Can you be healthy at any size?

I had a client chat to me about how they feel right now about their health status, and said something along the lines of ‘I know I shouldn’t worry as much about my size, as obesity doesn’t increase the risk of other health issues.’ And it was said with such a definitive tone I was really surprised.
 
This wasn’t my client’s fault at all. This was the message that had been gleaned from social media with organisations and influential people in the diet space suggesting that indeed an individual can be healthy at any size. This idea has definitely gained traction over the last few years (or, at least, on social media it has) – and there is a spectrum of what is being advocated. At one end (and best possible scenario) if you do carry excess body fat yet have none of the health markers that indicate metabolic dysfunction, then you needn’t worry about your health risk. This is, in fact, healthy. Obesity (or excess body fat) should not be used as a determinant of health risk.
 
I want to be clear here before I move on. This isn’t an opinion on how someone looks. This isn’t about aesthetics. This isn't about body shaming or fat shaming or anything else that falls into the same camp. This is about health.
 
Can you actually be healthy at any size?
 
In the short term, clearly the answer appears to be ‘yes’ – if there are no overt markers that are out of normal reference ranges and as such, are ‘healthy’ then how could someone argue this is not optimal?
 
In the long term though research is showing that metabolic disease greater in these individuals than in someone who is at a healthy weight and has a good metabolic profile.
 
A large study from the UK looked at data from approximately 380,000 individuals to explore the relationship between metabolically healthy obesity (MHO) and health outcomes, and how these outcomes compare to those of other BMI and metabolic health categories. The researchers investigated markers related to metabolic health such as BMI, blood pressure, C-reactive protein, triglycerides, LDL-cholesterol, HDL-cholesterol, and HbA1c. Participants were categorised based on their BMI and metabolic status into four groups: Metabolically Healthy Non-Obesity (MHN), Metabolically Healthy Obesity (MHO), Metabolically Unhealthy Non-Obesity (MUN), and Metabolically Unhealthy Obesity (MUO). These people were followed up over a period of approximately 11 years. Metabolic health was determined by having normal levels for at least 4 of the 6 metabolic biomarkers mentioned earlier.
 
The study found that the risk of cardiometabolic conditions were significantly higher in those with MHO compared to those in the MHN group. Notably, the risk of type 2 diabetes was four times higher in this group, and rates of heart failure, and respiratory diseases were higher compared to individuals without obesity — regardless of their metabolic status.
 
Other studies (such as this) since have found similar results. Researchers analysed data from 2,339 European participants in the FLEMENGHO and Hortega studies to investigate the relationship between metabolically healthy obesity (MHO) and cardiovascular risk. The participants were classified into six subgroups based on BMI and metabolic health status, with metabolic health defined by criteria such as blood pressure, waist-to-hip ratio, and absence of diabetes. The researchers were able to analyse blood markers of glucose and triglycerides and profile individuals based on these results. The study found that during the 9.2-year follow-up period, metabolically unhealthy individuals had a higher risk of cardiovascular events regardless of their BMI. However, those with MHO were not at increased risk at that time.  Despite that there was no change at risk in the short term, the MHO exhibited markers in their blood work that suggested they would be at higher risk in the future.

In another study examining the risk over a 5-year timeframe in over 2.8 million people), those who were MHO had a higher risk of new onset heart failure and atrial fibrillation, but not cardiovascular events. There is the potential that the time frame was too short to show this. Finally, this study analysed data from over 500,000 participants in the Korean National Health Insurance Service-National Health Screening Cohort. Results showed over a median follow-up of 7 years, 5,406 participants (1.5%) developed heart failure. Compared to the metabolically healthy non-obese group, those in the MHO had a higher risk of heart failure.
 
A focus on metabolic health regardless of body size is warranted as we age. There are clear risks associated with this. However, what population-based studies are also showing is that body size does matter and carrying excess body fat as we age places us at significantly higher risk of cardiometabolic disease. Perhaps the markers used to establish what ‘metabolic health’ is are missing one that has been shown to be intricately tied to health risk (insulin, as discussed last week).
 
I’ll say again – this isn’t about aesthetics, it is about health and living healthy as we age. If you carry excess body fat, yet your cholesterol markers, HbA1c and blood pressure are still within normal range, the best bet to keep them that way is to lose excess body fat. It doesn’t have to be dramatic, really – simple shifts in your dietary patterns or exercise routines can make big differences over time (here's 50 of these small tips here).