A Doctor's View

Challenging the 'Obesity Paradox': The Truth Behind Being 'Fat but Fit'

• Dr Paul Polyvios • Episode 56

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Ready to debunk the myths, lies, and half-truths about obesity and healthy living? Listening to this episode will challenge the 'health at any size' idea that obesity and health can coexist. I dive into a dissection of the 'obesity paradox' and 'fat but fit' - a term that has been doing rounds on social media and even within medical circles. The episode looks at the World Health Organisation's definition of health and discusses a study that proves that metabolically healthy obese people are at a higher risk of coronary heart disease than their normal weight, metabolically healthy counterparts. 

I don't stop at challenging the 'obesity paradox'; we also take a hard look at the controversies around obesity and health, explaining why being 'metabolically healthy' doesn't necessarily mean you're healthy if you're obese. I bring to light the risks of obesity, including complications during pregnancy and other health issues, often ignored in popular discussions, including the impact of obesity on fertility. 

This episode also talks about the dangers of taking everything you see online at face value and dispel some of the myths about caloric intake and the role the laws of thermodynamics has in weight gain and loss.


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Dr Paul Polyvios:

And listening to these people talking about how, even though they're morbidly obese, they're healthy and their diet is healthy and that they're fitter than they ever were when they were slimmer, and that, if you disagree with their preaching, you're not a scientist, doctor or someone with a common sense or a sensible opinion based on truth and logic. You are fatphobic and bigoted Because remember everyone it's far easier for everyone else to be the problem and results of blaming a lack of acceptance and to be a victim than it is to admitting that you have a problem and dealing with that problem. Dealing about it in a way that will impact not just you but the others around you and impact them in a positive light. Welcome to Doctor's View with me, dr Bolivios. Join me as I discuss everyday topics in health and medicine and provide the insights into everyday hospital life. Sit back and enjoy the show. Hello everyone. Welcome to Doctor's View. I'm Dr Polyvios.

Dr Paul Polyvios:

Today's episode is a more complicated one than I initially thought when drafting it out. I want to revisit obesity and the idea of obesity and health, and we're going to talk a bit about metabolic health and some of the lies that we're hearing on social media and, sadly, other people within the medical profession who are propagating the idea of obesity and health and saying that the two go hand in hand and are not mutually exclusive, which, if you've been a long time listener of the show, you will know that it's against what I believe and against what the evidence actually shows. And we're going to talk about some of the evidence that favors the obese and healthy argument and some of the theories as to why there is a so-called obesity paradox in a number of different studies. So to clarify, firstly, my main reasons to why I don't believe that you can be obese and healthy is quite simply, regardless of anything else that happens to your health as a consequence of obesity. The World Health Organization defines health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. So if you're in a state where you are addicted to food to the extent that you have allowed your body to reach morbid obesity, you cannot be in a state of physical, mental and social well-being. In the same reason, you cannot be a smoker and be in a state of physical, mental and social well-being because you're suffering from an addiction. Now you may not be displaying any physical symptoms or problems and indeed blood tests may be completely normal. However, it doesn't tell you the whole story. So we know there's been a number of studies that demonstrate time and time again that obesity is associated with several cardiometabotic abnormalities. It's a major risk factor for not only cardiovascular disease but also mortality, and it counts for one in five deaths worldwide. And a major study was conducted with three and a half million people and it demonstrated that after following these people up from nearly five and a half years later, they found that even the metabolically healthy obese people had a higher risk of coronary heart disease than normal weight metabolically healthy people. So this has been proven.

Dr Paul Polyvios:

There's been a lot of discussion and a lot of airtime given to this so-called obesity paradox, and the obesity paradox is where studies have shown that being morbidly obese or overweight has no impact on, in some cases, actually had a better outcome in certain diseases than if you are a patient of a normal body mass index. This has actually been debunked several times with several studies, and some of the reasons why we get these results is because of the way the studies were conducted and the inherent bias within the study process and the methodology itself. For example, there is an obesity paradox which talks about the incidence of developing problems with type 2 diabetes in metabolically healthy, obese people versus metabolically unhealthy, normal weight people. The study shows that you're more likely to develop type 2 diabetes if you're metabolically unhealthy and of a normal weight versus a metabolically healthy, overweight individual, suggesting that metabolic health is what matters the most, and not obesity. What the studies fail to take into account is actually other external factors, such as smoking and other lifestyle factors, which play a huge part in the health of an individual. And it's also been shown that BMI is not necessarily the best indicator of outcomes in a lot of these studies, for example, you can be a personal trainer or a muscular athlete and potentially have a BMI which makes you in the morbid obese category, purely because muscle weighs more than fat, even if your actual body percentage fat is very low. And there's also been a number of studies to show that the waist to height ratio is a better indicator of outcomes in patients with heart failure. So we must acknowledge that when studies are talking about high BMI and the obesity paradox, what they perhaps should be focusing on is more body fat percentage and the distribution of fat, because that has been shown to be a much better predictor of outcome.

Dr Paul Polyvios:

The paradox continues with heart failure and cardiovascular problems, and I think this is where the health at any size movement got most traction. Studies have shown that patients who are morbidly obese with heart failure or heart disease have better outcomes than heart disease patients of a normal weight, and that may well be the case. However, there's something that's often led out in this discussion, and that's if the heart disease patients who were overweight or obese in the study were of a normal weight to begin with, the chances of them developing the heart disease and subsequent health problems would be far less to begin with, so they wouldn't actually be in that situation in the first place. The patients who are of a normal weight with heart disease may actually have a number of health issues to begin with which could be a consequence of other lifestyle factors, as we said before, smoking or drug use or, sadly, genetic and family history, and outcomes may well be worse when compared to other patients who have no other risk factors for development Heart disease other than their obesity. Now, this doesn't detract from the fact that if it wasn't for their obesity, these patients wouldn't be in the study to begin with, and that's because they wouldn't have the heart disease. So we also can't forget the fact that, whilst metabolically healthy, obese people have a lower risk of developing certain cardiac diseases than metabolically unhealthy people, the risk is still higher than a metabolically normal weight person metabolically healthy, normal weight person.

Dr Paul Polyvios:

But unfortunately, studies like this have been taken out of context and spun to make it seem that obese people are healthier than slim people, and that's not the case at all actually far from it, and it doesn't take much to see this. So that's why I don't believe in the obesity paradox. It does not consider a lot of other factors. The I'm healthy and fat is just a contradiction in terms when you think about the problems that arise because of obesity, which starts from a young age and actually only just get worse when time goes on. We talk a lot about being metabolically healthy and I've done a podcast on this in the past, speaking to Dr Philip Avadia, a cardiothoracic surgeon in America about this, and he went to great lengths to talk about metabolic health with me and its importance, and it was a very interesting discussion and I learned a lot from it.

Dr Paul Polyvios:

But sadly, the term metabolic health now seems to have been misrepresented with this metabolically healthy obesity. It is debated whether any form of obesity can ever be considered healthy or whether the metabolically healthy obese phenotype is merely a stage in transition to developing a metabolically unhealthy obese phenotype over time. In the same way, for example, how a lifelong 60 a day smoker doesn't have any problems as a consequence of smoking. Yet Give it another 10 years and the chances of that still being the case are very slim indeed. And yes, we all know the odd person who has lived to 100 and they had the unhealthiest lifestyle imaginable. They are anomalies. They are not the normal distribution, they are the outliers and that's why they're called outliers. They are not in the normal. Very good for them. But to take these one or two outliers and apply that as a generalized rule for everyone is not only unscientific but it's actually quite foolish.

Dr Paul Polyvios:

Part of the contention with metabolically healthy obesity may actually also relate to how it's defined, and to date there's no university accept is standard for defining metabolically healthy obesity. So far, more than 30 different definitions have been used to create these phenotypes in studies. Broadly speaking, metabolically healthy obesity has been defined frequently by the absence of metabolic disorder, the absence of cardiovascular disease, including type 2 diabetes, absence of dyslipidemia, hypertension and atherosclerotic cardiovascular disease in a person with obesity. However, most studies define Metabolically healthy obesity is having either none of these things, one of these things or even two of these metabolic syndrome components. So therefore, you've got a lot of people being reported as being metabolically healthy obese, but they're not metabolically healthy. They simply have fewer metabolic abnormalities than those with who are being defined as metabolically unhealthy. So this is, since that's a so much conflation of the term metabolically healthy obesity to essentially say that if you only have one or two metabolic problems, you're metabolically healthy and that just means you're healthy whether you're obese or not, and that's just plain rubbish. And, even more tragically, this is being used to feed the fat acceptance movement and the healthier any size movement, when in fact what we should be doing is encouraging people to obtain a normal body fat percentage.

Dr Paul Polyvios:

Let's take another account or another example, where you may be inclined to say someone is obese and healthy. I wonder what happens when you put that body under undue stress. I wonder if they would still be healthy. So let's take pregnancy, for example, something which is a massive strain on the body and genuinely a heroic and dangerous process for any woman to undergo, and up until not that long ago lots of women were dying in childbirth. So let's take pregnancy and couple that with obesity.

Dr Paul Polyvios:

So what are the risks of being obese and pregnant? Well, let's talk about it. You've got thrombosis. This is a blood clot that can go in the legs. That can form in the legs and then go into your lungs and cause pulmonary embolism, which is a life threatening problem. Gestational diabetes this is diabetes during pregnancy. If your BMI is above 30, you're three times more likely to develop gestational diabetes. If your BMI is over 25, the risk of developing high blood pressure and preeclampsia is two to four times more likely compared to someone with a normal weight.

Dr Paul Polyvios:

Mental health problems Problems again, this has been shown to impact greater if you're overweight. And then you've got the actual problems that occur with the baby itself. The normal risk of miscarrying in an early pregnancy, say at the age of 35, is about 20 percent. If you've got BMI of 30 or above, that risk increases to 25. If you're overweight before pregnancy or in early pregnancy, this affects the way the baby develops in the womb. Overall, about one in a thousand babies in the UK are born with neural tube defects. And if your BMI is over 30, your risk is nearly doubled and if you're overweight, you're more likely to have complications during the birth, and the risk is doubled from seven to a hundred in two to fourteen to a hundred. Also, the overall risk of having a stillbirth unfortunately doubles to one in a hundred instead of, say, one in two hundred. You may also need additional scans and overall it's just more difficult to move around and stay active because of body habitus.

Dr Paul Polyvios:

The actual pregnancy aside, we haven't even spoken about the impact of obesity and fertility. Excess body fat impacts the production of gonadotropine release in hormone and this is even more likely to be a risk In hormone, and this is essential to regulating ovulation in women and the production of sperm in men. Specifically, gonadotropine releasing hormone releases Lutinizing hormone and follicle stimulating hormone, and both of these are critical to the development of eggs and sperm. I also just want to take this moment to discuss the number of lies that we hear online and just listening to some people talking on YouTube and how there are a number of videos of people who are morbidly obese talking about the amount of exercise they're doing each day swimming, running, cycling and if that is true and they're doing an hour straight nearest exercise every day for the last five years and they're still the size that they are, then the amount of food that these people must be eating is, quite frankly, scary. Either that or they're lying about the amount of exercise that they're doing. I believe it's actually a mixture of both, and probably no exercise and eating a huge amount of food.

Dr Paul Polyvios:

And listening to these people talking about how, even though they're morbidly obese, they are healthy and their diet is healthy and that they're fitter than they ever were when they were slimmer, and that if you disagree with their preaching, you're not a scientist, doctor or someone with a common sense or a sensible opinion based on truth and logic. You are fat phobic and bigoted because remember everyone, it's far easier for everyone else to be the problem and results of blaming, a lack of acceptance and to be a victim. Then it is to admitting that you have a problem and dealing with that problem, dealing about it in a way that will impact not just you but the others around you and impact them in a positive light. Just seek help, take responsibility for your own actions, rather than making yourself insufferable to listen to, gaslighting entire audiences of vulnerable people who need to hear the truth about their health instead of actually what they Believe they want to hear, all while just fueling their own narcissism and sanctimonious narcissism is that. And as a doctor advocating a healthy diet and size, I meant to believe that I'm the enemy. If your body is in a state of obesity, where you're constantly in a state of inflammation, suffer with sleep apnea or even just discomfort as a consequence of your sides, and you're struggling to walk because you have joint pain or difficulty doing simple tasks because of your body habits, I don't care what the definition of metabolic health is or whether you consider yourself to be metabolic healthy. This is not a picture of health, and perhaps those advocating that it is including some healthcare professionals of my time take a very long hard look at the reality of the damage that their message is doing. The path of least resistance is always the easier one, and walking to the fridge is always going to be easier than walking to the gym. But stop saying that the gym and the people that encourage going to the gym are the enemy. They are not. They are trying to help, and the fat acceptance movement and those advocating health at any size are just part of the problem.

Dr Paul Polyvios:

Another main contributor is actually a lack of education. So, for example, one thing people don't really know much about is calories. Nor can many people actually define what a calorie is If you stop someone on the street I actually saw a video of this many years ago someone with a microphone and a camera was stopping everyone on the street and asking what a calorie was, and only one person was able to define it. And they happen to be a dietitian as well. So that's kind of unfair.

Dr Paul Polyvios:

The definition actually has changed, admittedly, as time has gone on, but a calorie is a unit of energy. It's the equivalent to the heat energy needed to raise the temperature of one gram of water by one degree centigrade. So I don't know if you remember this at school, but we would set fire to a peanut back when you were allowed to have nuts in school and we'd heat a beaker of water, one liter of water, with a thermometer in it and your time. How long it would take for that beaker of water to raise, the temperature, for the water to raise by one degree Celsius, with the lit peanut underneath heating it up, and from the time it took to go up by one degree centigrade, you could then work out the number of calories in that peanut and you had the weight of the peanut before you set fire to it and there was an equation, you could work out exactly how much energy was in that peanut. So that's what calories in food are. It's a measure of energy in that food. So when you see calories on a packet, simply telling you how much bang for your buck are you getting really in terms of, in terms of calorific intake? Some things have very, very high amounts of calories, some things have very low amounts of calories, and it all depends on the type of food content that it that it contains.

Dr Paul Polyvios:

A concept which people have difficulty in discussing and explaining, and a concept which, unfortunately, the fat acceptance movement refuses to believe, is that the first law of thermodynamic states you cannot create energy from nothing. It's merely changing form. So you can't create or destroy energy, and so what that's trying to say is if you don't take energy in the form of food, you cannot gain fat. It's not possible. If you burn 2000 calories a day and you eat 3000 calories a day, you will gain weight. It's as simple as this. With regards to the weight gain, if you burn 2000 calories a day and you eat 1800 calories a day, you will lose weight. It's simple laws of thermodynamics. It's simple physics.

Dr Paul Polyvios:

There are some rare conditions that will increase your ability to gain weight. For example, if you have a poor functioning thyroid, where your basal metabolic rate will be reduced, or circutern conditions, where you retain a lot of water, your weight will increase, but not necessarily the amount of fat. But this is not the normal. This is, again, outliers. Most overweight people don't have any of these problems. And for those that are constantly adamant that this is the cause of obesity for most people, well, that throws the argument of healthy obesity out the window, because you can't have a condition which causes you to be obese and then be obese and healthy.

Dr Paul Polyvios:

Paradoxical and also a lie. And if you've ever tried to calorie count, it's really apparent just how quickly, how little food is needed to make up 2000 calories. And I think where we as a society are going wrong. Not only is food far more addictive nowadays than it ever has been, with the amount of salt and sugar and just general yumminess of food, especially processed food, but we don't realize just how many calories and useless calories are in such small quantities of food. A simple, small donut, for example, is often over 400 calories and that might not sound like much, but that's a huge chunk of your daily allowance and it will take about 10,000 steps to burn off. Now, 10,000 steps not many people do 10,000 steps a day. I know a lot of people try and use that as a barometer of fitness, but very few actually achieve it, and it's it's very easy to see how, even with just a few biscuits, with your tea and coffee, you've already eaten a tenth of your daily calorific intake, or in some cases even more. And that's not considering breakfast, lunch, dinner or any other drinks, because, remember, drinks have calories too, not just alcoholic drinks but other drinks. So, aside from not moving enough, as a nation we're just eating far too much.

Dr Paul Polyvios:

I've spoken about basal metabolic rates and by this I mean essentially the energy you need to just stay alive. So if you're in satin a chair all day just breathing, that's how much you'll burn off in a, in one day, and this will depend on your size, your weight, your age and whether you're male or female. Of course. As you start moving, this goes up. So that's where we get this rough 2000 to 2500 calorie a day mark that most people need, depending on how active you are, because most people with basal metabolic rate might be around 1400 to 1600 calories plus the amount of exercise you do so very little mobility you're going to burn around 1800, 2000 calories a day. The bigger you are, the higher your basal metabolic rate is, and that's why if a morbid le obese person starts to diet, initially they lose weight very, very quickly because you've got a very high basal metabolic rate and then as soon as you start having a calorie deficit diet, you lose rate very fast and then as you lose the weight, your basal metabolic rate will go down and then it becomes harder to lose that extra weight. As time goes on, so things do plateau.

Dr Paul Polyvios:

I see a lot of reels and posts from so called health gurus showing people what they eat on a daily basis, often advocating an 1800 calorie diet, and they're often very slim and attractive and all the meals that they eat look yummy and healthy, with lots of nuts and porridge and avocado, with three set meals and snacks, and all of this food is actually very calorie dense and they portray this image that you can eat all of this whilst talking about how few calories each of their meals is, and I think this is all bull. I don't believe that the calories that they are consuming in the day is what they actually say. I believe that the meals and snacks that they show when made at home have far more calories than they are actually suggesting. I have a theory that they are probably eating half of the amount of food that they actually showing online to maintain that shape or size, or they are eating this amount of food, but the thing that they're not showing you is the huge amount of working out and exercising that they are doing on a daily basis to keep them at a healthy weight. One thing is for sure it's certainly easier to grow a following and sell diet plans as an attractive and slim health guru, I use that term loosely when people like what that diet plan shows and what its apparent results are. And don't get me wrong, it's absolutely fine to consume 3000 calories a day if you are doing a strenuous gym workout three times a week and have a high muscle mass and I'm maintaining a high basal metabolic rate as a consequence Absolutely you need your 3000 calories, if not more, a day. But very few people who are actually eating 3000 calories and above a day are doing any exercise whatsoever.

Dr Paul Polyvios:

Animals store most of their excess energy as fat. So, to put that into perspective, there are nine calories in one gram of fat. So if you're overeating by 500 calories a day, that's a one small dessert or a couple of beers. Even over a period of a week, you're overeating by three and a half thousand calories. That's nearly 400 grams a week in fat being stored extra on your body. So in a month, that's a gain of 1.6 kilos. Now you can see, however, a period of just four months.

Dr Paul Polyvios:

You've gained a stone, and how often have you heard someone say it's only small or it's healthy? It might well be small or healthy, and you justify eating that small or healthy thing to yourself, but if you're eating more calories than you need, you will gain weight. If I eat 3000 calories in fruit and vegetables a day, believe me, I will gain weight. Energy is energy. Youtubers and influencers another term I use very loosely are very good at telling people exactly what they want to hear. It generates popularity and income. Unfortunately, though, they are not able to change the laws of thermodynamics, regardless of how nice their avocado toast with pine nuts looks.

Dr Paul Polyvios:

And, for the record, I'm in absolutely no way saying that being skinny means healthy either. Being underweight is equally as dangerous, as being overweight and just because you are of a normal weight does not make you immune to problems or health issues. You almost certainly can be unhealthy and of a normal weight, but the one thing I will not stand for is this idea that you can eat whatever you want to the point of obesity without any consequence, in being told that this is a form of healthy living. If a child was encouraged by their parents to smoke cigarettes, they would be taken away by social services, and yet when we encourage children to eat absolute junk and allow them to become overweight at a very young age, we seem to be applauding this nowadays, even though the health consequences can be just as destructive.

Dr Paul Polyvios:

So whilst I aim to be healthy, I certainly have a long way to go in having the best diet and the healthiest lifestyle, despite being a normal weight. So over the last few weeks, I've made active steps to try and change this, starting with a far more vigorous exercise regime and with the help of a personal trainer as well, and I'll be producing a few more episodes on this in the future to talk about the benefits of exercise, but also the benefits of having someone to help you and advise you on how to improve your exercise and fitness levels, and also the benefits that exercise and improving strength has, not only in physical aspects, but also mentally as well. So I really look forward to sharing that with you very soon, and with that I will leave you. As always, please look after yourself. I'm Dr Polyvios. Goodbye.

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