A recent study in the Journal of the American College of Cardiology raised questions about the concept of “healthy” obesity and the idea that a patient can be “fit, but fat.”

MedpageToday contacted dietary and cardiology experts and a variety of healthcare professionals and asked:

Should the conversation with the patient change based on the Fit-Fat data from this study?

The participants are:

Carl “Chip” Lavie, MD, FACC, medical director, cardiac rehabilitation, and prevention at the John Ochsner Heart and Vascular Institute in New Orleans

Leslie J. Bonci, MPH, RD, CSSD, LDN, director, sports nutrition at the University of Pittsburgh Medical Center Center for Sports Medicine in Pennsylvania

Jana Klauer, MD, a physician in private practice in New York City

Martin Binks, PhD, associate professor, nutritional sciences, behavioral medicine, and translational research lab at Texas Tech University in Lubbock

Bruce Y. Lee, MD, MBA, director, Global Obesity Prevention Center (GOPC) at Johns Hopkins University Bloomberg School of Public Health

Merle Myerson, MD, director, Center for Cardiovascular Disease Prevention at Mount Sinai Luke’s and Mount Sinai Roosevelt hospitals in New York City

Elizabeth Kitchin, PhD, RD, assistant professor, division of clinical nutrition and dietetics at the University of Alabama Birmingham School of Health Professions

Beyond BMI

Carl Lavie, MD: “In a perfect world, everyone would be lean, fit, and metabolically healthy (meaning good blood pressure, glucose, and lipids) throughout life, but the most important factor for long-term prognosis is fitness, which is much more important than fatness, for long-term risk. The major determinant of fitness is regular physical activity. The bottom line is that lean and fit and overweight/obese and fit stay healthy by maintaining high levels of physical activity. Therefore , a major decrement in health (and metabolic health) is due to decrements in physical activity and therefore fitness.”

Leslie Bonci, MPH: “The results of the study demonstrate that long term, being obese does have a negative impact on health. But that does not mean we need to focus on diets or extreme exercise. Instead, the emphasis is on gradual changes, educating patients on how to get healthier and finding the deal maker for that patient. The consequences of behavior should be to live long and live well, with strategies that are attainable, maintainable. and sustainable.”

Martin Binks, PhD: “It is always prudent to focus on increasing physical activity and fitness and also to ensure that our patients value this at least as much if not more than the number on the scale. In some cases, due to a wide range of factors noted above, weight loss is essential in combination with improved fitness, in other cases it may be more important to focus primarily on improved health overall with far less emphasis on the scale.”

Jana Klauer, MD: “While BMI is a quick assessment of body weight, the more important variable is percentage of body fat and how it is distributed. Body fat that is concentrated around the abdomen raises the risk for disease, independently of BMI. Measurement of waist size should be part of every physical exam; I am surprised by the number of physicians who do not measure this!”

Applications for Patient Care

Bonci: “We should address physical, nutritional, and emotional fitness. Ask your patients about energy levels, what they do to move, or how much of their time do they spend sitting, Do they tire more easily? Do they choose stairs or elevator, does walking make them winded or cause pain. Nutritionally ask about the number of meals consumed daily, as well as plate, food preferences, and beverage choices. Ask about emotional fitness — what is motivating them, what would they like to change and how can we be of help.”

Elizabeth Kitchin, PhD: “As a behaviorist and patient counselor, I look at patients more as individuals than as a population. If I have a patient who is overweight or obese, and that patient is physically active, eating an overall healthy eating pattern, and has most of his or her numbers in a fairly healthy range, I am going to encourage them to continue those healthy behaviors. However, I would probably make it clear that too much weight is risky – so avoiding weight gain over the years is really important.”

Bruce Lee, MD: “A given body mass index could have different consequences for different people, meaning what might be healthy for one person might be unhealthy for another. A patient is a very complex system, therefore, a single measure cannot assess a single system. Similarly, a single measure cannot determine a person’s health. Physicians use a combination of various measurements to gauge a patient’s health such as blood pressure, heart rate, exercise tolerance, ability to perform daily tasks, blood tests (e.g., blood sugar, cholesterol), urine tests, symptoms, and findings on a physical exam.”

Merits of the Study

Klauer: “The Whitehall 2 study is important because it followed both men and women over a long period of time – 20 years – measuring weight and charting their health conditions. By classifying obese individuals at the start of the study as ‘metabolically healthy’ (absence of cardiovascular disease or diabetes) or unhealthy, the study was able to assess the effect of extra weight on health. The sobering finding that 20 years of obesity resulted in 8 times the progression to metabolic illness than those who were not obese shows just how dangerous extra pounds can be. In fact, only 10% of obese healthy individuals were able to maintain their health for 20 years. In my own practice, all obese, or overweight, patients are informed of this study.”

Lee: “As the study shows, although many healthy obese individuals do progress to becoming unhealthy obese, just because a patient has a higher BMI does not mean he or she is destined for more health problems. Additionally, the study reminds us that it’s very important to follow how BMI and all health measures change for a patient over time. Are these measures stable or worsening over time? This reemphasizes the importance of patients establishing stable relationships with their healthcare providers so that all of the appropriate measures can be followed.”

Binks: “The popularly held notion of ‘healthy obesity’ is misleading. While it is true that people of every size can potentially be healthy; most current conversations on the topic focus only on cardio metabolic health and not the wide range of other negative potential consequences of excess weight (e.g. mobility, musculoskeletal health, heightened risk for certain cancers, sleep apnea, depression, and overall quality of life, to name just a few). Also, absence of disease is not necessarily ‘health’ so when considering if one is healthy we need to assess a wide range of medical and psychosocial factors influenced by weight.”

Limitations of the Study

Lavie: “A very major limitation of this study and the paper that they reference from Kramer and colleagues from the 2013 Annals of Internal Medicine is that neither of these studies were fit versus fat studies, as neither study addressed any information about cardiorespiratory fitness or aerobic exercise capacity, which is a critical predictor of prognosis. My colleagues, especially Dr. Steven Blair, and I have published numerous papers demonstrating that fitness is more important than fatness in predicting long-term risk, and a paper by Barry and colleagues with Dr. Blair last year in Progress in Cardiovascular Diseases analyzed 10 studies that basically demonstrated that those who were overweight or obese but fit had half the long-term mortality as did those who were lean and unfit and had similar survival compared with those who are lean and fit. Basically, these results demonstrate that if one is at least relatively fit, BMI really was not relevant — normal, overweight, or obese, at least mildly obese, all had a good prognosis. (These data, however, may not apply to severe or morbid obesity.)”

Kitchin: “One of the things not well-spelled out in this publication was whether or not the participants were participating in healthy behaviors. It just said that they started out metabolically healthy but didn’t stay that way. A big question I have is: what if they are exercising?”