From the DUH! Files: Ain't no such thing as fit and fat

[DianaCox]

http://www.nbcnews.com/health/diet-fitness/fat-fit-theory-mainly-flops-long-term-study-n278836

The notion that it's possible to be obese and healthy finally may have been debunked.

While some obese people show no signs ofheart disease, a new study suggests it's just a matter of time before the consequences of carrying substantial, excess pounds ultimately take a toll.

British researchers followed more than 2,500 men and women for 20 years, tracking their body mass indices (BMI), cholesterol counts, blood pressures, fasting glucose amounts and insulin resistance levels. Among many of the study subjects who were obese, heart disease risk factors eventually appeared, according to the study, published Monday in the Journal of the American College of Cardiology.

"Based on this the state of healthy obesity should be regarded as a high risk state," said lead author Joshua Bell, a researcher in the department of epidemiology and public health at University College London in England. "Over the long term there is a tendency to progress to unhealthy obesity rather than staying stable or becoming healthy non-obese."

The findings would appear to refute long-standing arguments that people can be obese and remain completely healthy.

Bell and his colleagues defined "healthy obesity" as obesity with no metabolic risk factors for heart disease.

But over the course of 20 years, there was a trend for the "healthy obese" subjects to develop those risk factors, which include high blood pressure, diabetes and high cholesterol. By the end of the study, more than 51 percent had moved into the unhealthy category.

People with a BMI score of 30 or greater are considered "obese," according to this body-mass calculator offered by the National Institutes of Health. People with BMIs of 25 to 25.9 are classified as "overweight."

As for the other 48 percent, "you need to pay attention to the trend," Bell said. "Twenty years is a long-time follow-up for research purposes, but it's by no means a full-life course. The trend is for increasing numbers of the healthy obese people to become unhealthy obese. There may well be people who maintain stability over a lifetime, but we are talking about a small group of people. This doesn't seem to be the norm, but rather the exception."

At the study's outset, 181 study participants were classified as obese, with 66 of those people designated as healthy. After five years, 32 percent of the "healthy obese" people had developed risk factors and at 10 years, 41 percent had been reclassified as unhealthy obese.

"I think that we Americans all want someone to confirm the idea that being obese is not all bad all the time," said Dr. Kathryn Berlacher, an assistant professor in the University of Pittsburgh School of Medicine and a cardiologist at the school's Magee-Womens Hospital.

And while there may be a very small percentage of the population that can maintain good health while obese, "the large majority won't be able to achieve that over the long term," Berlacher said.

Dr. Andrew Freeman compares the developing science examining obesity to past findings on cigarette smoking.

Just as experts long ago documented the damage cigarettes can do in pack-years, modern researchers must assess the toll extra pounds take over time, said Freeman, director of clinical cardiology at National Jewish Health Medical Center in Denver.

The longer a person carries all of those extra pounds, the more potential there is for serious health damage, Freeman said.

"Obesity affects virtually every organ in the body," Freeman added. "Fat itself is hormone secreting tissue. This article suggests that the longer you are obese, the less likely it is that you will stay healthy."

 

[Larra]

Duh indeed!
Every now and then someone posts (here or elsewhere) about how they are MO but in good health. Usually they are saying that they are unwilling to subject themselves to the risks of bariatric surgery when they are in good health. I have answered such posts with the knowledge that these health problems, and others, are coming. they don't develop overnight, and I can't tell someone what day they will be diagnosed with something serious, or what condition it will be, but it WILL happen.
And there is more. The risk of many cancers is increased with obesity. That wasn't even looked at in this study.
AND there are people with type 2 diabetes - lots of them - who have it but don't know they have it. They aren't going to develop it 5 years from now. They have it now, they just don't know. I would assume that doesn't apply to the people in this study because they were receiving medical care, and were evaluated at the beginning of the study. But it does apply to the general population.
The risks of surgery are real, and I make no attempt to minimize those risks. But for the MO, unless they lose a significant amount of weight without surgery, the risks of NOT having bariatric surgery are just as real, they are only less immediate and more difficult to perceive. But they are there.

 

[robs477]

Another angle to consider here is why do you think that insurance companies are deciding more frequently of late that it’s actually in their best "Financial interests" to cover WLS. The numbers (the math) must be reasonably compelling for them to recognize this?? I know maybe Govt regs factor in also, but that has to be part of the equation or they’d be fighting it more??

 

[Parousia]

I'm kinda curious as to the percentage of non-obese people who developed risk factors over that time period. It would be an interesting comparison, I think.

Off to do some investigating, lol...

 

[conceit]

I've held this view for a while, that past a point (morbid obesity and beyond) fatness ceases to be healthy. it's possible to still have normal blood sugar, cholesterol etc. but IMO this is not something one should take too much consolation in. the term "morbid" obesity exists for a reason. the damage takes place silently and surreptitiously for some, but it does take place. i have alienated some friends in the fat acceptance community who categorically denounce WLS and push for the healthy at any weight message. i can't, in good conscience, be a part of a movement (or groups within the movement) that shames people for wanting to improve their lives and gain better control of their health. it's easy to patronize people on the internet; it's a whole another deal to lose limbs to diabesity or drop dead of a heart attack.

i firmly believe that fat bodies should not be stigmatized, that all bodies and sizes should be treated with respect, but i don't support the view that a person can be genuinely healthy in a wholistic sense at 600 pounds (as an example) and counting, even if they happen to be among the few who happen to have normal blood sugar, cholesterol etc. so far. wellness is more than that, and all kinds of damage is being done by obesity which may not have shown in measurable ways yet, for some, but will at some point.

 

[Munchkin]

Another angle to consider here is why do you think that insurance companies are deciding more frequently of late that it’s actually in their best "Financial interests" to cover WLS. The numbers (the math) must be reasonably compelling for them to recognize this?? I know maybe Govt regs factor in also, but that has to be part of the equation or they’d be fighting it more??

I wish more people had coverage for WLS. Years ago I had the opportunity to discuss the DS for DM2 with someone in the insurance industry. This was pre-ACA. To me, it should be simple. You get diagnosed and you go get a few feet of intestine lopped off and there's a 90% chance you will be cured. Voila!

But hell no. Here's how THEY see it. You will change insurance carriers on the average every 3 years. They are betting, just like a hand of poker, that you will need only maintenance care while they are insuring you. By the time you go blind or need something amputated, you will have moved on to another carrier and stick them with the bill. They love all those old pre-existing conditions loopholes.

It's all about the money. And playing the odds. They care not one whit about you or your health.

 

[Munchkin]

I have always despised every ounce of my flubber. But over the years I have had many fat friends and acquaintances who argued the fat can be fit premise. Some even embraced it as a lifestyle and joined organizations like NAAFP. Most of these folks eventually became SSMO. We had to agree to disagree to remain friends.

The decades passed and I got old. So did they. I am happy to say most of my fat friends are still around but at this point I can't guess for how long. They are now all in dismal shape health-wise. One is even contemplating moving to a nursing home because she needs help with daily living tasks. And another is always being hauled off in an ambulance because of all her issues with CHF. And it hurts my soul to see these folks using walkers and wheelchairs when they should still be out dancing. Discussing CPAP settings instead of new lovers.

Some of them still have their blinders on. They just refuse to see they have lived half a life because of their size and it's only going to go downhill faster. A couple of them still think I am a nutbag to have opted out of old age as a fattie. Sigh. Somehow they just can't see the difference between us is that I got rid of the fat.

Anyway, after observing all these folks for decades, I can say for sure fit and fat is seriously flawed and does not stand up over time. Some say that having WLS makes you medicalized for life. Compared to what these people are going through now, our medical issues are nothing.

 

[more2adore]

Well said, Munchkin. I was a card-carrying member of NAAFA for quite some time. I still strongly believe that size doesn't have to hold us back from dating, from social lives, etc. and that fat people deserve to be treated equally and with respect. And I do also believe that it's not true that health chickens will come home to roost for EVERYBODY. You can't tell someone's health just by looking at their size. But I do know that for me, existing at 600 pounds was not maintainable. It wasn't life. And when I started a new life with a new husband, I wanted more out of life for myself. I didn't want this half-life where I have to constantly be cognizant of seating in restaurants, or how much walking might be involved with going somewhere (and opting out). I know many people who do not feel held back by their size, who do not have health issues - and it is THEIR body, and their right to do whatever they want, whenever they want with it and be happy. It wasn't until this year that I really started feeling held back. I want life to the fullest, and I want it now. I only wish I had been mentally ready a decade ago so I wouldn't have missed out on so much. But I wasn't ready - and I likely would have had RNY probably and failed. So.. things happen when we're ready for them. Different people become ready at different stages of their lives. No need to feel sorry for them or pity them - they wouldn't want it, and it would in fact likely make them angry. Let them live their lives. If eventually things do go downhill for them, it will be their choice then what, if anything, they want to do about it. Body autonomy.

 

[DianaCox]

Well said, Munchkin. I was a card-carrying member of NAAFA for quite some time. I still strongly believe that size doesn't have to hold us back from dating, from social lives, etc. and that fat people deserve to be treated equally and with respect. And I do also believe that it's not true that health chickens will come home to roost for EVERYBODY. You can't tell someone's health just by looking at their size. But I do know that for me, existing at 600 pounds was not maintainable. It wasn't life. And when I started a new life with a new husband, I wanted more out of life for myself. I didn't want this half-life where I have to constantly be cognizant of seating in restaurants, or how much walking might be involved with going somewhere (and opting out). I know many people who do not feel held back by their size, who do not have health issues - and it is THEIR body, and their right to do whatever they want, whenever they want with it and be happy. It wasn't until this year that I really started feeling held back. I want life to the fullest, and I want it now. I only wish I had been mentally ready a decade ago so I wouldn't have missed out on so much. But I wasn't ready - and I likely would have had RNY probably and failed. So.. things happen when we're ready for them. Different people become ready at different stages of their lives. No need to feel sorry for them or pity them - they wouldn't want it, and it would in fact likely make them angry. Let them live their lives. If eventually things do go downhill for them, it will be their choice then what, if anything, they want to do about it. Body autonomy.

You had me until "I do also believe that it's not true that health chickens will come home to roost for EVERYBODY." Unless you mean by that the rare 400+ person who lives to be 80 (the average lifespan for a woman), that is essentially not true.

http://www.cancer.gov/newscenter/newsfromnci/2014/ClassObesity

The Y axis is YEARS OF LIFE LOST. Meaning DIED early. "To provide context, the researchers found that the number of years of life lost for class III obesity was equal or higher than that of current (versus never) cigarette smokers among normal-weight participants in the same study."

http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001673

Table 3 compares total and cause-specific mortality rates (deaths per 100,000 persons per year) for the class III obesity and normal-weight groups separately by sex. Total mortality rates for class III obesity participants were 856.0 in men and 663.0 in women. The differences in mortality rates for the two BMI groups were 509.3 and 382.5 in men and women, respectively. Heart disease was the most common underlying cause of death for the class III obesity group (mortality rate differences were 238.9 and 132.8 in men and women, respectively), followed by malignant neoplasms (mortality rate differences were 36.7 and 62.3 in men and women, respectively), and diabetes (mortality rate differences were 51.2 and 29.2 in men and women, respectively). Higher rates of death were also observed for nearly every other major cause of death that we examined, apart from cerebrovascular disease in men and malignant neoplasms of respiratory and intrathoracic organs and diseases of the arteries, arterioles, and capillaries in women, although not all of these differences were statistically significant because of the relatively small numbers of deaths in the class III obesity group for some of the major causes (e.g., malignant neoplasms, chronic lower respiratory disease, and nephritis/nephrotic syndrome/nephrosis deaths in men). The negative rate differences that were observed were also based on small numbers of deaths in the class III obesity group (five, eight, and five deaths due to cerebrovascular disease, malignant neoplasms of respiratory and intrathoracic organs, and diseases of the arteries, arterioles, and capillaries, respectively).

http://www.plosmedicine.org/article...ournal.pmed.1001673.t004&representation=PNG_L

Table 4 shows the minimally adjusted and multivariable-adjusted HRs [hazard ratios] for death across categories of BMI and for continuous (per 5 kg/m2) values of BMI restricted to the BMI 40.0–59.9 kg/m2 range. In minimally adjusted models, we observed a sharp gradient in relative risk with higher values of BMI across the class III obesity levels that was consistent with a linear increase. The HRs from models of BMI categories were slightly, but not fully, attenuated with additional adjustment for race/ethnicity, education, alcohol intake, and physical activity level. Compared with adults with BMI in the 18.5–24.9 kg/m2 range, multivariable-adjusted HRs (95% CIs) for those with BMI of 40.0–44.9, 45.0–49.9, 50.0–54.9, and 55.0–59.9 kg/m2 were 2.25 (2.07–2.43), 3.32 (2.92–3.77), 3.48 (2.82–4.31), and 5.91 (4.24–8.24), respectively. This trend of increasing risk of death with increasing level of BMI was apparent in categorical and continuous models (HR per 5 kg/m2 = 1.40, 95% CI: 1.31–1.51) after restricting to the BMI 40.0–59.9 kg/m2 range.

I wonder if anyone can find out how many 400+ lb 70 or 80 year olds there are? I'm trying to figure out how to search that.

 

[southernlady]

Not disagreeing, Diana but studies show a phenomena called the "Obesity Paradox" esp in heart disease. But it seems to be just in the overweight and obese, not those classed as MORBIDLY obese.

http://care.diabetesjournals.org/content/36/Supplement_2/S276.full

Obesity paradox in overweight and obese patients with coronary heart disease
Ten years ago, Gruberg and coworkers observed better outcomes in overweight and obese patients with coronary heart disease undergoing percutaneous coronary intervention compared with their normal-weight counterparts. This unexpected phenomenon was described as “an obesity paradox” (2). Normal-weight patients had higher incidence of major in-hospital complications, including cardiac death. Moreover, at 1-year follow-up significantly higher mortality rates were observed in low- and normal-weight patients compared with obese and overweight. A systematic review of 40 cohort studies with 250,152 patients found significantly lower risks for total mortality (RR 0.87) and cardiovascular mortality (RR 0.88) in overweight patients (3). These mortality risks were not increased in obese patients (BMI 30–35 kg/m2) compared with normal-weight subjects. However, severely obese patients (BMI ≥35 kg/m2) exhibited the highest risk (RR 1.88) for cardiovascular mortality (3). The obesity paradox was also confirmed in patients with hypertension and coronary heart disease (4). In hypertensive patients, the occurrence of death, nonfatal myocardial infarction, or nonfatal stroke was lower in overweight patients (RR 0.77), class I obese patients (RR 0.68), and class II and III obese patients (RR 0.76) than in patients of normal weight. In this large cohort of hypertensive patients (n = 22,576), an obesity paradox was driven primarily by a decreased risk of all-cause mortality. Furthermore, in a recent Dutch study with a 7-year follow-up, overweight, but not obesity, was associated with a lower risk (RR 0.60) for all-cause mortality after percutaneous coronary intervention (5). This is in line with the previous study of Hastie et al. (6), who also found the best prognosis after percutaneous coronary intervention in overweight patients. Those with a BMI ≥27.5 and <30 kg/m2 were at reduced risk of dying during 5-year follow-up (RR 0.59). A recent study on an association of BMI with mortality in patients with acute myocardial infarction requires special attention (7). BMI was inversely associated with a crude 1-year mortality rate: normal weight 9.2%, overweight 6.1%, obese 4.7%, and morbidly obese 4.6% (P < 0.001). This protective effect of overweight and obesity was not modified by age, sex, or the presence of diabetes. However, the mortality hazard in patients with myocardial infarction increased in subjects with BMI >40 kg/m2. The manifestation of this obesity paradox was also shown in older patients with coronary artery calcification (8). In 9,993 patients (mean age 66.6 years) with clinically significant coronary lesions who had undergone percutaneous coronary intervention, an inverse relationship between BMI and coronary artery calcification was observed. This finding supports a “calcification paradox,” whereby reduced bone mineral density in the elderly is related to increased vascular calcification (9).

For others reading this:
The most commonly used definitions, established by the World Health Organization (WHO) in 1997 and published in 2000.
BMI (kg/m2) Classification
< 18.50 underweight
18.50–24.99 normal weight
25.00–29.99 overweight
30.00–34.99 class I obesity
35.00–39.99 class II obesity
≥ 40.00 class III obesity

Some modifications to the WHO definitions have been made by particular bodies. The surgical literature breaks down "class III" obesity into further categories whose exact values are still disputed.[19]

• Any BMI ≥ 35 or 40 kg/m2 is severe obesity.
• A BMI of ≥ 35 kg/m2 and experiencing obesity-related health conditions or ≥40–44.9 kg/m2 is morbid obesity.
• A BMI of ≥ 45 or 50 kg/m2 is super obesity.

As Asian populations develop negative health consequences at a lower BMI than Caucasians, some nations have redefined obesity; the Japanese have defined obesity as any BMI greater than 25 kg/m2[20] while China uses a BMI of greater than 28 kg/m

 

[more2adore]

I just meant nothing is true of absolutely everybody. There are exceptions to every rule. Also, as people get older (80s and beyond) many tend to lose some weight naturally... at least, that's what seems to happen to the people in my family. They lose their sense of taste and smell to some degree to the point where food isn't as appetizing and the eat much smaller portions. There's a reason for the existence of the senior menu.

I do know some older (60s and 70s) morbidly obese women, some of whom are even still relatively healthy. Like I said... exceptions to every rule. But the older I get the more I do believe that health issues will happen for most people as they get older, ESPECIALLY for those 400+ pounds. I'd get booed out of the size acceptance community for saying even that, probably.

 

[DianaCox]

I note all of the above is true, but that following must also be taken into account:

• The obesity paradox applies to a population I was not discussing - the less-than-morbidly obese. And while the obesity paradox applies to coronary artery disease, I don't believe it applies to the other diseases and comorbidities of obesity.
• My own mother is nearly 83, has been morbidly or super morbidly obese essentially her whole life, and is not dead yet. And she too has lost weight over the last few years, and may be under 300 lbs now (though not by much - and she is or was nearly 6' tall). But she is also essentially housebound in her retirement home apartment; people bring her meals to her, she is incontinent of both urine and stool, can barely walk due to the damage to her knees, can't get in and out of bed unassisted so she lives in a recliner, has T2D and severe cellulitis in her legs and some sort of edema (probably lymphedema) in her yards of excess skin - it is not much of a life. And of course she won't do anything about any of it, other than FINALLY agreeing to get her legs wrapped. So yes, it is possible (albeit unlikely) to LIVE longer - but in what kind of shape?
• A six times higher hazard ratio - i.e., the ratio of the rate of death per unit time between the reference population and control - for BMI > 55, is obviously hugely significant.

I'm just a stickler for correct application of statistics and especially absolutes.

 

[conceit]

@more2adore

I agree that simply being fat doesn't mean a person is necessarily unfit. But, as I said, there's a certain point (past a certain weight) where the chances of remaining healthy diminish steadily. I don't advocate telling people what to do with their bodies, but I won't lie that people in the size acceptance community who push the healthy at any weight agenda make me all kinds of irritable. People have a right to make informed choices, and any social movement that promotes an agenda, contrary to available evidence and scientifically validated research (which even when questioned from every angle, makes it hard to confirm that obesity at any size is possible for most), and enforces it with social sanctions, is utterly misguided. Bodily autonomy is not about encouraging or hell socially coercing people (however subtly and passive aggressively) on a fast track to ill health to stay fat even when WLS would improve the quality of their life and health. Autonomy is about respecting the right to individual choices. In presenting and pushing biased and even harmful information on people to the point where getting WLS at 500 pounds+ has gotten them ostracized or to the point where even saying what you did would get a person alienated from their peers..the movement and the community do a great disservice. It's also extremely hypocritical to push for body autonomy, and then not respect people for choosing surgical options.

And the obese folks who choose their ill health by refusing to even consider WLS (not talking about those who have their hands tied financially or want it but are struggling), instead choosing to sneer at and shame those who do, make it hard not to feel sorry for having blinders on to the point where loyalty to a misguided message keeps them from making the best choice for their situation. Of course, I am not saying anyone should express this around them, directly or indirectly, but we have a right to our private thoughts. And, these are mine. I am just not ever going to be on board with the fit at any size message, personally. We can respect people's right to make their own choices without necessarily agreeing with the choices they make. I am sorry you've been treated poorly in the community for choosing WLS.

 

[DianaCox]

"People have a right to make informed choices, and any social movement that promotes an agenda, contrary to available evidence and scientifically validated research (which even when questioned from every angle, makes it hard to confirm that obesity at any size is possible for most), is utterly misguided."

In high school, I had a deaf girlfriend, whose parents raised her away from the deaf community. She was given an intensive education in speaking, lip reading and integration with the hearing community. But she ended up attending Gallaudet University (for the deaf) and became a part of that community as well - and eventually became a deaf advocate - during those years, we drifted apart (both because of interests and physical distance). We had just reconnected in our early 30s when she was murdered by a deaf man who was obsessed with her, but in whom she was not interested. I bring this up mostly to establish my passing familiarity with some of the deaf community issues. Because there is a somewhat related issue in the deaf community - whether to allow cochlear implants in deaf children of deaf parents. Many people in the deaf community take a hard line about deafness being treated as a disability. See this article: http://www.dailykos.com/story/2013/11/17/1256259/-The-Cochlear-Implant-Controversy

Language development is very much on a time clock - so cochlear implants for profoundly deaf children should be done when they are infants or toddlers in order to get the best results in both hearing and language. So these are decisions that have to be made by parents, not the deaf child. But cochlear implants can also help deaf adults, and that's where the philosophical reasons behind some of the decisions to get them or not really parallels the decision to get bariatric surgery to some degree. Of course, people don't DIE of deafness, but the deaf culture/fat acceptance philosophical discussion is very similar.

 

[conceit]

The parallels are truly striking, Diana, and personally, no less aggravating. That entire piece was full of red herrings, strawmen (it doesn't matter if some deaf people can't get CIs because of anaesthesia problems, because advocates for CI are not saying that people for whom it is medically suitable go for it regardless) and false analogies (comparing deafness to having blue eyes'). I don't believe that obesity and deafness should be treated as pitiable conditions (which is patronizing and disrespectful, a good term i learnt on everydayfeminism.com was "concern trolling" which applies here) or seen as crippling or unquestionably wholesome all or/nothing states of the body which basically sets up a bunch of misleading false dichotomies in these types of emancipatory movements and interest groups, as per their goals - either you are with us (no WLS or CIs)/against us sort of mindsets that ultimately cause tangible damage. Deafness by definition is a disability, which can't be wished away. Demanding dignity, non-discrimination and so on for the affected is not mutually exclusive with the fact that deafness is a disability or that obesity is a medical condition. Claiming obesity is not a medical condition and WLS is traitorous is nothing but a bunch of unscientific illogical bullshit, and morally problematic because of the hypocritical contradictions I pointed out re: the concept of autonomy that is promoted in these circles.

I am sorry about your friend. She could have had a much better quality of life, and possibly, even a longer life had she not been as limited by deafness. A CI would have made a difference.