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Obesity, Health, and Metabolic Fitness
by Glenn
Gaesser, Ph.D .
Associate Professor of Exercise Physiology, Univ. of Virginia
Fat. F-a-t. Perhaps no other
word in our language is despised as much, nor focused on so intensely.
Americans are obsessed about fat--body fat--and how to get rid of it.
We have been conditioned to view health and fitness in strictly black
(fat) and white (fit) terms: A “fat” body cannot possibly
be fit and healthy. This fat-versus-fit dichotomy, made popular in the
1970s with the publication of fitness guru Covert Bailey’s “Fit
or Fat?” (5), has become the mantra of many a fitness and health
professional. You don’t have to read any more than the title to
grasp the fundamental message of this perennial best-selling fitness
bible: A person is either fit, or fat--but not both.
The implications of this myopic fitness
philosophy are obvious: The road to a fitter and healthier body is a
very narrow one indeed. In order for a fat person to become fit and
healthy, that person must lose weight and become lean. This of course
implies that “lean” is inherently good and “fat”
is inherently bad. Not only is this lipophobic paradigm overly simplistic,
it does not stand up against a substantial amount of medical and scientific
evidence.
Obesity-Heart Disease Link
Challenged
Take coronary artery disease (atherosclerosis), for example--the number
one killer in the United States. Conventional wisdom tells us that obesity
itself is a major cause of clogged arteries--the rationale being that
more fat on the body equals more fat in the blood stream equals more
fat build-up in the arteries. However, most of the studies that have
looked at the relationship between body weight (or body fat) and atherosclerosis--via
coronary angiography or by direct examination of artery disease at autopsy--find
that fat people are no more likely to have clogged arteries than thin
people (4, 11, 27). In some instances results entirely opposite to conventional
wisdom are observed. For example, when researchers at the University
of Tennessee (4) evaluated coronary angiograms of more than 4,500 men
and women, they found that the risk of having a clogged artery actually
decreased as body weight increased. In other words, it was the fat men
and women who had the cleanest arteries. Although this finding is exceptional,
the preponderance of angiography studies of this nature do undermine
the notion that obesity inevitably results in clogged arteries.
Furthermore, the findings
from angiography studies are consistent with countless autopsy studies--dating
back to the middle of this century--of the link between body weight
(or body fat) and arterial disease. The large-scale International Atherosclerosis
Project (27), for example, conducted in the late 1950s and early 1960s,
concluded after analyzing 23,000 sets of coronary arteries--obtained
at autopsy--that no measure of body weight or body fat was related to
the degree of coronary vessel disease. The obesity-heart disease link
is just not well supported by the scientific and medical literature.
Thinner is Not Necessarily
Healthier
The same could be said for the notion that thin people are healthiest
and can expect to live longer than everybody else. Contrary to the prevailing
medical mind-set, the “thin-live-longest” studies frequently
cited by the more vocal of the anti-fat crusaders (26) are far outnumbered
by studies demonstrating that body weight--aside from the extremes--is
not really all that strong a predictor of death rates, or overall health
for that matter (10, 11, 15, 29, 37, 38, 41). A 1996 publication by
researchers at the National Center for Health Statistics and Cornell
University illustrates perfectly (41). After analyzing the results from
dozens of published reports on the impact of body weight on death rates,
encompassing more than 350,000 men and nearly 250,000 women, the researchers
found that moderate obesity (no more than about 50 pounds in excess
of the so-called ideal body weight) increased the risk of premature
death only slightly in men, and not at all in women, during follow-up
periods lasting up to 30 years. In fact, the researchers found that
thin men--even within the range recommended by the current U.S. government
guidelines--had a risk of premature death equal to that of men who were
extremely overweight. The researchers warned in their summary comments
that “attention to the health risks of underweight is needed,
and body weight recommendations for optimum longevity need to be considered
in light of these risks.”
Ever since the Metropolitan Life Insurance
Company introduced its tables of “ideal” weights in 1942
(21, 22)--the company called them “desirable” weights in
1959 (30), and did away altogether with the terms “ideal”
and “desirable” in 1983 (31)--we have been operating under
the weight loss industry-reinforced assumption that weighing more than
what the height/weight charts say we should weigh is a sure sign of
poor health and greatly increases risk of premature death. However,
the majority of body weight-mortality investigations have shown that
weighing 20 pounds, or 30 pounds, or even 50 pounds in excess of the
height-weight chart recommendations is associated with little, if any,
increased risk of an early check-out. For example, the current U.S.
government guidelines indicate that a 5’4” woman should
weigh between 111 pounds and 146 pounds, and a 5’10” man
should weigh between 132 pounds and 174 pounds. According to the 1996
study previously mentioned (41), a 5’4” woman and 5’10”
man could weigh close to 200 pounds before their risk of premature death
goes up appreciably (excess body weight seems to be riskier in men than
in women). This suggests that there are a great many “overweight”
Americans--especially women--who are agonizing unnecessarily about those
numbers on the bathroom scale.
So if being a little fatter than average
might not be so bad, and being thin (at least for men) might not be
so good, what does this say about body weight and health? If the concept
of an ideal weight is little more than statistical fiction, should we
just chuck the bathroom scale, kick back on the sofa with a bag of chips
in one hand and the remote control in the other, and nestle into total
couch-potato-hood? Of course not (although chucking the bathroom scale
is probably a good idea). It’s just that body weight, and even
body fat for that matter, do not tell us nearly as much about our health
as lifestyle factors, such as exercise and the foods we eat. Consider
the following scenario.
Randomly select a few hundred men
and women (matched for age and smoking habits) and divide them into
two groups based on body fat: lean and fat. Next take each person’s
blood pressure, draw some blood and determine each person’s serum
lipid levels, and have each person perform a glucose tolerance test
(to get an idea of each person’s insulin sensitivity). I guarantee
that you will find, on average, higher blood pressures, unhealthier
blood lipid profiles, and poorer glucose tolerance/insulin sensitivity
in the group of fat men and women.
Does this mean that the higher body
fat levels caused the health problems? No. It just means that you are
more likely to find these kinds of metabolic disorders in fat men and
women. But associations do not prove cause-effect. Just because you
are more likely to observe high blood pressure, elevated blood lipids
and glucose intolerance in fat persons does not prove that body fat
is the cause of these health problems, nor does it mean that a fat person
has to become lean in order to resolve these health problems. The proof
of this assertion is quite straightforward. Get these fat men and women
to start an exercise program and eat healthier foods--and see how they
do. Numerous research studies have done just that. A few examples are
described below.
Weight-Related Health Problems Resolved
Independently of Weight Loss
Results from the Dietary Approaches to Stop Hypertension (DASH) clinical
trial, published in the New England Journal of Medicine in 1997 (3),
proved that blood pressures can be effectively lowered by simple changes
in diet, without losing weight. Among 133 men and women with high blood
pressure, just eating more fruits and vegetables, and consuming low-fat
dairy foods with reduced saturated fat, was sufficient to reduce systolic
blood pressure by an average of 11.4 mmHg, and diastolic blood pressure
by an average of 5.5 mmHg, within two weeks after changing their diets.
The reductions in blood pressures were comparable to those observed
with initiation of pharmacotherapy--but without the side-effects which
sometimes accompany antihypertensive medications. Most significantly,
the blood pressure reductions were achieved without any weight loss.
To prove that it’s fat in the
diet--and not fat on the body--that is the primary cause of blood lipid
abnormalities, such as high cholesterol, researchers at the National
Public Health Institute in Helsinki, Finland, placed 54 middle-aged
men and women on a low-fat (~24% of total calories) diet for six weeks
(16). Total cholesterol dropped from 263 mg/dl to 201 mg/dl in the men,
and from 239 mg/dl to 188 mg/dl in the women. Body weight did decrease
modestly, by about 2 pounds. The subjects were then switched back to
their usual diet (~39% of total calories from fat) for six weeks. Total
cholesterol levels returned to their original levels--despite absolutely
no change in body weight--requiring the researchers to conclude that
the fat content of the diet, not weight change, was responsible for
the changes in cholesterol levels.
Combined exercise and nutrition programs
have provided even more compelling results, as illustrated by the changes
observed in the more than 4,500 men and women who have completed a 3-week
stay at the Pritikin Longevity Center in Santa Monica, California (6-9).
The Pritikin program consists of eating a low-fat, high-complex starch,
high-fiber diet (with no emphasis on rapid weight loss) and daily moderate-to-vigorous
aerobic exercise. Within three weeks the average cholesterol level dropped
from about 234 mg/dl to about 180 mg/dl; low-density lipoprotein cholesterol
(the unhealthy kind) decreased from around 151 mg/dl to 116 mg/dl; and
triglycerides were reduced by one-third (from 200 mg/dl down to 135
mg/dl) (6).
Pritikin program participants lowered
their blood pressures by an average of 5-10%, and more than one-third
of the men and women with high blood pressure were able to discontinue
antihypertensive medications (7, 8). Those with type II (adult onset)
diabetes also experienced tremendous improvements: 39% of those taking
insulin and 71% of those on oral hypoglycemic agents were able to discontinue
medication entirely (7, 8).
All of these improvements in health
profile while on the Pritikin program were observed within three weeks.
Although participants do lose weight (typically about 7-11 pounds, or
about 5% of their initial body weight), statistical analysis indicates
that less than 5% of the improvements in health can be attributed to
changes in body weight. Most important to the question at hand is the
fact that most men and women who enter the program obese leave the program
obese--but with one major difference: They no longer have the health
problems thought to be caused by excess body fat.
Just as risk factors for heart disease
can be affected by changes in lifestyle independent of changes in body
weight, the actual disease itself can be influenced by lifestyle modification--without
changes in body weight. The results of the Cholesterol Lowering Atherosclerosis
Study illustrate (14). Eighty-two moderately overweight middle-aged
men with heart disease were placed in a two-year intervention program
designed to reduce consumption of dietary fat. Men who reduced their
fat intake to 27.5% of total calories showed no new fatty deposits in
their coronary vessels (as determined by examination of coronary angiograms
taken before and after the two-year study). On the other hand, men who
failed to make significant changes in fat intake (34% of total calories
from fat) didn’t do as well--they all showed some evidence of
new lesions in their coronary vessels. Because neither group lost any
weight during the two-year study, the researchers concluded, in a 1990
article published in the Journal of the American Medical Association,
that “the appearance of new [coronary artery] lesions can be influenced
without weight change by voluntary selection of acceptable foods.”
Health and Longevity: Being
Fit More Important Than Being Thin
All this evidence suggests
that as far as one’s health is concerned, lifestyle is far more
important than body weight. This goes for longevity prospects as well,
as the ongoing--since 1970--Aerobics Center Longitudinal Study at the
Cooper Institute for Aerobics Research, in Dallas, Texas, demonstrates
(10, 13). Data on more than 32,000 men and women indicate that the fittest
men and women have the lowest death rates--regardless of what they weigh.
In other words, a heavier-than-average person who is physically fit
has a better chance of living a long life than does a thin couch potato.
Furthermore, a separate analysis of nearly 10,000 of the men in this
study who performed at least two exercise stress tests separated by
an average of about 5 years (thereby allowing the researchers to evaluate
the impact of changes in physical fitness on subsequent death rates),
revealed that improving physical fitness level reduced death rates during
the 5+ years of follow-up. Men who were initially classified as unfit
(defined as being in the bottom 20% of fitness levels for a given age),
but who--via increasing physical activity--improved their fitness level
by the second fitness examination, reduced their mortality rate during
the subsequent 5+ years of follow-up by 44%. Most significant in terms
of the weight debate was the fact that the improved longevity prospects
were not at all dependent upon weight loss. Results from the ongoing
Harvard Alumni Study (33) provide similar results: Sedentary Harvard
alums who increased their level of physical activity experienced a 23%
reduction in all-cause mortality rate. Because alums who lost weight
were no better off healthwise than those who did not lose weight, the
reduction in all-cause death rate observed in the more physically active
men was in no way attributable to slimming down.
Health Hazards of Obesity
Exaggerated
Despite all this evidence
suggesting that lifestyle is far more important than body weight in
terms of health, and that it might be more prudent to focus on getting
people fit and healthy rather than trying to make them thin, the weight
loss industry still barrels along like a runaway freight train. Aside
from the cultural obsession with slimness, health professionals have
done much to sanctify this quest for a lean body--primarily by fueling
a medical rationale for fat phobia: Obesity is a major killer. The most
blatant--but unjustified--example of this scare tactic is the widely
publicized claim that obesity kills 300,000 Americans every year. Former
U.S. surgeon general C. Everett Koop asserted as much when he launched
his Shape Up America! campaign in 1994. Since then, this figure has
taken on a life of its own, appearing in scientific and medical journals
(1) and mentioned repeatedly in the media--each time reminding us of
the “fact” that obesity is the second leading cause of preventable
death in America.
The problem, however, is that there
is absolutely no way to prove this assertion. In fact, the most frequently
cited source of this statistic, a 1993 article in the Journal of the
American Medical Association (28), shows just how misinterpreted this
statistic actually is. The article, titled “Actual Causes of Death
in the Untied States,” attributes the 300,000 deaths per year
to “diet/activity patterns”--not to obesity. Obesity is
a physical trait; diet and physical activity are behaviors. To equate
them not only is unjustified, it is absurd. While poor diet and lack
of physical activity may lead to obesity, the truth of the matter is
that the studies used to generate the 300,000 figure looked at the health
impact of poor diet and sedentary lifestyle across the entire weight
spectrum, not just among fat persons. [There are a great many less-than-healthy
couch potatoes with poor dietary and exercise habits who--via luck of
the genes--will never be fat.]
Emphasis on Weight Loss Misdirected
and Hazardous
I am not advocating that we
should be complacent about obesity. It’s just that continued focus
on weight loss seems counterproductive, and may be quite hazardous to
the health of those who continually battle their weight. Each year roughly
70 million Americans--nearly one-fourth of the entire U.S. population--attempt
to lose weight, shelling out between $30 billion and $50 billion in
the process (32). But despite our perennial efforts to shed pounds,
our waistlines are getting bigger, not smaller. It seems what ever we
lose, we gain back--and then some. Not only can this be damaging to
our self-esteem and mental health, chronic fluctuations in body weight
may also do physical harm (12, 17, 25). In fact, most of the epidemiological
studies on weight loss alone show that weight loss increases risk for
premature death, primarily from heart disease (2, 12, 20, 25, 34). This
obviously represents a paradox, because weight loss is thought to improve
cardiovascular disease risk factors. But this is not always the case.
One of the most popular weight reducing
strategies of the past 35 years, the low-carbohydrate diet, actually
raises cholesterol levels (especially low-density lipoprotein cholesterol)
and reduces high-density lipoprotein cholesterol (the heart-healthy
kind) despite weight loss (24, 36). This suggests that going on a low-carbohydrate
diet may actually increase risk of atherosclerosis.
Another possible explanation for the
paradoxical finding of weight loss being associated with increased risk
of dying from heart disease is the recent evidence which shows that
dieting depletes body reserves of heart-healthy omega-3 fatty acids,
thus raising the possibility that weight loss via calorie restriction
may actually make the body more vulnerable to atherosclerosis (39).
The researchers who reported these findings warned that “a subtle
but chronic risk state could be established if recurrent dieting depletes
omega-3 reserves and intake during maintenance does not allow effective
repletion.”
Metabolic Fitness: An Alternative
Health Paradigm
We need a new approach to
health and fitness--one that places less emphasis on body weight (or
body fat) and more emphasis on healthy metabolism--becoming “metabolically”
fit. To achieve “metabolic fitness” does not require having
a lean body, nor does it depend upon having the cardiovascular system
of an endurance athlete.
In scientific/medical terms, metabolic
fitness can be defined in terms of how the human body responds to the
hormone insulin (9, 35). “Insulin sensitive” bodies tend
to have excellent glucose tolerance, normal blood pressures, and heart-healthy
blood lipid profiles. Therefore, insulin sensitive people tend to be
at lower risk for type II diabetes and heart disease than people who
are “insulin resistant”--a metabolic condition in which
the body’s cells (mainly those in skeletal muscle, liver and adipose
tissue) don’t respond normally to this hormone, and which ultimately
may result in disordered lipid metabolism and elevated blood pressures.
Insulin resistance is associated with high risk for type II diabetes
and heart disease (9, 18, 35).
Although genes play a role, the major
causes of insulin resistance are lack of exercise and consuming a diet
high in fat (especially saturated fat) and refined sugar, and low in
fiber--a description that fits many Americans (9). Because these behaviors
also promote obesity, the “insulin resistance syndrome”
(also known as the “metabolic syndrome”) is observed more
often in fat people than it is in thin people. But as I have pointed
out already, a fat person with the metabolic syndrome does not have
to become lean in order to become insulin sensitive (i.e., obesity is
not the underlying cause of the syndrome). Also, one does not have to
be obese to be insulin resistant. An estimated one-fourth of non-obese
men and women in the United States are insulin resistant and don’t
realize it (35).
Substantial improvements in insulin
sensitivity can be changed in a matter of days or weeks (7, 8, 19),
which explains why dramatic improvements in glucose tolerance, blood
pressures, and blood lipids can be observed so quickly after starting
an exercise program or eating healthier foods. If we can accept the
fact that metabolically fit and healthy bodies can come in all shapes
and sizes (40), then the public health message becomes quite simple:
be more physically active and consume a healthier diet.
As for exercise, moderate-to-vigorous
activity (heart rate in the range of ~60-75 percent of maximum) for
~20-40 minutes per day on most days of the week is suitable for improving
metabolic fitness (9, 23). Intensity and duration of exercise can be
modified to suit individual needs. If time is not a constraint, duration
can be emphasized while exercising at the lower end of the intensity
range. Just as effective, however, is high-intensity exercise of only
20-30 minutes duration. As for nutrition, the best foods to boost metabolic
fitness are those you find primarily near the base of the USDA food
guide pyramid: Whole grains, fruits and vegetables, and legumes (beans).
These foods have plenty of fiber and have been shown to improve health
regardless of weight and independent of weight loss (3, 9, 19).
The Road to Fitness is Wide
Enough For All
It may seem intuitive that
exercising more and eating better will naturally result in weight loss.
This generally is true, but with a major caveat. Not everyone will lose
weight, and it is virtually impossible to tell how much any one person
will lose. Most exercise programs and typical diets result in a weight
loss of no more than 5-10 pounds (32); the average “overweight”
U.S. adult wants to lose 20-30 pounds! This discrepancy between what
Americans want and what exercise and healthy eating are able to deliver
highlights the fundamental problem with using weight loss or reductions
in body fat to judge the success of an exercise program or nutrition
plan. Exercise and healthy eating should not be viewed merely as means
to an end (weight loss), but rather as having their own intrinsic value.
If someone quits an exercise program out of failure to reach a particular
weight loss (or reduced body fat) goal, then all the benefits of the
exercise are lost as well. And far too many people who start exercise
programs don’t stay with them. Yo-yo fitness is becoming as common
as yo-yo dieting.
In America today millions of men and
women (and boys and girls) stigmatized as “too fat” are
engaged in a perpetual war with their bodies. Isn’t it about time
we called a truce? Let’s face biological reality. Some people
are naturally meant to be thin, some naturally meant to be fat. Exercise
and diet can modify our genetic destiny only so much. The human body
is not an infinitely malleable mass of calories that can be burned down
to any shape and size desired. But that doesn’t mean we can’t
all be as metabolically fit as our lifestyle will allow. In terms of
health and longevity, the scientific evidence is abundantly clear: It
is far more important to be fit than it is to be thin. Contrary to prevailing
dogma, the road to a fitter and healthier body is not so narrow after
all.
Our special thanks to
Dr. Gaesser for letting us reprint this article with his permission.
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