Friday Favorites: Is the Obesity Paradox Real or a Myth?

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How do we explain studies that suggest overweight individuals live longer?

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Below is an approximation of this video’s audio content. To see any graphs, charts, graphics, images, and quotes to which Dr. Greger may be referring, watch the above video.

Martin Luther King, Jr. warned that human progress is neither automatic nor inevitable, and the same may be true of the human lifespan. In the 1800s, life expectancy was less than 40, but has been steadily increasing over the last two centuries, gaining about two years per decade. That is, until recently. Longevity gains have faltered or even reversed. Thanks to the obesity epidemic, we may now be raising the first American generation to live shorter lives than their parents.

The downward trend in longevity is expected to accelerate as the current younger generation (who started out heavier and earlier than ever before) ages into adulthood. If the obesity epidemic continues unchecked, current trends signal a potential “looming social and economic catastrophe.” In the coming decades, some predict we may lose two to five or more years of life expectancy in the United States. To put that into perspective, a miracle cure for all forms of cancer would only add 3.5 years to the average American lifespan. In other words, reversing the obesity epidemic might save more lives than curing cancer.

The evidence that being overweight increases your risk for debilitating diseases like diabetes is considered indisputable, but surprisingly, there’s controversy surrounding body weight and overall mortality. In 2013, CDC scientists published a meta-analysis in the Journal of the American Medical Association suggesting being overweight was actually advantageous. Yes, grade 2 or 3 obesity (like being average height, 5’6″, and weighing about 215+ pounds) was associated with living a shorter life, but grade 1 obesity (between about 185-215 pounds at that height) was not, and just being overweight (155-185 pounds) appeared to be protective compared to those who were normal weight (115 to 155 pounds). The overweight individuals—BMI 25 to 30—appeared to live the longest.

Headline writers were giddy: Being overweight can your extend life, “Dreading your diet? Don’t worry… plump people live LONGER.” Extra pounds might mean lower chance of death. Not surprisingly, the study ignited a firestorm of controversy in the public health community. The study was called “ludicrous,” “flawed,” “misleading.” The chair of nutrition at Harvard lost his cool, calling the study “really a pile of rubbish,” fearing the food industry might exploit this study in the same way the petroleum industry misuses “controversy” over climate change.

Public health advocates can’t just dismiss data they find inconvenient, though. Science is science. But how could being overweight increase the risk of life-threatening diseases, yet at the same time make you live longer? This became known as the “obesity paradox.” The solution to the puzzle appears to lie with two major sources of bias, the first being confounding by smoking.

The nicotine in tobacco can lead to weight loss. So, if you’re skinnier because you smoke, then no wonder you’d live a shorter life with a slimmer waist. The failure to control for the effect of smoking in studies purporting to show an “obesity paradox” leads to the dangers of obesity being “grossly underestimated.”

The second major source of bias is reverse causality. Instead of lower weight leading to life-threatening diseases, isn’t it more likely that life-threatening diseases are leading to lower weight? Conditions such as hidden tumors, chronic heart or lung disease, alcoholism, and depression can all cause unintentional weight loss months or even years before they are even diagnosed. It’s normal to be overweight in this country. So, people who are “abnormally” thin (in other words, ideal weight) could actually be taking care of themselves, but may be heavy smokers, elderly and frail, or seriously ill with weight loss from their disease.

To put the obesity paradox issue to the test once and for all, the Global BMI Mortality Collaboration was formed, reviewing data from more than 10 million people from hundreds of studies in dozens of countries—the largest evaluation of BMI and mortality in history. To help eliminate bias, they omitted smokers and those with known chronic disease, and then excluded the first five years of follow-up to try to remove from the analysis those with undiagnosed conditions who lost weight due to an impending death. And…the results were clear: being overweight, and all grades of obesity, were associated with a significantly greater risk of dying prematurely. So, adjusting for these biases leads to “eliminating the obesity paradox altogether.” In other words, the so-called obesity paradox appears to be just a myth.

Indeed, when intentional weight loss is actually put to the test, people live longer. There are bariatric surgery studies like the SOS trial that show weight loss reduces long-term mortality, and randomizing people to weight loss though lifestyle changes shows the same thing. Losing a dozen pounds through diet and exercise was found to be associated with a 15 percent drop in overall mortality. Now, exercise alone may extend lifespan even without weight loss, but there also appears to be a similar longevity benefit of weight loss through dietary means alone.

Please consider volunteering to help out on the site.

Video production by Glass Entertainment

Motion graphics by Avocado Video

Below is an approximation of this video’s audio content. To see any graphs, charts, graphics, images, and quotes to which Dr. Greger may be referring, watch the above video.

Martin Luther King, Jr. warned that human progress is neither automatic nor inevitable, and the same may be true of the human lifespan. In the 1800s, life expectancy was less than 40, but has been steadily increasing over the last two centuries, gaining about two years per decade. That is, until recently. Longevity gains have faltered or even reversed. Thanks to the obesity epidemic, we may now be raising the first American generation to live shorter lives than their parents.

The downward trend in longevity is expected to accelerate as the current younger generation (who started out heavier and earlier than ever before) ages into adulthood. If the obesity epidemic continues unchecked, current trends signal a potential “looming social and economic catastrophe.” In the coming decades, some predict we may lose two to five or more years of life expectancy in the United States. To put that into perspective, a miracle cure for all forms of cancer would only add 3.5 years to the average American lifespan. In other words, reversing the obesity epidemic might save more lives than curing cancer.

The evidence that being overweight increases your risk for debilitating diseases like diabetes is considered indisputable, but surprisingly, there’s controversy surrounding body weight and overall mortality. In 2013, CDC scientists published a meta-analysis in the Journal of the American Medical Association suggesting being overweight was actually advantageous. Yes, grade 2 or 3 obesity (like being average height, 5’6″, and weighing about 215+ pounds) was associated with living a shorter life, but grade 1 obesity (between about 185-215 pounds at that height) was not, and just being overweight (155-185 pounds) appeared to be protective compared to those who were normal weight (115 to 155 pounds). The overweight individuals—BMI 25 to 30—appeared to live the longest.

Headline writers were giddy: Being overweight can your extend life, “Dreading your diet? Don’t worry… plump people live LONGER.” Extra pounds might mean lower chance of death. Not surprisingly, the study ignited a firestorm of controversy in the public health community. The study was called “ludicrous,” “flawed,” “misleading.” The chair of nutrition at Harvard lost his cool, calling the study “really a pile of rubbish,” fearing the food industry might exploit this study in the same way the petroleum industry misuses “controversy” over climate change.

Public health advocates can’t just dismiss data they find inconvenient, though. Science is science. But how could being overweight increase the risk of life-threatening diseases, yet at the same time make you live longer? This became known as the “obesity paradox.” The solution to the puzzle appears to lie with two major sources of bias, the first being confounding by smoking.

The nicotine in tobacco can lead to weight loss. So, if you’re skinnier because you smoke, then no wonder you’d live a shorter life with a slimmer waist. The failure to control for the effect of smoking in studies purporting to show an “obesity paradox” leads to the dangers of obesity being “grossly underestimated.”

The second major source of bias is reverse causality. Instead of lower weight leading to life-threatening diseases, isn’t it more likely that life-threatening diseases are leading to lower weight? Conditions such as hidden tumors, chronic heart or lung disease, alcoholism, and depression can all cause unintentional weight loss months or even years before they are even diagnosed. It’s normal to be overweight in this country. So, people who are “abnormally” thin (in other words, ideal weight) could actually be taking care of themselves, but may be heavy smokers, elderly and frail, or seriously ill with weight loss from their disease.

To put the obesity paradox issue to the test once and for all, the Global BMI Mortality Collaboration was formed, reviewing data from more than 10 million people from hundreds of studies in dozens of countries—the largest evaluation of BMI and mortality in history. To help eliminate bias, they omitted smokers and those with known chronic disease, and then excluded the first five years of follow-up to try to remove from the analysis those with undiagnosed conditions who lost weight due to an impending death. And…the results were clear: being overweight, and all grades of obesity, were associated with a significantly greater risk of dying prematurely. So, adjusting for these biases leads to “eliminating the obesity paradox altogether.” In other words, the so-called obesity paradox appears to be just a myth.

Indeed, when intentional weight loss is actually put to the test, people live longer. There are bariatric surgery studies like the SOS trial that show weight loss reduces long-term mortality, and randomizing people to weight loss though lifestyle changes shows the same thing. Losing a dozen pounds through diet and exercise was found to be associated with a 15 percent drop in overall mortality. Now, exercise alone may extend lifespan even without weight loss, but there also appears to be a similar longevity benefit of weight loss through dietary means alone.

Please consider volunteering to help out on the site.

Video production by Glass Entertainment

Motion graphics by Avocado Video

Doctor's Note

If you missed my other videos in this series on the ABCs of obesity, see:

I cover all of this and more at length in my book How Not to Diet. Its companion—The How Not to Diet Cookbook—has more than 100 delicious Green-Light recipes that incorporate some of my 21 Tweaks for the acceleration of body fat loss.

Why are people obese in the first place? I have a whole series of videos on that topic, including:

The original videos aired on June 4, 2021

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