Is There Really an Obesity Paradox?

ObeseA couple weeks ago, I linked to an article discussing the “obesity paradox”—the idea that across many different studies and populations, people with slightly overweight and even obese BMIs often have the lowest mortality risk. The author is Harriet Brown, a supporter of the “Health At Every Size” movement, comes down hard on the side of overweight/obesity as safe and even beneficial. At first glance, she makes a strong case. She appears to cite compelling research. She talks to obesity researchers who’ve found protective links between higher BMIs and better health and been lambasted by their colleagues. And if the general consensus is right, and carrying extra weight is so unhealthy, why are obesity and overweight consistently associated with a lower risk of death?

Brown claims that no other researchers “have been able to make the paradox go away.” She highlights and dismisses two possible explanations for the paradox. First, that heavier people visit the doctor more often and receive more and better medical treatment than normal weight people. Although Brown calls this “the most popular” of the explanations before proceeding to (rightly) demolish it, I haven’t heard many obesity researchers give it serious thought. The second explanation is the “unhealthy weight loss” one. If people who are normal weight because they lost weight due to cancer, smoking, sarcopenia, or another wasting condition are lumped in with people who are normal weight because they’re lean, fit, and healthy, the correlation between normal BMI and mortality is skewed. After admitting “there’s some evidence to back up this argument,” Brown pivots to the opinion of a single researcher, who says “it certainly does not seem to make the paradox go away.”

Okay. How comprehensive was Brown’s coverage of the explanations for the paradox? Did she leave anything out?

As it turns out, there are several other explanations for the obesity paradox.

Body fat as glucose sink for diabetics.

Somewhat higher BMIs than normal are associated with improved mortality risk in type 2 diabetics. We often forget that body fat isn’t just there for the hell of it; it acts as a storage facility for excess fat and glucose that cause health problems if allowed to circulate unchecked. Having high levels of sugar circulating throughout your body is dangerous. Unchecked hyperglycemia creates too many reactive oxygen species, depletes glutathione, increases AGE formation, and hyper-activates the enzyme responsible for many diabetes complications; it can increase the risk of complications requiring amputation, cause neurons to shrink, pancreatic beta cells to die, and endothelial function to plummet. When you’re insulin-resistant and your tissues aren’t responsive to insulin-mediated glucose transport, body fat becomes a useful, if unattractive glucose sink. That may be why a recent study found that among type 2 diabetics who’d just had heart attacks, the obese patients had lower rates of kidney disease (which is a byproduct of unchecked hyperglycemia) and lived longer than the normal weight patients. It also explains why increased BMI (at least until you hit extreme obesity) lowers the risk of amputation in diabetics.

Of course, that doesn’t mean everyone worried about diabetes should gain weight. For one, losing weight is a great way to reduce one’s chances of becoming diabetic in the first place. Two, diabetics who attempt to lose weight live longer than those who don’t and those who successfully lose weight enjoy drastic improvements to lifespan. Only unintentional weight loss was linked to increased mortality.

BMI as marker of lean mass reserve in heart disease patients.

BMI measures weight, nothing else. It doesn’t distinguish between muscle, bone, fat, tendon, or the rolls of quarters in your pockets. If gravity acts on it, it’ll show up in BMI. One study examined BMI, body composition, and mortality risk in men with coronary heart disease. Sure enough, overweight BMIs were the most protective against mortality in this population. But when you looked closer and incorporated body composition in the analysis, it turned out that lean muscle mass was responsible for the high BMI-low mortality link. Another study found that among heart failure patients, BMI was a better predictor of lean mass than body fat.

Low-normal BMI as marker of disease.

When an obese person develops cancer, they’ll often lose enough weight (from the disease itself and the treatments) to reach a normal or even underweight BMI. If they die from the disease, their BMI is noted and that death counts as a “normal BMI death.” But the thing that killed them happened when they were obese. A recent study examined this exact issue, using “maximum BMI” to control for the disease-induced weight loss confounder. They found that “the percentage of mortality attributable to overweight and obesity among never-smoking adults ages 50-84 was 33% when assessed using maximum BMI. The comparable figure obtained using BMI at time of survey was substantially smaller at 5%.” when you include the obese and overweight people who got sick and then lost weight before they died, obesity and overweight is responsible for a third of deaths in non-smoking elderly. When you don’t, obesity and overweight is only responsible for 5% of deaths.

I’m sorry. I’m not buying it. There’s no paradox. The relationship between bodyweight and mortality is complex and complicated, but there’s always an explanation—and it’s not “being obese is healthy!” Higher BMIs might be associated with improved mortality, particularly in certain populations. But what exactly do you mean when you say “BMI”? Body fat? That contributes to BMI. Muscle? That, too. What about the distribution of the body fat? Does that matter?

Yes. “Weight” doesn’t have an effect. What comprises the “weight” determines the effects.

BMI isn’t the best way we have to assess obesity and the associated health and mortality risks. It’s just the easiest and the cheapest.

It comes down to body fat. If you’re of normal weight but obese based on the amount of body fat you carry, you have a much higher cardiometabolic mortality risk.

It comes down to where you carry your body fat. Abdominal obesity is consistently associated with poorer health outcomes, metabolic dysfunction, and mortality.

It comes down to gender. In women compared to men, slightly higher body fat levels in general and lower body fat (within reason) in particular are linked to better health.

It comes down to muscle mass, the single best predictor of longevity in the elderly. If you’re strong, you’ll live longer than if you weren’t.

When you factor in things like disease-induced weight loss, smoking-related low BMI, and loss of lean mass, the ideal BMI for health and longevity is actually around 20-21. That’s exceedingly normal. Overweight is 25-29. Obese is 30 and up. Having a decent amount of lean muscle will increase the “low-mortality” BMI allowance.

If you want a simple measurement that can replace BMI, waist circumference—the distance around your belly—is a better predictor, and it lines up with conventional views on health and obesity. Higher waist circumference, worse health outcome and higher mortality.

And even if you take at face value the author’s claim that being overweight or obese either improves or has no impact on lifespan and only “slightly” increases the risk of heart disease and “other life threatening conditions,” what about the other things that matter, things that might not show up in studies? What about climbing the stairs without huffing and puffing? What about chronic joint pain preventing a heavy person from going on hikes, starting a training program, keeping up with their kids? What about sex drive and frequency, both of which studies show drop in the overweight and obese and increase with weight loss?

I’m not disparaging overweight or obese people. Heck, they’re the people I set out every day to help! I care deeply about them. And I know how hard weight loss can be.

I just don’t think articles like these are helpful. The author ignores a huge body of research showing the damaging health effects of excess body fat and tries to normalize an extremely dangerous mindset: complacency and apathy. After her review of the evidence, Brown even wonders if there’s “any point trying to diet to lose weight.” Yes, for the majority of people, there absolutely is a point. Just ask my readers.

Losing weight isn’t easy, but it’s not impossible. Losing weight may not be a panacea, but it’s certainly not a waste of time and it does provide health benefits across the board. Intentional weight loss—the kind achieved through dieting, rather than wasting away from disease or smoking—is actually linked to a 15% reduction in all-cause mortality.

That’s where I stand. There’s no paradox. There’s just a complicated relationship between bodyweight, muscle, body fat, body fat allocation, and health that shouldn’t be reduced to “gaining weight is healthy.” That’s just dishonest and it does the people who need the most help a major disservice.

What do you think, everyone? Where do you stand on the obesity paradox?

Thanks for reading, everyone.

Prefer listening to reading? Get an audio recording of this blog post, and subscribe to the Primal Blueprint Podcast on iTunes for instant access to all past, present and future episodes here.

About the Author

Mark Sisson is the founder of Mark’s Daily Apple, godfather to the Primal food and lifestyle movement, and the New York Times bestselling author of The Keto Reset Diet. His latest book is Keto for Life, where he discusses how he combines the keto diet with a Primal lifestyle for optimal health and longevity. Mark is the author of numerous other books as well, including The Primal Blueprint, which was credited with turbocharging the growth of the primal/paleo movement back in 2009. After spending three decades researching and educating folks on why food is the key component to achieving and maintaining optimal wellness, Mark launched Primal Kitchen, a real-food company that creates Primal/paleo, keto, and Whole30-friendly kitchen staples.

If you'd like to add an avatar to all of your comments click here!

49 thoughts on “Is There Really an Obesity Paradox?”

Leave a Reply

Your email address will not be published. Required fields are marked *

  1. Use of BMI as a measurement is, itself, a paradox. It is over 200 years old and tells us really nothing about anything. It is, however, easy to use. This makes it an excellent way to sell books and diet products.

      1. I’ve known many a Marine who’s career was ruined because they tended to be outside the Marine Corps BMI standards more times than was acceptable. And these were good, capable people we should’ve worked to retain. Unfortunately, it’ll never go away for either of our services, because whether it’s healthy or not, we have to look good in uniform.

      2. Measuring neck and waist circumference is more accurate than BMI…

  2. Definitely interesting. I’m certain that when things don’t make sense, there’s usually a better explanation that does. And BMI just doesn’t give enough info for any situation.

  3. Essentially, it is the same mistake over and over again. People tend to conflate leanness, low BMI, and/or fitness, with health. As I have learned from Mark you can be very fit, very lean, have a low BMI and still be unhealthy. One factor does not make you healthy. You need to be lean, strong and relatively fit. Weight/BMI in a of itself tells you very little and by itself is more likely to leave you misinformed.

  4. Wow, a lot to think about here. Bottom line is, it’s a complex situation. I know people that would be considered overweight, but live active, full lives, eat well, and are enjoying life. And I know people who probably have what would be considered excellent BMIs that are putting processed crap into their bodies and have lots of aches and pains. Either way, I completely agree with Mark. There is no obesity paradox. You can’t make a blanket statement that gaining weight is healthy. Or that
    losing weight is healthy. It’s much more involved than that.

    1. “There is no obesity paradox. You can’t make a blanket statement that gaining weight is healthy. ”

      That’s not what the obesity paradox purports to say. It is not that “gaining weight is healthy”; it is that higher bodyweights are much less risky than was thought.

  5. BMI is perhaps leading (most useless) measure in the Pantheon of such muddled measures that also includes the common: LDL-C, PSA, TC and TSH.

    If one were to correlate BMI with health outcomes a century ago or earlier, it might be suggestive. Today, it’s junk [science].

    I would not be the least bit surprised if the majority of slender people today are so due to pathologies (including pathological diets). The number who are slender due to being on optimal diets for their phenotypes is a tiny fraction of the data set.

  6. I can’t agree more with the BMI item. Whenever I go to the doctor, I trigger the weight management item and they always ask me if I am aware that I need to monitor my weight. I am a 5’4 female weighing 165.

    But when I ask my body-building brothers, or anyone else, to guess my weight – they usually put it in the 130s. I have a lot of muscle and wear size 8 pants. But you can’t tell that from a scale. I used to be 2 sizes larger at 155.

    Weight tells a very small part of the story.

  7. Until genetics start getting factored into all these studies, I’m going to pretty much shrug when I read them. Looking at photos of my grand and great grandparents, there were few who would be considered thin by today’s standards. With the exception of one of my great aunts, they all lived to be over 85. My parents, products of a “convenience food” world didn’t fare so well.

    Looking at trends is a good thing, but the results should be taken with a grain of salt. The stress of trying to be a certain weight when your genes are screaming to be another weight can’t be healthy. We all know people who’ve been trying to “lose weight” all their lives.

    Eat the most wholesome food you can afford. Walk, get sun, laugh a lot. Even if you don’t live to be 100, you’ll at least be happier than you would be trying to conform to whatever the PTB is spouting is optimal weight this decade.

  8. Right on Mark! Glad you took on this one. As a “moderately overweight/mildly obese” female, I can say that this helps me feel better. I’ve always known, long before my BMI was regularly tested that I have a bit of muscle and a lot of fat, mostly in the wrong places. I don’t need some new book, or philosophy to tell me its “all ok, I’m not so fat after all”. I know better and it helps me to hear you say it. That is REAL encouragement. Thanks for all you do.

  9. Mark, your explanation makes sense. What needs to happen is a change in the lingo!

    Instead of saying “You need to lose weight”, we need to say “You need to lose fat, and gain muscle”. That is the mindset we need to encourage!

    1. So true! Imagine if everyone focused on the muscle percentage, not the weight number.

  10. I’ve once read an article about sudden death and heart attacks during marathons, and it said that young people having a heart attack have a much lesser chance of survival than old ones. That’s not because age is a “protective factor”, but because the younger an athlete, the more serious and unusual the cause of the attack in the first place, and the more rapidly it progresses.

    So when I heard about the “obesity paradox” it was the first thing that came to mind: this thing needs a more bayesian approach, since it deals with a posterior distribution and doesn’t take into account the risk of getting such a disease in the first place.

  11. Evolution favored body fat retention – to a point – as protection against starvation. Now, of course, TOO much body fat can be detrimental. But that doesn’t mean that we were all meant to walk around in an ultra-lean state or anything like that. The fact that hunter-gatherer populations DO often have defined, sinewy muscles is an artifact of the very real possibility of starvation and the constant search for calories. So basically, it makes sense that we should be able to carry more than a baseline amount of fat as starvation insurance, without damaging our health.

    Now, if lean muscle mass, more than body fat percentage, is the key, then the people I’m gonna put my money on are the “Strongman”-type people. Or perhaps you’ve heard it called “farm strong.” They are big and bulky and may carry a little extra, but they can throw hay all day AND survive the winter.

    1. THANK YOU.
      I recently spent 2 weeks working on a farm, and the farm owner is 70 years old. She’s not what anyone would call thin or svelte, but she’s STRONG. She’s absolutely not “fat,” but she does have some meat on her bones, which is crucial for healthy aging. She makes farmstead cheese with the milk of her own dairy herd, and lemme tell ya, that is hard work! Lots of heavy lifting, bending, hauling equipment — and she was on it better than a lot of folks would be capable of at half her age.

      Aesthetics and the modern Western beauty ideal aside, in older age, it’s probably better to have a little meat on the frame than to be so frail and fragile you can’t even carry groceries out of your car, or you look like you might blow away in a light breeze.

      This probably goes for younger people, too. Strength and hardiness might be more important than the size of one’s jeans. (But I say this knowing what a rough road this is to walk in modern society. I’m not immune to it…constantly trying to get to a lower weight and “thinner” body, despite my body fighting me on it most of the way.)

  12. Mark,

    Thank you for refuting Harriet Brown’s crap. As someone who has been struggling to live a healthier life, I find her drivel to be annoying at best and harmful at worst. It provides arrows to sling at me when I pass on the cake and ice cream at a party or say no to drinks. I don’t want to count how many times her crap has been posted to my facebook page by “friends” trying to convince me that losing weight is a bad idea. Here is the rub. I have the weight to lose. When I started my journey I weighed almost 430 pounds. I am down to somewhere between 255-260, not ideal but better. One aspect that Brown totally misses is how much better I feel psychologically a bit smaller. Movie theater seats, cars, walking around my block all fit me better. Now at a size 38 pants, I don’t fear my pants ripping and not being able to buy a replacement pair. If that happens, I can just go to virtually any store and buy a pair. Those are little things but added together, they add up.

    1. Congratulations on what you’ve accomplished so far! I hope to read your success story someday, even well short of whatever your target is. The 70+ pounds that you’ve already lost is significant!

    2. Congratulations, Ben! A 170# weight loss is a huge accomplishment! I second the request for a success story regardless of your ultimate goal.

    3. Amazing, and great to hear you say ‘I feel better’. So often we miss that simple aspect amidst all the ‘science’ and ‘dogma’ spouted.

  13. BMI also doesn’t take into account body type and genetics. I once had a Samoan coworker about my height, not overweight, or a weightlifter. He probably weighed 70 lbs. more than me, and his knees and wrists (bone structure) appeared to twice as big around. At similar levels of fitness, we should weigh very different amounts depending on our ethnic backgrounds and individual genetics.

    Toss your scale and get an occasional DEXA.

  14. You see old people, and you see fat people. But you never see old, fat people. Why is that?

    1. I understand the point you’re trying to make, but I see old fat people all the time, lol.

    2. I know quite a lot of old, fat people – who are healthy and active. My MIL is 92 and she’s fat. Been fat most of her life. Blood pressure is low, no diabetes, never any brush with cancer, no heart disease despite familial hypercholesteremia. Three of my uncles were quite tubby, and they all lived into their 90s. A family friend, rotund, but very active, died at 98, having survived liver cancer for 40 of those years. Let’s look at my mother: decidedly obese, very unhealthy, 78 years old. BUT all her health conditions started when she was young and thin! She had her first heart attack at 36, when she weighed 130lb, at 5’5″ tall. Her kidneys were damaged by toxaemia in each of four pregnancies, and she was thin for all of them. I’ve seen photos of her during her pregnancies, and she was downright scrawny apart from the bump. She started to pack on the pounds in her mid-40s. Blaming my mother’s current ill-health on her current obesity would be a huge mistake. She was just as sick when she was thin. So, in the same way as Mark says that thin people who are sick after losing weight became sick while fat, maybe a lot of obese people were getting sick while they were thin?

  15. Excellent article. Thank you very much. My own take on health: High-quality food, frequent activity, occasional high-intensity exercise, sufficient social interaction, plenty of laughter, of music, and frequent practice of kindness and thankfulness.

  16. The timeliness of this article was amazing as I just heard a story about this on public radio yesterday. While I don’t think it is their intention, I hate that these articles suggest that it’s ok, or even healthy, to be obese. If they signal to even one obese person that it’s OK for them to be sedentary and eat junk, then that’s tragic.

  17. I have mixed feelings about this article. As someone who has spent much of her life at a low to normal bmi (anywhere from 15 to 20) I can say that there’s definitely a reason that low bmi is associated with higher mortality than a normal to slightly overweight bmi- while I thought pursuing my leanest possible body would bring health benefits, instead I lost my period for 4 years, developed osteoporosis at age 22, developed jaundice and liver disease. It wasn’t until my GP recommended I gain enough weight to put my bmi at 21-25 that I finally began to heal. My mind felt calmer, and by having a bit of extra body fat I felt that If anything were to happen, such as accidents, injuries or illness, I would have enough reserve that my body could cope for a little bit. My periods returned and my bloods normalized.
    This is not to say that being overly obese is ideal for optimum health- I just have a feeling that being slightly overweight is probably much healthier than being underweight or having a low-normal bmi, especially in the elderly (who are more susceptible to ailments).

    1. YES!! Thank you, eb!
      I think being “obese” (whatever the exact definition might be, in terms of pounds or BMI) is probably not healthy, but being 5-15 pounds above one’s “ideal” weight? (Again, whatever the exact definition might be.) That’s probably not a problem at all, if other measurable markers are where they should be — or, rather, where we *currently* believe they should be, in order to ward off chronic degenerative conditions. (HDL, trigs, CRP, AST, ALT, glucose, insulin, and all the rest.)

      I firmly believe that carrying around a few extra pounds is likely less detrimental to long-term health than the extreme measures some people may be taking in order to lose “the last ten pounds.”

      Overweight people have been stigmatized for so long, and we have a knee-jerk association between extra weight and poor health that we — some of us in the Paleo, Primal, and LCHF communities, in particular — automatically *assume* someone is a ticking time bomb if they don’t have six-pack abs, can’t do an unassisted pull-up, and *don’t* fast for 18 hours a day.

      Being *underweight* — especially in older people — is more metabolically harmful than having a little extra padding. I’m not talking about morbid obesity, but a few extra pounds? Might be better to leave them where they are than to take potentially dangerous measures to get rid of them at all costs for little more than vanity purposes.

  18. “I’m sorry. I’m not buying it. There’s no paradox.”

    Thanks, Mark, for interjecting some sanity into the rising notion that obesity is the new “normal.” While it’s not okay to discriminate against fat people, it is also not okay to delude them into thinking that being overweight is in any way healthy.

  19. Thanks for this analysis, Mark. I wasn’t sure what to make of the Harriet Brown article, so I appreciate your weighing in (at an “exceedingly normal” BMI)!

  20. Maybe that’s why it’s always so hard to “lose that last 10 pounds”, maybe your body is telling you it wants to hold on to that little extra bit for “dear life” (pun intended)

    1. Right? Research has demonstrated that hunter-gatherers burn the same amount of calories each day that an office worker does, because their metabolisms have adapted to the energy demands of their lifestyle.

      At 3500 calories a pound, ten extra pounds is 35,000 calories a person can use to sustain their life when times get tough. If we assume the average person burns 2500 calories a day, ten pounds is potentially two weeks of food stored on one’s body.

      Evolution would be stupid to create animals (us) whose optimal physical state can only exist on the brink of starvation. The life-saving benefits of walking around with two extra weeks of life on one’s body are so crucial to survival in harsh climates that I can’t see where evolution would penalize our health for it.

      Now, to be sure, there’s a point in the accumulation of body fat where the law of diminishing returns kicks in. But it’s probably *not* in the “carrying a little extra” category. After all, if a food crisis occurred and calories became scarce again, how many people would still be intentionally chiseling their six-pack abs? Nobody. All of those ultra-lean types would be busy trying to conserve every calorie that comes their way.

      1. Interesting viewpoint – as a recovered IM triathlete I can attest to the fine-line aspect of “lean ness” and “trained ness”.

        Coaches often push athletes to that very fine line to maximise performance, but 1 % over and you break, are ill, lose performance rapidly and often get injured to boot.

        1. Exactly! When human survival was a tightrope act, evolution wanted to make sure we would have a caloric safety net in the form of stored fat. Are we potentially faster, stronger, or more agile without the net? Possibly. But the benefits of the net far “outweigh” the costs, up to a certain point.

          No hunter-gatherer would ever have intentionally taken themselves down to the “fine line” you mention – in societies that are food-insecure, there is simply too much at stake.

  21. Hmmm maybe the junk food companies are really behind that article, if overweight people feelbetter justified about being overweight then maybe they’ll keep buying the junk food.

  22. This is a case of the data being artificially skewed. In 1998 the NIH changed the criteria for overweight and obese, lowering the numbers of what constituted a healthy weight. Why? Who knows but I bet it wasn’t because of sound science. Effectively a female who was 5’4 and 155 would have been considered healthy but the change would have required her to drop to 145 under the new guidelines. Makes sense right?

    For example I’m 5’8 170 lbs and 14% BF by caliper. No six pack here but I’m healthy by any reasonable standard yet I’m technically overweight. I was lectured by an obese doctor at one of my latest physicals to adopt a low fat diet and lose weight. Really? Under the old standards I would be normal. Under the new standards I would have to lose 6 lbs and get to 10% BF.

    There are people who are genetically overweight and there is prudence in the anti-fat shaming movement. Losing weight is hard, I was obese most of my adult life. However I see much of the HAEW movement as nothing more than an excuse. Trying to interpolate results of being overweight or slightly obese on paper to justify true obesity as healthy and normal is not a good message.

  23. Who cares about mortality rate. Isn’t the point of Primal living to be healthy now. To enjoy eating nourishing, life giving food. Sure an unhealthy person will lose weight as a byproduct of primal living, but that is not a worthy goal in my opinion. Mark makes a good point that this kind of article is irresponsible, but selling weight loss as the solution is also a never ending cycle of lose/gain. If we aren’t in it for all the life giving benefits, we will never know long term success.

  24. After struggling with the aches and pains and added weight as the direct result of my sugar addiction, I a can honestly say that life extension is not one of my goals.. As the saying goes “it’s not about the years in your life, it’s about the life in your years.” My entire nutritional goal is just to restore my health so that I can enjoy the things I was able to do in my twenties. Who cares if you can live to be a 100 if you can’t enjoy a quality of life for the last 40 years. What an ignorant point of view to present and glorify “fat people live longer.” Even if it is true, I can attest to one thing, fat ain’t much fun.

  25. Tee hee… obesity writer “ignores a huge body of research”.

  26. There seems to be a lot of mention of BMI here today. But none of the anti-BMI contributers so far seem to realise that there are alternatives hovering in the background, some even catching the attention of the medical profession!. About a year ago I came across a father and son team who devised an alternative. I could not find my browser reference to their (?) site, but have unearthed a reference to their work and a few alternatives. Although I’m a little over-fat/under-muscle my weight is about right, but as a T2 diabetic my main concern is viseral fat, hence personally I’m not too concerned regarding BMI, or its alternatives. But I thought I’d add this tiny iota of knowledge into the fray, it may provide one of you with ammuntion to defend yourself against GPs and nurses, you may be able to knock them off their high horses. In my experience this closes down the nagging very effectively, as they usually don’t have the detailed knowledge of alternatives to their training to effectively respond.

  27. There seems to be more animus against HAES than is justified, in my opinion. HAES does not in any way support gorging on junk food or lying on the couch with a remote control in one’s hand. To the contrary – there’s strong emphasis on eating healthfully, and finding some form of pleasurable physical activity. There’s a lot of emphasis on looking at health markers. Where the uncrossable divide comes in, as I see it, is that HAES believes that you can be healthy at every size! They’re trying to get the focus off body size, especially large sizes, and onto actual health. The two can be decoupled! It might well be that an obese person who throws away the digital scale, decides to eat well, and finds something fun to do that involves bodily movement might lose weight – but even if s/he doesn’t, s/he will be healthier than before. Feeling better, in terms of actually feeling more well, increases the chances of feeling good – and feeling good becomes addictive. Constantly telling somebody that s/he cannot possibly be healthy while fat is cruel and counter-productive. What I like about HAES is its rejection of body-shaming tactics and its emphasis on health.

    1. I want to give you a thank-you hug, SuzU! You’ve said this so well. There are obese triathletes, obese marathoners, and obese people who eat very well but have other issues complicating fat loss. The HAES movement is really not at all about glorifying obesity. It emphasizes lifestyle habits and healthy diets, rather than the effects those habits might or might not have on the size of one’s pants. As a nutritionist, I’ve worked with plenty of people at “healthy” (or “normal”…ugh) BMIs who were complete trainwrecks on the inside.

  28. Mark, with all due respect, I want to point out what I see to be a contradiction in what you say. You write: “I’m not buying it. There’s no paradox.” And yet, you then go on to give a bunch of possible reasons for the paradox — i.e. assuming the paradox to exist — like abdominal adiposity, muscle mass/strength, and so on. And I agree with you! Those ARE reasons for the paradox. But that means that there IS a paradox — at least with respect to the common (generally unquestioned) conception that overweight = big huge health risk. As it turns out, overweight or high BMI *per se* are simply not quality indexes of health. Other things that are sometimes (but not necessarily) *associated with* overweight, such as abdominal fat or high waist circumference, are much better indexes.

    Bottom line: there IS a paradox, but (for several reasons, some of which you mention) it cannot be reduced to simplistic nonsense like “being fat is OK”.

    Better bottom line: when is everyone going to focus on REAL RISK FACTORS AND MARKERS, like cardiorespiratory fitness, various chemistries (lipids, etc.), relevant anthropometrics (waist:hip ratio, lean mass %, etc.), diet quality, and so on, TO THE EXCLUSION of stupid, inferior, almost-meaningless, misleading numbers like bodyweight and BMI?

    PS: really nice review of the paradox:

  29. Well. The study

    “A pooled analysis of waist circumference and mortality in 650,000 adults.”

    seems to suggest (image 3) that being slightly overweight (BMI between 25 and 30) carries lower risk than hitting your optimal BMI of 20-21. You can have 10 to 15 cm more belly before reaching the lowest documented risk of the low-normal BMI range! That bears further thought.

    Maybe being in that 25-30 often means packing more muscle, or at least more added muscle than fat compared to the 20-22.5 group.

    But that’s in line with the general message of this article: low BMI alone does not make you healthy, apparently. High belly circumference definitely makes you unhealthy.

  30. Thank you for your sensible points refuting what is a pseudo-science article masquerading as research. There are benefits to eating well and it isn’t as tough as what the fat acceptance camp likes to think.

    Most of us are normal folks working in normal jobs. Thus, our lifestyles and eating habits can be a little more flexible. It isn’t an excuse, however, to eat any quantity of any food we want without being physically active.

  31. Another factor that is rarely discussed when talking about “weight” as a measure of health is HOW a person reached that weight. If a calorie means anything, then in theory, overeating broccoli and steak can still make a person gain extra weight that gets stored as fat. The balance between the calories taken in and their nutritional composition might tell more about the individual’s health outcome. That said, it is unlikely that a person who gains weight eating broccoli and steak is going to reach massive adipose proportions. But the flip side of that is that I think the health benefit to those of us with metabolic disturbances which might prevent us from losing weight at a caloric intake that would cause adipose reduction in a metabolically healthy person (I am 5’4” 195 lb female eating between 1000-1500 calories a day depending on my activity level and struggling to maintain my weight) are still reaping benefits from eating Primal, even if those benefits are not necessarily reflected in a change in body mass or composition. The damage of the “fat paradox” is more its oversimplification than its message. Like so many other studies, it neglects to take into account a whole host of factors (most of which have already been covered in the article and comments) that would help explain variations among different overweight populations. A study that could serve to protect people who are essentially taking good care of themselves from giving in to destructive weight loss methods because their doctor looks at their weight alone and says “you have to lose weight or you’re going to die,” instead just appears as permission to be fat.