Doctors say we are focusing too much on weight, but thin people can sometimes carry the most dangerous kind of fat—and not know it
When Elizabeth Chanatry was 16 years old, she was diagnosed with type 2 diabetes. You’d never know it by looking at the 5-foot-3-inch tall, 117-pound 19-year-old, but even Chanatry admits that she’s not as fit as she could be. “My sister and I are not toned, but we are thin,” she says. Chanatry has genetics to thank for her physique, but also for her diabetes—her older sister and father both suffer from the disease too. For as long as she could remember Chanatry drank Diet Coke and asked for sugar-free syrup to avoid too much of the sweet stuff, but when she started to get symptoms for diabetes, she knew it hadn’t been enough.
Obesity is a serious epidemic in the U.S., but the problem, doctors say, is that we are putting too much weight on weight. When the CDC released obesity numbers last week, we cheered that the rate had fallen so drastically for children ages 2 to 5, even though obesity rates overall remained relatively flat. People with stellar metabolisms and magical genes may not look the part, but they can have the same medical issues as an obese person: type 2 diabetes, high blood pressure, high cholesterol, and out-of-control blood sugar. It should be obvious, but a culture obsessed with weight doesn’t always remember that appearances of health can be skin deep.
“I see these people all the time,” says Dr. Daniel Neides, medical director at Cleveland Clinic’s Wellness Institute and Chanatry’s doctor. “On the outside they look incredibly healthy, but on the inside they’re a wreck.” You likely know someone who’s “skinny fat.” They never eat vegetables, love steak, and haven’t exercised since eighth grade gym class—and yet they’re still thin. Perhaps it’s you. But while some of us are envious of our svelte peers who don’t count calories or think twice about having a donut for breakfast, doctors say we shouldn’t be. Skinny fat is a real, and remarkably common, phenomenon—deadly even.
Dr. Neides cites a male patient who, at 46 years old, was a normal weight and what’s generally considered healthy BMI. But when he decided to stop taking his blood pressure medication, he had a stroke that has since left him wheelchair bound.
A 2008 study found that about one-fourth of U.S. adults with normal weight have some form of an unhealthy heart, like high blood pressure or cholesterol. Older adults with normal BMIs (well-known to be an imperfect measurement) but high levels of body fat are at greater risk for cardiovascular disease and death than previously realized, according to a 2013 study published in the American Journal of Cardiology. More recently, a 2014 report on people with “normal weight obesity”—normal BMI, high body fat—found that they have a significantly higher risk of metabolic problems and death from these diseases than any other group.
“When you’re eating a diet high in sugar and processed foods, it causes visceral fat storage, and that can lead to all sorts of risk factors of being overweight,” says Dr. Mark Hyman, author of The Blood Sugar Solution 10-Day Detox Diet. Sometimes a person may not have a lot of fat stored up overall, but what they do have is the most dangerous kind. So a person may not be heavy, but their organs could be coated with visceral fat, whose origins, researchers recently discovered, are genetically different from that of subcutaneous fat. This can cause metabolic syndrome—when someone has several conditions, like high blood pressure and high blood sugar, that put him or her at a high risk for heart disease, diabetes, or stroke.
While the U.S. continues to battle the bulge, many of us are forgetting about the importance of also getting fit. The reaction to a 2012 study that showed that overweight people can be fit goes to the heart of our misunderstanding about fitness. “Everyone got really fixated on the people who were obese but not metabolically sick due to high fitness levels, but what was lost in the message was that we had plenty of people with a BMI below 25 but were unfit and at a high risk,” says Dr. Timothy Church, lead author of the study.
Weight is just one clue doctors look to for an indicator of poor health. But to see what’s really going on, they have to peek under the hood. “The scale is not a proxy for your health,” says Dr. Church, director of the Laboratory of Preventive Medicine at Pennington Biomedical Research Center in Baton Rouge. More research on lifestyle changes is showing remarkable impacts on chronic disease. A 2013 study found that people at a high risk for developing type 2 diabetes could avoid the disease by developing healthier diets, exercising daily, managing stress, and quitting smoking.
It’s another reminder of the importance of the yearly exam, where doctors can screen for measures like high blood pressure and cholesterol and, if something looks off, they can also screen for C-reactive proteins (CRP), which are indicators for inflammation. High inflammation levels account for the majority of diseases that affect Americans.
For her part, Chanatry has no illusions about weight being an indicator of health. “I’ve never associated [diabetes] with obese people because it’s always been a part of my life. I’ll always have it. People look at us and think we’re healthy, but they don’t know.”
New research shows you can’t judge a person’s fitness by looks alone. Here, the surprising new thinking on size and exercise.
Originally published in FITNESS magazine, June 2013.
Your Weight and Fitness
There are two large women who’ve been in boot camp with me for years. They almost never miss a class and never take it easy. Yet as I’ve lunged, squatted, and planked alongside them nearly daily, I’m ashamed to admit that one question has occasionally bounced around my brain: With all that exercise, after all this time, why aren’t these women in better shape?
Then came the 2012 Olympic Games. The world was poised to witness its most formidable female athletes lock horns in London. And what did we hear? Slams against Australian swimmer Leisel Jones, declaring the eight-time medalist fat and thus unfit to represent her country. Cheap shots about muffin tops and saddlebags on the British women’s beach volleyball team. And tweets about British swimmer Rebecca Adlington’s physique that became so vicious, she dropped off Twitter altogether. “These women made it to the Olympics, for god’s sake. How unfit could they be?” I found myself ranting at the TV.
Then I thought, sheepishly, about the women at boot camp. It became clear to me that the knee-jerk connection I and apparently others might make between how much a person weighs and how physically fit and healthy she is needed some serious reevaluation.
The New Thinking on Weight
Recent research suggests that being overweight or even obese may not, in and of itself, be the health threat we think it is. A 2012 study from the National Cancer Institute found that moderately obese people actually lived about 3.1 years longer than normal-weight women and men. Another study, published in theEuropean Heart Journal, showed that when obese people are metabolically healthy — which means their blood pressure, cholesterol, blood sugar and other indicators fall within a healthy range — they are at no greater risk of dying from heart disease or cancer than those who are of normal weight.
“What we’re learning is that a body that exercises regularly is generally a healthy body, whether that body is fat or thin,” says Glenn Gaesser, PhD, a professor of exercise and wellness at Arizona State University and the author of Big Fat Lies: The Truth About Your Weight and Your Health. Case in point, the metabolically healthy participants in the European Heart Journal study were generally more physically fit than their obese peers. “The message should really be that if you are exercising regularly, you shouldn’t necessarily be looking at the scale to determine how healthy or fit you are,” Gaesser says.
There are a multitude of reasons that movement is such strong medicine: Because muscles are the largest consumers of sugar in the body, increased muscle mass reduces the chance of excess sugar accumulating in the blood, which is essentially what diabetes is. Regular physical activity reduces inflammation in the cardiovascular system and affects the secretion of clotting hormones, allowing blood to flow more easily to muscles and preventing the formation of deadly clots. Moderate exercise (at least 150 minutes a week of medium-intensity exercise like walking) combined with diet changes can also reduce the amount of potentially deadly fat in the liver. And study after study has shown that overweight and obese people who work out can reap such benefits and improve their metabolic health even if they don’t shed a pound.
How Fat and Weight Affect Your Health
The Skinny on Fat
None of this is to say that we can pack on pounds without worry. Carrying a lot of weight around increases stress on joints and can make us less inclined to be active. There’s also the plain reality that the more overweight you are, the more likely it is that your metabolic health will take a hit, now or in the future. “Given the choice, I come down almost always on the side that being overweight is a bad thing,” says Walter R. Thompson, PhD, a professor of exercise science at Georgia State University in Atlanta.
But choice is a loaded word for many obesity experts, as well as for countless individuals who have waged a lifelong war with their weight. “I spent the first part of my life struggling with being fat. I would lose weighton diets, gain it back, and each time end up feeling horrible about myself,” says Hanne Blank, the author ofThe Unapologetic Fat Girl’s Guide to Exercise and Other Incendiary Acts. “Only as I’ve come into my own as an adult have I made peace with the fact that I may always be big.” It’s a brutal realization that seems to bear itself out in the big picture: As many as two-thirds of us end up regaining more weight than we lose while dieting.
Pinning ambitious weight-loss hopes on exercise hasn’t panned out too well, either. At five feet four inches and 172 pounds, Sherry Norris, 42, of Norcross, Georgia, knows this firsthand. A dedicated exerciser, Sherry alternates running and working out to the Insanity DVD program on most days and ran her first marathon last year. “I’ve followed all the directions and done the training plans, and I’ve lost exactly five pounds. At this point I have no idea how to get the weight off,” she says.
Within the past few years numerous studies have borne out exactly what Sherry is experiencing: Despite the extra calories we burn, many of us fail to lose weight — and may even gain some — after embarking on an exercise program. This could be because our appetite is triggered by vigorous activity; we reward ourselves for our efforts with food, or we spend more time vegging out on the couch when we’re not at the gym.
Then there’s the tricky topic of metabolism. “Exercise doesn’t rev up the metabolism, as we’ve been led to believe,” says Diana Thomas, PhD, an author of a study from the Center for Quantitative Obesity Research at Montclair State University in New Jersey. “We found that when volunteers who were put on an exercise regimen began to lose weight, their metabolic rate — how many calories they would burn while sitting and doing nothing — actually began to drop.” Thomas and her colleagues suspect that metabolic slowing may be the body’s protective attempt to preserve energy when it senses that more calories are being burned through exercise. Plus a fit body operates more efficiently — the heart doesn’t have to pump as fast, breathing is less rapid — and that also reduces how many calories we burn all day.
Making long-term weight loss even more elusive is the fact that we each may have our own personal set point, a range of about 10 to 20 pounds in which the body biologically tries to stay despite our efforts. This means that weight loss is biologically resisted in some people. Also, our appetite makes it too easy to override the upper threshold of our set-point range, so we gain weight, says Linda Bacon, PhD, the author of Health at Every Size: The Surprising Truth About Your Weight.
The net result of these many hurdles: Even if people do lose some weight from exercise, they often don’t lose as much as they expect to. For many, that’s reason enough to abandon boot camp and head back to the couch.
Eyeing a Different Prize
That, Thomas says, is a crying shame. Because even if pounds don’t disappear, a big fat change is probably taking shape. “Adding regular physical activity can reduce the proportion of fat to muscle and affect where fat is distributed,” Thomas says. In particular, as little as a 20-minute daily walk can reduce the amount of visceral fat that reaches deep into the abdomen. That’s the fat that health experts worry about, because it is linked to heart disease, diabetes, and a higher mortality rate. There’s even evidence suggesting that exercise stimulates the production of a substance called irisin in muscle tissue. This hormone appears to transform white fat cells, like those in belly fat, into brown fat cells, which are metabolically active and actually burn calories.
“The scale doesn’t necessarily reflect all of this,” Thomas says. Neither does the body mass index (BMI), which uses only height and weight to estimate how much body fat we ostensibly have. This is why a growing number of doctors are now measuring patients’ waist circumference as part of their standard physical exams. And it’s why Thomas and colleagues at Pennington Biomedical Research Center in Baton Rouge, Louisiana, have devised an index that takes body shape into account when assessing a person’s health. The body roundness calculator (pbrc.edu/bodyroundness) uses hip and waist measurements in addition to weight and height. The closer to a circle shape a person is, the more visceral body fat she has. “We’re catching people who are out of the ‘safe shape’ zone but who are not visibly apple shaped. There are also people whose BMI may indicate obesity but whose body roundness is healthy. It’s a much better reflection of a person’s health overall,” Thomas says.
Overweight and Athletic
But can women who are packing an extra 25, 50, or even 75 pounds on their frame actually kick ass athletically? “They might pay a price when it comes to speed,” says Chuck Hobbs, the head coach for Fit2Train, a triathlon team in Dallas. But in terms of strength and endurance, the answer is, hell, yes. Consider the group of athletes recruited for a recent study at the Institute for Exercise and Environmental Medicine at Texas Health Presbyterian Hospital of Dallas. All of them are seriously accomplished, having participated in multiple Ironman competitions, marathons, or distance cycling events. And all of them are obese, with fat making up more than 30 percent of their body weight. “From a cardiorespiratory standpoint, they are very strong and very healthy,” says the study’s lead author, Santiago Lorenzo, PhD, a cardiopulmonary researcher at the institute. “They have outstanding endurance and are comparable in fitness to fellow athletes of normal weight.”
What’s more, Lorenzo and other experts suspect that an obese athlete’s body can actually become stronger from carrying its own weight. In essence, the extra pounds provide built-in resistance training, especially for the lungs, which can have trouble inflating fully when there is a lot of fat in the chest cavity. “The bodies of the obese athletes in our study have adapted after years of conditioning,” Lorenzo explains. “They have developed an ability to generate higher airflow and deliver ample oxygen to their blood and muscles. For typical obese people who want to become active, this may mean that they are not going to have the limitations we previously assumed they would.”
Minor Changes, Major Benefits
For those who set their sights on the fat-but-fit paradigm and aspire to a healthier body, metamorphosis doesn’t come easy, however. Packing extra poundage can make it hard to get down on the floor or up from it or to move freely. There’s also an emotional component: “They need to find environments where they won’t be bullied and where they can actually enjoy and excel at what they’re doing,” Hobbs says. “When they are confident about what their body can do, they become more motivated to take good care of it. Real change begins to happen.”
When the author Hanne Blank retrained her focus on exercise instead of food, her eating habits and her weight finally reached an even keel after years of yo-yoing. And every one of the active large women interviewed for this story drove home the fact that making regular exercise a part of her life has caused her to feel happier as well as more empowered, attractive, and inclined to take on greater physical challenges.
All of which is reason for us to stop using the word normal when we talk about weight and start focusing on realistic goals and expectations, including exercising regularly and being more active every day. These are words to live by for Blank, who is happy just to get out and get sweaty. “It’s been almost 10 years since I took my life off hold and decided to become physically active in spite of my weight. I’m out there almost every day, walking, biking, hiking, or weight lifting. I feel comfortable in my body. I’m energetic and healthy,” Blank says. “But even people close to me sometimes shake their heads and ask why I’m still fat. And I tell them, ‘Because I am. That’s just what I’ve got!'”
Are You Heavy?
Don’t stop moving just because the scale has. If you’re feeling discouraged, keep these important points in mind.
There’s no need to suffer.
If you detest every minute you spend on a treadmill or Spinning bike, you’ll never stick with it. Find an activity — kickboxing, ballroom dancing, walking with friends — that you’ll want to make a near-daily part of your life.
You’re not alone.
Does being surrounded by smaller, buff bodies at the gym sound like hell? Sign up for tours at several clubs near you to find one where you’ll feel comfortable and that has classes that appeal to you. Party-atmosphere Zumba classes are particularly welcoming, as are CrossFit classes, where there’s a team dynamic.