You can be obese but healthy: Fact or fiction?

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Mark Faries, PhD, College of Medicine adjunct assistant professor and associate professor and state extension health specialist at Texas A&M AgriLife Extension, breaks down what it means to be healthy and what the relationship is between health, fitness and weight.

Episode Transcript

Mark Faries: Welcome to Health Hullabaloo. I’m here with Tim Schnettler. Hey Tim.

Tim Schnettler: Hey Dr. Faries, how are you?

Mark Faries: Good. Again, my name is Dr. Mark Faries and we are trying to find some clarity in the commotion and confusion related to health and fitness medical type myths. Hullabaloo, Tim, do you know it means noisy, uproar?

Tim Schnettler: Yes, sir.

Mark Faries: We see that right? We see stuff on the internet, we read things, we hear things, it’s good one day, it’s bad the other. It doesn’t cause cancer and then one day it does cause cancer. And so, we really want to focus on trying to, again, dispel some of these myths, or determine if it’s a myth at all. Sometimes we think it’s a myth and it’s not. So, the one today is can you be fat but fit? You’ve heard this before?

Tim Schnettler: I’ve heard this before, and as a former fat kid, I’m really interested in this topic.

Mark Faries: Well, there’s some other folks that we just talked to that interested as well. It’s interesting for numerous reasons I think. One, I think, because weight loss is so hard for some people and the idea that, oh wait, I could be fit and not have to lose weight, it’s almost like a relief at times. But also, because of that difficulty, it’s bothersome because then you’re saying that maybe it removes any of the health risk from being overweight or having excess fat which I think can be somewhat dangerous. Now, there’s confusion even on this topic to some degree at the academic researcher expert clinical level. So that bleeds down to all of us as well. Where did this all get started? There was, I guess three decades ago now, the Aerobic Center longitudinal study. Cooper Clinic in Dallas did a study where they followed over ten thousand men and over three thousand women and they were followed for eight years. And so the better cardio respiratory fitness, so that’s the fitness part that we’ll talk about in just a second. That was associated with a decreased risk of what they call all cause mortality, so dying from anything within that eight year span. So again, what they’re referring to they’re calling cardio respiratory fitness, or aerobic fitness, it’s the ability of our lungs, so to speak, to pull in air, grab the oxygen out of that air, get it into the blood and then get it to the muscle. That muscle then can get the oxygen from the blood into itself and then use it for whatever reasons that it needs, usually to actually function and do aerobic based activities. So the idea is a more fit person will breathe in likely more air but specifically get more oxygen from the air into the lungs, into the blood, and then subsequently into the muscle than an unfit. So what they do is they put people on a treadmill. It’s a graded exercise test where every few minutes…Have you all done this?

Tim Schnettler: I’ve done one. I actually did a study with the Health and Kinesiology Department here where they put us on treadmills and raised it as we went along.

Mark Faries: That’s it. So, there’s different protocols and you go until what?

Tim Schnettler: Til you can’t do it anymore

Mark Faries: You bonk. You go until you just can’t go

Tim Schnettler: You go until you pass out

Mark Faries: And so, it’s an odd test but what that’s getting is what’s called max VO2, volume of oxygen. So they’re looking at, as you do that, they’re measuring the oxygen that you breathe in and the oxygen that you breathe out. The difference between those two things represents the amount of oxygen that you kept in your body. So, if you and I both breathe in, at that point where we bonk, at the end we’re both breathing in, let’s say, 100 milliliters of oxygen and I breathe out 80, I only kept 20. But, if you breathe in 100 and breathe out 20, you kept in 80 milliliters of oxygen, thus you would be more fit, or classified as more fit.

Tim Schnettler: Right.

Mark Faries: Okay, so that’s what they did in this study is they brought everybody in. These thousands and thousands of people did that test and then looked at their risk over time. Largely what they found was the higher your cardio respiratory fitness, as measured by this test, the lower the risk, again, of dying prematurely within that eight years from any cause including cardiovascular disease. Now, the interesting thing was that, where related to this fat versus fit idea, is that they found the reduction in risk despite the person’s body mass index or their weight. You’ve heard BMI, we hear that, and that’s really the fat component of this potential myth. Body mass index is a measure of how much you weigh for your height. We were talking about this a little bit before we got started. I remember years ago when Nintendo Wii came out. Did ya’ll play that?

Tim Schnettler: Yes, sir.

Mark Faries: Alright so, I was at my brother’s and I had not done the fitness game that came with it or you could buy with it. So you have to establish your little Wii character remember that?

Tim Schnettler: I remember this.

Mark Faries: Put hair on it, or no hair, or whatever and I had to put in my height and weight. And, as we were talking earlier, I’m technically, by BMI, I’m overweight category. And so I put in my height weight and my little Wii character got this belly and he got this little sad face. Well my sister-in-law saw it and she’s like what happened. I was able to explain to her that well it’s looking at my height and weight. Doesn’t know where the weight’s coming from it just knows that for my height, my weight, I’m classified as overweight. So that’s the way this works. It’s your weight divided by your height squared. It’s kilograms per meter squared is most common. You can go online and find a calculator. All you do is you enter in your weight, enter in your height, and it will spit out a number. So generally speaking the categories are this: If your BMI comes back as 18.5 to 24.9 you’re considered normal weight, If it comes back from 25 to 29.9 you’re considered or classified as overweight, and then 30 or above is the common classification for obese. It’s a long story where that came about, which is sort of interesting, but right now we find that as people fall into those three classifications, so if I go from normal weight to overweight to obese, my risk of chronic disease, disability, arthritis, orthopedic issues, mental issues increases as well. We’ve known that for a long, long time and actually as it relates to cardiovascular disease, we know cardiovascular disease is the number one cause of death in the U.S. by the CDC and in 2015 it accounted for, as it says here, 23% of all deaths. But obesity is it’s own risk factor for cardiovascular disease as well. Actually, for all chronic disease, obesity is listed here. Almost 40% of the U.S. adults are considered obese right now. That equates to annual health care costs for obesity related health issues from 147 to 220 billion dollars for just obesity. Now, because BMI is just, as we said, weight to height, we don’t really know where that comes from. So when you hear BMI, the real concern is, how much of your weight comes from fat. The concern is not so much how much comes from muscle. You have athletes who are probably fit cardiovascularly that end up having a little more weight from muscle, thus their BMI might be higher. Here’s the thing though. At the population level, if you look at all Americans. Why is their weight increasing? Is it from muscle? Or is from fat? So the conclusion we find that it’s again, most people the way they eat the way we do and they’re inactive the way we are in the U.S., their weight increases from fat. That’s why their health risk increases, their mortality risk increases, their disease risk increases. But, if everybody was getting heavier from lifting so many weights and getting jacked, then we wouldn’t have the health issues that we have. But here’s the problem right. Like we just talked about with the Nintendo Wii, if you apply BMI to an individual, it may or may not work. But, at a population level, it tends to work pretty well. Some people dismiss BMI because of that issue. Well, yeah, I’m big boned right? Or, I gotta bunch of muscle for my weight, and then that might be true, but again, it’s not another reason to dismiss it.

Tim Schnettler: And to me, BMI’s a scary thing, when you go into a doctor and he tells you you’re BMI is this, you’re obese, or you’re morbidly obese. That’s a scary thing to hear.

Mark Faries: It is and there’s stigma involved with that. It’s even avoided by health care practitioners. I don’t want to tell somebody that they’re, and we’re even moving away from saying you’re obese. We’re trying to say look, you’re classified as obese. You’re classified as overweight. So, that’s the medical stigma, we identify these areas, the social stigma that come with it is where we really don’t like. You have, even health care providers who unknowingly sometimes make some subconscious decision that oh because they’re classified as obese, now subsequently they’re lazy or they don’t know what they’re doing. And that may not be true at all. So you’re exactly right. It’s not only scary for the patient, it’s scary and risky for the health care practitioner as well.

Tim Schnettler: What I remember as a young kid, as I said, I was overweight, and I remember going to my doctor, my family doctor, and he basically read me the riot act. And I mean he shamed me basically (laughs) So, growing up that way I was always scared of it and you get that feeling that I don’t want to go to the doctor because he’s gonna get after me.

Mark Faries: Yeah, and it is a common source of health care avoidance. Generally speaking, this is interesting because any time we have to engage thoughts about ourselves, especially negative thoughts, we really don’t like that right. We don’t like hearing where we fall short. We don’t like hearing we’re not matching up to a standard or where we want to be. And so, experiential avoidance, or avoidance of this information, is really, really common across the board. That’s why people don’t get cancer screenings a lot of times. I don’t want to know that I have cancer. I don’t want to know I have this or I don’t want to send that email, I don’t want to talk to this person. The same thing as I don’t even want to know what my weight is. Especially if the fitness instructor, the trainer, or the health care practitioner is like, Mrs. Smith you need to go lose that weight and then they don’t, they don’t want to come back and hear it again. But, at the same time, you don’t want to shame but you don’t want to not talk about it either. It’s like we can’t not tell people where their issues are. It’s just getting better and better, and more tactful and proper in sharing this sort of information. But, yeah, times have changed. (both laughing) On how we do present that and should present that information. Because the goal is to look at, and let people know that, there is a risk of increased fat. Especially where we store it. And so that’s another limitation of BMI and a potential limitation with this fat but fit potential myth is that where we store the fat on our bodies makes a difference as to the risk of health or disease or premature death. And so, if I store fat, let’s say, under the skin we call that subcutaneous fat. Subcutaneous fat doesn’t have near the risk for disease or premature mortality, premature death, dying before our time than what we call visceral fat and that’s the fat that is stored inside, mainly the torso, around the organs, around the heart. We hear about android obesity, if you’ve heard that, that is the obesity in the gut area, the apple shape.

Tim Schnettler: The spare tire (laughs)

Mark Faries: Spare tire, keg, whatever names come up to describe the fat stored in the gut. Now, generally speaking, men are more prone to get that. That’s actually why our sort of cut offs for body fat are lower for men than women. Cause, generally speaking, this is not everybody, but generally speaking, women tend to store more fat in the buttocks, hips, thigh leg region. That doesn’t really increase risks of disease or heart rate. Actually, there’s some evidence to show, especially the Omega three fatty acids that can be stored in that area for women, are beneficial for the offspring’s cognitive ability and some other health benefits that naturally occur there. Again, don’t come from the Twinkies, but come from natural storage processes. But the idea is that we do store it and that’s gynoid storage. And so, if we look at the apple pear shape, we are more concerned with the apple, android, spare tire type storage. (both laughing) That’s why we see also that waist circumference is so great at predicting risk. If there’s something you can do to look at you risk, grab the tape and wrap it around. I did see one thing, I need to look back at it, but they measured height, then did around the belly button and did a ratio which shows to be predicting risk pretty well too. I’ll have to look that up, but again, the idea is why does that work. It’s because of the fat that’s stored there. So again, it’s not just about weight. It’s where it comes from and the fat. There was one study that I know of that looked at risk of dying with cardio respiratory fitness and total body fat percent, and they still found the same thing. In other words, even if you’re a higher body fat percentage, not real high but high, and you had good cardio respiratory fitness, you’re risk was still low just like you were normal weight but had high cardio respiratory fitness. Any questions Tim you can think of up to this point?

Tim Schnettler: Not at this point I think we’re good. Let’s keep going. This is very interesting and a lot to digest.

Mark Faries: It is.

Tim Schnettler: So we’ve heard about, you’ve talked about can you be overweight and healthy. What about someone who is skinny fat? I mean, is there such a thing as skinny fat?

Mark Faries: Years ago the skinny fat, or fat but skinny, somebody told me the word finny. I don’t know if that’s still around but that was the idea and actually, when I was in graduate school and in one of my nutrition classes we had to do a project, and I was teaching a weight training class at that time, as a part of my graduate assistantship. There were several girls, women undergraduate students in that class that were always complaining about body image. They were there to lift weights, they didn’t want to lift weights. They did a lot of aerobic exercise, they ate very little. But the reason they were complaining about their body image at least for them, was because they were mushy, they were skinny but they were fat, whatever their concern was. So I actually did a project on them where I brought them in and put them on what we called the Dexa scanner, where you get total body fat percentages. It’s the most accurate way to get that. It gives you amount of muscle, total pounds of muscle, total pounds of fat. So I brought them into the lab and we scanned them. We found that most of them, by body fat percentage, were overweight or even obese. Now I’m talking five two, three, four, low one hundreds, so they looked fine, so to speak, but by body fat percentage level they were overweight or obese classification. We see this in Asian populations as well. Who tend to be smaller but their body fat percentage is higher. Subsequently their risk is higher. That’s the great thing about this fat versus fit idea, is that it’s not just talking about you can be fat but fit, but it’s also telling us that look, you can be unfat. Is that a word? Did I invent that? Unfat and unfit, or you can be unfit and so it’s like yes you can be normal weight.

Tim Schnettler: But still be considered fat.

Mark Faries: Skinny fat.

Tim Schnettler: Yeah.

Mark Faries: And you can be normal weight and unfit. And still have increased risk. So, if you’re fit and overweight, that’s probably better than if you’re normal weight and really unfit—and unfit—It gets to this point to where excess body fat, especially stored in particular areas around the organs, obesity as we would call that. By the way, obesity, when we hear that, it’s really referring to an excess storage of fat to the point that our health is adversely affected. So just because somebody is overweight, or even their body fat, doesn’t mean they’re technically obese. It does have this indication that health is adversely affected. Sometimes we lose that cause we see things all the time about somebody’s overweight or obese and we try to look at people and determine their health status. You just can’t do that. So that though, that excess storage of fat in particular areas of the body around the organs, does increase risk and is an independent risk factor. So we can’t dismiss that. So this idea that I’m just gonna focus on fitness and not worry about how much fat I get, I’m gonna eat whatever I want. Diet, technically, in the largest cross sectional study to date that just came out again, there was a 2014 pub and a 2018 publication, dietary risks are the number one risk factor for premature death in the U.S. Accounting for, in this study the large study, about 25% of all deaths. So we can’t just dismiss diet. We can’t dismiss the burden that excess fat and weight can put on us. Not only cardiovascular risk wise but potentially risk of cancer, orthopedic issues, arthritis, gout, etc. But fitness, cardio respiratory fitness in particular, this aerobic fitness is also an independent risk factor. So where’s the benefit? Well, let’s say I am a little overweight, or even classifieds as obese. Isn’t that wonderful? I can start being active. I can get out and I can start walking. I can choose any activity I want that gets my heart rate up, start working that cardiovascular system, and start getting reduction in risk. Cause, one thing we didn’t get to talk about, in this early Aerobic Center longitudinal study, the big thing to me too was that they found that if you go from really low fitness based on their classifications, to even a moderate level of fitness your risk goes down

Tim Schnettler: Your risk goes down

Mark Faries: You don’t really get that much more risk reduction if you’re really, really fit. So, in other words, you don’t have to run marathons and do this extreme level of fitness to get the health benefits, to get the reduction risk benefits from, again, dying from all causes or dying from cardiovascular disease. That’s why we hear our recommendations currently are 30 minutes a day, five days a week, or 150 minutes of a moderate intensity aerobic activity. There is online, you can go search for the Compendium of Physical Activities, and you can search that, find it, they’ll be a section, and you’d look at the different categories. It is based on these activities or divided up by what’s called a MET value, a metabolic equivalent of a task. All you need to know is that a moderate intensity activity is anywhere from three to six METs. If you go above six METs it’s called vigorous. But at least moderate. In other words, you can go and look on that compendium and there’s hundreds of activities that fall between three and six METs. I can do any of those for my 30 minutes daily. I can do them all in one day, I can do one one day and change it up the next day. I can garden this day, I can do a brisk walk. That would be an example of a moderate intensity. Something like a brisk walk, where you can actually feel your heart rate getting high, and you do that continuously at least for 10 minutes at a time. So if we walk into work, 15 minutes, get a brisk pace in, and then I walk back from work or to the car or whatever and get 15 minutes. There’s a whole other topic we can do on what’s called non exercise activity thermogenesis, which is all about the non activity that we do and the benefits of that. In other words, not sitting, which we will likely have public health recommendations for in the coming years. You gotta be this active and you can only sit this much. But again, what a great benefit for those who are at an increased risk because of excess body fat. They can start getting their aerobic fitness up because, based on this data, it’s probably a stronger predictor of risk than the weight anyway. But the conclusion is that we don’t want to forget about obesity and just focus on fitness. But we don’t want to forget about fitness thinking that weight loss alone is gonna reduce our risk either

Tim Schnettler: Will do it

Mark Faries: Cause, as we talked before, there’s numerous ways to lose weight that don’t include exercise, that don’t included healthy eating. They can, but they don’t have to. There’s drugs, supplements, surgeries, fad diets, that actually could be increasing risk of disease, risk of premature death and other risks. So, really the idea is, you okay with concluding, You can be fat or fit but fit

Tim Schnettler: Yeah (laughs)

Mark Faries: But, let’s focus on both and try to improve both.

Tim Schnettler: Very interesting. Thank you very much Dr. Faries.

Mark Faries: Yeah, this was fun, thank you, Tim. Until next time, I hope that does clarify for everybody this question can you be fat but fit. And again, thank you for joining us with this episode of Health Hullabaloo. Again, I’m Dr. Mark Faries here with Tim Schnettler.