MANAGING YOUR CV RISK: the Obesity Paradox pt 1: What is it? Who cares?

Today, I’m going to introduce a
mini-series on “The Obesity Paradox: When Thinner Means Sicker and Heavier Means
Healthier” This is actually the cover from a book by Carl La Vie. Carl – Dr.
La Vie is a physician and he’s not a lightweight, emotionally-driven, “this is
what I think of the world” kind of guy. He’s a heavyweight academically. He’s
written several articles on this issue. He’s an endocrinologist and this was a
article that I’ll cover, again, later in a summary – a summary video. But this is in
nature reviews for endocrinology. As you see, he’s the front author. Actually, let’s
go over a couple of items out of that – out of that journal, and then we’ll
finish up with a couple of other comments and even a bottom line on this
issue which comes out of key points in this article. So what we’re talking about
is that healthy obesity versus unhealthy lean, it’s – there’s a paradox there. This
was in, as I said nature journals 2015. He makes a couple of points. We’re
getting fatter in the US, as well as most of the rest of the world, and controversy
has surrounded the idea that some individuals with obesity can be
considered healthy with regards to their metabolic and cardio respiratory fitness. That’s been termed the “Obesity Paradox” The – the controversies are reviewed in
this article and they discuss programs on patients with obesity who have no
metabolic abnormalities and who have preserved their fitness. Now, the article
also suggests the greater emphasis should be placed on improving fitness
rather than weight loss per se in primary and secondary prevention of
cardiovascular disease. At least in patients that are moderately overweight
and have class one obesity – that is a BMI 30 to 35. The morbidly obese clearly need
to focus priority on weight loss. So that’s part of the
issue here. It’s this whole question of “which is more important: weight loss or
getting in shape?” Now, if this sounds weird, again, this is a – this is a big
discussion. This article touches on it as well and I’m just going to read a couple
of points about this one. One of the clues here is the journal that
it came from and the name of the journal – the Journal of Cachexia, Sarcopenia, and
Muscle. Now, it’s a – it’s also a review and facts and figures. I’m not going to go
into details on that one but the reason I said the title of the journal is a
clue – sarcopenia and muscle, this isn’t that – if you’ve seen other videos of mine,
this is not the first time you’ve heard about sarcopenia and how – how dangerous it can be, especially for people over 65, Well, wait a minute. What’s sarcopenia? It’s muscle loss and, again, I’ll put a – I’ll put a reference to
these articles, as well as this video in the description below, and what you see
here become – starts to become much clearer. You remember in that series –
basically, what we said is when people lose muscle loss or lose muscle mass,
they become unhealthier and so this thing about “Oh, well. He’s just a little
old man.” or “She’s just a little old lady.” Especially talking about people 65 and
older; that’s not just a little problem. In fact, I did another video where we
talked about Docs tend to miss that 90% of the time. They just
think “Well, you know – that’s a little old lady” That’s not good. This is a problem
and, again, this is – there is a major overlap between this question of the
obesity paradox and what’s known about the lethality of sarcopenia or muscle loss and, again, you see it in this image here, where a 25 year old
with mostly muscle in his thigh, versus a 63 year old with much less muscle and
still the same thigh circumference but a significant amount of fat there. Now, in other videos on this – on this topic, I’m
gonna go into a thing called Mendelian randomization studies and a
meta-analysis of – is cardiovascular, I mean, is obesity actually really linked
to heart disease? Now, what does that mean? what a we know what a systematic review
is it’s a meta-analysis it’s the sort of things that you review with Cochrane
studies but Mendelian randomization – Here’s what Mendelian randomization is
and we explain that further in the – in that video. I think it’ll come out next
month. There are certain things that you can’t do. A randomized clinical trial on,
for example – Does obesity actually cause heart disease or does it – Is… is it – does
the same thing – is there something related to both of
them? First of all, you’re not going to do a randomized trial where you have a
study group that you make obese at random, and another control group where
you’re not obese and here’s the second thing you just – you can’t do that. Even if
you could do that, which you can’t do, you’re not gonna blind people to it
either. I mean – you can’t tell some – you can’t blind the patient or the subject
to the fact that you’ve made them obese. They’ll know it. So will they die? So
Mendelian randomization takes a – takes advantage of the fact that genetics
tends to be randomly distributed, whether you get – if your mom has blue eyes, you
and your dad has brown eyes; there’s some random component of which you’re gonna get what eye color you’re going to get but as you can see, that can start getting
really deep. That’s not for this video. We’re just going to wrap up on this
video to go back to La Vie study in Nature Reviews endocrinology and he
brought up some key points which I think will help bottom line this issue of the
obesity paradox. The prevalence of obesity is increased in most of the
world. Over the past few decades, patients with obesity have more cardiovascular
and metabolic risk factors than people with normal weight and have increased risk of developing cardiovascular disease. Now, data suggests that metabolically
healthy obesity, especially when combined with a high level of fitness, is
associated with, at most, a minimal increase in overall risk of
cardiovascular diseases, and mortality; And again, this gets much more important as we get older into our mid 60s and beyond. In patients with established
cardiovascular disease and other chronic conditions such as kidney disease, severe
arthritis, those with overweight and class-one obesity have a better
prognosis than lean patients that – that’s the obesity paradox that they’re talking
about. Now, many of us (myself included) will automatically start thinking, when
you read that point – Well, there’s got – there’s clearly going to be an
association with a severe disease like kidney disease, severe arthritis as when
that’s coupled with cardiovascular disease and clearly these are maybe the
lower BMI – the thinner people are selecting for people that have
significant illness and yes, that’s part of this question as well. That’s part of
what happens when you start digging into the studies and the data. Now, the last
two points I think are very, very important here. And, again, the last one
itself is the bottom line. Fitness is more important than fatness for long
term prognosis. Again, especially for older folks in the obesity paradox,
fitness markedly alters the relationship between adipose or how much fat you have and long-term health outcomes so it’s critical to
exercise. High intensity intervals, resistance training, and other things
like some endurance training, but the first two are most important – High
intensity intervals and resistance training.
Despite that, here is the bottom line on this entire obesity paradox so you can –
those of you who say “Brewer, just bottom-line it. Don’t confuse me with all
these facts.” Here’s the bottom line, guys, despite accumulating evidence on the
obesity paradox, the available data still support purposeful weight loss for
long-term health, particularly when combined with increased physical
activity, muscle strength, and fitness. So, again, we’ll get a little bit deeper and
go into some interesting and maybe geeky things like the Mendelian randomization
but if you’ve made it this far, again, I appreciate your interest.


  1. Do you believe that lipid control (specifically having very low LDL and total cholesterol) can affect the endocrine system? I’ve had a sharp drop off in testosterone (to abnormally low) levels coincident with rosuvastatin + ezetimibe. I’m having trouble building muscle and am concerned about sarcopenia, as well as other effects.

  2. That was a problem for me in the past. Under 190 pounds on a (at the time almost 6'3" frame) low immunity was hitting me all the time. Ended up with it setting off shingles at 21. Haven't been right since, and that was over 30 years ago, as it triggered gene of HLA-B27. I was heavier as a teen and lost weight and muscle in very bad ways in my late teens to my early 20's, so muscle loss would explain thanks for bringing that to my attention Dr. Brewer. Had not thought of that. Always afraid of getting under 200 even now because of the past. I struggle to keep muscle mass as I have trouble with inflammation keeping me off my feet….literally.

  3. Very interesting Doc! I remember reading somewhere, or perhaps in a lecture, that everyone has a genetic "Set Point" for how much they are supposed to weigh & that trying to change it by losing weight is not an easy thing for them to do. So I guess if someone appears to be obese & the doc reads them the riot act about losing weight, he may be doing them an injustice as their system will always want to return to that set point. I think it's people in that catagory that wind up doing the Yo-Yo routine of constantly losing & gaining weight for most of their lives. Obviously, this does not apply to the morbidly obese population. Any thoughts on this? Thanks

  4. The "obesity paradox" sounds to me like some kind of analog of "plus models" you can find these days in mass media.

  5. Dr Brewer, of the items to help decrease arterial plaque, what is the order of efficacy? Is rosuvastatin responsible for say 50% of the improvement and ramipril the next 25 %, niacin 15%, etc?
    What is the relative benefit of them lined up?
    I imagine some of them are synergistic with others so it may be a complicated question to answer.

  6. Dr Brewer, a TED talk by Eran Segal reported that following 2,000,000 blood sugar tests correlated with 5,000 meals, food diary, personal dna and gut biome dna that diet advice is more complex than expected.
    One person's blood sugar spikes with rice but not ice cream and another perdon is the opposite
    His team developed an algorithm that predicted meal plans that evens out blood sugar spikes.
    Do you think that if we were to follow his paradigm and level out blood sugar spikes through diet it would amplify the relative benefits of niacin, rosuvastatin et al?

  7. Thanks for another informative video. I am 70 years old and lift weights as well as mike in the mountains. I am 6' 1" at 212 lbs., which gives me a BMI of 28 – overweight. However, I carry more muscle than the average 70 year old, just by comparing myself in tears of what I can lift to others my age, and I have little fat around my middle.The reason I work on maintaining muscle mass is because of my observation of our aging parents. They got to the point where they could not step up 1 stair. They blamed it on age, but they also did nothing to build muscle thinking that they were too old. Unfortunately, none of their doctors recommended serious muscle building exercise. I hope more older people begin to understand they can get stronger and not accept decrepitude. Thanks again.

  8. Very interesting. I think there are a complex set of variables, pros and cons here. The increase of human longevity, in tandem with better nutrition, medicine, sanitation, and body size, is noteworthy. Body Mass has gone up almost 40 pounds in 150 years in America; from a mean of 23.5 kg.m<2 in the United States Circa 1896-1912 (estimates from Insurance records), up to BMI 29 by the year 2016 in USA (CDC). relative estimates of Civil War recruits from DOD studies suggest in their 20s, they had a Body fat percentile of about 17-18%, at BMI 22, with 117 pounds of Lean Mass (5 ft 7.7, 144 lbs), v.s. A modern American man at 29% body fat, and BMI 29 (5 ft 9.1, 196 lbs), and 140 pounds of lean mass – An almost doubling of estimated body fat, yet paradoxically longer life expectancy. Still, the fact that Diabetes was practically unheard of or undiagnosed in the 1860s, coupled with the reality that about 85-90% of modern Type 2 diabetics have overweight >25, and Obese >30 BMI, bodies, as well as generally higher blood pressure per BMI point increase, lipids, and other vital signs, in accordance with the increased adiposity and body mass. Maybe the BMI scale should be revised for age by age basis, like 19-25 BMI for age 18-40 years(Young Adult), 20-30 BMI for age 40-65 (Middle age), 20-35 BMI for seniors etc? I see quite a few hefty, and robust 75 to 85 year olds walking around these days, in the 25-35 BMI range, but statistically very few overweight 90-100 year olds. I think some studies on centenarians (aged 99-110) in Loma Linda, CA, Okinawa, France, and Sardinia showed they had very lean aggregate mean BMI's, like in the 19-25 range, with a few upper 20s outliers – the hundred year old person phenotype is a bird like, 22 BMI, slightly elevated glucose (around 100-110), cholesterol around 200, and mild systolic hypertension, like 130s- 140/70's.

  9. Having a good appetite might indicate being healthy. If you are thin and sickly, you might be unhealthy to begin with. You might weigh less but are by no means more healthy. You might not feel like exercising. A little fat on your frame along with extra muscle is a good thing.

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