There’s been a simmering debate in the medical community (not to mention the popular press) over whether it’s time to stop making weight loss the primary goal of obesity treatment.
Obesity, as you probably know, is a disease state that’s defined by a BMI of more than 30. What’s that mean in actual numbers? I’m 5’9” (or 175 cm) tall and at 150 pounds, I’m considered normal weight. At 170 pounds (77 kg) I would be classified as overweight. If my weight crept above 200 pounds (91 kg), I would be classified as obese.
Losing weight (mostly) doesn’t work
Most people suffering from obesity would be a lot healthier if they lost weight. The problem is that many (or even most) of them don’t succeed in losing weight—even when they really try to. We can debate why people are so unsuccessful in these attempts. We can blame the diets, the environment, the food supply, the media. Many are tempted to blame the people suffering from obesity for simply being unwilling to do what they need to do.
But all this finger-pointing—and the competing solutions that arise from it—isn’t solving the problem. A large and growing percentage of our population, including our children, now suffers from seemingly intractable obesity and all the health risks that go with it.
If we can’t actually help people lose weight, maybe we should focus instead on what else we can do to reduce those risks. Or so the argument goes.
Should we promote fitness over weight loss?
In a paper published last month, Glenn Gaesser and Siddhartha Angadi argue for a weight neutral strategy for the treatment of obesity. To support their contention, the authors present data from over a hundred individual studies and meta-analyses on the relationships between weight loss, exercise, disease risks, and mortality.
They point out that achieving moderate-to-high levels of physical activity or cardiovascular fitness can be just as effective in reducing the risk factors associated with obesity, even if those people don’t lose any weight. (Which is a good reminder that weight loss is not the primary benefit—or outcome—of exercise.)
They also note that weight cycling, where people repeatedly lose and gain weight, has a lot of negative health impacts. In fact, losing and regaining weight may actually be worse for you than not losing it in the first place. In other words, telling people with obesity to lose weight may be doing more harm than good, especially if this goal is prioritized above (or to the exclusion of) improving fitness.
So, should we actually stop recommending that people pursue weight loss and just focus on helping them get more fit?
Is fitness an easier sell than weight loss?
I can see the logic to this argument: Let’s not allow what we can’t do keep us from doing what we can. But for those with obesity, I’m not sure that achieving moderate-to-high levels of physical activity or cardiovascular fitness is any less daunting than achieving significant weight less.
Excess body weight—which can limit endurance and mobility—can make even light exercise very challenging. People with overweight and obesity are more likely to suffer from back problems, knee pain, and are more prone to exercise related injuries. Of course, you can (and should) start wherever you are—even if it’s just walking 5 minutes a day—and build from there. But it’s not an instant or easy solution to the problem. As with weight loss, achieving significant improvements in fitness may take a lot of time, effort, and patience. Sustaining a higher level of activity requires a long-term commitment.
Must we choose?
There’s no doubt that a fitter body—of any size—is a healthier body. But at the same time, I’d like to think that this can be a Both/And, instead of an Either/Or. And that seemed to be the general consensus among a group of health professionals discussing this study recently on LinkedIn. The real take home here is not that weight doesn’t matter but that the emphasis should not be on weight loss to the exclusion of other measures.
The emphasis should not be on weight loss to the exclusion of other measures.
Social scientist Marlena Hanlon stresses that it’s really about the focus of the intervention. “If you focus on exercise and healthy habits, weight loss may follow, but if it doesn’t, better health still will. Conversely, if you focus on weight loss, there is nothing which inherently ensures better health outcomes.”
Especially, I would add, because weight loss is a goal so infrequently and fleetingly achieved. In fact, as the authors of this recent paper point out, some data suggest that a person with obesity who is in good shape may have a greater life expectancy than someone of normal weight but below average fitness. But, they are quick to point out, “physically active adults in the normal weight BMI range had the lowest risk.”
It’s not necessarily just the health professionals who are overly focused on weight loss, however. Dr. Jonathan Ehrman, who runs a preventive cardiology program for a Michigan hospital, points out that most of his patients with obesity “first and foremost want to lose a significant amount of weight.”
Weight is not the only thing that matters
Part of the problem certainly lies in how we approach weight loss. Dr. Tom Rafai of the Harvard Medical School of Lifestyle Medicine deplores approaches based in extreme food restriction. “In my opinion, there are better ways to achieve health, and even weight loss, than one that worships at the altar of the scale or meal replacements.” Hear, hear!
So, let’s not pretend that weight doesn’t matter to your health. It does matter. It’s just not the only thing that matters. Let’s continue to work on understanding and resolving the issues that make weight loss so difficult. But let’s use all the tools in our toolbox to help people live the healthiest lives they can. And, finally, let’s work towards a society where people are not stigmatized, judged, or discriminated against because of the size of their bodies.