If You’re ‘Fit But Fat,’ Do You Really Need To Lose Weight?

The short answer from a preventive cardiologist

Q: I am active and exercise regularly, but I am still overweight. My BMI is 32. I have read that being “fit but fat” is fine in terms of future heart risk. Why should I lose weight if I remain fit?

A: “Fit but fat” is sometimes referred to as metabolically healthy obesity (MHO), meaning overweight but lacking other cardiovascular (CV) risk factors.

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At any given point in time, the future cardiovascular risk in people with MHO appears similar to that of people of metabolically healthy normal weight. However, this may not be the case when observed over time.

A recent analysis from the Multi-Ethnic Study of Atherosclerosis (MESA) reported that despite conferring a risk similar to normal weight at baseline, MHO did not reliably predict future risk. The reason is that in more than 12 years of follow-up, nearly one-half of individuals with MHO and no CV risk factors at baseline developed metabolic syndrome (MetS), which increased the risk of cardiovascular disease 60 percent, compared with those with stable MHO or healthy normal weight.

MetS is characterized by multiple factors, including obesity, high blood pressure, elevated blood sugar, elevated triglycerides and low HDL cholesterol.

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Underestimating risk at a single point in time has implications for long-term follow-up. Preventing MetS, and treating it if it develops, is critical.

The best way to prevent MetS is to prevent further weight gain, maintain regular physical activity/exercise and follow a diet that reduces saturated fats, refined sugars and carbohydrates.

If you are “fat but fit,” you should watch for and promptly treat high blood pressure, cholesterol abnormalities and rising blood sugar levels to help minimize your CV risk. Although cardiac fitness and the absence of metabolic abnormalities may be more important than weight alone for predicting what will happen over time, losing weight can help prevent MetS, has many other health benefits and is worth considering.

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Leslie Cho, MD, Co-section Head of Preventive Cardiology and Rehabilitation

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