One of the things I’ve long been skeptical of is the assailment of BMI. If you’re unfamiliar:
- Body Mass Index (BMI) is a simple, quick way to try and determine someone’s metabolic health.
- It uses two variables, your mass and height.
- Because the equation uses only your mass and height, it’s not telling you a whole lot about a person’s function, the type of weight they have on them (e.g. muscle versus fat), not to mention all the other aspects that go with health.
This “type of weight” aspect is where the fitness world gets all bent out of shape. The problem, to them at least, is because the equation doesn’t differentiate between muscle and fat, too many people who have a good deal of muscle on their frame are still equated -BMI wise- with being overweight or obese.
Take your average height male, 1.78 meters (5 feet 10 inches). Let’s say he’s 91 kilograms (200 pounds). According to the BMI scale, this person is flirting with obesity. Where the fitness world will chime in is, “But we don’t know if that 200 pounds is with 10% body fat or 30%. If this person lifts weights that 200 pounds could be from having extra muscle on their frame, which is perfectly fine.” In fact, many in the fitness arena seek this profile.
As someone who has had a high BMI but low body fat, I never felt “healthy” during that time. Having that much muscle on my frame was work. It was a lot of intense resistance training, it was a lot of calories to take in, and I had to be aware I wasn’t burning many calories either. Beyond that, part of me has always felt at some point, weight is weight. Is it better to have it as muscle? Yes. Once you get beyond a certain point is it unhealthy regardless? I’ve always had an inkling it might be.
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Enter “healthy obesity”
I don’t think it’s hard to grasp there’s not much research on the above group. In terms of getting an adequate sample size, there’s not many obese but jacked people walking around. From a research perspective, this isn’t exactly a pressing issue either. I think we can look at this in a slightly indirect manner though.
Healthy obesity is the idea despite having a high BMI, a person may still have a good metabolic profile. You know, healthy blood pressure, cholesterol, glucose levels, your typical blood work at the doctor visit. Where even though the person’s overweight or obese, they seem to be doing alright.
Researchers have wanted to know if, despite having healthy blood work, these people were still less healthy than someone with a “normal” BMI and healthy blood work. You and I are both healthy metabolically, I’m at a normal BMI but you’re at an obese level, should you be concerned?
Most recently (April 2014) a study which looked at 14,828 Korean adults found:
“Metabolically healthy obese (MHO) participants had a higher prevalence of subclinical coronary atherosclerosis compared to metabolically healthy normal weight participants, supporting that MHO is not a harmless condition. This association, however, was mediated by metabolic risk factors at levels below those considered abnormal, suggesting that label of metabolically healthy for obese subjects may be an artifact of the cut-off levels used in the definition of metabolic health.”
Because researchers like to write in language only they understand, let me see if I can clarify that quote: Even if you’re “metabolically healthy,” if you’re obese you’re more likely to have some build up in your arteries. To the point it’s a concern? These researchers believe yes. By current standards? Eh.
This is a consistent finding in this type of research. Where it’s been given the term “subclinical atherosclerosis.” The researchers felt so strongly about their results, and this subclinical phenomenon, they believe the current standards of healthy blood work should probably be revised. From the other papers I’ve read, this subclinical arterial build up is, consensually, a concern for this population.
I want to also point out this study qualified people as obese if their BMI was over 25, not 30. Further supporting the researchers arguments. If you’re starting at a lesser BMI qualification point, then those who qualify are likely to be healthier. In other words, from a health perspective, it’s better to have some of your sample have a BMI between 25 and 30, compared to all of your sample having a BMI over 30. By U.S. standards, this paper could say “Metabolically healthy overweight and obese participants display a harmful condition.”
Next, from December 2013:
“Researchers reviewed the data of 61,386 individuals in eight separate studies from the past decade. Each study observed adults defined as normal weight, overweight, and obese (body mass index or BMI of 30 or greater). Each study evaluated the individuals’ metabolic status, i.e. cholesterol levels, blood sugar levels, and blood pressure. The studies compared fatal and nonfatal cardiovascular events such as heart attack and stroke, as well as other causes of death, across the three weight categories.
The comparative risks for premature death in the three weight groups became especially apparent after 10 years of follow-up.
The key finding is that even in the absence high blood pressure or cholesterol (in other words, a metabolic problem), an obese person whose BMI is 30 or greater may be at 24% additional risk for cardiovascular event or premature death compared to a person of normal weight, says Dr. Retnakaran.”
I don’t want to make this some rigorous analysis. This is more of a food for thought post. (I’ll get to the eating in a second.) However, please note above, over sixty THOUSAND people were looked at in that study. (Full paper here.) This has been a contentious topic in the research world. I want to point out the studies I’m referencing are the most recent research, with huge sample sizes. The type of research you tend to place your faith most in.
Furthermore, this paper seemed to clear up a lot of the contention. Some studies have found this “healthy obesity” is nothing to worry about while others have found it is. If you read enough of the papers, you see it slowly come out that the research with longer follow ups, at least 10 years, are the papers which find an issue. In the above research, they found there weren’t many issues when you looked at the healthy but obese group from 0-10 years, but once you got to ~10, issues were clear. While being heavy with good blood work is ok in the short term, over time it can come back to haunt you. [1]
In September 2013 Harvard Health ran a story about healthy obesity. They covered some physicians who have looked into this. The physicians:
“…identified several characteristics of metabolically healthy obesity. These include a high BMI with
- a waist size of no more than 40 inches for a man or 35 inches for a woman
- normal blood pressure, cholesterol, and blood sugar
- normal sensitivity to insulin
- good physical fitness”
The above characteristics are damn near exactly the characteristics of what the fitness field has been saying for at least a decade: You can have a high BMI and not worry about it if you’re in good shape. Well, since September 2013 about 75,000 people say that’s probably not true. That, regardless of how you look or what type of weight you have on you, you probably want to give some careful thought to how much weight is on you, period.
Here’s one way to look at this. Going back to our hypothetical male, the 5 foot 10 inch, 200 pounder:
- If you’re a low body fat percentage, say 8%, you’d have 16 pounds of fat on you.
- If you’re 155 pounds (BMI of 22 – right in the middle for a “healthy weight”) at 8% body fat, you’d have 12.4 pounds of fat on you.
The point is no matter how shredded you are, given the same body fat percentage, the heavier you are the more fat you will ALWAYS have. Have you ever seen someone say “I went from X weight to Y weight with no gain in fat”? They often follow this up with “That’s right, I went from X to Y and stayed at the same body fat percentage.” They don’t realize their latter statement disqualifies their former.
- If you go from 155 pounds to 180 pounds and stayed at 8% body fat, per above, you HAD to gain fat. 8% of 155 pounds will always be less than 8% of any number bigger than 155 pounds.
My theory is beyond a certain point, more fat is more fat. And, more than likely, more muscle isn’t always better. That there is probably some threshold you don’t want to cross. Once you do, more weight is more weight.
This seems like common sense. The body is full of these “lines.” Water is great, but too much can kill you. Aerobic exercise is amazing for our health, but marathon training isn’t. We all love the sun, until it burns us. Where is that threshold for our weight? Call me crazy now, but that good ole BMI equation seems to be some help.
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[1] Like I said, I didn’t want to make this a dense post, but a few words on this research: I believe this study (one with over 60,000 subjects) was about as good as we currently have for this condition. That said, the researchers do a great job mentioning why more needs to be done. A lot of research has been done on this but it’s all been done slightly differently, and it’s all missed some factors.
Next, while the metabolically healthy obese and overweight were both found to have increased risks in some form or fashion, the increase in absolute risk for having a cardiovascular event, when you’re a metabolically healthy obese person, compared to a healthy normal weight person, was 0.7%.
I mention this 1) I’m sure for many, looking a certain way (“jacked”) will outweigh having a smaller risk of a heart attack 2) As a health professional, for now, you CANNOT say being obese is ok, under any condition. You cannot attack BMI, you cannot tell your clients or facebook followers to ignore how much they weigh. You can say “The research could be better, there seems to be a risk but overall it’s small, however, relative to a healthy, normal weight person, as far as we know, you increase your odds by a good amount of say, having a heart attack, when your body goes beyond a certain weight.”
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Chris
May 9, 2014
Great post. I’ve also always wondered about how this plays out long term. Strength training gets addictive and I have let my body weight go up while chasing performance goals in the past. I tend to feel healthier and more energetic at a lower body weight (and when training with less intesity).
People often cite the issue of the tendency towards muscle loss while aging as their argument for the benefits of strength/hypertrophy training. There is obviously a lot of benefit to engaging in some level of resistence training, but I think that you are right that a line can get crossed fairly quickly to where what started as a pursuit of health and longevity begins to detract from that very goal.
reddyb
May 12, 2014
Hey Chris,
Your experience is very similar to mine, and is the type of person I thought of when I wrote this.
I’ve heard about the relationship between muscle and aging but I’ve never looked thoroughly into it. While I think resistance training is something practically everyone can benefit from, sometimes I wonder how much people could get away with if they simply were on their legs more / moved a lot more everyday. I feel as if every time I run into or hear about someone who is kicking ass in their elderly years the theme of “I walk a lot” always comes back. Yet I rarely hear “I lift weights.”
(I talk about the relationship between bone rigidity and amount of movement here: http://b-reddy.org/2014/05/02/which-modern-day-athletes-look-the-most-like-our-ancestors-on-how-were-supposed-to-move/ )
Chris
May 13, 2014
Thanks for responding. I loved the post that you linked and agree wholeheartedly with regards to the activities of those who age well. Three of my grandparents lived into their 90s and I doubt any of them ever picked up a weight (other than in buckets and shovels, etc.). They were, however, very active. I’m not aware that they ever hurled spears into saber toothed tigers or ran for their lives from attacking war parties, but I suppose I don’t know their whole life stories. I do know that they all loved ice cream, so that’s clearly a key to longevity.
reddyb
May 13, 2014
Maybe Dairy Queen could start an advertisement campaign from this. “Come to DQ and get our new Geriatric Blizzard! It comes with extra calcium to help those old bones!” Cut scene to three 90 year olds chowing down ice cream
Chris
May 14, 2014
Dairy Queen could have their 90 year old “Jared” (Subway). It could change the whole fast food market landscape. We should work for Dairy Queen…
Jason
July 15, 2014
Hi Brian
Just a question – I imagine most of your clients are older people who are looking to mostly just lose weight and get out of pain. However how would you approach training a younger 20-30 year old client with interests in weight lifting and body building? Is there any exercises that you would contraindicate at all costs?
The reason I ask is because it seems to me that these sports(activities?) fly in the face of the movement first approach that you generally advocate on your site and so I’d be interested in hearing your thoughts.
Jason
reddyb
July 16, 2014
Hey Jason,
The approach always depends on the person. In general, one of the biggest missing aspects of bodybuilding programs is the amount of volume of horizontal pushing and pulling (horizontal and vertical) in relation to the volume of overhead work. That is, there is a ratio of approximately a shit ton to none.
Beyond that, it all depends on how a person is.
I’ll go off on a tangent here and use an example. Shoulder problems are probably the most common ailment of this group. When someone is in the pain state, which is what a lot of my writings are about, then yes, it can be very hard to “bodybuild” and get rid of pain at the same time. In a 20-30 year old, because they are almost guaranteed to be in decent health -they aren’t prediabetic- I don’t care about bodybuilding in the beginning. I care about getting them out of pain. I care about them not having surgery, how their shoulder is when they’re 50, you get the idea.
So, for a person suffering from shoulder problems, a problem usually stemming from bodybuilding:
-Bench pressing is a no.
-Any and all pulling is a no.
-Any and all horizontal pushing is a no.
-Bicep curls are a no.
-Squatting with a conventional barbell on the back is out (Safety Squat Bar is ok, but few have access to this).
-Front squatting with a barbell is out.
-If the person’s shoulders are realllllly jacked up, how they hold weights will need to be modified. (I write about this some here: http://b-reddy.org/2013/07/25/musings-on-scapular-winging-anatomy-muscular-and-nerve-causes-and-exercise-considerations/ )
(You’ll notice overhead work is not axed. I write about this here: http://b-reddy.org/2013/09/05/a-progression-to-lifting-your-arms-overhead-pain-free/ )
So, in a bodybuilding sense, we aren’t left with much. The reason these things are out is because 1) They either cause pain or 2) They aren’t helping the person get out of pain.
I get plenty of people where I take these things out and they aren’t the happiest, but it’s the fastest way to getting their shoulder(s) feeling better. As the person starts to feel better (typically 1-3 months), then certain elements can be slowly added back in. I have progressions I use to go about this. Which exercises I start with, volume, etc.
I have plenty of people who bench press, do chin ups, DB presses, OH presses, squat heavy, I mean you name it, I have people do it. In a healthy person, it’s rare I don’t do these things. But, those people 1) Don’t have a shoulder history 2) Don’t have current shoulder problems 3) Have been out of pain for a while and had these things gently put back in to where they can get away with doing them again. That said, the volume of what they do (mentioned in the beginning) needs to be carefully considered. You don’t just go back to doing a shit ton of bench pressing and pulling and expect your shoulder pain to stay at bay.
Hopefully that makes sense. I used the shoulder as an example, but the same principles apply to other areas.
In terms of your classic movements, the most common stuff out there, the only thing I’ve gotten to the point where I just don’t bother with it anymore is deadlifting. I’ll write about this one day, but suffice to say I’d give someone a lot of money if they could persuade me to have an everyday client deadlift. And this includes 20-30 year olds.
Jason
July 17, 2014
Brian – thanks for the response. I definitely agree with your approach but the biggest problem I’ve found is that it’s hard to get people that age to back off their normal training routine for a few weeks or months. So pretty much even though we might focus on eliminating their pain during their routine, odds are pretty good that they’ll go and bench, row, squat, etc. later on that week or even that same day. That’s why lately my thinking has started to shift to something like “Ok, how can I keep the load heavy enough so that the client is sore enough NOT to do more stuff after their session.” as oppposed to “Ok, don’t do this, this, that, oh and that too.” There’s usually a thin line you can walk with the first approach but at least it’s better than them going home and running wild on their own.
reddyb
July 20, 2014
Hey Jason,
I decided to make my answer to this its own post as I wanted to talk about some different things. The post is here, hope you find it useful: http://b-reddy.org/2014/07/20/bodybuilding-programming-issues-and-dealing-with-stubborn-clients/
Rob
April 5, 2017
The studies you cite apparently do not directly relate to the title you provided.
Here’s what I mean.
Lumping together anyone with a higher BMI and good blood work, but not separating out variables such as amount and location of body fat, only yields an indication that good blood work is not a good long-term predictor of health for the group.
The data is too generalized to support your conclusions.
Dr. Hu, one of the physicians responsible for the Harvard study you have cited in your post, stated that the study “supports the idea that we shouldn’t use BMI as the sole yardstick for health, and must consider other factors.” In fact, the concerns of the study were for the tendency of people to move from MHO (metabolically healthy obesity) to MUO (U=unhealthy) later in life, not for the relative predictor of health due to muscle mass. As you mention, more research is needed. So we can get to actual root causes, studies on other factors would be beneficial, covering variables such as changes in joint health that limit continued exercise among MHO individuals.
In other words, your statement that “you cannot attack BMI” is NOT SUPPORTED by the evidence provided.
I am not suggesting that we should discard BMI. I am stating that the evidence is insufficient to use BMI, on its own, as an easy or authoritative measurement of long-term health. BMI is only one leading indicator, the relevance of which will vary depending on each individual situation.
The danger of leaning too heavily on a single metric can be dangerous as well, especially one intended to generalize an entire population. It is important that each person guide their health behaviors based on what is relevant rather than on what is “easy”. For someone with low visceral fat and heavy bone strucure, BMI may not be relevant as a warning. For someone with a low BMI but high visceral fat, it may provide false security.
Perhaps the danger is in those who provide health advice that is not individualized.
reddyb
April 7, 2017
Hey Rob,
Your concerns were addressed in the post. To reiterate, such as the title concern,
I even said “this is more of a food for thought” post.
If you want to be 100% direct, if you have research on some 100,000, or even 10,000, people fitting the profile you’re mentioning, please send it over. Or if there is a perfectly conducted genetic study and a sequencer cost friendly enough all of us can have our clients use it for their 100% individualized advice, I’m happy to take a look. But
1) by this logic of health advice that is solely individualized health articles would cease to exist, as would the field of public health.
(e.g. smoking cessation awareness for lunge cancer would have never happened, as most people who smoke do not get lung cancer. Rather than try to spend who knows how many years getting the profile of smoker => lung cancerer (we’re *still* trying to do this!), we instead said “People should stop smoking. There doesn’t appear to be any benefit in it.” What’s the benefit of a high BMI?)
2) until then you’re parsing out one variable e.g. where is the fat located, and now saying none of the rest applies. I parsed out most other variables and said “this is as close as we can probably get.”
You’re implying I should tell my clients “Well, I have to weigh your bones first.” I’m saying “One old school method of measuring bone is count it as 5lbs for every inch. If a person is 5’11” vs another who is 6′, we assume the 6′ person will be 5lbs heavier strictly from their height.” In other words, BMI already accounts for bone weight because it is height based. Does it 100% get the weight of someone’s bones? No. Does it get close enough? The post is arguing it may very well.
Who is debating BMI should be the sole yardstick? Or the single metric? The post is saying we shouldn’t throw away BMI merely because someone is muscular. The fitness industry has attempted to discard it because it doesn’t fit the profile many want. The post asks “Is that ok?” It’s not saying if somebody…smokes, is out of shape, alcoholic, yet has a healthy BMI then they’re fine.
As for what seems to be your big bugaboo, fat location. Again, this is going to be, not perfectly, included in the data. Those with a healthy blood profile are *more* likely to have *less* visceral fat storage.