mildly obese by BMI standards might achieve optimal health by staying exactly as they are in terms of pounds and stones, he suggests. 'You don't have to lose weight and you may be better sustaining a BMI of between 25 and 30 or even slightly above that,' he says.
Dr Lavie disparages what he calls the anti-fat, pro-exercise industry and says that while fat is being demonised, endurance sports and rigorous exercise are being unjustly glorified. Too much exercise can actually shorten our life span.
'The real killer today isn't necessarily obesity,' he notes in one chapter. 'What's much more damaging to our health and wellbeing is not just the immense pressure we put on ourselves to lose weight and follow unrealistic diets but the metabolic harm we inflict on our bodies long before obesity becomes established.
'This metabolic injury often results from a lethal combination of chronic blood sugar imbalances and inactivity - both of which have absolutely nothing to do with weight per se - and can occur in someone who looks slender and who seemingly epitomises health on the outside.'
He gives this example. Picture three people - the first is a person who is unmistakably obese from a visual standpoint and who cannot walk fast or far without feeling bad physically; the second person is outwardly skinny with little or no muscular definition; the third individual is unquestionably overweight but can breeze through an aerobics class and hold a plank position for minutes in a yoga class. 'The skinny girl who gets winded climbing stairs or lifting a heavy object is no match for the person carrying an extra 10 to 50 pounds who is fit and enjoys sports,' Dr Lavie says. 'Having a little more padding and athleticism is a powerful body type to possess if you're trying to beat the odds of getting diagnosed with an illness that will shorten your life.'
He explains further: 'Over the last five decades there's been a massive decline in physical activity and I believe that's really the fundamental cause of our weight gain and the obesity epidemic, rather than calorific overload.
'But just as fat is not always bad, exercise is not always good. There have been many studies that show that the benefits of running can come to a screeching halt later in life. If you draw the blood of a person who has just run 26.2 miles in a marathon, about a third of them will have released the same enzyme that's released in heart failure. If you do scans of their heart, about a third of them have dilation of the heart, particularly the right side of the heart. These abnormalities go away within days or weeks but it shows that this extreme level of exercise has some toxicity.
'So if somebody does a marathon and never does it again, even if they get the abnormality they'll recover in a few days, but people who do this over and over again are risking chronic damage.'
A runner himself, he says the key is to run at a comfortable speed and not too far. 'I want people to know that you don't have to do lots of exercise because that can be off-putting to many people,' he adds. 'If you are exercising for your health, you probably get maximum benefits after cycling, running or working out in the first 35 or 40 minutes. Everything you do over that, you may be burning calories, but you're not getting health benefits.' Even 15 minutes of exercise four or five times a week will lead to major health benefits.
Dr Lavie hopes the conversation about fat in the future shifts to one that is less weight-centric. 'We live in a society that leads us to believe that the thinner we are, the healthier we are and that a diagnosis of obesity is a nail in the proverbial coffin. We have to loosen the reins on our obsession with the bathroom scales and not beat ourselves up while trying to get down to what we think is an ideal weight. We need to change the context of the conversation around our obesity crisis to our physical inactivity crisis.'
If you have to choose, he says, between being fit or fat, 'Go for fit even if it means being heavier.'
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