Lisa, a 43-year-old mother of two, came to see me shortly after her 40th birthday. Her concern was a common one: 40 hit and the formation of a spare tire came right along with it. Lisa has always been, in her words, pudgy, but at 43, her body mass index (BMI) hit the official “obesity” number and it scared her.
The person not scared, however, was her doctor. After all, her lipid panel, blood sugar and blood pressure were still within normal range. She was obese, yes, but in her doctor’s mind, still healthy due to a lack of any adverse changes in her metabolic profile. I encouraged Lisa to listen to her initial gut reaction, acknowledge her fear and continue working with me to reach a normal weight. It was not too late to keep those beautiful numbers her doctor loved to see. One day, however, they could all go up.
“Healthy obesity” was coined almost 40 years ago
The concept of healthy obesity emerged in the 1980s as a way to describe obese individuals who had no metabolic risk factors. Recently, however, the idea has been challenged. A 2015 study that tracked more than 2,500 men and women for 20 years found that over time, more than half of the obese study participants developed elevations in metabolic risk factors.
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The most common disease that plagued the once-healthy obese participants was heart disease. In fact, a 2017 study looking at over 3.5 million individuals found that metabolically healthy obese individuals had a higher risk of heart disease, stroke and heart failure. A 2018 study confirmed these results as well when it showed in over 6,000 individuals that half of the participants with 30 or more pounds to lose developed metabolic syndrome within 10 years.
"Healthy obesity" and "skinny fat" are not the same
"Healthy obesity" is different from another popular term “skinny fat,” which describes someone with a normal BMI, but with a higher percentage of fat and low muscle mass. "Skinny fat" individuals, however, may share the same future outlook that "healthy obese" individuals have as well — it works until it doesn’t work. In time, age and other factors may contribute to even greater decreases in muscle mass, and with them, increases in fat mass as well.
The term “healthy obese” may keep you from reaching your weight loss goals
Not everyone who falls into the obese category will develop a disease. Genetics plays a role, and where the fat is distributed matters as well. For example, carrying fat in the central trunk region, where it is metabolically active and close to organs, has been shown to be more dangerous than fat that's distributed in the buttocks and thighs.
Finally, your ratio of muscle-to-fat also should be assessed. I know body builders who have a BMI in the obese category that’s due not to being obese, but because the weight is contributed by an extremely high muscle mass.
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For everyone outside of these outliers, though, it’s time to change. Some medical experts fear the term “healthy obese” discourages both physicians and patients from thinking about weight loss as an approach to disease prevention. I’ve seen it in my own “healthy obese” patients who come to me with the goals of eating better, but don’t want to have a conversation about having to lose weight as well.
What to do if you feel you are “healthy obese”
First, take a look at what lifestyle changes you might need to make to start reaching for a normal BMI. For some people, it’s managing stress; for others, it’s starting an exercise routine that includes resistance training, aerobic training, or both; and for others, it’s about eating better and/or eating less.
Here’s what not to do: Ignore the fact that you need to lose weight because your risk factors aren’t showing up at a doctor’s appointment. Doing so may not only sell yourself short, but your life eventually could be cut short as well.
Kristin Kirkpatrick, MS, R.D., is the manager of wellness nutrition services at the Cleveland Clinic Wellness Institute in Cleveland, Ohio, and the author of "Skinny Liver." Follow her on Twitter @KristinKirkpat.