For the Overweight, a New Definition of Health

Obesity is widely viewed as the nation’s biggest health problem. But research last week showing that one-third of obese people are “metabolically” healthy suggests that health can’t be judged by fat alone.

Indeed, there’s a growing body of evidence suggesting that many of our attitudes about health and weight are misguided. While excess weight clearly is a risk factor for poor health, it doesn’t appear to be the most important issue. About half of overweight people and one-third of obese people have normal “good” cholesterol, blood pressure and other cardiovascular risk factors. And several studies show physical activity is a far more important predictor of health than body size is.

“We know that obesity by itself is a major coronary risk factor,” said Dr. Kenneth Cooper, the fitness expert who launched the aerobics movement. “But you can’t just rely on weight. You’re better off being fat and fit than skinny and unfit.”

To read more about weight, fitness and health, read my full Well column here and then post your comments below.

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This issue gets more and more complicated.

Common sense tells us that obesity is not an indication of good health.

Medical science / the Diet Industry and our societal images of health and beauty tell us that obesity is bad.

The Size/Fat Acceptance movement stands up for its members to fight back against discrimination due to size/obesity.

As they have gained confidence they have spread their message of Health at EVERY Size far and wide.

As a result, what was once a private issue has evolved into a topic full of rancor spread all over the internet.

What a mess.

Let’s look at what we actually know:

Discrimination against people based on their size / obesity is wrong. It’s no different than racial, religious or sexual discrimination.

Obesity is linked to a large number of chronic lifestyle diseases – Heart disease, Diabetes, Metabolic Syndrome, Cancer…

Obesity is not the only marker, but it may be the most OBVIOUS marker.

We can’t see high BP or C-Reactive Protein or Inflammation or stress or depression LDL cholesterol or…

We also know that:

Obesity and inactivity are closely related

Lack of obesity does not guarantee perfect health – Thin people can have heart attacks.

Scientists are paid to investigate hypotheses.

Science costs money.

Big companies pay to fund science.

Everybody has an axe to grind.

I am a personal trainer. Therefore when I see a medical issue like obesity or high BP, I immediately think of the interventions that involve exercise, nutrition, supplements, mind-body therapies, etc…

I look at other options as well, but my prejudice leans towards the therapies that I am involved with every day.

I believe that the same can be said about Dr. Kenneth Cooper.

His claim that that “fitness — determined by how a person performs on a treadmill — is a far better indicator of health than body mass index” clearly indicates his bias towards aerobic fitness as the end all and be all of physical fitness.

Cooper’s bias towards aerobic fitness is obvious. It has been his life’s passion for many years.

No disrespect towards Dr. Cooper, but aerobic fitness is not the only indicator of fitness.

In 1984, Jim Fixx, America’s original running guru died at the age of 52 of a massive heart attack, after his daily run. The autopsy revealed that atherosclerosis had blocked one coronary artery 95%, a second 85%, and a third 50%.

Aerobic fitness couldn’t help Fixx overcome his family history of heart problems.

That doesn’t mean that aerobic fitness is bad or ineffective. Heck, it may even have extended his life. Without running, he may have died in his 40s.

So what does this all mean?

While I agree with Tara that it’s:

Better to Be “Fat and Fit” Than “Skinny and Unfit”,

It is even better to be Skinny and Fit.

And you should probably try to reduce your stress and meditate and quit smoking and have a healthy sex life and walk more/drive less and live in a walkable neighborhood and eat organic foods and have lots of friends and…


So, TPP, just because being obese means that a person has a one out of three chance of being metabolically healthy, doctors are now going to stop telling obese patients to lose weight? If anything, given that 66% of obese people are metabolically unhealthy, this argues strongly that obese people should lose weight. That is, this study reinforces the idea that obese people should lose weight to avoid the two out of three chance of being metabolically unhealthy. I’ve heard that 1 out of 5 heavy smokers get lung cancer, if that many, and look how strongly doctors advise against smoking. I don’t see how this study should change in any way the practice of medicine with regard to obese patients. If doctors judged the health of obese patients only by their size, all they’d have to do is weigh them. Obviously, there is more to health than size and I don’t know of any medical school that teaches otherwise.

And yes, I do understand that you are saying that if one out of three obese people are metabolically healthy this is different than assuming that all obese people are metabolically unhealthy. So what? A two out of three chance of being metabolically unhealthy is pretty lousy odds. I’d bet my money on those odds, though, before I’d bet my life.

DUH DUH DUH DUH! The research that said 300,00 people die from obesity didn’t actually say that. It said 300,000 people die from having a sedentary lifestyle, which means you skinny. It’s just discrimination, which will be found throughout the health section in the snarky comments of readers who were born thin or medium and feel superior through no cause of their own.

I think it would be interesting Ms. Parker-Pope if you would do a posting of pictures of various people (anonymous or not) and their BMIs. I think a lot of people when they hear overweight or obese, as you noted in your article, picture the people who need scooters to get around in instead of the people who are 20 to 30 lbs over the “normal” BMI weight. People’s perspectives are skewed by seeing all the Hollywood people “oh I dieted and lost 6 pounds to get back to 115 lbs and I am 5ft 11″ type of thing. When people are “overweight” they aren’t necessarily the headless people in the “fat” pictures.


FROM TPP — There’s a really interesting online project called the Illustrated BMI project that does pair pictures with BMI. I wrote about it in a post called Pictures of Health.

the so-called “measures” are guidelines, but just that and nothing more. out of curiosity i just checked in on a few to see where i’d net out. i am a 41 yr old non-smoking mother of 2 small kids. i am 5’2″ and weigh 145, and have good a good thick eastern european peasant build. i also race olympic distance triathlons, ski all day w/out stopping, box, and like the scary farmer dude in the movie “trains, planes & automobiles” said, “she’s little but she’s strong.” i have a few extra pounds on my frame to be sure, but the bulk of the weight is from big juicy fully functional MUSCLES!! and i am healthy as a horse, according to my md. my clothes look good on me, i can do anything, and i feel great. but all those objective “measures” have told me i am unfit. ha! they just WISH they were as “unfit” as i am!

Wow, so tired of reading about weight issues.

This should not be read as an endorsement of obesity. Nor should it be another way we harangue those who are overweight. It should be viewed as another piece of evidence in support of the importance of physical activity for overall health, regardless of weight.

How does this study suggest “that many of our attitudes about health and weight are misguided”? Which attitudes?

Re: #3 sweetieforhillary

Let me get this straight.

You believe that a sedentary person is just as likely to be skinny as to be obese.



If that is true, then maybe all disease is genetically predestined….And it doesn’t matter what I do… And I have no control over my health and quality of life….And…

Damn, I feel sad now.

Oh well, off to buy some cigarettes and have some unprotected sex.


This comment was brought to you by the letter S…for sarcasm

I’m not surprised by the flip side of this — that skinny people are not necessarily fit or healthy.

Ten years ago I developed hyperthyroidism. Before the illness, I was overweight — and I hiked 5 miles every weekend. During the illness, I lost 25 pounds, was in the normal weight range, and got lots of compliments — but couldn’t climb a flight of stairs without becoming breathless.

I’m now losing weight again, without trying, and frankly, it makes me nervous. My MD checked my thyroid levels (normal), concluded it’s anxiety, and prescribed an SSRI.

Personally, I’d rather be a little overweight and feel great, than to be in the “normal” weight range and feel lousy like this.

Thank you for this post Tara.

For most if not all heavy people the issue of losing weight is loaded. People either can’t lose no matter what they try, lose and gain it back, lose a little but are still considered fat, or the very few who lose and keep it off by making it a full time job.

So now health professionals can give advice to heavy people (light people too for that matter) to exercise, exercise, exercise. A lot of heavy people don’t exercise because it is tied into the whole craziness of losing weight, dieting, gaining weight, self esteem, problems that come when you are on the futile attempt to become skinny.

The strongest message for heavy people is to exercise for exercise sake alone – Not to lose weight! You will feel better, live longer, etc…. if you exercise. Forget about losing weight and just move!

By the way so many people here say that fat people have all these other problems, they can’t move easily, their knees hurt, they are out of breath easily, etc… These are problems associated with not exercising, NOT with being heavy.

I checked the abstract on the web site of the journal. The criteria did not include any measure of total cholesterol or LDL cholesterol (the bad cholesterol), even though these are two of the most important indicators of cardiovascular health.
So there is simply no question about it, this study is worthless. A person could have a cholesterol of 300 mg and be obese and very unhealthy, and this would be considered evidence that obesity doesn’t affect cardiovascular health.
The NY Times should interview the authors of the study and ask them for an explanation.
In the mean time, we’ve been fooled!

FROM TPP — It included HDL cholesterol which is widely viewed as a better indicator of heart risk. Also, this is one study that looked at the issue from one angle, but it’s not the only evidence we have to support a new definition of health for obesity. The CDC/NCI finding showing that the overweight have longer life expectancies and the Cooper JAMA data showing that fitness is a stronger predictor of mortality than fatness — along with many other studies — show there is a large body of evidence. One other point, as I’m sure you are aware, total cholesterol is an unreliable marker of cardiovascular health. Half of people who die of heart attacks have normal total cholesterol.

One problem with the study is that BMI was the only criteria used to classify overweight and obese people without regard for body composition. Using BMI alone, most athletes (both professional and amateurs) would be classified as overweight since muscle tissue is fairly dense. Had the researchers used percentage of body fat to classify the subjects, the results may have been different with less of the “fit: people being classified as overweight.

FROM TPP — Interesting point but it’s worth noting that in the JAMA report last year on fitness and weight, body fat composition was not a reliable predictor of mortality.The JAMA study is linked to in the above post.

I am very glad to see that being overweight is not a death sentences.
On the other hand, as a European living in the US, it’s hard for me not to chuckle when I see being fit defined as the ability to walk at an increasingly brisk pace for … a few minutes.
Perhaps “Wall-E” really did show American society just a couple of decades down the timeline?

FROM TPP — It was at a brisk pace and on an incline. That said, it’s good news. It shows that it doesn’t take a whole lot of effort to improve fitness and that simply walking for a half hour, five days a week, goes a long way toward improving health.

1. losing weight is harder for some than others, but it can still be done by everyone who does it correctly. it might take me a week to drop 7 pounds while someone else takes a month. so if it takes a month, the sooner you start the sooner you get there. stop whining and get it done.

2. for two equally “fit” people, being overweight will always be better than being obese.

3. for two equally “fit” people, not being overweight will always be better than being overweight.

4. we need to stop making excuses for why we are overweight or obese and start doing something about it.

5. there is a difference between losing weight and maintaining weight. too many people think that after they’ve lost some weight they can go back to their old habits, which is what got them overweight in the first place.

6. eating less, or eating healthier, will do very little to drop weight unless you exercise.

7. i have friends and relatives who eat like horses, but they also exercise like horses because they understand what it takes to eat everything they love. too many people are great at the eating part, but they haven’t figured out the exercise part.

8. who wants cake!

We keep focused on the wrong things, use the same inappropriate terms and ask the wrong questions.

Wrong Focus: We focus on what doctors have to say. Doctors say this, that and the other thing are risk factors regarding health. Translation: Doctors say things that they have been taught to say, seeing health through the prism of the path they each take in medicine. What they say with few exceptions have a built in bias-come see me today.

Despite the fact that their risk designated factors are increasing in numbers as is weight generally, they are unable to say, “Hey! This is not working. There are other factors working here which I have little control over and for which I have little education or training. Many of these fear factors are in question and most of the medical model approaches are ineffective if not potentially harmful.”

The medical model is one way to treat disease but it is not a satisfactory way to prevent disease (including what they call obesity or being overweight).

Inappropriate Terms: Terms as fat and skinny are judgmental, emotional and discriminatory. They have the same impact as black and white. They do nothing to help people see what might be correct in attaining wellness and health. They lead some people to become overly sensitive and reactive and others to become grossly insensitive and intolerant. When we get to the point that we can see this, we will have addressed a major health goal-making our own attitudes better in relationships with others and most importantly, with ourselves.

Wrong questions: As we focus and use inappropriate terms, we are led to ask wrong questions. Mostly this discussion is led by people who got an education and training in medicine, not health, wellness, primary prevention, nutrition, motivational skills, movement and can do less with the quality of the food, air and water we consume every day.

But important questions about what can be done to have a healthy attitude, healthy nutrition, healthy supplements, healthy breathing, healthy water, healthy rest, etc. are left unasked and unanswered.

There are underlying principles that cause poor health, disease and illness. That is where we need to go, to do independent research and to consider other models that offer effective and manageable actions.

In summary, let’s try this another way by asking a simple (wrong) question:

“For any person (especially a Jew, an outspoken Catholic priest, a gay or lesbian, a Gypsy, a member of some minority, a communist, a socialist, anyone labeled as being generally an undesirable) Was it Better to Be Fat and Fit Than Skinny and Unfit in Nazi Germany?

The answer should be self-evident.

I don’t see anyone “making excuses” for being overweight, or suggesting that doctors stop talking about weight with patients (not on this thread so far). The ever more apparent truth is that weight isn’t the best indicator of health. It may be the easiest to see, but it isn’t the best. If you’re an MD and your unwilling to further examine a patient to assess health beyond weight b/c weight is the “most obvious” I hope your patients find a new doctor. If you aren’t an MD it is not your place to judge the health of others, period. So it shouldn’t matter that weight is “obvious” since the only people who are relying on the obvious to pass judgment are the ones who shouldn’t be passing judgment in the first place.

Interesting article, thank you for posting! And obvious to some of us… just because that’s how we live. I, my mother and sister are all big girls, and we do not eat large amounts of food, and we eat very healthily. We are also all in incredible shape. My mom, at almost 70, has been swimming and strength training 6 days a week since she was in her 20s. My sister has a personal trainer, spins, and can weight lift insane amounts. I do cardio kickboxing 3 to 5 days a week. Our doctors tell us we are very healthy.

But we are not small, and if some of the more judgmental posters here were to step into our bodies and try to lose weight I think they would be enlightened as to what this information really means. I was skinnyish for several years from high school to college, and it was hell; not only exercising like a mad thing, but eating so carefully it was painful. Now that I simply exercise vigerously, pick my food battles but don’t let it rule my life, I feel incredible and am very happy.

It is only better to be ‘skinny and fit’, DR, if it’s possible to achieve without putting your health at risks in other ways, and your body is comfortable at skinny. It disturbs me that as food research highlights what is obvious it almost seems to upset the old guard of nutrition and exercise.

RMV, ‘stop whining and get it done’ is unfair, and it’s missing the point of this article and why it’s important. For people for whom it is very, very difficult to lose weight(which, I really, truly don’t think you understand how difficult that is for many, the flippant ‘just do it’ attitude is what makes so many overweight people despise the fitness industry and stay away from it), the point is that if they simply concentrate on exercise, getting themselves fit and moving they will be healthy.

And their goals will become more realistic. You tell someone to whom losing weight is hellishly hard to ‘just do it and lose it’ and treat them with contempt if they don’t meet the goals set for them they are going to slink away from that exercise routine never to routine. If you tell them “Don’t concentrate on the weight – concentrate on how you FEEL. Concentrate on how much better you move, on how much better you sleep, and breath, and…” you are possibly going to get exercisers for life.

Which is what everyone needs to be, and I believe is the base point of this research.

Could Tara explain how the BMI was developed, and how it came up with its categories? Its idea of what constitutes “normal” seems so limited. fwiw, I am 5’5” and ideally about 153. My blood pressure is typically below 110/70, and I do the 60-mile breast cancer walk, yoga, jog, and snowshoe in winter. My BMI index no. is 25, so technically, I am overweight. In my case, clearly, having a few extra pounds (or curves), does not seem to have affected my health.

The BMI. Not sure if it helps, or hinders. Now they send BMI reports out from the schools. Parents really don’t know what to think about it. If your child is of normal BMI, then most think it is great. It reinforces your “good” parenting skills. If they are in the overweight category, then they feel the school should stay out of their private business, as it makes them feel “bad” about their parenting skills. All the kids seem fit; they can all run and play, no problem. And it seems that the BMI in children is not an indicator of health, so why do it? It seems to add more stress and does nothing but make people feel shameful.

Same with adults. The BMI is not something that helps anyone learn healthy habits. Here you are going along wearing size 6 clothes, walking everyday and enjoying life. Then you calculate your BMI. Says you are overweight. Now you feel bad about yourself. Seems silly to me.

Better to know your own body type. Yes, some people were born bigger, so what. Why does society have to judge them so harshly? Why does our society allow celebrities who are grossly underweight to define what looks good? Many of those women are so unhealthy, doing drugs, smoking and drinking diet Coke to stay thin. Ridiculous.

I still maintain that a little bit of fat as we age is protective. Our bodies naturally want to gain weight as we age, especially women. People need to pay more attention to other indicators of health, such as a normal LDL, HDL, c-reactive protein and homocysteine levels. Inflammation in the body increases cardiac risk, this is a known fact. (Dr. Andrew Weil’s anti-inflammatory diet is a good one to follow.) So does heredity and smoking and stress. Being really heavy is never a good thing, either. But the BMI simply sets us up for failure. It says to many, why bother? It says you are overweight no matter what you do.

BTW, as I have worked with many terminally ill cancer patients over the years, I have to say that I care for more “thin” adults than any other category. And they didn’t lose weight from their treatments or disease. They were thin prior to diagnosis. Makes me wonder.

You know, we are all going to die of something. These studies do nothing more than alarm people, and I think stress kills more people than donuts any day.

One theory I saw in NYT not long ago is that obesity may be caused by specific viral infections.

This week I read that frequent ear infections may play a role because they destroy part of the nerves that make up taste sensation, predisposing people to have more receptivity to sweet, calorically dense foods.

A third theory, the Hygiene Hypothesis, posits that we lack certain necessary parasites and bacteria due to our propensity to eradicate “germs.” This lack fuels autoimmune conditions, like asthma, allegies, and bowel disease, and may play a role in obesity.

A clear case of genetically caused obesity is Turner syndrome in women. It’s when a woman is missing one of the two X chromosomes women usually carry. It’s the most frequent genetic mutation in women, but it often goes undiagnosed because doctors don’t look for it.

My point is, there *are* many medical conditions that contribute to obesity.

Wow TPP, you are a glutton for punishment! I’m sure you’ll continue to get a lot of the “but, but, but” from people very attached to the idea that fat = bad. Thank you for continuing to challenge conventional wisdom and trying to ‘think outside the box’. This is what I read the NYT for.

#18, I think you are absolutely right-on. It’s time to stop making assumptions about what someone’s body size can tell us about their health. It’s increasingly clear that it can’t tell us much. So many larger people give up on exersize because their bodies just don’t want to lose weight. So they miss out on all the benefits of physical activity because they’ve been taught to focus on the wrong thing – the fat – rather than how they *feel* and what their bodies can *do*.


I’m so glad Tara wrote about this. The message is a great one for everyone to hear. Our culture has created an obsession among Americans (especially women) that causes them to continuously feel that they are over weight and need to “diet”. The focus is on weight as both a moral and “health issue”, and encourages a harmful “quick fix” approach to losing weight; something that will not lead to making behavioral changes that can be sustained. In my research I’ve discovered that this can actually undermine losing weight and MISfocus women on a goal to drop weight as quickly as possible rather than improve her well-being quality of life through lifestyle changes such as exercising. A new study I just published shows that healthy women in midlife who exercise for reasons related to losing weight and health benefits do the least amount of exercise and have the poorest motivation profiles, controlling for their BMI. Guess who does the most exercise? Those women who exercise for sense of well-being and stress reduction. It’s interesting that aiming to change your behavior for “health” reasons can also undermine an individual’s motivation because the behavior is then experienced as a “should” rather than a “want”. Who has time to fit exercise in if it’s something we “should” do? (Is it effective to tell kids eat your veggies – they are GOOD for you?) When I coach midlife women on making lifestyle changes that they can maintain, I help focus them on “improving fitness and sense of well-being” instead of “decreasing fatness”. This RE-focus helps women make healthy lifestyle changes that may feel more like positive affirmations of the self instead of punishment for being a certain way which ultimately leads them to develop a more intrinsic motivation and have long-term sustainability. Creating long-term sustainability in lifestyle changes is THE KEY to maintaining one’s health and controlling weight. I completely agree with Emily’s comment above, focus not on weight but on how you FEEL. Ironically, to achieve these aims, it may be more effective to help women change their mindset and reasons away from these goals to ones that will help them enhance their daily sense of well-being.

Michelle Segar, PhD, MPH
The Institute for Research on Women and Gender
University of Michigan

I think this all goes back to everything in moderation, nothing in excess. Period. Try to live a well-balanced life in all aspects. And keep your fingers crossed that you’re not one of the 47 million without health insurance because then you won’t have access to much of the preventive medicine that can save your life in the future.

I believe that being fat is-without a doubt, the biggest health problem that a person has. Being fat is not only a physical issue; it is also a mental problem that often leads to low self esteem, discomfort and unhappiness. I believe that society will be experiencing a great deal of problems in the near future due to the overweight population. Our medium of transportation; trains, planes etc, are not designed for overweigh individuals, there are obvious dangers here, Not to mention the increases in health care cost that will be a direct result of those overweight smokers that eventually get sick.