Fat and Fit?

Written by: Kelly Bruno, MD

Can an individual be overweight or obese and still be considered healthy?

I’m not usually one to take a hard stance on a topic, especially when it might be an unpopular position, but there are occasions when it’s worth it. This is one of those times. This is a topic that hits close to home, both as an athlete and as a physician, and I think it’s worth a quick review on the current medical literature.

The original article that got me thinking about this topic was published in a running magazine about a 250lb runner who had just finished a 50k race. The tag line – is it possible to be fat and fit? While it was an inspiring human-interest story and this runner’s accomplishment deserves credit, the article completely failed to address the original question it posed – is it possible to be fat and fit?

According to Dr. Caleyachetty of the Institute of Applied Health Research, who presented the results from a study of 3.5 million ‘healthy’ obese subjects at the 2017 European Congress of Obesity, the answer is NO. He found that individuals who were obese (BMI > 30) but without metabolic abnormalities had a 50% increased risk of coronary heart disease, 7% increased risk of cerebrovascular disease, and two times the risk of congestive heart failure compared to ‘healthy’ non-obese subjects.

Although this study was not directed specifically at athletes, the results are extremely telling and relatable to this population. The findings suggest that obesity, regardless of exercise or “metabolic fitness,” puts you at increased risk for long-term health issues. These are health issues that could otherwise be prevented. For me, this hits close to home as an anesthesiologist who provides medical care to patients undergoing surgery.

As a physician who trained in North Carolina, a state that’s ranked #22 for obesity, I am intimately familiar with the health impacts of obesity- obstructive sleep apnea, high blood pressure, diabetes mellitus, and cardiovascular disease. Despite growing pharmaceutical inventories, the only true treatment for obesity is weight loss, which, I’ve generally found is an unpopular topic for discussion.

In my day job, as an anesthesiologist, I rarely even broach the subject with my patients, given the very brief encounters I often have. A few pleasantries, a brief review of medical history, a focused physical exam, and before you know it you’re on the operating room table counting down from 10….and then waking up in the recovery room wondering when the surgery will occur.

But as a physician who dabbles in coaching (as the co-founder of Complete Human Performance, I’ve directly coached dozens of athletes ranging from weight loss and general fitness clients to elite athletes), I find that I have an opportunity, even an obligation, to put forth the data on obesity. There is no doubt that the average American is overweight. You can easily pull those numbers up on Google. But what about athletes? How many meet the criteria for being overweight or obese? What criteria do you even use to categorize athletes as overweight or obese? And how does their weight impact their long-term health?

Although I can’t answer the first question about how many athletes are overweight or obese (the data just doesn’t exist), it’s likely higher than one might expect. Consider athletes who compete as a super-heavyweight (or comparable weight class), Clydesdale, or Athena athlete in powerlifting, Strongman, weightlifting, boxing, wrestling, MMA (and many other combat sports), triathlons, duathlons, aqua-bike events, running, etc. For most of these sports, the weight class requires the entrant to be over 200 lbs. In fact, many strength sports have multiple weight classes for athletes over 200 pounds before the super-heavyweight level is even reached.

By definition then, most of the athletes who compete in the weight classes listed above will meet the criteria for being overweight as defined by body mass index (BMI), which calculates a ratio of body mass to height in an attempt to quantify tissue mass in an individual. Many athletes have spurned BMI because the ratio doesn’t consider physical composition. For this ratio, fat and muscle are weighted equally as they contribute to total body mass. And while this is true, it simply doesn’t matter!

Yes, I said it. Total body mass matters regardless of body composition. I literally see it every day in the operating room. If you’re going to have surgery, and many of you will if you’re planning to have a long career in your respective sport, then total body weight absolutely matters. Regardless of body composition, higher weight has many impacts on medical procedures, reactions to anesthesia, and surgery in general.

Surgery and anesthesia is never without risk, but these risks are amplified for individuals with significantly higher total body weight. For one thing, positioning on the operating room table is more difficult. Imagine how heavy your arm or leg is when it’s completely relaxed- essentially it becomes dead weight. If not positioned correctly, the weight from the body can press on nerves, which will go unnoticed until you wake up, by which time permanent nerve injury may have occurred.

Individuals with increased body weight can also have more facial tissue and/or a larger neck, which has several implications during and after anesthesia. It can be more difficult to get air into the lungs or place a breathing device after giving medications that cause unconsciousness. This can mean oxygen levels might get too low or repeated attempts to place a breathing device could cause a sore throat or trauma to teeth, lips, or gums. In the same vein, more weight over the chest can make it more difficult to get air or oxygen into the lungs during artificial ventilation or during the wake up process.

BMI aside, neck and waist circumference are also meaningful measures. Neck circumference (independent of BMI or body composition) is a risk factor for respiratory complications after surgery. Specifically, a neck circumference greater than 17 cm for men (and 15 cm for women) puts at individual at risk for obstructive sleep apnea (OSA). During and after surgery, factors related to OSA puts the individual at increased risk for irregular heart rhythms, low oxygen levels, and changes in blood pressure.

Proper medication dosing is also poorly understood in patients who fall outside the normal weight range. The studies conducted by pharmaceutical companies often exclude overweight and obese subjects, which means pharmacokinetic and pharmacodynamics data is lacking in this patient population. This translates to a higher chance that too much or too little medication will be given to maintain sedation or provide pain relief before, during, and after a medical or surgical procedure.

What about all those outliers who state that although their bodyweight is obese, their body fat percentage is healthy? If we defined a “healthy” body fat percentage as < 20% for men and < 28% for women, a simple calculation using the Fat Free Mass Index (FFMI) can be run to determine how common an obese BMI but healthy bodyweight actually is.

The FFMI is calculated as follows:

Lean body mass = Weight * (1 – (body fat % / 100)

FFMI = (Lean body mass / 2.2) / ((Height in ft x 12.0 + in) x 0.0254)2 x 2.20462

Adjusted FFMI = FFMI + (6.1 x (1.8 – ((Height in ft x 12.0 + in) x 0.0254)))

Any FFMI over 25 is considered suspect- in other words, it would be exceptionally hard to attain without the use of steroids, which of course would negate ANY health benefits of being lean!

 If we were to take a 6’0” male, any bodyweight over 221 is considered obese. At 221 pounds, the MOST lean body mass this individual could carry without the use of steroids (assuming near genetic perfection and near his natural limit of lean mass gain) would be 185 pounds, give or take, equating to a body fat of less than 17%. (FFMI 25) Any LEANER than 17% would suggest that the individual were using exogenous muscle building compounds. Therefore, there is a relatively narrow band of body fat levels where an individual can be “obese” according to BMI, yet “healthy/lean” according to body fat levels. Chances are, all these “ripped but obese” individuals are either A) on steroids, or B) not being honest with themselves about their body fat percentage.

This all trickles down to daily life too. Although a healthy and active lifestyle has its benefits, cardiac issues continue to plague those who are heavier, even if active. A larger body means the heart has to work harder and the joints are subject to additional stress. Regardless of body composition, risk factors for medical issues like obstructive sleep apnea, high blood pressure, and stress impacts on the joints still apply. The surgical implications, as described above, are significant and real as well.

Honestly, if you’re an athlete, being prepared for surgical and medical procedures should matter to you. You don’t need to sacrifice your goals, but you do need to consider that your weight may put you at higher risk for medical and surgical complications. At the end of the day, we all have a choice. The decisions we make today about our athletic goals can absolutely impact our future health.


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