Metabolically-Healthy Obesity: An Oxymoron? (Series Pt 1/5)

Welcome to our 5-part series delving into the fascinating and seemingly paradoxical research on people who despite being obese, remain metabolically-healthy. Today, we’ll start with an introduction.

To date, countless epidemiological studies have shown that as you move from a normal weight (BMI = 18.5-24.9 kg/m2) towards overweight (BMI = 25-29.9kg/m2) and obesity (BMI ≥ 30 kg/m2) the risk of many diseases increases exponentially.

Does this imply that every individual carrying excess weight is guaranteed to develop diabetes, cardiovascular disease, cancer, or some other disease?

Although this belief prevails, the cumulative research suggests the answer to the above question is a resounding “NO!”

It all started in 1965. Two researchers, Albrink and Meigs, were performing a general investigation into the health of factory workers, and noted a rather counter-intuitive result: that “many obese men had normal triglycerides.”

Subsequently, in 1982, Ethan Sims first included the designation of “healthy obese” subtype in his classification of obesity, thereby first identifying a unique subset of obese individuals that appear to be at least partially protected from the development of the metabolic disturbances generally attributed to obesity.

Today it is believed that approximately 25-30% of obese individuals ­remain metabolically healthy (normal blood glucose, blood lipids, blood pressure, and cytokine profile) despite their excess weight. However, despite awareness of the metabolically-health obese phenotype for close to 30 years, there currently exist no established criteria by which to define these individuals. Not surprisingly, there is significant variation in the predicted prevalence of these individuals within the total obese population.

The defining characteristics of the metabolically healthy obese phenotype, in contrast to obese individuals with metabolic risk, include limited abdominal, particularly visceral fat accumulation, an earlier onset of obesity (<20 years) and high levels of physical activity. Additionally, black obese individuals have a greater tendency of being metabolically-healthy in contrast to white obese.

Japanese sumo wrestlers are often used as a popular example of metabolically healthy obese. They are morbidly obese and yet due to their high level of activity have very little visceral fat accumulation, tons of muscle mass, and a healthy metabolic profile – until they stop training, that is. Once they stop training, their fitness drops significantly, they accumulate excess fat in deleterious locations, and their metabolic profiles deteriorate. Football linemen are also a popular example of metabolically healthy obese, when they are training.

As a important caveat, there are countless other health issues brought on by carrying excess weight that are not always metabolic (i.e. joint problems due to excess load, skin infections, etc.). Thus, it is often argued that despite being metabolically-healthy these individuals may still be far from optimal health.

Nevertheless, it is important to note that excess weight alone doesn’t absolutely guarantee the presence of metabolic disease.

There is certainly truth to the notion that there is more to health than the number on one’s bathroom scale.

Join us tomorrow for part 2 of the series when we discuss the risk of diabetes and cardiovascular disease among these obese, but metabolically healthy individuals.


References and Further Reading:

Albrink, M., & Meigs, J. (1965). THE RELATIONSHIP BETWEEN SERUM TRIGLYCERIDES AND SKINFOLD THICKNESS IN OBESE SUBJECTS Annals of the New York Academy of Sciences, 131 (1 Adipose Tissu), 673-683 DOI: 10.1111/j.1749-6632.1965.tb34830.x

Sims, E. (2001). Are there persons who are obese, but metabolically healthy? Metabolism, 50 (12), 1499-1504 DOI: 10.1053/meta.2001.27213

Karelis, A. (2004). Metabolic and Body Composition Factors in Subgroups of Obesity: What Do We Know? Journal of Clinical Endocrinology & Metabolism, 89 (6), 2569-2575 DOI: 10.1210/jc.2004-0165

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43 Responses to Metabolically-Healthy Obesity: An Oxymoron? (Series Pt 1/5)

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  2. Janis says:

    Dude, sumo wrestlers and football players are also YOUNG when they are training. Most unhealthy practices take some time to show their effects on the body. Young people can get away with terribly unhealthy behaviors that will shred them the second they hit 40.

  3. Janis – you are certainly correct; age is a very important risk factor in terms of development of chronic disease. Additionally, it has also been shown that the duration of obesity may be positively linked with the degree of metabolic dysregulation – the longer you’ve been obese the greater your problems. Paradoxically, this subset of obese individuals who are metabolically healthy commonly have an earlier onset of obesity – that is before adulthood. There is some suggestion that the age at which one becomes obese has some influence on the specific way by which they accrue excess fat. When this happens earlier in life, one increases fat mass by the accrual of plentiful adipocytes or fat cells (hyperplasia) whereas if this happens later in life, the gain occurs predominantly in the size of existing adipocytes (hypertrophy). It is now fairly established that obesity characterized by plentiful but small adipocytes is much less metabolically detrimental than one accomplished by the enlargement of few adipocytes. We will certainly be looking more into this fascinating research in the future.

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  5. Clem says:

    Could it also be something to do with the appalling measure used to determine whether a person is obese.

    BMI takes no account of build and muscle mass for example.


    • Clem, you are absolutely correct in your criticism of BMI. I have previously discussed at length the limitations of BMI in determining health risk. In this case however, it does not appear that total adiposity separates healthy from unhealthy obese – in most studies that have measured these outcomes using CT or MRI, you see very similar amounts of total body fat. And yet, some are metabolically healthy and others are bordering on diabetic. Once clue is the location of the fat deposition – the healthy obese have very little visceral or intra-abdominal fat despite a large amount of subcutaneous (under the skin) fat. They may also have less ectopic fat storage – in liver, muscle, etc.

  6. Jo says:

    Random question… how do sumo wrestlers get so large and heavily obese looking, while maintaining their level of physical activity? How does that work?

    • Jo – As long as caloric intake exceeds energy output, you will gain weight. In this case we are talking about a large amount of energy output in their training, but a HUGE amount of calories consumed to continually gain weight.

      • bonita says:

        Thanks Peter, I’ve always wonder why I am so small and never gain any weight. My BMI is 17.037 which is underweight and my kcal intake is about 2000 daily which is larger than most people I know. I don’t do much physical exercise maybe just 30 minutes walking daily. I guess to gain weight I either need to eat more junk or use less energy. lol

  7. Roy Huggins says:

    @Jo: Put simply, they eat fattening things and are often predisposed to being big (pics of sumo wrestlers tend to be the heavyweight guys, btw. There are definitely smaller competitors, too, but they all appear obese.) I’m a huge white guy who towers over most Japanese (despite this generation in Japan being of what Americans would consider relatively average height), but in Tokyo I’ve passed sumo wrestlers on the metro and I can tell you those guys are clearly born to be big.

  8. Buster B says:


    I must say I am one of the 25%, but then again I am a genetic mutant freak, overall. My fasting cholesterol tests are usually 150-170 despite being a carnivore, and 6’3″ tall and 300 pounds. My resting heart rate is 70, and my blood pressure is always 120ish over 70. I am also in my 40’s. Funny thing is, I have outlived two doctors already who told me I was doing everything wrong, and I would be dead by now. Then again, I was also chastised by a vegan dietician who had cholesterol in the 300’s.

    Given the other genetic ‘abnormalities’ I have, I guess this one really shouldn’t surprise me. Talk about winning life’s lottery. 😉

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  36. Jim says:

    The assumption that high triglycerides, obesity, etc., cause heart disease and other illnesses is completely wrong as I have discovered.

    I had high cholesterol, non-alcoholic fatty liver disease, was obese, borderline high blood pressure among other things. However, the case of all these things was found to severe malnutrition. This is despite receiving treatment for b12 deficiency for years. Once the inflammation caused by the vitamin deficiency was dealt with by vitamin, mineral and efa supplementation, my cholesterol fell to normal levels, blood pressure normalised and liver function too.

    So, IMHO, healthy obese people have good nutrition(and exercise), unhealthy obese people have serious nutritional problems. What is more, I think the nutritional problems precede the obesity, I.e. obesity is a symptom and not the cause of the health problems. This is clearly the case given the existence of the healthy obese.

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