#3 Is it Possible to be Healthy and Obese?

Is it possible to be metabolically healthy and overweight or obese? In this episode, we discuss the science of what makes fat healthy or unhealthy. We discuss how metabolic dysfunction in fat tissue can affect the rest of the body. We also review evidence pertaining to the “obesity paradox” and explore explanations for the associations of body mass index (BMI) and changes in the risk of disease complications and mortality. We discuss how metrics of central obesity can be used to obtain a better picture of an individual’s metabolic health. Lastly, we discuss the critical link between exercise capacity and future health, as well as how to begin to transform our existing fat stores into a healthier state.


00:00 – Introduction
00:50 – Healthy Obesity as an Idea
02:36 – Concepts of Healthy vs. Unhealthy Fat
02:59 – Subcutaneous, Visceral, and Ectopic Fat
05:22 – Adipocyte Hypertrophy
06:36 – Fat Cell Insulin Resistance
08:19 – The Obesity Paradox
12:23 – BMI & Age
13:53 – Bariatric Surgery
15:51 – Limitations of BMI
16:26 – Lifetime Maximal BMI
16:37 – Metrics of Central Adiposity
18:30 – Metabolically Healthy Obesity
21:38 – Exercise & Metabolically Healthy Obesity
22:36 – Improving the Health of Fat
24:03 – Exercise Capacity & Risk of Death
25:29 – Zone 2 Training
26:51 – The Effects of Weight Loss (Fat Loss)
27:55 – Summary


Powell-Wiley, Tiffany M., Paul Poirier, Lora E. Burke, Jean-Pierre Després, Penny Gordon-Larsen, Carl J. Lavie, Scott A. Lear, et al. 2021. “Obesity and Cardiovascular Disease: A Scientific Statement From the American Heart Association.” Circulation 143 (21): e984–1010.

Stenkula, Karin G., and Charlotte Erlanson-Albertsson. 2018. “Adipose Cell Size: Importance in Health and Disease.” American Journal of Physiology. Regulatory, Integrative and Comparative Physiology 315 (2): R284–95.

Russell-Jones, David, and Rehman Khan. 2007. “Insulin-Associated Weight Gain in Diabetes–Causes, Effects and Coping Strategies.” Diabetes, Obesity & Metabolism 9 (6): 799–812.

Fujikura, Junji, Muneya Fujimoto, Shintaro Yasue, Michio Noguchi, Hiroaki Masuzaki, Kiminori Hosoda, Takao Tachibana, Hajime Sugihara, and Kazuwa Nakao. 2005. “Insulin-Induced Lipohypertrophy: Report of a Case with Histopathology.” Endocrine Journal 52 (5): 623–28.

Dixon, J. B., G. J. Egger, E. A. Finkelstein, J. G. Kral, and G. W. Lambert. 2015. “‘Obesity Paradox’ Misunderstands the Biology of Optimal Weight throughout the Life Cycle.” International Journal of Obesity  39 (1): 82–84.

Myers, Jonathan, Kusum Lata, Shilpy Chowdhury, Paul McAuley, Nikhil Jain, and Victor Froelicher. 2011. “The Obesity Paradox and Weight Loss.” The American Journal of Medicine 124 (10): 924–30.

Pepper, Dominique J., Cumhur Y. Demirkale, Junfeng Sun, Chanu Rhee, David Fram, Peter Eichacker, Michael Klompas, Anthony F. Suffredini, and Sameer S. Kadri. 2019. “Does Obesity Protect against Death in Sepsis? A Retrospective Cohort Study of 55,038 Adult Patients.” Critical Care Medicine 47 (5): 643–50.

Petrelli, Fausto, Alessio Cortellini, Alice Indini, Gianluca Tomasello, Michele Ghidini, Olga Nigro, Massimiliano Salati, et al. 2021. “Association of Obesity With Survival Outcomes in Patients With Cancer: A Systematic Review and Meta-Analysis.” JAMA Network Open 4 (3): e213520.

Gonzalez, Maria Cristina, Carla A. Pastore, Silvana P. Orlandi, and Steven B. Heymsfield. 2014. “Obesity Paradox in Cancer: New Insights Provided by Body Composition.” The American Journal of Clinical Nutrition 99 (5): 999–1005.

Sedlmeier, Anja M., Sebastian E. Baumeister, Andrea Weber, Beate Fischer, Barbara Thorand, Till Ittermann, Marcus Dörr, et al. 2021. “Relation of Body Fat Mass and Fat-Free Mass to Total Mortality: Results from 7 Prospective Cohort Studies.” The American Journal of Clinical Nutrition 113 (3): 639–46.

Banack, H. R., and A. Stokes. 2017. “The ‘obesity Paradox’ May Not Be a Paradox at All.” International Journal of Obesity 41 (8): 1162–63.

Donini, Lorenzo Maria, Alessandro Pinto, Anna Maria Giusti, Andrea Lenzi, and Eleonora Poggiogalle. 2020. “Obesity or BMI Paradox? Beneath the Tip of the Iceberg.” Frontiers in Nutrition. https://doi.org/10.3389/fnut.2020.00053.

Elagizi, Andrew, Sergey Kachur, Carl J. Lavie, Salvatore Carbone, Ambarish Pandey, Francisco B. Ortega, and Richard V. Milani. 2018. “An Overview and Update on Obesity and the Obesity Paradox in Cardiovascular Diseases.” Progress in Cardiovascular Diseases 61 (2): 142–50.

Wiggins, Tom, Nadia Guidozzi, Richard Welbourn, Ahmed R. Ahmed, and Sheraz R. Markar. 2020. “Association of Bariatric Surgery with All-Cause Mortality and Incidence of Obesity-Related Disease at a Population Level: A Systematic Review and Meta-Analysis.” PLoS Medicine 17 (7): e1003206.

Sjöström, Lars, Kristina Narbro, C. David Sjöström, Kristjan Karason, Bo Larsson, Hans Wedel, Ted Lystig, et al. 2007. “Effects of Bariatric Surgery on Mortality in Swedish Obese Subjects.” The New England Journal of Medicine 357 (8): 741–52.

Adams, Ted D., Richard E. Gress, Sherman C. Smith, R. Chad Halverson, Steven C. Simper, Wayne D. Rosamond, Michael J. Lamonte, Antoinette M. Stroup, and Steven C. Hunt. 2007. “Long-Term Mortality after Gastric Bypass Surgery.” The New England Journal of Medicine 357 (8): 753–61.

Maciejewski, Matthew L., Edward H. Livingston, Valerie A. Smith, Andrew L. Kavee, Leila C. Kahwati, William G. Henderson, and David E. Arterburn. 2011. “Survival among High-Risk Patients after Bariatric Surgery.” JAMA: The Journal of the American Medical Association 305 (23): 2419–26.

Di Angelantonio, Emanuele, Shilpa N. Bhupathiraju, David Wormser, Pei Gao, Stephen Kaptoge, Amy Berrington de Gonzalez, Benjamin J. Cairns, et al. 2016. “Body-Mass Index and All-Cause Mortality: Individual-Participant-Data Meta-Analysis of 239 Prospective Studies in Four Continents.” The Lancet 388 (10046): 776–86.

Coutinho, Thais, Kashish Goel, Daniel Corrêa de Sá, Charlotte Kragelund, Alka M. Kanaya, Marianne Zeller, Jong-Seon Park, et al. 2011. “Central Obesity and Survival in Subjects with Coronary Artery Disease: A Systematic Review of the Literature and Collaborative Analysis with Individual Subject Data.” Journal of the American College of Cardiology 57 (19): 1877–86.

Gadekar, Tukaram, Puja Dudeja, Ipsita Basu, Shruti Vashisht, and Sandip Mukherji. 2020. “Correlation of Visceral Body Fat with Waist–hip Ratio, Waist Circumference and Body Mass Index in Healthy Adults: A Cross Sectional Study.” Armed Forces Medical Journal, India 76 (1): 41–46.

Camhi, Sarah M., George A. Bray, Claude Bouchard, Frank L. Greenway, William D. Johnson, Robert L. Newton, Eric Ravussin, Donna H. Ryan, Steven R. Smith, and Peter T. Katzmarzyk. 2011. “The Relationship of Waist Circumference and BMI to Visceral, Subcutaneous, and Total Body Fat: Sex and Race Differences.” Obesity 19 (2): 402–8.

Xu, Hanfei, L. Adrienne Cupples, Andrew Stokes, and Ching-Ti Liu. 2018. “Association of Obesity with Mortality over 24 Years of Weight History.” JAMA Network Open 1 (7): e184587.

Yu, Edward, Sylvia H. Ley, Joann E. Manson, Walter Willett, Ambika Satija, Frank B. Hu, and Andrew Stokes. 2017. “Weight History and All-Cause and Cause-Specific Mortality in Three Prospective Cohort Studies.” Annals of Internal Medicine 166 (9): 613–20.

Stokes, Andrew, and Samuel H. Preston. 2016. “Revealing the Burden of Obesity Using Weight Histories.” Proceedings of the National Academy of Sciences of the United States of America 113 (3): 572–77.

Stokes, Andrew. 2014. “Using Maximum Weight to Redefine Body Mass Index Categories in Studies of the Mortality Risks of Obesity.” Population Health Metrics 12 (1): 6.

Smith, Gordon I., Bettina Mittendorfer, and Samuel Klein. 2019. “Metabolically Healthy Obesity: Facts and Fantasies.” The Journal of Clinical Investigation 129 (10): 3978–89.

Matthias Blüher, Metabolically Healthy Obesity, Endocrine Reviews, Volume 41, Issue 3, June 2020, bnaa004, https://doi.org/10.1210/endrev/bnaa004

Gaesser, Glenn A., and Siddhartha S. Angadi. 2021. “Obesity Treatment: Weight Loss versus Increasing Fitness and Physical Activity for Reducing Health Risks.” iScience 24 (10): 102995.

Valenzuela, Pedro L., Alejandro Santos-Lozano, Alberto Torres Barrán, Pablo Fernández-Navarro, Adrián Castillo-García, Luis M. Ruilope, David Ríos Insua, José M. Ordovas, Victoria Ley, and Alejandro Lucia. 2022. “Joint Association of Physical Activity and Body Mass Index with Cardiovascular Risk: A Nationwide Population-Based Cross-Sectional Study.” European Journal of Preventive Cardiology 29 (2): e50–52.

Frandsen, J., F. J. Amaro-Gahete, A. Landgrebe, F. Dela, J. R. Ruiz, J. W. Helge, and S. Larsen. 2021. “The Influence of Age, Sex and Cardiorespiratory Fitness on Maximal Fat Oxidation Rate.” Applied Physiology Nutrition and Metabolism 46 (10): 1241–47.

Mandsager, Kyle, Serge Harb, Paul Cremer, Dermot Phelan, Steven E. Nissen, and Wael Jaber. 2018. “Association of Cardiorespiratory Fitness With Long-Term Mortality Among Adults Undergoing Exercise Treadmill Testing.” JAMA Network Open 1 (6): e183605.

MacLean, P. S., J. A. Higgins, E. D. Giles, V. D. Sherk, and M. R. Jackman. 2015. “The Role for Adipose Tissue in Weight Regain after Weight Loss: Adipose Tissue and Weight Regain.” Obesity Reviews: An Official Journal of the International Association for the Study of Obesity 16 (S1): 45–54.

Lee, Young Ju, Ayoung Lee, Hye Jin Yoo, Minjoo Kim, Minkyung Kim, Sun Ha Jee, Dong Yeob Shin, and Jong Ho Lee. 2018. “Effect of Weight Loss on Circulating Fatty Acid Profiles in Overweight Subjects with High Visceral Fat Area: A 12-Week Randomized Controlled Trial.” Nutrition Journal 17 (1): 28.

Bianchi, Vittorio Emanuele. 2018. “Weight Loss Is a Critical Factor to Reduce Inflammation.” Clinical Nutrition ESPEN 28 (December): 21–35. 

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