Here is the short(er) version:

Does the above image make sense? That curve above includes approximately 7 billion human beings and it means the majority of us naturally has a body mass index (BMI) of 23-31.



Can you see, by looking closely at that line, where the sick people are? No? That’s correct. Because there are both ill and healthy people scattered all the way along that line.



Weight is not a measure of health. Weight is not a predictor of sustaining your health either.



When the National Institutes of Health convened a Panel on Obesity in 1998, the committee members identified cut-off points that would denote increasing risk of ill health and early death (morbidity and mortality risk) based on BMI.



That’s how you found out that being BMI 25 is “overweight” (or even pre-obese for the truly deterministic) and being BMI 30+ is “obese”. The report suggests that people on the right hand side of the peak of that line are either sick and dying, or at risk of being sick and dying.



Here’s what you don’t know about how the POO arrived at these pronouncements (couldn’t resist an acronym like that for Panel On Obesity):

The Chair of the Panel received or receives research and grant support from: Novo Nordisk (new weight loss drug) and Merck (new weight loss drug). He additionally acts as a paid consultant and advisory board member for: Novo Nordisk (diabetes mellitus, obesity), AstraZeneca (obesity), McNeil Nutritionals (non-caloric sweeteners) and Weight Watchers (obesity).

In fact 8 of the 9 members of the POO have, or had, ties to the weight loss industry. Those conflicts of interest were not published in the NIH POO report but were uncovered by two journalists: Kitta MacPherson and Ed Silverman. 42 For more recent conflict of interest issues for the Federal Guidelines Panel on Obesity, you can check out this New York Times Graphic. The two primary peer-reviewed published data upon which the POO based their pronouncements that BMI correlates with increasing health risks and early death are not credible. The first does not confirm obesity as a contributing factor for early death and the authors have actually made attempts to stop having their data misrepresented as it has been by the POO [NEJM, 1999]. The second study failed to control for activity levels, genetic pre-dispositions, presence of other serious illnesses, history of weight cycling, use or misuse of diet drugs, use of bariatric surgery, etc.

As such, the POO has no data upon which to base the BMI cut-off points as credible identifiers for increased health risks.

The POO has serious (and unpublished within the report) conflicts of interest and has no science upon which to relay to all of us that BMI 25+ is a health risk or that BMI 30+ is a death sentence.



If you inherit an optimal BMI of 41 then there is absolutely nothing in that number that tells you that you are sick and dying. Not one thing.

If you inherit an optimal BMI of 18.5 then there is absolutely nothing in that number that tells you that you are healthy and immortal. Not one thing.

Obesity as Disease

Fat people are sick people. The POO tells us it is so and therefore we accept the claim as fact.

I don’t want to re-hash all the data I have already amassed within the Fat Series so again go read it if you want to be sure of the details.

Here are the high points:

The relative risk increase of diabetes mellitus Type II onset with obesity is equal to that of the relative risk increase of diabetes mellitus Type II onset with a psychiatric disorder. 43 In one study Type II diabetes mellitus prevalence in obese vs. nonobese patients with coronary artery disease 54%% and 34% respectively. In yet another study, 60% of the over 35,000 people studied over an 8 year period had diabetes and were not obese. 45 And while diabetes mellitus Type II is confirmed to be the same chronic condition in both obese and non-obese patients 46, obese patients with diabetes have better morbidity and mortality outcomes than their non-obese counterparts. 47 Diabetes is also over-diagnosed in our society due to fasting blood glucose cut-off point changes that lack evidence to support the new cut-off. 48 While sleep apnea, hypertension and cardiovascular disease are correlated, 50% of those with sleep apnea are not obese. 49 Angiographic studies repeatedly show fattest men and women have the cleanest arteries and an analysis of 23,000 sets of coronary vessels confirmed there was no relationship between heart disease and body fat. 50,51 Being BMI 25-29.9 generated 86,094 fewer deaths than expected when reviewing NHANES data. Therefore the “overweight” category has the lowest mortality rate. 52 Correlations of obesity and certain cancers fail to rule in or out the presence of inflammation and insulin resistance and therefore misconstrue correlation with causation. 53 And while increased body weight is associated with increased death rates for all cancers 54, these results may be attributable to obese patients receiving both inadequate diagnostic testing and in particular intentionally inadequate chemotherapeutic dosing. 55 “Among US adults, there is a high prevalence of clustering of cardiometabolic abnormalities among normal-weight individuals and a high prevalence of overweight and obese individuals who are metabolically healthy.” 56

Not only is being larger than average not a disease, it is not the cause of disease either.

But There ARE Sick Fat People

Yes there are. There are sick fat, average and thin people everywhere. There are even dying fat, average and thin people everywhere too.

There are sick and dying blue-eyed people, red-haired people, tall people, brown-eyed people, and even people with eyes that are different colors as well.

Shockingly, there are also healthy 600 lb. people out there. And even more shockingly, there is a very good chance (given the readership of this site is disproportionately dealing with eating disorders) that that 600 lb. person is actually very much healthier than you are too.

But there is unequivocally one death per person. No way around that one. To paraphrase Nortin Hadler: “By age 50 there are several things in you that are already vying to be listed as proximal cause of death when your time eventually comes.”

Getting sick is not preventable through diet. Reversing the symptoms and damage associated with some chronic illnesses can sometimes be achieved through dietary changes. And unfortunately almost everyone thinks those same dietary changes can prevent the illness in question.

I’ve talked about this fallacy in thinking in many a thread on the forums of 2012. I’ll leave discussions on restrictive diets for another post coming up and let’s get back to all the “morbidly obese” that have our societies so traumatized, terrified and also condescendingly didactic all at once.

What Peter Attia Gets Right

The increasing size of the fat organ in response to the onset of metabolic chronic illness is likely a health protective mechanism.

The increasing size of the fat organ in response to the onset of metabolic chronic illness is likely a health protective mechanism.

Yes, I meant to repeat that sentence. Let it sink in for a moment.

Who is Dr. Peter Attia?

He is a physician who developed diabetes despite being incredibly fit and average-weighted at the time. That humbling experience has spurred him on to identify what really causes diabetes mellitus. Although he falls prey to the same mistake we all do of presuming that the treatment for insulin resistance also will ensure the prevention of the onset of the condition, he is nonetheless keen to allow himself to be taken where the science goes.

A fat organ that is capable of increasing in size in response to various stressors is more health and life protective than a fat organ that is less capable of increasing in size. This fact is wrongly referred to as the “obesity paradox*”.

*obviously there is no “paradox” when you understand that obesity is not a life-limiting condition or disease of any kind.

Various stressors might cause the fat organ to have to increase in size to protect your life: persistent insomnia, unrelenting and out-of-your-control stress, various prescription drugs impacting either pulse rates and/or levels of various reproductive, digestive, and/or metabolic hormones, the exposure to various endocrine disruptors in everyday hygiene, make-up and household products, various disease states and of course unknown genetic predispositions as well.

Restriction of food intake is a monstrous stressor. However, although the time span is variable, the fat organ will usually return to its optimal heritable size when the stressors that caused it to have to work harder (and increase in size) resolve.

Fat is the largest hormone-producing organ in your body. The size or increase-in-size of the fat organ is not correlated to food intake or activity levels. You'll need to read Weight Gain Correlates in Literature Part 1 and 2 if you need the definitive science on those facts.

Yet we still cling to the idea that we just need to “eat healthy” and “get out more” and that’s that.

In other words, people with diabetes and/or cardiovascular disease, don’t have those conditions because they are fat.

The causes of the onset of those metabolic conditions are largely unknown and most certainly multivariate, but the increase in size in the fat organ in response to the presence of such a condition appears to happen in an effort to try modulate and alleviate the impact of the metabolic condition on the body.

That’s why fat people with metabolic chronic illness are less likely to die than average-weighted people with the same metabolic chronic illness. 57,58,59

But Wait! How Many of Us Are Actually Sick Anyhow?

To hear the medical industrial complex tell it, we are all ticking time bombs. Millions of us are walking around with absolutely no symptoms— a silent disease (or several) lurking within us that, if only caught early enough, will be neutralized so that we might realize the immortal and healthy lives we are owed.

We are just one screening test away from having our mortal selves transcended utterly and completely.

As Nortin Hadler notes in his book Worried Sick: A Prescription for Health in an Overtreated America, the “public-health world is alarming us about yet another epidemic that the public-health world itself is creating by virtue of changing the rules for labeling.” (p.48)

And these epidemics are not of disease states, they are of risk factors identified by changing cut-off points alone.

Screening an asymptomatic well person for disease is not the same as applying diagnostic testing to a symptomatic sick person.

Screening an asymptomatic well person may identify a risk factor.

Applying diagnostic tests to a symptomatic sick person may identify the underlying disease.

A risk factor is not a disease.

I have celiac disease and presumably several of my relatives who do not have the disease, may have the genetic risk factor. Critically, they can eat gluten and I cannot. And eating gluten will not turn that risk factor into the disease for my asymptomatic relatives either.

Have high-blood pressure? Not a disease.

Have sleep apnea? Not a disease.

Have poor cholesterol levels or ratio? Not a disease.

Have bad fasting blood glucose levels? Not actually a disease.

Have polyps in the colon? Not a disease.

Have plaque build-up in the arteries? Not a disease.

Have high intraocular pressure? Not a disease.

The above are all risk factors in the same way as the genotype for gluten-sensitive enteropathy is a risk factor for developing celiac disease. Many will live out their lives with the above risk factors never developing into a disease state. And with newer more aggressive cut-off points, the argument that there is actually a measurable risk factor present is just that— merely an argument and not evidence-based medicine.

Do you screen for disease in the absence of symptoms? And then do you treat a risk factor? Well that’s entirely up to you, but I won’t. I won’t because there are no compelling data that such intervention actually removes the risk of the possible anticipated disease in future. And there are reasonable data that such treatments are going to cause more harm than leaving well enough alone.



Edited to add:

When this post was first published, one person was kind enough to comment on the above paragraph to let me know that she hoped I got cancer and died — ah, the internet.

All this is by way of pointing out that a huge amount of the information you have read about the deadliness of obesity as it relates to weakly correlated disease states is actually based on risk factor identification and not even disease. Furthermore, the risk factors are themselves becoming weaker and weaker in context, as the cut-off points are progressively lowered.

You Are Being Conned

In 1992, the Synar Ammendment was enacted by the US Congress to require that states enact laws prohibiting the sale of tobacco to minors. 60

The tobacco conglomerates finally found decades' worth of marketing manipulation and suppression of clinical data unraveled to the point where it became difficult to hide that cigarettes unequivocally contribute to a host of illnesses and cancers. At that point many states in the United States decided to sue tobacco companies for health care reimbursement costs. These litigations were successful and many states were recipients of significant payouts.

In 1997, then Governor of the State of Florida, Lawton Chiles, decided to apply some settlement monies towards an effort to try to stem the ever-increasing smoking rates found amongst youth in that state.

The linchpin of the project was the Florida Youth Tobacco Survey with a representative sample of over 22,000 middle and high school students across the state.

With feedback and input from the Students Working Against Tobacco (SWAT) chapters that were set up across the state, the marketing director of that program (then 18-year-old Jared Perez) determined that the $25 million advertising budget would focus on how teens were being lied to by the tobacco industry, rather than spelling out the usual health consequences of taking up smoking. It was called the “truth” campaign and the annual survey monitored its success.

“By the end of the first year, each measure of tobacco use behavior was significantly lower in Florida than the nation.” 61

After just one year, tobacco use dropped by 19% for middle school students and 8% for high school students in Florida. 62

But in 1998, a $206 billion annual settlement with major tobacco companies occurred. This was the master settlement between Philip Morris, RJ Reynolds, Brown & Williamson and Lorillard and 46 states, allowing for the tobacco industry to avoid a state-by state litigation and settlement process. However, that settlement requires that the companies not be “vilified” in any anti-smoking advertisements. 63

Needless to say the Florida “truth” campaign was neutralized as its entire focus had been to let teens know they were being lied to by the tobacco industry. That emphasis most certainly “vilified” the industry and was therefore going to risk counter-litigation by the tobacco industry to force “anti-vilification” compliance.

“It is difficult to get a man to understand something, when his salary depends upon his not understanding it.” — Upton Sinclair

But That Was The Evil Tobacco Industry

“Finance Director of Weight Watchers explained that it’s the ‘perfect business model,’ because people are doomed to fail.” 64

So let’s say I say to you “You’re fat and to get healthy you have to lose weight.”

Your first question to me should be: “Who the hell are you?” and not “Oh my god, how do I lose weight now?”

The weight loss industry reaped an estimated $61 billion in the US and $180 billion worldwide in 2012. 65 In the same year, by comparison, the tobacco industry generated sales of $491 billion worldwide but only $35 billion in the US. 66

In other words, the weight loss industry in the US now pulls in double the revenue of the tobacco industry in that same country.

You’ll also be happy to know that forecasts suggest that the North American weight loss management market is expected to increase to $139.5 billion by 2017. 67

Just try to find a peer-reviewed published study that indicates obesity is a contributory cause of X or Y disease wherein the researchers are not affiliated in some way to that weight loss industry (that includes, by the way, pharmaceutical options as well as surgeries in addition to things you might equate more readily with the industry like Weight Watcher’s or Jenny Craig).

Upton Sinclair most certainly uttered a timeless observation that has turned out to be far from an industry-specific truism.

Recap

Your body has its own inherited height, weight and body mass index. It’s yours and tell people that you own it outright. If it’s under construction right now thanks to recovery, then it knows where it’s heading and just leave it alone to do its job.

The “theory” in weight set point theory is the unproven ways in which the body keeps its weight stable, not that we don't know if it keeps it stable (it does).

We are a bit heavier, taller and live longer now. Celebrations are a reasonable way to acknowledge these facts.

The words “overweight” and “obese” are not synonyms for “sick and dying” or “ooo, probably going to get sick very soon if you don’t do something now!”

The POO exercised poetic forms of interpretation (or possibly financial interest) to say that a point to the right of the peak of the BMI bell curve graph predicts increased levels of illness and premature death. They are out there dancing with sparklers on that one – no evidence to be had.

“Obesity” is so not a disease that even putting the two words in the same sentence makes me want to disinfect this entire post with a scrub brush and lye.

Metabolic chronic conditions are present in people who are below average, average and above average weight.

If a metabolic chronic condition does appear, then a body that responds by getting fatter has generated both a health and life protective response. And that body has better morbidity and mortality outcomes too.

Many things that are billed as metabolic disease are actually rather nebulous risk factors with ever more questionable cut-off points as well.

Treating risk factors is popular with the medical industrial complex, but in almost all cases there is no proof it offers the actual sought after preventative outcome (namely that the disease will not manifest down the line).

While the tobacco industry is considered in a class on its own when it comes to super villainy, it’s unwise to end up living out that oft repeated quote: “Those that fail to learn from history, are doomed to repeat it.” (presumably Winston Churchill).

Now the next section is really just an addendum that is not necessary reading at all. If you stop here, you have practically everything you need to know about weight and obesity that is scientifically known to date.

Skepticism Is A Practice

The ultra-detailed among you will have noticed I mentioned intraocular pressure (IOP) in the list of things that are not diseases, but rather risk factors for disease.

Well, that’s one where it turns out I had to admit to still being a novice skeptic despite years of dedicated practice and commitment. Just the mere act of practicing skepticism is a practice in humility.

I am currently reading Alan Cassels most recent book: Seeking Sickness: Medical Screening and the Misguided Hunt for Disease. As you know his previous book, co-written with Ray Moynihan, is already listed in suggested reading on this site (Selling Sickness). Well, I begin in chapter one feeling self-satisfied with how much I already know as Cassels reviews the questionable value of full CT body scans. “Hmm, yes. So true! How clever is this author clearly, as I wholeheartedly agree and he reflects admirably my own great brain reasoning,” I think to myself.

Then I hit chapter two “Screening for Eyeball Pressure”. I think I can best describe the response as follows: first, a slow increase in intentional focus and curiosity…

Ever had an eye exam where they puff a bit of air at your eyeballs? It’s called air-puff tonometry and it is designed to identify intraocular pressure.

And thanks to many public service announcements (at least in Canada) we likely all know that this test prevents glaucoma.

Ah yes, well it doesn’t prevent glaucoma. And it does not detect glaucoma either. It detects high intraocular pressure that is a risk factor for one kind of glaucoma: open angle glaucoma. 50% of all glaucoma cases do not include high intraocular pressure as a symptom. And not all incidences of high intraocular pressure progress to glaucoma either.

Glaucoma is damage to the optic nerve that usually leads to progressive and irreversible vision loss. Only 0.6% of the US population has glaucoma and of those only 6% are functionally blind. Treatment, depending on the form of glaucoma, involves medications and surgeries to prevent further vision loss.

Now here’s the thing, I’ve had the tonometry test. I did so without even knowing ahead of time what a positive result might then involve for me. That’s a big no-no. Never undergo screening as an asymptomatic individual with no accompanying risk factors unless you know what a positive result might involve.

High intraocular pressure can be misdiagnosed due to operator error and can appear for fleeting reasons such as atmospheric and temperature changes. 68 Prescription eye drops are used to treat high intraocular pressure but side effects include changes in eye color, blurred vision, redness, stinging, itching and burning. And in rare cases patients can even experience a decrease in blood pressure, memory problems and kidney stones. 69

My tonometry test was negative. But had it been positive I would not have known nearly enough to identify that I would be treating a risk factor. And like most risk factors, it might not ever develop into a disease state and yet the treatment of the risk factor might have harmed me.

Everyone needs to know those odds ahead of time even if each individual might make different decisions when faced with the choice of treating a risk factor that may or may not develop into a disease state.

…And we wrap up my unintentional learning moment with a final realization:

Common nonsense seeps into our brains because we do not live hermetically sealed away from our society. So don’t forget to ask yourself first whether you know what you know, or whether you just think you do. Be skeptical of yourself.