Why Weight? Why Not Health?
August 31, 2016As a child, appointments with my pediatrician, shopping for new pants, and visiting relatives, all triggered a feeling of dread because they shared a common theme – each experience was certain to bring up the fact that I was overweight. Moving into adolescence and adulthood, my weight would go up and down, and with it, a sense of failure or accomplishment.
While many may be able to relate the emotional roller coaster that comes with a weight struggle, the rise in weight-related diseases such as diabetes among children and adults alike has brought the health consequences of overweight and obesity into sharp focus. As a person with prediabetes and severe sleep apnea, I agree that we should all be concerned, but as a weight management physician, I disagree with the widely held notion that when weight increases health declines and when weight decreases health improves. This oversimplification of the relationship between weight and health creates an atmosphere of weight loss anxiety that promotes the pursuit of weight loss ‘by any means necessary’, ultimately endangering the original goal of health improvement.
Rethink Weight Loss = Health Gained
There are several reasons to rethink the equation weight loss = health gained. In my own experience, I routinely see patients in my practice with BMIs above 40 or 50 with no weight-related medical conditions; while at a BMI of 26, I have two! More generally, in the case of diabetes, the American Diabetes Association calls the idea that “being overweight or obese means you will develop diabetes”, as a myth: “most overweight people never develop type 2 diabetes, and many people with type 2 diabetes are at a normal weight or only moderately overweight.”
All too often physicians tell their patients that their life will be cut short if they don’t lose weight, but a 2013 study of nearly 3 million people published by CDC researcher Katherine Flegal created much controversy when she found that being overweight (BMI 25-30) was associated with reduced mortality. Furthermore, if you ask your doctor to calculate your 10-year risk for heart disease, he or she is likely to use the ASCVD risk calculator from the American College of Cardiology, inputting your age, gender, ethnicity, presence of diabetes or hypertension, smoking status, and cholesterol numbers, but weight is conspicuously absent.
4 Behaviors Critical for Health Improvement and Helpful for Weight Loss
How could this be? Have we been lied to? Don’t get out the pitchforks just yet - these discrepancies can easily be explained when we understand that the relationship between weight and health is heavily influenced by one key factor: Behavior. Certain behaviors improve both health and weight. However, while the effect of a behavior on overall health may be consistently strong, its effect on weight may range from small to neutral. This can result in a disconnect in the relationship between weight and health.
1. Exercise - Exercise is a great example of a behavior that will both improve your health and weight loss.
Steve Blair, the lead researcher of the Aerobics Center Longitudinal Study, has been researching the effects of exercise and other lifestyle behaviors on mortality in more than 55,000 people over 30 years. Similar studies have shown that the risk of dying associated with ages greater than 60, BMI greater than 30, emphysema, diabetes, hypertension, or smoking, can be counteracted with sufficient exercise.
Steve Blair's research has shown that being sedentary carries a higher risk of death than diabetes, smoking, and obesity – combined!
On the other hand, the impact of exercise on weight is mixed: while multiple studies have shown that exercise is instrumental in preventing weight gain, research has consistently shown that weight loss is mainly driven by eating fewer calories as opposed to burning more calories in exercise. Therefore, since exercise’s effect on prolonging life expectancy is much stronger than its effect on weight loss, it provides a good example of how a behavior can disrupt the assumption that weight loss = health gained.
2. Sleep - Sleep is a behavior that demonstrates a strong relationship with health but a relatively weaker relationship with weight.
According to the Centers for Disease Control and Prevention, 30-40% of Americans don’t get the 7-8 hours of sleep recommended for optimal health and wellness.
Sleep deprivation has far-reaching health effects: it can increase your risk for depression by 500%, and reducing sleep duration from 7 hours to 5 hours doubles your risk of early death.
Shift Work Disorder, a condition where insomnia and excessive sleepiness is associated with working and sleeping at non-standard times, has been shown to increase the risks of cancer, metabolic syndrome, hypertension, diabetes, and heart disease. But while sleep deprivation can have a significant impact on health, its impact on weight can be variable. It can increase sedentary behavior, appetite, and the desire for sweet or starchy food, resulting in the consumption of 200-400 extra calories per day.
On the other hand, being awake longer means people are burning more calories and maintaining higher metabolic rates. Yet another example of how a behavior’s stronger relationship with health, as opposed to weight, weakens the relationship between weight and health.
3. Social Connectedness - Social connectedness holds a similar tight association with health, but a variable impact on weight.
In fact, this behavior is not only foundational for our health but is also essential to our very existence. Our brains process the threat of social disconnection as a fundamental threat to our survival. Consider how being connected to a tribe was vital for our ancestors who depended on each other to find food, treat illness, and defend against predators. The physiological responses that result from social disconnection impact blood pressure, heart rate, cholesterol, insulin sensitivity, and the immune system.
Social isolation impacts our mental health as well. It not only increases our risk for depression, but it also carries a 50% increased risk of death compared to people who report satisfying social connections, which is a health risk comparable in magnitude to smoking.
Studies on healthy aging such as the National Geographic survey of communities with the longest life expectancies in the world, known as ‘blue zones’, and the Harvard Grant Study, which surveyed 725 men over 75 years, confirm the age-old wisdom that love from family and friends is essential for long-term wellness.
Conversely, the similar connection between social connectedness and weight are much weaker. This is probably because social isolation affects everyone's eating behaviors differently, ranging from eating very little to binge eating on comfort foods. In the end, being socially isolated is likely to be much worse for a person’s overall health than their weight.
4. Unhealthy Eating - Unhealthy eating is the behavior most commonly associated with weight and health problems.
The common understanding is that more calories = more weight, no matter where the calories come from. However, when it comes to the impact that sugar has on both weight and health, there is growing evidence that all calories are not the same. Awareness around this issue has even begun to translate into public policy, where communities are starting to tax sugar-sweetened beverages.
Dr. Robert Lustig, a pediatric endocrinologist from UCSF, has been sounding the alarm about the negative health effects of sugar for several years. Dr. Luistig and has called on the FDA to reevaluate the safety of sugar consumption. In a 2015 study, Dr. Lustig recruited 43 children with obesity, as well as another condition, such as elevated blood sugar, hypertension, high triglyceride levels, or a marker of fatty liver disease. Over nine days, he provided them with all their meals, snacks, and beverages. The diets maintained the same fat, protein, carbohydrate, and calorie levels as their previously reported home diets. The only difference was that sugar was substituted for starch.
Overall their diets contained three times less sugar than their intake at home. If they started to lose weight, they were asked to eat more. At ten days, though there was no change in weight, there was an improvement in blood sugar, insulin resistance, blood pressure, and cholesterol. Dr. Lustig’s findings strongly suggest that the negative health effects traditionally attributed to weight gain, may likely be the result of toxicity associated with excessive sugar intake, casting further doubt on the weight loss = health gained assumption.
The effect of weight on health can also be different for different people because all weight loss is not necessarily healthy weight loss. Losing muscle and bone weight, also known as lean body mass, has a very different effect on health than losing fat.
For example, up to 45% of the weight loss experienced through bariatric surgery can be attributed to muscle and bone loss caused by inadequate vitamin/mineral supplementation and/or insufficient protein intake. A similar example of the negative health effects related to loss of lean body mass is known as the ‘obesity paradox.' Several studies have shown that maintaining a heavier weight actually reduces the risk of death among the frail elderly or among patients with advanced emphysema, heart failure, or kidney failure. Weight loss in these groups likely reflects worsening nutrition status causing loss of muscle and bone, leading to worsening health status and higher mortality risk. These examples clearly show that the idea of weight loss = health gained is too general and that weight loss achieved in the wrong manner can lead to severely negative health consequences, even death.
While lean body mass versus fat mass comparisons are relevant to health, it is important to note that not all fat is dangerous. The fat that we can see and feel under the skin, or subcutaneous fat, is much less dangerous than fat that is stored in and around organs such as the liver, pancreas or heart, also known as visceral fat. Sumo wrestlers train for several hours per day, maintain an average BMI of 37 with 40% body fat by eating massive quantities of rice and skipping meals, but yet they have normal blood pressures, cholesterol, and blood sugar levels, similar to the average Japanese male with a normal BMI. Why? Abdominal CT scans of sumo wrestlers compared to normal weight men show that all their fat is concentrated in the subcutaneous compartment, whereas their visceral fat compartment, looks the same as men of normal weight.
This is possibly a result of their all-day, intensive exercise and training regimen. The opposite is also true: individuals with congenital lipodystrophy have a rare genetic disorder that prevents them from making normal fat cells. They look like bodybuilders because they literally have no fat under their skin due to the absence of fat cells. Unfortunately, they have high rates of type 2 diabetes, often starting in adolescence or early adulthood.
Once again, abdominal CTs tell the story – since their subcutaneous fat compartment is non-existent, their body stores nearly all their fat in the visceral compartment (in and around internal organs). These examples show that when we think about the connection between weight and health we should: stop looking ‘skin-deep’, but rather remember ‘it’s what’s on the inside that counts.’ Several studies have confirmed the link between heart disease risk and visceral fat, but more compelling is the fact that 5-10% weight reduction via healthy behaviors like sleep, regular, exercise, and consuming less sugar/refined carbohydrates, can reduce our visceral fat by 30%, resulting in major health benefits.
Ultimately, the idea that weight is not a direct measure of health helps us create an intellectual understanding regarding the relationship between weight and health, but perhaps what is more important is to understand how this knowledge can impact the emotional part of our weight loss journey. When we think weight loss = health gained, we develop an 'ends justifies the means' mindset, meaning ‘as long as we lose weight, how we do it doesn’t matter.' As a result, we start 'BMI chasing' with the goal of achieving a ‘normal’ BMI of 25 or less, polluting our efforts with ‘weight scale anxiety’, over-inflated expectations, and unrealistic goals. This becomes a vicious cycle when these goals and expectations are not met and erode our motivation/inspiration to make more behavioral changes.
Takeaways for Weight Loss and Health Improvements
Finally, when we don’t get to the finish line (BMI 25 or lower), we tell ourselves "I’ve failed", and when we keep failing, we ask "Why try?" This final stage of frustration is likely the most dangerous consequence of the weight loss = health gained mentality. Irrespective of how much weight we may or may not lose pursuing healthy behaviors, the more we practice them, the more our health is benefitted.
If frustration with behavioral changes and lack of weight loss causes us to quit trying to adopt healthy behaviors, we risk making the grave mistake of ‘throwing the baby out with the bathwater,’ pulling away from the factors most essential for safeguarding our health. Instead of torturing ourselves on this emotional roller-coaster, let us steady ourselves by embracing the wisdom that how you lose weight is more important to your health than how much weight you lose because weight does not determine health as much as behaviors determine health (sleep, building healthy relationships, exercise, and reducing processed food intake).
The bottom line is when it comes to the relationship between serious health risks and weight, fat is more important than weight. Visceral fat is more important than subcutaneous fat, and relative weight loss (minimum 3% of starting weight) achieved by adopting specific behavioral changes is more important than absolute weight loss (reaching BMI 25) achieved by any means necessary.
It is okay to have a weight loss goal, but it is not okay to be a slave to it.
Instead of being held captive by "all or nothing," success versus failure thinking and a number on the scale, why not focus on incrementally practicing health behaviors such as sleep, exercise, and avoiding sugar/refined carbohydrates, in the company of individuals with similar struggles, goals, and degrees of sincerity?
As a 25+-year veteran of my own personal war on weight, I have learned that, like life, this struggle cannot be defined by the destination, but rather by the journey itself. So when it comes to health and weight loss, instead of constantly asking "how much?" why not challenge our assumptions and ask "why focus on weight alone, why not behaviors, culture, and overall health?"
Watch Dr. Murali's TEDx talk - How to make hard things easy, and lose weight too!
 | ABOUT THE AUTHOR Dr. Sameer Murali is a bariatric medicine physician providing weight management services for approximately 120,000 obese adult Kaiser Permanente members in San Bernardino County. He is the Kaiser Permanente physician lead for Bariatric Surgical Services for the Southern California region. He completed medical school and internal medicine residency at UT Southwestern in Dallas, and completed a masters in health services research at UCLA.Read more articles from Dr. Murali. |
