The Obesity Paradox

Explain Yourself Than Lucy

There are the easy explanations that seemingly do factor in for many of the above results…

• Studies looking to discover risk factors study risks of Nml to Ob, vs Obesity paradox studies are more comparing Obese to Nml. More minor, but could play a role.
• Obviously BMIs of 20 in a patient with a disease increase mortality from a cachexia stand point.
• The disease itself has caused the lower weight. (Reverse Causality study flaw)
• Ppl at Nml BMI could be “more sick” or have a more aggressive form of the disease.
• Maybe symptoms are more prominent in the Ob (shortness of breath, increased pain) and thus seek more medical care.
• Maybe even the obese are targeted earlier by the medical community for earlier prevention, or have more stringent risk management modifiers.
• Maybe Nml BMI people are overlooked because it is taken for granted they are “healthier” and thus at less risk.

BUT...There could be a more complex factors affecting some of the population. I mean come one we are physicians, we don’t settle with easy 😉

1. The idea that exposure to some "harm" is protective. We see this in other places...nature animals being exposure to low dose of some food that are poison actually cause the animal to turn on some gene expression that help them in other ways. (I am completely blanking on this term today for some reason, someone please help me out!). Even to if low doses of UV exposure is healthier, and maybe some people shouldn't be wearing as much sunscreen?!? [please don't come after me dermatologists 😉 ]
2. No fat is created equal:

Subcutaneous fat in the thighs

SubC fat in abdomen

Visceral fat

“Dysfunctional fat” basically it is what happens if the adiposites do not develop healthfully... with adequate blood flow sources, abundant mitochondria, and or supportive structures. If they start to lack in any of these factors, especially when they hypertrophy, hypoxia occurs, the fat cells die and cause inflammation ---> lots of downstream bad things. 

Fat cells that developed in the thighs for example have the least amount of propensity to become “dysfunctional," vs fat around the heart and liver tend to be the worst. And even relatively small amounts of dysfunction fat can be more detrimental, compared to larger volumes in the thighs, for example.

This could explain why a “thin” patient with a small “belly pouch” could have a worse outcome could when compared the the guy next door but with more a pannus(subcutaneous abdominal fat). Especially after some hypotensive event where the fat cells are now exposed to a low oxygen environment they otherwise would not have been exposed to.

3. The Metabolically healthy obese person - 

These people are thought to have a higher capacity to store fat that is less “metabolically active,” to have "benign" fat essentially.

Side note: one might be able to improve our genetic expression of factors to help promote good fat….exercise!

“A metabolically healthy obese phenotype can be promoted by exercise, but is also linked with intrinsic AT(adipose tissue) molecular characteristics such as efficient fat storage and lipid droplet formation, high adipogenesis capacity, low extracellular matrix fibrosis, angiogenesis potential, adipocyte browning and low macrophages infiltration/activation. Such features are associated with a secretomic profile of human AT which is protective for the cardiovascular system. In the present review, we summarize the existing knowledge on the molecular mechanisms underlying the 'obesity paradox' and whether fatness can be healthy too.”

study link: https://www.ncbi.nlm.nih.gov/pubmed/28549096

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So what to do with all this??

After all, we still pretty much know a Nml BMI is associated with decreased risk of pretty much all cause morbidity and mortality compared to a high BMI, and not only that we do see health benefits in decreasing abnormally high BMIs.

Basically I see this information as being helpful in two basic ways:

Stop thinking about weight loss in terms of body image. It is easy to get lost in how we "should" look based on cultural pressure. But how many times have culture pressures been wrong?...many, many times through history have people gotten things wrong...like lots.

And thus a good reminder weight loss is not all about the scale. Each person is different.

And also for my own personal admin of WPWI, with recent posts...there is no way for me to screen everyone, know everyone, know their medical and family hx. All we know is pretty much what you have let us know about you through your posts and pictures. That is it.

For my first official Friday Informational 😉 I didn’t want it to seem like I am “picking” on normal weight ppl by posting information of why we do not support weight loss in people with nml BMIs.  So to prove I am not out to “pick” on anyone, which I have been accused of, I thought I would start with an actual presentation that even in some overweight/obese people weight loss might not actually be the key to improving outcomes! Probably not all OW/Ob people, but in some people...like that female who does not smoke with HTN, BMI 27, maybe she is wasting her time and mental happiness always worrying about weight. Maybe she should more be taking the time making sure she knows about more just eating healthy, and exercise. Exercise not to lose weight, but more to decrease CV risks, but also now to continue to, or continue to have her body promote fat mass being stored in thighs, vs in visceral tissue.

Next week, yes we will be talking more, presenting evidence about why WPWI is a support group of those with a history of having elevated BMI to lose weight for potential health benefits. #headsup 

***As always please being kind and forgiving of grammatical errors,a physician women only has so much time in her day. #editingstinks ***