It is Better to Be Fit and Overweight than Normal Weight / Lean and Unfit

Last year, I wrote about the disconnect between how thin or fit we look and how healthy we actually are. Most of this is driven by a worldwide focus on weight and weight loss, which has led to a mistaken belief that being of ideal weight automatically implies good health, a belief further reinforced by the beauty industry that drums into our heads every single day that an ideal weight and a flat tummy are goals you should be striving for.

The problems start with the definition of overweight and obesity, which are based on BMI (body mass index), which is a flawed unidimensional parameter that does not take into account the body composition, the amount of fat and lean mass and all the other factors that go into determining where you actually stand with your weight and health.

As Ivan Illich said in his book, “Medical Nemesis“, the moment we create definitions and cut-offs, we start categorizing people into normal and abnormal and create artificial situations that slot people into different categories and allow society, institutions and governments to exert undue control over our lives. If you are overweight (say BMI of 28), you are considered to be unhealthy (even if you are not) and everyone, from your doctors to your friends to the health insurance company, will keep pushing you to lose weight, and even believe they have the right to comment on your appearance, without your permission, even if you are otherwise healthy and fit. This again comes down to do the mistaken belief that a BMI < 25 equals good health.

This is what the weight loss industry thrives on. While morbid obesity clearly needs management with bariatric surgery and weight loss medications, those who are overweight (BMI of 25-29) and obese (BMI of 30-35) and even those who have an ideal BMI are constantly pressurized into special diets or programs that promote weight loss as the ideal way to increase healthspan and lifespan.

In the past two weeks, two prominent writers, Eric Topol and  Scott Alexander have extolled the virtues of a drug called semaglutide, which is a GLP-1 receptor agonist that first came into the market as an anti-diabetic medication, but now has been shown to be excellent at reducing weight, mainly by suppressing appetite. Both of them believe that this drug is a game-changer, because people who want to quickly lose weight can do so in most instances with semaglutide injections or tablets, which are currently quite expensive (Rs. 300 odd per 14 mg tablet and Rs. 20,000 per 1 ml injection), but will likely become cheaper as their usage increases worldwide. They are a bigger game-changer though for the company that makes them (Novo-Nordisk).

Both Eric and Scott start with the assumption that obesity is bad and needs weight loss and since most people can’t lose weight with food control and the vast majority refuse to be physically active, medications will be the norm in the future. As with all new drugs, no one really knows what the long term side effects and consequences are and will be and everyone except Lindyman, who experimented with semaglutide on himself just to understand what happens and how it works and then stopped because it all felt unnatural, are just riding the new shiny bandwagon, as happens with every new phenomenon (e.g. crypto, AI) that is the new flavor of the month.

But what if being overweight or obese is fine, as long as you are physically fit?

A recent study by Quesada and colleagues [1] looked at 899 women with evidence of ischemic heart disease, between 1996 to 2000 with 11 years of follow-up. Fit women across all BMIs had a lower mortality and cardiovascular event rate than unfit women of all BMIs. More importantly, overweight-fit and obese-fit women did better than normal BMI-unfit women as well as normal BMI-fit women, underscoring the fat-but-fit theory and paradox. The same is true in men [2]. Initial studies on fat-but-fit were observational, but now prospective randomized controlled trials have confirmed that physical fitness trumps the supposed downsides of being overweight or obese and that it is better to be fit and overweight / obese than unfit, whether normal weight or otherwise.

What does this mean for you and I? In our atmasvasth quest to live long, healthy, focus on physical activity and fitness. Stop bothering about your weight. Period.

Footnotes:

1. Quesada O et al. Body weight and physical fitness in women with ischaemic heart disease: does physical fitness contribute to our understanding of the obesity paradox in women? Eur J Prev Cardiol. 2022 Sep 7;29(12):1608-1614.

2. Faselis C et al. Body mass index, exercise capacity, and mortality risk in male veterans with hypertension. Am J Hypertens. 2012 Apr;25(4):444-50.