“What Does It Mean to Have a Healthy Body?”: New research has reopened the debate on fat
Dec. 27, 2017
Sarah Taylor is the type of athlete who swears by the runner’s high: the longer you run, the
etter it feels. She has been dedicated to living and promoting a healthy lifestyle for the last
two years, cataloguing it all through her social media platform @sarahtaylorsjourney. Scrolling
through her feed reveals an impressive list of accomplishments: Taylor is a former Miss Plus
Canada, a model, a certified personal trainer, a beauty diversity advocate, and someone who
deadlifts 150 pounds on a regular basis. Standing at 5 feet 10 inches tall and weighing 255
pounds, she is also the type of athlete who forces us to confront our stereotypes of what “fit
and healthy” looks like.
The medical community describes obesity as a chronic and often progressive health problem,
not to mention a global epidemic. Six million Canadians are considered obese—approximately
17 percent of the population. That’s no small number. Obesity costs more than four percent of
Canada’s total health care budget yearly, according to the Canadian Obesity Network.
According to the World Health Organization, it costs $6 billion globally.
Many people, however, including Taylor, would balk at being described as part of a “health
epidemic,” arguing that their overall health cannot be defined by numbers on a scale. And, in
ecent years, doctors have indeed found that some individuals have obesity without any of the
health problems often associated with it, such as diabetes, high blood pressure, high
cholesterol, and /or certain types of cancers. Hence the term “metabolically healthy obesity”
(MHO), which doctors coined to describe those who have obesity, but do not experience any of
the (presumed) associated health issues. As many as 5 to 20 percent of those who have obesity
are thought to fall under the MHO category.
At the same time, the term is controversial. Obesity specialists cannot agree on whether MHO
is a defined entity—i.e., a permanent state—or just a
ief moment in the health of somebody
who will go on to have, for example, diabetes or high blood pressure. The controversy only
increased in September after UK researchers, led by epidemiologist Rishi Caleyachetty and his
colleagues at the University of Birmingham, published the most comprehensive study on MHO
to date in the Journal of American College of Cardiology. That study, which looked at 3.5 million
individuals in the UK, suggested that healthy obesity is a myth—and argued that obesity
emains a major risk factor for future health complications.
The study results indicate that 15 percent of the 3.5 million individuals were initially free of any
disease and classified as MHO. But researchers wanted to know if healthy obese adults could
maintain their metabolically healthy profile over a five-year follow-up period. Of the people
who were initially MHO, about 6 percent developed diabetes, 12 percent developed abnormal
lood fats, and 11 percent developed high blood pressure. Even more distressing, compared
with those who were considered to have normal range on Body Mass Index (BMI) and no
metabolic disease, the study concluded that those in the MHO category developed a 50 percent
increased risk of heart disease and a 7 percent increased risk of stroke.
“Our results couldn’t be explained by age, sex, smoking, or socio-economic status,” says
Caleyachetty. “There is enough evidence accumulated from our study, and a few others, to
accept that, when we look at populations of people, metabolically healthy obese is not a benign
condition.” He believes the data shows that obesity is a complex public-health issue. The study
has since sparked a significant shift, with physicians starting to once again question whether
you can have a lot of excess fat and be fit.
As a physician myself, I understand why many doctors are reluctant to em
ace MHO as a
concept. While it’s true that poor lifestyle choices—such as smoking, stress, and poor diet—also
cause high blood pressure and diabetes, obesity is still the leading cause worldwide.
Still, studies like Caleyachetty’s look at a population, and not the entirety of a person. It’s
entirely conceivable that other factors might allow somebody to be healthy and also be
classified as obese. Certainly, there are many people who, like Taylor, have obesity and are
living healthy lives without health problems. So where does all this leave the thousands of
Canadians who are wondering how to reconcile exercising regularly and eating a balanced diet
with being classified as obese and at increased risk of having a heart attack? What if they are
committed to a healthy lifestyle, but the number on the scale is not budging?
“This is a funny question,” says Dr. Sean Wharton, an obesity specialist in Toronto. “It’s like
asking, ‘What can I do if am a dark-skinned black person and I am smart and doing well in all
areas except I’ve got dark skin?” He goes on: “Dark skin defines nothing besides ‘sheer beauty’
in many people’s eyes. We know that some people look at it as negative, but we tell these
people to get with the program and get rid of this label that does not define the person.” And
yet, we don’t we do the same with obesity.
Part of the challenge is how we think about and classify fat. Doctors and researchers still rely on
the Body Mass Index to define obesity. Considered the standard method for measuring obesity,
BMI was adopted into routine practice nineteen years ago as a screening tool for doctors to
determine which people were at risk for health problems related to excess body fat. It is a quick
calculation requiring only information your doctor has at her fingertips: your weight and height.
The number obtained from the calculation is then used to categorize whether a person is
underweight, normal weight, overweight, or obese, depending on the range. Obesity is further
oken down into categories. Those with BMI of XXXXXXXXXXfall under class II obesity, and those
with a BMI of greater than 40 are slotted under class III. Class III goes further to define super
idly obese”—those with a BMI in the 40−49 range—and “super mo
obese”—those with a BMI over 50.
Despite its popularity, BMI has long been criticized for its limitations. As a simple estimate of
ody mass, it does not take body composition into account. Some people are more muscular
than others and, as such, their BMI may not accurately reflect their actual fitness level. Many
professional football players, for instance, have BMIs that would put them into the “obese”
category, largely owing to their muscle mass. And yet, they have better cardiovascular health
than the average population. What’s more, if we look at BMI as the sole determinant of health
and fitness, it leads to the assumption that having a low BMI is healthy, even if your diet
consists of foods high in sugar and fat. “The key is movement,” says Vicki Hiltz, a registered
dietician and fitness expert in Toronto. “If you can do your daily activities without getting
winded and you go up flights of stairs, you are healthy. It’s not your BMI, it’s you.”
There is a wide variety of body types, she adds. More than that, Hiltz says, people have
variations in the way their muscle, bone mass, and fat are distributed throughout their body—
all reasons why BMI should not be the sole method for determining a person’s healthy body
weight. Body-positive activists have long argued that you cannot determine their health by
looking at how much fat they are ca
ying around. Together with obesity and fitness specialists,
they are trying to encourage discussions of obesity and health which focus not on BMI but look
at the entire individual, their activity level, and how their weight is distributed. “Everyone’s
arometer for health is different,” says Hiltz. “Weight doesn’t determine your health—your
Part of the solution, say some medical authorities, is to expand past the field’s reliance on BMI.
“We have to assess a person in terms of their health and not based on purely, and oftentimes
not at all, their size or shape,” says Dr. Sean Wharton, an obesity specialist in Toronto. Experts
like Wharton and Hiltz agree that BMI was not developed as a stand-alone tool to determine
healthy body weight—even if that’s how it’s often used today. Rather, it was meant to be
considered along with other measurements, such as waist circumference and waist-to-hip
circumference, the latter of which, Wharton argues, is likely a better tool than BMI to
determine health risk. That’s because waist circumference above a certain threshold co
with high amounts of visceral fat—the fat around our belly and organs. Eventually, higher
visceral fat leads to heart disease such as high blood pressure, heart attack, and stroke. Taken
together, such measurements paint a fuller picture of an individual’s risk of health
complications related to obesity.
Why has the public been so eager to em
ace studies such as Caleyachetty’s? Certainly, the
study fits into the well-worn na
ative that all obesity is unhealthy and that urging the
acceptance of all body types is dangerous. Opponents of the body-positive movement argue
that promoting larger bodies as beautiful and healthy may be silently killing those bodies. Yet
even Caleyachetty acknowledges that obesity is complex. The results of studies like his are
persuasive, but we cannot discredit the lived experience of people like Taylor, who has
maintained athletic prowess while having a BMI considered obese. Such experiences should not
e negated by these studies—rather, they should motivate the medical community to devise
studies that use more accurate measurements of body composition. Who knows what research
would find if it started by challenging its own biases and limitations?
“I would never say I am fat—I have fat,” says Annika Reid, a body-positive health activist and
yoga enthusiast in Toronto. Body-positivity advocates are trying to shift the language from
classifying people as obese to talking about people who have obesity as one of many other
qualities. If someone has poor eyesight, they are not defined by their less-than-perfect vision
and called “poor-eyes.” If someone has obesity, though, he or she often becomes that label: fat,