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Don’t Believe Everything You Read, Part I: Debunking the Obesity Paradox

In 2020, the vast majority of adults in America will be overweight or obese and more than 50% will suffer from early to late stage diabetes, according to projections presented by Northwestern Medicine researchers at the American Heart Association (AHA) Scientific Sessions recently in Orlando.  83% of men and 72% of women will be overweight or obese this year. In 2020, 77% of men and 53% of women will have early to late stage diabetes. 

Less than 5% of Americans currently are considered to have ideal cardiovascular health. If current diet, alcohol and smoking trends continue, America’s health care costs, already projected to reach $1.1 trillion per year by 2030, will continue to rise even further.   Achieving a healthy weight through diet and physical activity, and not smoking is the most effective way to improve their heart health. Yet, one in five Americans still smoke.

When one sees staggering statistics like these reach new and higher peaks, it is becoming increasingly apparent that other adverse health conditions are also on the rise—mainly stroke, cancer, obstructive sleep apnea, and autoimmune disorders, all of which increase mortality (Higgins et al., 1998; Calle et al., 1999). 


Don’t Believe Everything Your Read 

You may have recently heard that being overweight, but not obese, actually increases your lifespan compared to people of normal weight. This is known as the "obesity paradox" because very few studies have linked obesity with longer life. This comes from a study that spread like wildfire, gracing the pages of TIME, WebMD, and NPR. 

You first have to understand body mass index (BMI), a simple calculation that divides weight (kg) by height (m2). BMI is a primitive tool for assessing weight but isn’t actually useful.  For example, those with excess abdominal fat and a normal BMI are actually at increased risk for heart disease. On the other hand, athletes with a lot of muscle mass may have an elevated BMI and be labeled as “overweight”.  In actuality, they are healthy and fit. Some “overweight” clients often say they feel quite healthy and do not feel the need to lose weight until their BMI suggested otherwise. 

The truth is, if you look hard enough, you’ll find an association between anything (i.e. an association between not wearing your hat and a car crash) —and this is the danger of a poorly designed research study that everyone hears about. The damage that this does is almost irreversible. Flegal and colleagues (2013) synthesized 97 studies (providing a sample size of more than 2.8 million people and 270,000 deaths) and found that being overweight (BMI between 25 and 30) is associated with significantly decreased mortality compared to being normal weight (BMI between 18.5 and 25). These results were backed by a relatively small number of studies that came before it (McGee, 2005; Janssen & Mark, 2007). 

But there are serious problems with the study design which invalidate its conclusions. Among its many issues, the aforementioned Flegal study fails to separate the effects of disease on weight from the effect of weight on risk of disease (i.e. there’s a difference between people who were normal weight for decades from people who were previously heavy and lost weight after developing a disease).

Clinically, we know that obesity (all grades of BMI greater than 30) has been associated with significantly higher all-cause mortality compared to normal weight BMI, but Flegal and colleagues only address BMI data sets, not body composition (visceral fat or body fat distribution), which we know is incredibly important. This is why we cannot believe everything we read, particularly with soundbite headlines. The sensationalism surrounding absurd claims ultimately end up creating more confusion than helping the health of the public.

As one more example, other researchers found that obesity was associated with lower mortality risk compared to people with lower BMIs, but only with certain health complications, like congestive heart failure (CHF). This is quite paradoxical, yet, in those with CHF, it may simply mean that obesity is an indication of better overall health status, but is not the reason for lower mortality (Kenchaiah et al., 2002). Again, if you look hard enough to find an association, you probably will find one, but it doesn’t mean that it’s a true association.

It’s quite possible that obese individuals may be "healthier" overall if they are (1) eating a cleaner, whole foods plant-based diet, (2) getting more exercise than their lower-weight peers, (3) non-smokers, (4) consuming little to no alcohol, and (5) less stressed. None of these factors are truly captured in a BMI measurement.

Consider, for instance, higher body weight could indicate better social support (access to food) and/or high functional status (self-sufficiency in food prep) (Fleischmann, Bower, & Salahudeen, 2002). Our social support systems are profoundly impactful on our health, and they should not be taken for granted. Plus, good cooks likely eat better than those who eat out all the time. The joy of cooking and sharing food as a social connection is huge in the happiness and quality of life factor. When you or a family member is a good cook, chances are your diet is more diverse and you are eating less processed foods, eating out less, giving you more control over your quality of nutrition. 

In sum, BMI is a basic measurement which cannot speculate one’s overall health risk. We don’t truly know enough about a person’s health until we look at what’s going on cellularly -- how the body interacts with our environment.

Dr. Bhandari and the Advanced Health Team Are Here to Support Your Health.

Our expert team of integrative holistic practitioners work with patients suffering from chronic health concern.  We help them reverse disease by better understanding how the body optimally functions and providing personalized treatment plan. To learn more and book an appointment, contact Advanced Health or call 1-415-506-9393.


Calle, E. E., Thun, M. J., Petrelli, J. M., Rodriguez, C., & Heath, C. W. Jr. (1999). Body-mass index and mortality in a prospective cohort of US adults. N Engl J Med, 341, 1097–1105.

Flegal, K. M., Kit, B. K., Orpana, H., & Graubard, B. I. (2013). Association of all-cause mortality with overweight and obesity using standard body mass index categories: a systematic review and meta-analysis. Jama, 309(1), 71-82.

Flegal, K. M., Carroll, M. D., Kit, B. K., & Ogden, C. L. (2012). Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999-2010. Jama, 307(5), 491-7.

Fleischmann, E., Bower, J. D., & Salahudeen, A. K. (2002). Obesity and survival on hemodialysis: weight gain portends better survival in a prospective cohort [abstract]. J Am Soc Nephrol, 13, 584A.

Higgins, M., Kannel, W., Garrison, R., Pinsky, J., & Stokes, J. III. (1998). Hazards of obesity: the Framingham experience. Acta Med Scand, 723(suppl), S23–S36. 

Janssen, I., & Mark, A. E. (2007). Elevated body mass index and mortality risk in the elderly. Obes Rev, 8(1), 41-59.

Kenchaiah, S., Evans, J. C., Levy, D., Wilson, P. W. F., Benjamin, E. J., Larson, M. G., . . . & Vasan, R. S. (2002). Obesity and the risk of heart failure. N Engl J Med, 347, 305–13.

McGee, D. L. (2005). Diverse Populations Collaboration. Body mass index and mortality: a meta-analysis based on person-level data from twenty-six observational studies. Ann Epidemiol, 15(2), 87-97.

Dr. Payal Bhandari Dr. Payal Bhandari M.D. is a leading practitioner of integrative and functional medicine in San Francisco.

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