Can You Be Fit and Fat? (original) (raw)

One day in 2018, Wendy Welsher picked up her bathroom scale and smashed it to pieces.

Finally, she was done. After decades of being told she isn’t small enough, after years of yo-yo diets and bingeing, purging, and overexercising -- only to hit a number that “never seemed good enough” —she reached a breaking point.

What, exactly, would qualify as good enough?

A gregarious blonde with blue eyes and a big smile, she skied competitively as a kid, took kickboxing classes in college, and ultimately found her way to kayaking, swimming, and competitive weightlifting. But her thick build and high body mass index (BMI) still earned her disapproving looks at the gym and calls from her doctors to lose weight.

So she took it all out on the scale.

“It was incredibly liberating,” recalls the 49-year-old “fat-positive” strength and conditioning coach from Sacramento, CA. “People look at people like me who live in larger bodies and automatically think we are lazy. But the reality is, you can be fit and fat.”

While the notion still seems controversial to some, decades of studies say it’s possible.

In fact, the most comprehensive review yet, published in November 2024 in the British Journal of Sports Medicine, found that fitness – not body mass index (BMI) – had the greatest impact on how long people lived.

“We covered every single study that has been published examining the issue at this point and the evidence is clear,” says Siddhartha Angadi, PhD, associate professor of exercise physiology at the University of Virginia and lead author of the review.

“Fitness is far more important than fatness.”

Way back in 1970, researchers started tracking health data from men who got checkups at a preventive medicine clinic in Dallas. By 1993, they had information on heart disease risk factors such as cholesterol, blood pressure, smoking, BMI, and aerobic fitness (based on treadmill tests) from 25,714 men.

Over the decades studied, death rates were – as conventional wisdom might suggest – highest for men with obesity, followed by overweight men, and lowest for men with normal BMI.

But a deeper dive into the data showed the findings were more complicated than that. Men with obesity were also more likely to smoke and have a history of heart disease – factors that could in themselves boost risk of death.

About half of the men with obesity were, otherwise, fairly fit when it came to heart health. And those men had a much lower risk of dying.

“If all obese unfit men in our cohort had been fit, there might have been as many as 44% fewer deaths among obese men in our study,” the researchers wrote in JAMA in 1999.

The same held true for overweight men and those with a "normal" BMI: The strongest predictor of who lived and who died wasn’t their BMI. It was how fit they were.

The authors urged doctors to start checking – or at least ask about – fitness for anyone with a BMI in the obesity range. “It is as important for a clinician to assess an obese patient’s fitness status as it is to measure fasting plasma glucose and cholesterol levels, evaluate blood pressure, and inquire about smoking habits.”

Reviews published in 2014 and 2018 drew the similar conclusion that lack of fitness, not extra pounds, could be driving an epidemic of heart disease and diabetes and shortening lifespan.

But those reviews, like that first study, lacked women.

The newest, from the British Journal of Sports Medicine, was much bigger and more diverse. It pulled from 20 studies done between 1980 and 2023, with nearly 400,000 participants worldwide. They all got their BMI measured and took a VO2 max exercise test to gauge their cardiorespiratory fitness.

The key finding: Fit people, regardless of their BMI category, had about the same risk of dying, including of heart disease, during the studies. And in at least one group, the people with obesity had an advantage: Those who were fit were half as likely to die during the studies as sedentary folks with a normal BMI.

Cardiorespiratory fitness strongly predicted heart disease and death from any cause, and “attenuates risks associated with overweight and obesity,” the researchers wrote.

The bottom line: When it comes to health, a low level of fitness was riskier than high BMI.

Other recent research, published in JAMA Network Open, estimates that about 15% of U.S. adults with obesity had “metabolically healthy obesity” (MHO). That means they somehow avoided the blood pressure, blood sugar, cholesterol, and triglyceride issues that so often accompany a high body mass index.

Meanwhile, structured weight loss programs – not including options like bariatric surgery or GLP-1 inhibitor obesity medications such as semaglutide (Wegovy) and tirzepatide (Zepbound) – often fail beyond the short term. As many people know all too well, the pounds have a way of coming back.

One research review, pulling from 29 long-term weight loss studies, found that people regained more than two-thirds of their lost weight within three years and regained about 80% within five years.

All this has some experts and body-positive trainers like Welsher calling for a seismic shift in public health messaging – away from the scale and toward the gym.

Angadi’s co-author Glenn Gaesser, PhD, professor of exercise physiology at Arizona State University, started saying this in the 1990s.

He’d been helping a colleague with a study looking at how exercise impacted health in people with obesity. After a few weeks, the study participants lost a few pounds but were still, according to their BMI, obese. Yet their measures of heart health and diabetes risk were radically improved.

“It got me thinking: Is it really the obesity that is causing these health problems?” Or was it a sedentary lifestyle?

In 1996, Gaesser published the book Big Fat Lies, challenging the conventional wisdom that obesity, in and of itself, kills. He’s published many studies and perspective papers since, arguing that it’s possible to have obesity and be healthy – as long as you exercise regularly.

But in a culture that often equates thinness with health and beauty, particularly for women, Gaesser’s message has been slow to stick.

“It’s hard to change people’s perceptions that have been ingrained for decades,” he says.

Gaesser argues that even the definitions of “overweight” and “obese” are fraught, as they center around BMI – a hotly contested measurement that fails to consider how much muscle a person has or where their body fat is distributed. (Deep belly fat, or visceral fat, is worse than fat under the skin, or subcutaneous fat.)

Contrary to popular belief, weight loss, in and of itself, won’t necessarily improve heart health or risk of death either, he says.

In 2012, researchers famously halted a weight loss study of 5,000 overweight or obese people with type 2 diabetes due to “futility.” The people assigned to the study’s intensive lifestyle program – including a calorie-restricted diet and exercise – did lose more weight than the control group. But even so, they reaped no benefit in their risk of heart attack or stroke over a decade. Other studies also show that losing weight does not reduce risk of death except in people who have obesity-related health problems. Physical activity and quality of diet should be considered, not just what people weigh, researchers have argued.

And trying to lose weight has its own risks, Gaesser notes.

Constant yo-yo dieting can wreak havoc on the body and psyche, with some studies showing it can actually boost risk of things like heart attacks, strokes, and early death. And if lowering the numbers on the scale is the only goal, there’s also the risk of losing muscle.

Exercise, on the other hand, impacts virtually every cell in the body in ways that improve cardiometabolic risk.It even changes the way some types of fat behave, making them more metabolically healthy.

“The fat on people who exercise is not the same as on people who don’t,” Gaesser says. “It’s fit fat.”

So should overweight and obese people still be advised to lose weight?

Gaesser says, typically, no. But other experts, including Samuel Klein, MD, chief of the division of nutritional science and obesity medicine at Washington University in Saint Louis, says yes.

“Obesity has adverse effects on every organ system in the body,” Klein says. Fitness may help the cardiovascular and metabolic health of someone who has obesity, but that doesn’t rule out all the other known health risks, Klein notes.

For instance, research strongly links obesity to a greater risk of certain cancers and mobility problems. And just because someone is fit and fat now doesn’t mean they always will be.

In people who have obesity, Klein says, “weight loss can prevent future conversion to metabolically unhealthy obesity, treat or decrease the risk of other obesity-related diseases, [and] improve physical function and quality of life.”

Gaesser argues that, when consulting with overweight or obese patients, doctors should prioritize exercise instead of weight loss – and it doesn’t take much.

In the recent meta-analysis published in the British Journal of Sports Medicine, most studies gauged fitness by how long people could walk or run on a treadmill, with anyone above the bottom 20th to 25th percentile considered fit enough to see protective effects.

Just going from nothing to something can have a huge “dose response,” Gaesser says. He recommends starting with short bursts of exercise and working up to the public health recommendation of at least 150 minutes per week of moderate intensity activity.

Welsher far surpasses those recommendations.

As a master’s level Olympic weight lifter, she trains four to five days per week. She also owns her own size-inclusive fitness studio, where she helps other big people get stronger and more flexible in a space where they feel welcomed instead of shunned.

She’s not hung up on numbers anymore.

When asked, she declined to share her BMI for this article. But she did share the numbers that matter to her: Recent blood work shows she doesn't have diabetes and, aside from slightly elevated cholesterol (which she attributes to menopause), she says her heart health is excellent. A recent body composition test shows she carries 179 pounds of lean muscle mass on her rock-solid frame.

Welsher says her relationship with her body is still a “work in progress.”

But she now sees food as fuel, not punishment; her body as a teammate, not an enemy.

“It carries me through life, allows me to do things I love, and deserves care and respect,” she says.