Can You Be Fat & Healthy?

By Jeffrey Kluger

By most measures, Kelly Bliss, 50, surely seems to have let herself go. The Lansdowne, Pa., resident stands 5 ft. 2 in. in her stockings but tips the scales at nearly 200 lbs. Run those numbers through the body mass index (BMI)--the statistical measure that factors height and weight to diagnose obesity--and Bliss scores higher than 35. Anything above 25 is overweight; anything above 30 is obese. In the nation's ongoing war with obesity-related health problems, Bliss is one more casualty, right?

Maybe not. In fact, we should all be as unhealthy as Kelly Bliss. Her blood pressure is often as low as 100/50. Her cholesterol and blood sugar are normal. When she lies on her back, she can pull her leg to her face and touch her nose--while barely bending her knee. Can you? Oh, yes, and while most Americans exercise grudgingly, if at all, Bliss never misses a day, walking 10 to 20 miles a week and teaching an aerobics class at a local church. "You look at me in a leotard," she says. "I'm a cute little chick."

In a culture that fetishizes slimness, the idea of being fat and happy raises eyebrows. The idea of being fat and fit is nothing short of apostasy. Yet Bliss is both--and she's not alone.

With 30% of American adults considered obese and as many as 50 million of us on some sort of diet--usually unsuccessfully--at any one time, perhaps we ought to be asking ourselves whether we're going about things all wrong. It's not the number on the scale or the size of your khakis that will kill you, after all; it's the elevated blood pressure and cholesterol and other nasty problems that come with moving to the relaxed-fit rack. If you eat well, work out regularly and walk away from your doctor's office with straight A's on your physical, what does it matter if you can't wriggle into slim-cut jeans?

That's a question more and more people have begun to ask, and lately they have been getting some answers they like. The explosive reaction in the press in April to a research report suggesting that Americans who are a bit overweight had a ("slight") reduction in the risk of dying over the course of the study compared with those of normal weight brightened the mood in buffet lines everywhere. Not surprisingly, the public largely overlooked the study's more important point--that obesity still cuts lives short. But even as the public seized on the slim hope that there really might be a free lunch, the experts have also begun questioning the received wisdom that fat is wholly anathema to good health.

"The idea that being a string bean is the best thing to be is too simplistic," says David Jacobs, professor of epidemiology at the University of Minnesota. "I think it's possible to be large and fit."

To be sure, no one is ever likely to deny the actuarial fact that staying lean and active is one of the best routes to a long life. Many studies point out that excess weight is associated not only with a lot of frequently cited dangers--diabetes, stroke, heart disease, sleep apnea and joint problems among them--but also with many less frequently cited ones, such as cancer. A recent study of 135 men, published in the American Heart Association (AHA) journal Circulation, seems to confirm this, acknowledging that while getting fit is associated with reducing a number of health risks, failing to tackle the fat problem is linked to many more. "Even if the overweight person doesn't have signs of disease," warns AHA cardiologist Gerald Fletcher, "they will develop them."

But for every expert who is worried that the last thing fat people need is one more excuse not to get thin, there are hints that the problem is in fact more nuanced than that. One is a study that comes from the nonprofit Cooper Institute in Dallas. Since the 1970s doctors there have been amassing a database of the more than 80,000 patients who have passed through their doors to be weighed, measured, pinched, blood-tested and to run on treadmills while their vital signs are monitored. Drawing on that rich lode of data, the institute concluded that overweight and active people may be healthier than those who are thin and sedentary.

Dr. Lawrence Cheskin of the Johns Hopkins Weight Management Center in Baltimore, Md., has concluded something similar. The patients who visit his clinic have an average BMI of 37--moderately to severely obese. Yet only about 30% of them have hypertension, and only 20% have diabetes. While he doesn't speculate about what's behind the low diabetes numbers, physical activity does appear to play a major role in keeping blood pressure in check. "Generally, the health benefits of fitness are cardiovascular," Cheskin says.

More common, if less headline making, than the fat-and-fit are people who are very heavy and not terribly healthy but at least improving. The New England Journal of Medicine recently published a study of 116,000 women and reported that lean but sedentary subjects had a 55% greater chance of dying prematurely than lean and active ones. Fat and active women were worse off still, with almost twice the risk of the lean-and-actives, and fat and sedentary women were worst of all, at nearly 212 times the risk. That's not the rosy picture the Cooper institute paints, but it does show that exercise helps, placing the subjects on a sort of sliding scale of danger. "Physical activity doesn't eliminate the effects of obesity," says Dr. Frank Hu of the Harvard School of Public Health, who co-wrote the study with the University of Minnesota's Jacobs, "but it can diminish them."

Not so fast, say other experts. For one thing, it's possible that unacknowledged weight loss is responsible for the improving health numbers. People who are very overweight often pick up or drop 10 or 20 lbs. at a time, fluctuations that get lost in the statistical noise of their overall battle with the scale. If you become physically active, it's hard not to lose at least a little more than you gained, and that little can mean a lot. Normally the greatest weight-loss benefit comes from the first few pounds you shed. A 240-lb. man who drops to 230 lbs. is healthier for the 10 lbs. he lost. But the 10 lbs. he dropped from 250 to 240 may have benefited him even more. "Even the first 5% of weight you lose is very helpful," Cheskin says.

Serious questions have also been raised about the Cooper client base, disproportionately made up of motivated people who are not terribly obese and, significantly, well-to-do and white--a more than trivial problem when the obesity crisis hits hardest in poor and minority communities.

Then, too, there is the chemistry of fat itself. In most parts of the body, fat is packed on under the skin and over the muscle. But fat around the middle also gets stored beneath muscle. This gut fat is far more metabolically active than peripheral fat, releasing inflammatory molecules that contribute to insulin resistance, diabetes and hypertension. Exercise may be a good idea, but until you lose the beer belly, you may still be putting yourself at risk.

But if exercise can't get you all the way to your metabolic goals, it may get you partway there. It certainly appears to have worked for Sandy Schaffer, 47. The 5-ft. 5-in., 280-lb. Schaffer began attending the In Fitness & In Health Wellness Center in New York City more than eight years ago, when she weighed an even more prodigious 350 lbs. She credits her workouts there not only with getting her weight down but also with some other impressive numbers. Her total cholesterol has dropped from 220 to 180, her blood pressure is good, and a recent cardiac-stress test showed that her heart is healthy. She now takes four or five fitness classes a week and teaches two or three herself. "Before I started exercising, I couldn't walk 10 yards without huffing and puffing," she says. "My mother's 80-year-old friends with bad knees were walking better than I was."

The club Schaffer attends is one of a growing number of gyms catering to plus-size patrons. Founder Rochelle Rice, who earned her master's degree in the decidedly specialized field of exercises for the overweight, knows that teaching such a clientele to get up and move is not the same as teaching the slender. "I do a lot of back work," Rice says, "because large breasts or weak posture pulls the body forward. I also do a lot of abdominal work to bring the pelvis back into alignment and shin and calf work to help with walking."

Life Time Fitness, a chain of gyms based in Minneapolis, Minn., that has 39 centers in eight states, is joining the trend. Trainers there have chucked the BMI and now tailor workout regimens to clients according to their aerobic capacity, cardiovascular fitness and more.

The problem with all such trends is that they often trivialize themselves into fads, easy to latch onto and easier to drop. Perhaps the key to the fat-and-fit movement is that there is no one key. In our effort to get healthy and look great, we have created an environment so hostile to the idea of obesity that overweight people have become marginalized, giving up on their well-being and sometimes failing to show up even for such routine tests as Pap smears and mammograms for fear of being hectored about their weight by their doctors.

Better to accept the idea that weight control is a multifront battle, with exercise, diet, understanding physicians and patients willing to try new things all part of the campaign. "This fight is won by persistence," says Cheskin, "not extreme firepower." Longtime veterans of the weight- loss wars can certainly vouch for that. --Reported by Anna Macias Aguayo/Dallas, Melissa August/Washington, Amanda Bower/ New York, Paige Bowers/Atlanta, Dan Cray/ Los Angeles, Sarah Sturmon Dale/Minneapolis, Laura Locke/San Francisco

With reporting by Reported by Anna Macias Aguayo/Dallas, Melissa August/Washington, Amanda Bower/ New York, Paige Bowers/Atlanta, Dan Cray/ Los Angeles, Sarah Sturmon Dale/Minneapolis, Laura Locke/San Francisco