Sarah Taylor is the type of athlete who swears by the runner’s high: the longer you run, the better it feels. She has been dedicated to living and promoting a healthy lifestyle for the last two years, cataloguing it all through her social media platform @sarahtaylorsjourney. Scrolling through her feed reveals an impressive list of accomplishments: Taylor is a former Miss Plus Canada, a model, a certified personal trainer, a beauty diversity advocate, and someone who deadlifts 150 pounds on a regular basis. Standing at 5 feet 10 inches tall and weighing 255 pounds, she is also the type of athlete who forces us to confront our stereotypes of what “fit and healthy” looks like.
The medical community describes obesity as a chronic and often progressive health problem, not to mention a global epidemic. Six million Canadians are considered obese—approximately 17 percent of the population. That’s no small number. Obesity costs more than four percent of Canada’s total health care budget yearly, according to the Canadian Obesity Network. According to the World Health Organization, it costs $6 billion globally.
Many people, however, including Taylor, would balk at being described as part of a “health epidemic,” arguing that their overall health cannot be defined by numbers on a scale. And, in recent years, doctors have indeed found that some individuals have obesity without any of the health problems often associated with it, such as diabetes, high blood pressure, high cholesterol, and /or certain types of cancers. Hence the term “metabolically healthy obesity” (MHO), which doctors coined to describe those who have obesity, but do not experience any of the (presumed) associated health issues. As many as 5 to 20 percent of those who have obesity are thought to fall under the MHO category.
At the same time, the term is controversial. Obesity specialists cannot agree on whether MHO is a defined entity—i.e., a permanent state—or just a brief moment in the health of somebody who will go on to have, for example, diabetes or high blood pressure. The controversy only increased in September after UK researchers, led by epidemiologist Rishi Caleyachetty and his colleagues at the University of Birmingham, published the most comprehensive study on MHO to date in the Journal of American College of Cardiology. That study, which looked at 3.5 million individuals in the UK, suggested that healthy obesity is a myth—and argued that obesity remains a major risk factor for future health complications.
The study results indicate that 15 percent of the 3.5 million individuals were initially free of any disease and classified as MHO. But researchers wanted to know if healthy obese adults could maintain their metabolically healthy profile over a five-year follow-up period. Of the people who were initially MHO, about 6 percent developed diabetes, 12 percent developed abnormal blood fats, and 11 percent developed high blood pressure. Even more distressing, compared with those who were considered to have normal range on Body Mass Index (BMI) and no metabolic disease, the study concluded that those in the MHO category developed a 50 percent increased risk of heart disease and a 7 percent increased risk of stroke.
“Our results couldn’t be explained by age, sex, smoking, or socio-economic status,” says Caleyachetty. “There is enough evidence accumulated from our study, and a few others, to accept that, when we look at populations of people, metabolically healthy obese is not a benign condition.” He believes the data shows that obesity is a complex public-health issue. The study has since sparked a significant shift, with physicians starting to once again question whether you can have a lot of excess fat and be fit.
As a physician myself, I understand why many doctors are reluctant to embrace MHO as a concept. While it’s true that poor lifestyle choices—such as smoking, stress, and poor diet—also cause high blood pressure and diabetes, obesity is still the leading cause worldwide.
Still, studies like Caleyachetty’s look at a population, and not the entirety of a person. It’s entirely conceivable that other factors might allow somebody to be healthy and also be classified as obese. Certainly, there are many people who, like Taylor, have obesity and are living healthy lives without health problems. So where does all this leave the thousands of Canadians who are wondering how to reconcile exercising regularly and eating a balanced diet with being classified as obese and at increased risk of having a heart attack? What if they are committed to a healthy lifestyle, but the number on the scale is not budging?
“This is a funny question,” says Dr. Sean Wharton, an obesity specialist in Toronto. “It’s like asking, ‘What can I do if am a dark-skinned black person and I am smart and doing well in all areas except I’ve got dark skin?ʼ” He goes on: “Dark skin defines nothing besides ‘sheer beauty’ in many people’s eyes. We know that some people look at it as negative, but we tell these people to get with the program and get rid of this label that does not define the person.” And yet, we don’t we do the same with obesity.
Part of the challenge is how we think about and classify fat. Doctors and researchers still rely on the Body Mass Index to define obesity. Considered the standard method for measuring obesity, BMI was adopted into routine practice nineteen years ago as a screening tool for doctors to determine which people were at risk for health problems related to excess body fat. It is a quick calculation requiring only information your doctor has at her fingertips: your weight and height.
The number obtained from the calculation is then used to categorize whether a person is underweight, normal weight, overweight, or obese, depending on the range. Obesity is further broken down into categories. Rhose with BMI of 35.0-39.9 fall under class II obesity, and those with a BMI of greater than 40 are slotted under class III. Class III goes further to define super obesity–“morbidly obese”—those with a BMI in the 40−49 range—and “super morbidly obese”—those with a BMI over 50.
Despite its popularity, BMI has long been criticized for its limitations. As a simple estimate of body mass, it does not take body composition into account. Some people are more muscular than others and, as such, their BMI may not accurately reflect their actual fitness level. Many professional football players, for instance, have BMIs that would put them into the “obese” category, largely owing to their muscle mass. And yet, they have better cardiovascular health than the average population. What’s more, if we look at BMI as the sole determinant of health and fitness, it leads to the assumption that having a low BMI is healthy, even if your diet consists of foods high in sugar and fat. “The key is movement,” says Vicki Hiltz, a registered dietician and fitness expert in Toronto. “If you can do your daily activities without getting winded and you go up flights of stairs, you are healthy. It’s not your BMI, it’s you.”
There is a wide variety of body types, she adds. More than that, Hiltz says, people have variations in the way their muscle, bone mass, and fat are distributed throughout their body—all reasons why BMI should not be the sole method for determining a person’s healthy body weight. Body-positive activists have long argued that you cannot determine their health by looking at how much fat they are carrying around. Together with obesity and fitness specialists, they are trying to encourage discussions of obesity and health which focus not on BMI but look at the entire individual, their activity level, and how their weight is distributed. “Everyone’s barometer for health is different,” says Hiltz. “Weight doesn’t determine your health—your health does.”
Part of the solution, say some medical authorities, is to expand past the field’s reliance on BMI. “We have to assess a person in terms of their health and not based on purely, and oftentimes not at all, their size or shape,” says Dr. Sean Wharton, an obesity specialist in Toronto. Experts like Wharton and Hiltz agree that BMI was not developed as a stand-alone tool to determine healthy body weight—even if that’s how it’s often used today. Rather, it was meant to be considered along with other measurements, such as waist circumference and waist-to-hip circumference, the latter of which, Wharton argues, is likely a better tool than BMI to determine health risk. That’s because waist circumference above a certain threshold correlates with high amounts of visceral fat—the fat around our belly and organs. Eventually, higher visceral fat leads to heart disease such as high blood pressure, heart attack, and stroke. Taken together, such measurements paint a fuller picture of an individual’s risk of health complications related to obesity.
Why has the public been so eager to embrace studies such as Caleyachetty’s? Certainly, the study fits into the well-worn narrative that all obesity is unhealthy and that urging the acceptance of all body types is dangerous. Opponents of the body-positive movement argue that promoting larger bodies as beautiful and healthy may be silently killing those bodies. Yet even Caleyachetty acknowledges that obesity is complex. The results of studies like his are persuasive, but we cannot discredit the lived experience of people like Taylor, who has maintained athletic prowess while having a BMI considered obese. Such experiences should not be negated by these studies—rather, they should motivate the medical community to devise studies that use more accurate measurements of body composition. Who knows what research would find if it started by challenging its own biases and limitations?
“I would never say I am fat—I have fat,” says Annika Reid, a body-positive health activist and yoga enthusiast in Toronto. Body-positivity advocates are trying to shift the language from classifying people as obese to talking about people who have obesity as one of many other qualities. If someone has poor eyesight, they are not defined by their less-than-perfect vision and called “poor-eyes.” If someone has obesity, though, he or she often becomes that label: fat, obese, morbidly obese.
As someone who weighs 240 pounds, my BMI is 40, technically putting me in the “morbid obesity” category. However, three to four days a week, I carefully wrap my wrists, knuckles, and fingers to protect them as I practice sparring at a kickboxing gym. I eat a well-balanced diet—well, most of the time. When I am facing the mirror and throwing a combination of kicks and punches, I’m not morbidly obese; I am an athlete who has obesity. Similar to Taylor, I have no heart or breathing problems; my main issue is simply the societal expectation that a healthy body comes in one size. “Not everyone is meant to be lean and petite,” says Hiltz. “The world is full of all different shapes and sizes.”
Taylor, for instance, has a BMI of 37.5. She is close, but she’s not yet in class III: severe or morbid obesity. Still, at obese class II, she is supposed to be at a moderate risk of having a heart attack, kidney failure, or a stroke. Yet by many other measures, Taylor is far healthier than many who weigh less than she does. Besides being a personal trainer, Taylor attends five hours of boot-camp class a week and plays a variety of sports, including flag football, softball, and basketball. Her blood pressure is a healthy 120/70, and at her last doctor’s visit she got a clean bill of health on her blood work for cholesterol and diabetes.
“My body is my body, my tool, and I’ve trained it to do whatever I want it to do,” she says as she grits her teeth through another set of sumo squats. “I push my body to be a machine, and it’s a beautiful machine.” For Taylor, BMI is simply a number and does not define for her what her body should look like to be considered healthy. Her focus as a trainer is to nurture women to love and be kind to their bodies and live in balance. For her, that means not ignoring obesity, but rather focusing on maintaining a balanced, healthy diet and engaging in exercise that makes you feel good.
That’s not to say Taylor doesn’t struggle with others’ perceptions. She often receives unsolicited comments from strangers as she navigates through life as a plus-size athlete, such as “Did you get medical clearance from your doctor before coming to this boot-camp class?” Others are patronizing, praising her for completing routine tasks like running for thirty minutes. Some take the comments further. Both Taylor and Reid have been told on social media platforms that body positivity is a movement for “fat chicks.” But their goal is be advocates of health at all body sizes. “If I don’t lose another pound, it wouldn’t change my happiness,” Taylor says. “The things that my body can do amaze me. My focus is being healthy, not to lose weight.”
I have often encountered well-meaning family members who use fluctuations in my weight to discuss whether I am at risk for an impending heart attack. For the record, I am not at risk. I don’t find that these conversations encourage health. I have come to believe that living with a larger body is a form of resistance—resistance to the dogma that fat and the possessor of that fat are not acceptable. I believe that we can, and must, talk about obesity and health without shaming people. Too often, those with obesity are reluctant to engage in these conversations, largely because they’re so used to being fat-shamed under the guise of health concerns. While their avoidance is understandable, space needs to be created for all members of the body-positive movement in our discussions.
For those who are both fit and have fat, it can be hard to fit in to either the athletic or plus-size communities. “If I discuss health, or lose some weight, I get comments that I’m betraying being a plus-size activist,” says Reid, noting that she also gets told she needs to work out more—exemplifying the lose-lose situation when it comes to public perception. For women in the movement, the polarizing comments are frustrating, but they also show why their work is so important. Attitudes need to change across the board.
“One of the least-studied aspects of obesity,” says Wharton, “is the mental health challenges that people with obesity face due to the stigmas that are pervasive in our culture.” Some women with obesity report bracing themselves when visiting a new doctor, preparing for the inevitable comments about needing to be healthy and to lose weight, even if the reason for their visit has nothing at all to do with their weight.
The pervasive stereotypes that individuals in larger bodies are subjected to—that they are lazy or lack the self-discipline to live healthy lifestyles—may in fact be among the most dangerous challenges they face. And they reveal more about our narrow view of health than they do about those who live with obesity.